Abstract
This study examines the concordance of jugular venous pressure assessments taken at the bedside vs remotely and compares these with invasively measured right atrial pressure.
Guideline-directed management of heart failure includes assessment of volume status,1 for which estimation of jugular venous pressure (JVP) is the most reliable bedside marker.2,3,4 Whether JVP can be assessed remotely, as would occur during a telemedicine visit, is unknown. Given the dramatic increase in telemedicine visits during the coronavirus disease 2019 (COVID-19) pandemic, this question has gained further importance. We conducted a prospective observational study comparing JVP estimates performed at bedside and over video chat with invasively measured right atrial pressure (RAP).
Methods
Between October 2019 and February 2020, we enrolled a convenience sample of adults with heart failure and reduced left-ventricular ejection fraction (≤40%) whose clinical care required right heart catheterization. The protocol was approved by the the University of Texas Southwestern Medical Center institutional review board, and all patients provided written consent. Each patient underwent 1 bedside JVP assessment and up to 4 remote assessments by different advanced heart failure cardiologists (J.T.T. and M.H.D., as well as several nonauthors). Remote assessments were completed using social media apps. A bedside house staff member (S.A.K. or K.B.S.) moved the smartphone, repositioned the patient’s head and the angle of the patient’s body off the horizontal, and (for 17 patients) held up a ruler, as directed by the remote evaluator. Each evaluator reported their JVP estimate and their associated confidence level (on a scale of 1 to 5) in that estimate.
Right heart catheterization was performed following JVP assessment, on the same day. All RAP waveforms were subsequently interpreted by a cardiologist (J.T.T.) blinded to the clinical assessments.
The R2 values for bedside assessments and remote estimates with RAP as the outcome, as well as between themselves, were calculated using linear mixed-effect modeling. Linear regression lines were derived from these models. We calculated how often the beside and remote estimates of JVP of 10 cm H2O or more or JVP of 14 cm H2O or more were consistent with each other. We also performed a similar analysis comparing both estimated JVPs (multiplied by 0.74 to convert to millimeters of mercury) to invasively measured RAP of approximately 7 mm Hg or more and approximately 10 mm Hg or more. A Wilcoxon rank sum test compared confidence levels between bedside and remote evaluators. Data analysis was completed with SAS software version 9.4 (SAS Institute Inc), and the threshold significance was set at 2-tailed P < .05.
Results
A total of 31 patients were enrolled, and 63 remote evaluations were attempted; JVP could not be estimated in 2 remote evaluations (3%). Prior to data analysis, 3 patients whose right heart catheterizations and bedside JVP assessments were performed by the same cardiologist were excluded, leaving a final cohort of 28 patients. Baseline characteristics and hemodynamics are shown in the Table; briefly, 21 participants (75%) were men, the mean (SD) age was 65 (11) years, and the mean (SD) left ventricular ejection fraction was 25% (7%).
Table. Baseline Characteristics and Invasively Measured Hemodynamicsa.
| Variable | No. (%) |
|---|---|
| Age, mean (SD), y | 65 (11) |
| Male | 21 (75) |
| BMI, mean (SD) | 28 (6.3) |
| Left ventricular ejection fraction, mean (SD), % | 25 (7) |
| Ischemic cardiomyopathy | 19 (68) |
| JVP estimate, mean (SD), cm H2O | |
| Bedside | 6 (4) |
| Remote (61 assessments) | 7 (3) |
| Hemodynamic findings, mean (SD) | |
| Heart rate, bpm | 76 (8) |
| Systolic blood pressure, mm Hg | 112 (21) |
| Mean arterial pressure, mm Hg | 81 (13) |
| Right atrial pressure, mm Hg | 8 (5) |
| Pulmonary artery systolic pressure, mm Hg | 43 (14) |
| Pulmonary capillary wedge pressure, mm Hg (n = 27) | 16 (8) |
| Cardiac index by thermodilution, L/min/m2 (n = 26) | 2.2 (0.4) |
| Recent symptoms | |
| Fatigue | 17 (61) |
| Dyspnea | 17 (61) |
| Chest pain | 5 (18) |
| Abdominal distention | 6 (21) |
| Edema | 6 (21) |
| Early satiety | 16 (57) |
| Orthopnea | 9 (32) |
| Paroxysmal nocturnal dyspnea | 5 (18) |
| Bendopnea | 15 (54) |
Abbreviations: BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); bpm, beats per minute; JVP, jugular venous pressure.
N = 28 unless otherwise specified.
The R2 between the bedside and remote JVP estimates was 0.635. The bedside and remote estimates of JVP were both equal to or greater than 10 cm H2O or both less than 10 cm H2O in 39 of 61 assessments (64%) and both equal to or greater than 14 cm H2O or both less than 14 cm H2O in 58 of 61 assessments (95%) (Figure, A). The R2 values between the bedside JVP and RAP and the remote JVP and RAP were comparable (0.521 vs 0.504, respectively; Figure, B). The JVP estimates and the RAP were both equal to or greater than 10 mm Hg or both lower than 10 mm Hg in 26 of 28 bedside assessments (93%) and 54 of 61 remote assessments (89%). Remote evaluators reported lower median (interquartile range) confidence levels than bedside evaluators (3.3 [2.8-4.0] vs 4.0 [4.0-5.0], respectively; P < .001).
Figure. Estimates of Jugular Venous Pressure (JVP).
A, Depiction of each bedside and remote estimate of the JVP, by patient. One bedside estimate and between 1 and 4 remote estimates of the JVP were performed. The R2 between these 2 estimates was 0.635. Shown are two 2 × 2 tables at meaningful JVP thresholds. The bedside and remote JVP estimates were both less than or both greater than or equal to 10 cm H2O in 39 of 61 assessments (64%) and both less than or both greater than or equal to 14 cm H2O in 58 of 61 assessments (95%). B, Scatterplots between the estimates of the JVP with the invasively measured right atrial pressure (RAP). Linear regression lines derived from the mixed-effects models for each comparison are shown.
Discussion
We found that both bedside and remote JVP estimates were comparably and significantly correlated with invasively measured RAP, despite a lower level of confidence among the remote evaluators in their estimates. Practitioners may find these data particularly useful, given the rapid increase in telehealth visits during the COVID-19 pandemic.
Lower confidence among remote evaluators may be secondary to less familiarity with that approach or inability to perform maneuvers such as palpation.3 While this study demonstrated feasibility of assessing the JVP remotely via video, a larger study is needed to provide reliable estimates of its diagnostic utility in the assessment of RAP. Likewise, whether health care professionals who are not advanced heart failure specialists can replicate these results using standard telehealth platforms, rather than commercially available smartphones, is unknown and requires further study.
References
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