Article, Cardiology

Jugular venous distension on ultrasound: sensitivity and specificity for heart failure in patients with dyspnea

Unlabelled imagejugular venous distension on ultrasound:”>American Journal of Emergency Medicine (2011) 29, 1198-1202

Brief Report

Jugular venous distension on ultrasound: sensitivity and specificity for heart failure in patients with dyspnea

Timothy Jang MDa,b,c,?, Chandra Aubin MD, RDMSb, Rosanne Naunheim MDb,

Lawrence M. Lewis MDb, Amy H. Kaji MD, PhDa,c

aDavid Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA

bDivision of Emergency Medicine, Washington University School of Medicine, Campus Box 8072, St. Louis, MO 63110, USA

cDepartment of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA 90509, USA

Received 3 June 2010; revised 2 July 2010; accepted 11 July 2010

Abstract

Background: Accurately diagnosing congestive heart failure (CHF) in patients with dyspnea can be difficult because clinical history and physical examination are often nondiagnostic and may be inaccurate, especially when patients have complicated comorbid conditions.

Objective: To prospectively assess jugular venous distension on ultrasound (JVD-US) performed by emergency physicians for identifying CHF on echocardiography by the department of cardiology (C-ECHO) in patients with dyspnea.

Measurements: This was a secondary analysis of a previously collected data set from a prospective study of JVD-US in ED patients with dyspnea due to suspected CHF. C-ECHO results were obtained and used as the criterion standard.

Results: Jugular venous distension on ultrasound had a sensitivity of 99% (95% confidence interval [CI], 92.2%-100%), specificity of 59% (95% CI, 40.9%-74.4%), positive likelihood ratio of 2.4 (95% CI, 1.6-3.6), and negative likelihood ratio of 0.01 (95% CI, 0.0007-0.20) for identifying CHF on C-ECHO in patients with dyspnea.

Conclusion: This initial study suggests that JVD-US by emergency physicians is predictive of CHF using echocardiography performed by the department of cardiology as the criterion standard.

(C) 2011

Introduction

Congestive heart failure (CHF) can be difficult to diagnose in patients with acute dyspnea because clinical history and physical examination are often nondiagnostic and may be inaccurate [1-6]. An S3, jugular venous distension (JVD), rales, and peripheral edema are used to diagnose CHF [7] but lack the appropriate sensitivity and specificity to accurately

* Corresponding author.

E-mail address: [email protected] (T. Jang).

diagnose CHF in the acute setting [1,8]. Furthermore, patients with CHF may have comorbid conditions such as chronic obstructive pulmonary disease or pneumonia that can complicate Acute diagnosis. Although echocardiography has been shown to improve diagnostic time and accuracy in the emergency department (ED) [9-11], it may not be immedi- ately available and Bedside echocardiography by emergency physicians (EPs) may misclassify patients 22% to 32% of the time [12,13]. Likewise, although B-type Natriuretic Peptide can be done to improve acute diagnosis [14,15], laboratory turnaround time may take over an hour, and point- of-care testing is not universally available.

0735-6757/$ – see front matter (C) 2011 doi:10.1016/j.ajem.2010.07.017

Jugular venous distension on ultrasound (JVD-US) was previously described as a rapid bedside test that could improve the diagnosis of acute CHF [4]. Therefore, the purpose of this study was to prospectively assess JVD-US by EPs for identifying CHF on echocardiography by the department of cardiology (C-ECHO) in ED patients presenting with acute dyspnea.

Methods

Study design

This was a secondary analysis of previously collected data from an institutional review board-approved prospective study of patients with acute dyspnea [16]. The study design, setting, participants, protocol, measurements, and data analysis will thus only be briefly described. Patients were conveniently sampled between June 1, 2004, and December 31, 2004, when 1 of 8 EPs was available to obtain consent and perform JVD-US, which was subsequently compared to the results of chest radiography (CXR) read by board- certified radiologists in the primary study. Our current study differs from the prior study because we further reviewed the cases for the results of C-ECHO within 2 weeks and read by board-certified cardiologists.

Study setting

The study was set at an urban, academic ED with 75 000 annual adult visits and a PGY-1 through PGY-4 residency in emergency medicine.

Selection of participants

All patients presenting to the ED with the primary or secondary complaint of acute “shortness of breath,” “difficulty breathing”, or “dyspnea” as determined by computerized ED nursing triage were eligible for participa- tion if at least 1 of 8 EPs was working in the ED. Patients were excluded if CHF was not considered in the differential diagnosis of the treating clinicians or they were unable to give informed consent in English.

Two of the physicians had previously performed US-JVD in fewer than 20 patients with dyspnea. The remaining 6 physicians had not previously performed US-JVD, but underwent a 5-minute hands-on demonstration of JVD-US on a normal volunteer before initiation of the study.

Protocol

Participating EPs consented the patients and performed JVD-US within 30 minutes of the initial physician assessment in the ED. The study EPs were blinded to all

patient data until after JVD-US was performed and results recorded on a predesigned data sheet. An investigator, blinded to JVD-US results, then recorded the results of C-ECHO for subsequent comparison.

Study measurements

Jugular venous distension on ultrasound was done using either an Aloka SSD 1400 with a 7.5-MHz linear array probe or a Siemens Sonoline G60S with a 10-MHz linear array probe to identify the jugular vein and Common carotid artery using either transverse or longitudinal views of the neck [4,16,17]. The jugular meniscus level was then identified with the patient at end-expiration and JVD was measured in standard fashion [5,7], whereby 5 cm H2O (the height from the right atrium to the sterna notch) was added to the vertical height of the jugular meniscus above the sternal notch to obtain JVD in units of millimeters of mercury. This method allows for comparable estimates of JVD regardless of patient positioning given the anatomic position of the jugular vein relative to the sternal notch and right atrium [5,7]. In the initial study, it was predetermined to consider the JVD to be 15 cm H2O if the meniscus was above the level of the mandible.

Criterion standard

Congestive heart failure by C-ECHO was determined by the final reading of board-certified cardiologists blinded to the results of JVD-US and all clinical data, including BNP. Moderate to severe diastolic dysfunction, moderate to severe global hypokinesis, or an ejection fraction less than 45% were a priori determined to be the criterion standard for CHF consistent with prior work [12,13]. Mild diastolic dysfunc- tion, mild global hypokinesis, or an ejection fraction between 45% and 55% were not considered diagnostic of CHF consistent with prior work [12,13].

Data analysis

Data were collected in an Excel database (Microsoft Excel, Microsoft Corporation, Redmond, Wash) and trans- lated into a native SAS format using DBMS/Copy (Dataflux Corporation, Cary, NC). Analyses were conducted using SAS version 9.1 (SAS Institute, Cary, NC). The sensitivity and specificity, as well as positive and negative likelihood ratios (LR+ and LR-) of JVD-US were calculated with 95% confidence intervals (CIs) to assess both statistical signifi- cance and clinical effect [18].

Results

One hundred nineteen patients were enrolled in the initial study with a mean age of 65 years (95% CI, 62-69

years) and median US-JVD measurement of 10 (inter- quartile range, 8-13) [16]. Fifty-six patients (47%) had pulmonary edema on CXR [16] with a median BNP of 444 (interquartile range, 167-1248). The baseline patient characteristics are shown in Table 1. Seventeen patients did not undergo C-ECHO and were, therefore, not included in this secondary analysis (Table 2).

Table 1 Baseline patient characteristics

Characteristic/comorbidity n (%)

Male 64 (54)

Diabetes 49 (41)

Hypertension 66 (55)

Hypercholesterolemia 34 (29)

known CAD 35 (29)

Two or more of the above risk factors 55 (46)

Prior CHF 41 (34)

Prior DVT/PE 8 (7)

Atrial fibrillation 5 (4)

Asthma 10 (8)

COPD 25 (21)

Prior CHF and COPD or asthma 12 (10)

ESRD 6 (5)

Chronic liver disease 4 (3)

Cancer 5 (4)

No PMH 15 (13)

CAD indicates coronary artery disease; COPD, chronic obstructive pulmonary disease; ESRD, end-stage renal disease; DVT, deep vein thrombosis; PE, pulmonary embolism; PMH, past medical history.

Sixty-eight patients had evidence of CHF on C-ECHO, all of whom had JVD-US 8 cm H2O or higher (ie, “true positives”). Twenty patients without evidence of CHF on C-ECHO had JVD-US less than 8 cm H2O (ie, “true negatives”). Fourteen patients without evidence of CHF on C-ECHO had JVD-US 8 cm H2O or higher (ie, “false positives”). No patient with evidence of CHF on C-ECHO had JVD-US less than 8 cm H2O (ie, “false negatives.”). Therefore, JVD-US 8 cm H2O or higher had a sensitivity of 99% (95% CI, 92.2%-100%), specificity of 59% (95% CI,

40.9%-74.4%), LR+ of 2.4 (95% CI, 1.6-3.6), and LR- of

0.01 (95% CI, 0.0007-0.20) for CHF on C-ECHO. The

clinical parameters of the patients with a false-positive JVD-US are shown in Table 3.

Limitations

Table 2 Patients who did not have echocardiography done within 2 weeks

This study had several limitations. First, the participating EPs were interested in performing JVD-US and knew that their results were going to be compared to a criterion standard, raising the potential for a Hawthorne effect. Our

Table 3 False positives of JVD-US

JVD-US

BNP

CXR with pulmonary edema? a

Final hospital diagnosis

1

5

b10

No

COPD

2

5

71

No

Aspiration pneumonia

3

6

10

No

COPD

4

6

58

No

Angina

5

6

87

No

Ascites, chronic liver

disease

6

6

131

No

COPD with pneumonia

7

7

23

No

COPD

8

7

99

No

Pulmonary embolism

9

8

54

No

Metastatic Lung cancer

10

8

66

No

COPD

11

8

576

No

Pulmonary embolism

12

9

162

No

COPD

13

9

247

Mild pulmonary

NSTEMI, CHF b

edema

14

9.5

216

Mild pulmonary

COPD

edema

15

10

56

No

Leaking aortic

aneurysm

16

15

2471

No

Acute on chronic renal

failure

17

15

4457

Mild pulmonary

Chronic renal failure

edema

with pulmonary edema

NSTEMI, non-ST elevation myocardial infarction; CHF, congestive heart failure.

a As determined by board-certified radiologists blinded to BNP levels and JVD-US.

b Echocardiography not done because of ventriculography showing

ejection fraction of 30%.

FP

no.

JVD-US

BNP

CXR with pulmonary edema? a

Final hospital diagnosis

1

8

58

No

COPD

2

8

228

No

Myocardial infarction

3

8

240

No

Tamponade

4

9

223

Mild pulmonary

Obstructive sleep

edema

apnea

5

9

310

No

COPD

6

9

468

Mild Pulmonary

Atrial fibrillation

edema

7

9

725

No

Pulmonary embolism

8

10

251

No

Tamponade

9

10

589

No

Mesenteric ischemia

10

10

761

No

Pneumonia

11

12

38

No

Tamponade

12

12

865

No

Unstable angina

13

13

444

Moderate

CHF

pulmonary edema

14

15

388

Mild pulmonary

Acute renal failure

edema

with pulmonary

edema

a As determined by board-certified radiologists blinded to BNP levels and JVD-US.

findings may not apply to less interested physicians who do not believe they are being “tested.”

Second, the study EPs could not be blinded to clinical parameters such as a patient’s level of distress, which could have biased the interpretation of their findings. However, this is also the case with C-ECHO and normative for clinicians performing ultrasound in the ED.

Third, neither C-ECHO nor JVD-US was performed or interpreted by a second clinician (cardiologist for C-ECHO and EP for JVD-US), reflecting standard clinical practice. However, this may limit our findings because we do not know the interrater reliability of JVD-US and small discrepancies can occur between cardiologists with C-ECHO.

Finally, timing of the JVD-US was not standardized relative to the timing of the C-ECHO, which may have been affected by interventions such as the administration of furosemide or vasodilator therapy. However, although diuretics and vasodilators may affect fluid status and afterload, they are not likely to completely eliminate evidence of CHF on echocardiography. Furthermore, it was not possible to guarantee immediate C-ECHO because some patients presented after hours and on weekends when the Cardiac Diagnostic Laboratory was closed. Likewise, the comparison to C-ECHO was done retrospectively. A study should be done to compare C-ECHO and JVD-US contemporaneously in a prospective fashion.

Discussion

Many patients with CHF present to the ED with dyspnea as the chief complaint, but history and physical examination are nondiagnostic much of the time and may be inaccurate [1-6]. Our data suggest that JVD-US could rapidly rule out patients with evidence of CHF on C-ECHO without removing them from the clinical treatment area or requiring cardiac sonographers to evaluate them in the ED. In our sample, JVD-US 8 cm H2O or higher had a sensitivity of 99% (95% CI, 92.2%-100%) and an LR- of 0.01 (95% CI,

0.0007-0.20) for identifying patients with evidence of CHF on C-ECHO, suggesting that an alternative diagnosis should be considered in patients with JVD-US less than 8 cm H2O. Some clinicians may question whether or not JVD-US is necessary because CXR can also be done in the clinical area with results obtained before BNP and C-ECHO. However, the sensitivity of CXR for detecting patients with decom- pensated CHF has been questioned [8,19,20], with almost 1 in 5 patients with decompensated CHF missed by CXR [19]. Likewise, in a prior case series looking at JVD-US in acute dyspnea, 5 of 8 patients diagnosed with CHF did not have

pulmonary edema on CXR [4].

On the other hand, echocardiography done by cardiac sonographers in the ED was shown to improve clinician Diagnostic certainty 50% of the time, while altering diagnosis 37% of the time and causing an appropriate change in

treatment 25% of the time [9]. Unfortunately, assessment of ventricular function by EPs may not always be accurate [12,13]. In a study of 4 EPs who completed 100 prior ultrasound examinations and 10 hours of training in the echocardiography laboratory, EP-performed echocardiogra- phy misclassified 23% of healthy patients as having moderately decreased cardiac function and 39% of patients with moderately decreased cardiac function as normal [13]. Likewise, in a study of 8 clinicians who had previously performed 150 ultrasound examinations and 5 prior echocardiograms, EP-performed echocardiography misclas- sified 15% of healthy patients as having moderately depressed to poor cardiac function and 22% of patients with moderately decreased function as normal [12]. Accordingly, the guidelines of the American Society of Echocardiography require much more extensive training for clinicians performing echocardiography in the ED [21,22].

Jugular venous distension on ultrasound provides less information than bedside echocardiography, but its simpli- city and sensitivity among novice operators suggest that it may be especially helpful for those who are not adept at performing bedside echocardiography. It could help exclude acute decompensation of CHF, especially when pneumonia is a possible exacerbating or causative factor. JVD-US can be done at the bedside without removing patients from the clinical area and results obtained before the availability of BNP levels or C-ECHO. This could be especially important when point-of-care BNP testing is not available. Given a sensitivity of 99% (95% CI, 92.2%-100%) and an LR- of

0.01 (95% CI, 0.0007-0.20), patients with JVD-US less than 8 cm H2O should not be assumed to have CHF as the primary cause of their symptoms. Thus, JVD-US may help guide the clinician to administer the most appropriate medications to the challenging patient with rales and hypotension: if the JVD-US is less than 8, then administer intravenous fluid rather than diuretics and vasodilators, as CHF would essentially be ruled out.

Conclusion

This initial study suggests that JVD-US by EPs is predictive of CHF using echocardiography performed by the department of cardiology as the criterion standard.

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