A 92-year old woman presented to the emergency department with worsening dyspnea. She was found to be in atrial fibrillation with rapid ventricular response. Physical examination revealed hepatojugular reflux with venous distension extending to the level of the maxillary vein (arrow). Chest radiograph showed new bilateral interstitial changes and pro-brain natriuretic peptide level was elevated.
Bedside estimation of central venous pressure (CVP) was described in 1930 by Sir Thomas Lewis who observed that the top of the jugular veins was similar to the top of the fluid column in a CVP manometer. While the internal jugular vein is preferred because it lacks valves and is more in line with the right atrium, the external jugular vein can be used, particularly in cases of extremely elevated venous pressure because the top of the internal jugular vein courses intracranially and cannot be visualized. The hepatojugular reflux maneuver is performed by applying pressure of 20–30 mmHg at the mid-abdomen for 10–30 seconds. If CVP rises >4 cm throughout the maneuver, this correlates with elevated right atrial pressure. In patients with significant volume overload, distant tributaries of the external jugular vein can become distended as well (video).
The patient’s dyspnea improved with heart rate control and diuresis.
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