What is the hepatojugular reflex?

Hepatojugular Reflex: Definition and Clinical Significance

The hepatojugular reflex (HJR) is a physical examination maneuver where sustained abdominal compression causes a sustained elevation in jugular venous pressure (≥3-4 cm for >15 seconds), indicating the right ventricle's inability to accommodate increased venous return and serving as one of the most specific and reliable signs of elevated right-sided filling pressures in heart failure. 1, 2

Technique and Interpretation

Proper Performance

• Apply firm, sustained pressure over the right upper quadrant or periumbilical region for at least 15 seconds while observing the internal jugular vein 3, 4
• The response stabilizes by 10-15 seconds, making this the minimum duration for accurate interpretation 3, 5
• A positive test is defined as a sustained increase in jugular venous pressure of ≥3 cm (some sources use ≥4 cm) that persists throughout the compression period 4, 5

Bedside Accuracy

• Bedside clinical assessment of HJR correlates strongly with invasive hemodynamic measurements during cardiac catheterization (K = 0.74, p <0.001) 3
• The test can predict right atrial pressure within 2 mm Hg in most cases 5

Pathophysiology and Hemodynamic Correlates

The HJR reflects a right ventricle that cannot accommodate augmented venous return, whether from intrinsic right ventricular dysfunction, elevated right ventricular afterload, or elevated left-sided filling pressures transmitted backward. 4

Hemodynamic Relationships

• HJR correlates most strongly with baseline mean right atrial pressure (r = 0.59) and right ventricular end-diastolic pressure (r = 0.51) 3
• A positive HJR has high sensitivity (1.0) and specificity (0.85) for predicting right atrial pressure >9 mm Hg 3
• It demonstrates 90% sensitivity and 89% specificity for right ventricular end-diastolic pressure >12 mm Hg 3
• In heart failure patients, positive HJR correlates with elevated pulmonary capillary wedge pressure (PCWP >15 mm Hg), with likelihood ratio positive of 6.7 6, 4

Clinical Significance in Heart Failure

The European Society of Cardiology and American Heart Association classify HJR as a "more specific" sign of heart failure, more reliable than peripheral edema or pulmonary rales in detecting chronic volume overload. 1, 2

Diagnostic Value

• In patients presenting with dyspnea, positive HJR predicts congestive heart failure with likelihood ratio positive of 6.0 4
• The test indicates chronically elevated left-sided filling pressures transmitted to the right heart, even when other signs like rales are absent 2

Prognostic Importance

• A positive HJR at hospital discharge independently predicts 6-month mortality in acute heart failure patients (hazard ratio: 1.689; 95% CI: 1.032-2.764; p = 0.037) after adjusting for age, renal function, anemia, NYHA class, and comorbidities 6
• Persistent positive HJR despite therapy indicates inadequate decongestion and increased risk for rehospitalization 6

Differential Diagnosis Beyond Heart Failure

While HJR most commonly indicates heart failure with volume overload, several other conditions produce a positive test: 2, 4

• Right ventricular failure from pulmonary hypertension, right ventricular infarction, or severe tricuspid regurgitation 2
• Constrictive pericarditis and restrictive cardiomyopathy (common causes of isolated positive HJR) 4
• Hepatic venous outflow obstruction (Budd-Chiari syndrome), typically with hepatomegaly and ascites 2

Important Exception

• Cardiac tamponade does NOT produce a positive HJR because the compressed right ventricle cannot accommodate any increase in venous return 4

Clinical Management Implications

Assessment Strategy

• The American College of Cardiology recommends assessing HJR at every heart failure visit as part of comprehensive volume status evaluation 2
• Check HJR throughout hospitalization and especially at discharge, as it serves as an important prognostic marker 6

Treatment Guidance

• A positive HJR indicates the need for diuretic therapy to reduce volume overload and congestion 2
• Persistent positive HJR despite standard diuretic therapy warrants consideration of invasive hemodynamic monitoring to guide further management 2
• For severe symptomatic volume overload with positive HJR, consider adding vasodilators (intravenous nitroglycerin or nesiritide) to diuretics, or ultrafiltration in refractory cases 2

Common Pitfalls

Technical Errors

• Insufficient compression duration (<15 seconds) leads to false-negative results, as the response requires time to stabilize 3, 5
• Inadequate compression pressure fails to augment venous return sufficiently 4
• Applying pressure in the wrong location (should be right upper quadrant or periumbilical, not left iliac fossa) 7

Interpretation Caveats

• The test has limited utility in patients with severe obesity where jugular venous assessment is difficult 8
• One older study from 1973 questioned the specificity of HJR, finding positive responses in some patients without heart failure, but this study used non-standardized technique and shorter compression duration 7
• More rigorous subsequent studies with standardized 15-second compression have validated the test's clinical utility 3, 6, 5