Bedside Ultrasound Detects Central Venous Congestion in HF


NEW YORK (Reuters Health) – Measuring jugular venous pressure (JVP) at the bedside using a handheld ultrasound device is an effective way to gauge central venous congestion in patients with heart failure (HF) or suspected HF, a new study suggests.

The findings of Dr. Libo Wang and colleagues at the University of Utah School of Medicine in Salt Lake City are based on a convenience sample of 100 patients undergoing right heart catheterization for HF indications. Their mean age was 60 years, 36 were women and 44 had preserved ejection fraction.

For each patient, JVP was estimated by handheld ultrasound device (uJVP) in a semi-upright and upright position and by traditional physical examination, immediately before invasive hemodynamic measurements.

Forty-three patients had elevated right atrial pressure (RAP) of 10 mm Hg or greater.

The uJVP was more reliably visualized than traditional physical examination and correlated with a range of RAP measured on right heart catheterization.

The uJVP in the semi-upright position accurately predicted elevated RAP greater than 10 mm Hg, with an area under the curve (AUC) of 0.84 and an odds ratio of 1.7 (95% CI, 1.4 to 2.2) for every 1-cm increase in uJVP.

“A uJVP of greater than 8 cm was chosen as the optimal threshold for detecting RAP of 10 mm Hg or greater, with a sensitivity of 72.7% (CI, 57.2% to 85.0%), a specificity of 78.6% (CI, 65.6% to 88.4%), likelihood ratio of 3.40 (CI, 2.00 to 5.80), and accuracy of 76%,” Dr. Wang and colleagues report.

A positive uJVP in the upright position was 94.6% specific for predicting elevated RAP.

The interrater reliability of uJVP was “robust regardless of ejection fraction,” the researchers note.

The uJVP AUC was 0.77 (95% CI, 0.65 to 0.89) in obese patients versus 0.95 (95% CI, 0.89 to 0.99) in non-obese patients for predicting elevated RAP. The traditional physical exam of JVP was also affected by obesity, with an AUC of 0.76 (CI, 0.55 to 0.96) in obese versus 0.91 (CI, 0.79 to 0.99) in non-obese patients.

Limitations of the study include a predominantly white cohort from a single academic institution, with scanning done by three cardiology physicians who had echocardiography and point-of-care ultrasound (POCUS) training.

“Decreasing accuracy of traditional physical examination methods – whether because of technical shortcomings or a changing (more obese) population – contributes to inaccuracies in estimates of central venous pressure (CVP). Other signs of central venous congestion, such as peripheral edema, have poor sensitivity at diagnosing congestive HF,” the authors note in their paper.

“This study of initial validation of JVP assessment by ultrasonography suggests that POCUS is promising in the detection of elevated RAP. Although obesity lowered its accuracy, semiquantitative ultrasound evaluation of the uJVP remained highly predictive of elevated RAP,” they write.

“Although not a replacement for physical examination, formal echocardiography, or invasive hemodynamics, the uJVP demonstrates accuracy and reproducibility in evaluation of central venous congestion. Further research of the uJVP’s predictive value in clinical outcomes and how best to use the combination of reclined and upright techniques to direct diuresis and decongestion is warranted,” the study team concludes.

SOURCE: https://bit.ly/3EybEJI Annals of Internal Medicine, online December 27, 2021.



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