Clinical value and a new jugular-orthopnea index to detect increased LV filling pressures in heart failure

Introduction

The clinical examination (CE), that is, the evaluation of symptoms and signs, is the first element in the diagnosis and monitoring of patients (p) with heart failure (HF).

Among the most relevant findings of the CE are orthopnea and assessment of the jugular veins.

It is our hypothesis that the joint evaluation of orthopnea and jugular veins (jugular distention and/or hepatojugular reflux) can be a simple and rapid tool to assess congestion in the ambulatory p with HF.

Objective

The present study is a comparative evaluation between CE with cardiac and tissue Doppler Echo (Echo) with special emphasis on the joint evaluation of orthopnea and the jugular veins, which we call "jugular-orthopnea index" (JOi) and its yield in the diagnosis of congestion in HF.

Method

Ambulatory patients with HF were included. After the CE that included the classic symptoms and signs of HF, a Cardiac and Tissue Doppler Echo (ECHO) was performed within 7 days. The Framingham Score for HF (FrS) was also used (Orthopnea, paroxysmal nocturnal dyspnea, jugular distension, positive hepatojugular reflux (HJR+), crackles and S3: 1 point; exertional dyspnea, MMII edema, tachycardia ≥ 120, nocturnal cough and hepatomegaly : 0.5 points). There were no therapeutic modifications or clinical changes between both evaluations. The Eco operators were blind to the EC. The iYO was considered positive (JOi+) when both findings were present.

The EC was compared with the Echo information as a reference standard. (cite)

Sensitivity (S), specificity (E), predictive values (PV) and likelihood ratios (LR) were evaluated. For categorical data, the chi square was used and p ≤ 0.05 was considered significant.

Results

Out of a total of 181 p included between March 2023 and March 2024, in 155 p it was possible to define LVEDP by Echo, of which 127 had an ejection fraction ≤ 40% and this was considered the study population.

The table shows the S, E, PV, the LR and the statistical significance of the CE with respect to the Echo. In particular, the JOi+ multiplies by more than 15 times the chance of diagnosis of increased LVEDP evaluated by Echo.

In this way, the elevated LVEDP evaluated by Echo can be defined with high certainty in a non-negligible percentage (one in six patients) of the population of patients with HFrEF.

Conclusion

The study highlights the diagnostic performance of the association of orthopnea with spontaneous and/or provoked jugular distention (HJR+) to detect elevated LVEDP with high specificity, PPV and LR+.For image description, please refer to the figure legend and surrounding text.