What is the hepatojugular reflex?

Hepatojugular Reflex: Clinical Definition and Significance

The hepatojugular reflex (HJR) is a physical examination maneuver that assesses right-sided cardiac filling pressures by applying sustained abdominal compression (typically over the right upper quadrant) for 15 seconds while observing for a sustained rise in jugular venous pressure of ≥1 cm, indicating elevated right atrial pressure and volume overload. 1, 2

How to Perform the Test

• Position the patient at 45 degrees and identify the internal jugular venous pulsation at baseline 2
• Apply firm, sustained pressure to the right upper quadrant (over the liver) or periumbilical area for at least 15 seconds—this duration is adequate for interpretation as the response stabilizes by 15 seconds in 95% of patients 2
• Observe for a sustained rise in jugular venous pressure of ≥1 cm during compression; a transient rise that returns to baseline during continued compression is negative 2
• The test can be performed at the bedside with excellent correlation to invasive hemodynamic measurements (κ = 0.74) 2

What a Positive HJR Indicates

A positive HJR is one of the most reliable physical examination signs of elevated right-sided filling pressures and volume overload in heart failure, more dependable than peripheral edema or pulmonary rales in chronic cases. 1, 3

Hemodynamic Correlations

• Best correlates with elevated right atrial pressure (r = 0.59) and right ventricular end-diastolic pressure (r = 0.51) 2
• Has high sensitivity (1.0) and specificity (0.85) for predicting right atrial pressure >9 mmHg 2
• Also correlates with pulmonary capillary wedge pressure (p = 0.006) and inferior vena cava size (p = 0.003-0.005), indicating chronically elevated left-sided filling pressures transmitted to the right heart 4

Clinical Significance in Heart Failure

• In chronic heart failure, rales and chest X-ray findings may be absent despite elevated filling pressures, making HJR more reliable than pulmonary examination 1, 3
• The American College of Cardiology recommends assessing HJR at every heart failure visit as part of comprehensive volume status evaluation 1, 3
• A positive HJR at hospital discharge independently predicts 6-month mortality (hazard ratio 1.689,95% CI 1.032-2.764) after adjusting for age, renal function, anemia, NYHA class, and comorbidities 4

Differential Diagnosis Beyond Heart Failure

While HJR is most commonly associated with heart failure, other conditions can produce a positive test:

• Right ventricular failure from pulmonary hypertension, tricuspid regurgitation, or right ventricular infarction 3
• Hepatic venous outflow obstruction (Budd-Chiari syndrome), typically presenting with hepatomegaly, ascites, and abdominal pain 3
• Important caveat: One older study suggested HJR may occur in patients without heart failure, but this has been superseded by more rigorous hemodynamic validation showing strong correlation with elevated filling pressures 5, 2

Clinical Management Implications

A positive HJR indicates the need for diuretic therapy to reduce volume overload and congestion. 3

Treatment Algorithm

• Persistent positive HJR despite standard diuretic therapy warrants consideration of invasive hemodynamic monitoring to guide further management 3
• For severe symptomatic volume overload with positive HJR, consider adding vasodilators (intravenous nitroglycerin or nesiritide) to diuretics, or ultrafiltration in refractory cases 3
• Always reassess HJR before hospital discharge—its presence at discharge is a powerful predictor of adverse outcomes and may indicate need for more aggressive decongestion 4

Common Pitfalls to Avoid

• Insufficient compression duration: Apply pressure for the full 15 seconds, as shorter durations may miss positive responses 2
• Confusing transient with sustained rise: Only a sustained elevation throughout compression is positive; a brief rise that returns to baseline during continued compression is negative 2
• Relying on peripheral edema or rales alone in chronic heart failure: These signs are less reliable than HJR for detecting volume overload 1, 3
• Ignoring a positive HJR at discharge: This finding has independent prognostic significance and should prompt reassessment of decongestion adequacy 4

Diagnostic Performance

A meta-analysis of 5,195 patients found HJR has low sensitivity (0.12) but very high specificity (0.96) for diagnosing congestive heart failure, with a diagnostic odds ratio of 29.7 6. This means:

• A positive test is highly specific and strongly suggests elevated filling pressures requiring treatment 6
• A negative test does not rule out heart failure, as sensitivity is limited 6
• The test is most useful for ruling in rather than ruling out volume overload 6