What is the hepatojugular reflex (HJR)?

From the Guidelines

The hepatojugular reflex is a valuable clinical examination technique used to assess right heart function and diagnose heart failure, particularly in patients with chronic heart failure where it is a more reliable sign of hypervolemia than peripheral edema. This reflex involves applying firm pressure over the right upper quadrant of the abdomen (over the liver) for 10-15 seconds while observing the jugular veins in the neck. In a positive test, this abdominal pressure causes a sustained rise in jugular venous pressure (JVP) of at least 3 cm, visible as distention of the neck veins 1. The test is based on the principle that the abdominal pressure increases venous return to the right heart, and in patients with right heart failure or volume overload, the compromised heart cannot accommodate this additional blood flow, causing backup into the jugular veins.

Key Points to Consider

• The hepatojugular reflex is particularly useful in the assessment of patients with chronic heart failure, as it can indicate volume overload even in the absence of peripheral edema or rales 1.
• The test should be performed with the patient's upper body elevated at about 45 degrees, breathing normally, and avoiding the Valsalva maneuver which could give false results.
• A positive hepatojugular reflex is a significant finding that suggests right heart dysfunction or volume overload, conditions that require careful management to prevent further cardiac decompensation.
• The reliability of the hepatojugular reflex in diagnosing heart failure is supported by guidelines that emphasize the importance of physical examination findings, including jugular venous distension and its response to abdominal pressure, in the assessment of volume status in patients with heart failure 1.

Clinical Application

The hepatojugular reflex is a simple yet informative bedside test that can aid in the diagnosis and management of heart failure. By incorporating this test into routine physical examinations, clinicians can gain valuable insights into right ventricular function and volume status, guiding therapeutic decisions and potentially improving patient outcomes. Given its non-invasive nature and the availability of necessary equipment, the hepatojugular reflex can be easily performed in various clinical settings, making it a practical tool for the assessment of patients with suspected or known heart failure.

From the Research

Definition of Hepatojugular Reflex

• The hepatojugular reflex (HJR) is a clinical test used to assess the ability to predict response during cardiac catheterization and to determine its significance in patients without heart failure, correlating it to their baseline hemodynamic parameters 2.
• It is defined as the venous pressure response to sustained abdominal compression, measuring change in internal jugular venous pressure and during right-sided cardiac catheterization measuring change in right atrial pressure 2.

Clinical Significance of Hepatojugular Reflex

• A positive HJR test is an independent predictor of 6-month mortality in patients with acute heart failure, and it serves as an important prognostic marker for postdischarge outcomes 3.
• The HJR test result correlates best with baseline mean right atrial pressure and right ventricular end-diastolic pressure, and it can predict right atrial and right ventricular end-diastolic pressures 2.
• A positive HJR has high sensitivity and specificity for predicting right atrial pressure greater than 9 mm Hg and right ventricular end-diastolic pressure greater than 12 mm Hg 2.

Diagnostic Accuracy of Hepatojugular Reflex

• The diagnostic accuracy of HJR in diagnosing congestive heart failure has been evaluated in several studies, with a meta-analysis suggesting that HJR has practical value for diagnosis of congestive heart failure with high specificity 4.
• The sensitivity and specificity of HJR in diagnosing congestive heart failure have been reported to be 0.12 and 0.96, respectively, with a diagnostic odds ratio of 29.7 4.

Validity of Hepatojugular Reflex as a Clinical Test

• The validity of HJR as a clinical test for congestive heart failure has been tested, with observations suggesting that it is a useful clinical test for detecting congestive cardiac failure 5.
• An increase of 3 cm in the height of neck vein distention is considered a reasonable upper limit of normal for HJR 5.