Short- and Long-Term Prognostic Implications of Jugular

Venous Distension in Patients Hospitalized With Acute

Heart Failure
Fernando Chernomordik, MDa,*, Anat Berkovitch, MDa,b, Ehud Schwammenthal, MD, PhDa,
Ilan Goldenberg, MDc, David Rott, MDd, Yaron Arbel, MDe, Avishai Elis, MDf, and
Robert Klempfner, MDd

The present study was designed to assess the role of jugular venous distension (JVD) as a
predictor of short- and long-term mortality in a “real-life” setting. The independent asso-
ciation between the presence of admission JVD and the 30-day, 1- and 10-year mortality
was assessed among 2,212 patients hospitalized with acute heart failure (HF) who were
enrolled in the Heart Failure Survey in Israel (2003). Independent predictors of JVD
finding in study patients included: the presence of significant hyponatremia (odds ratio
[OR] 1.48; p [ 0.03), reduced left ventricular ejection fraction ([LVEF] OR 1.24; p [ 0.03),
anemia (OR 1.3; p [ 0.01), New York Heart Association III to IV (OR 1.34; p <0.01) and
age >75 years (OR 1.32; p [ 0.01). The presence of JVD versus its absence at the time of
HF hospitalization was associated with increased 30-day mortality (7.2% vs 4.9%, respec-
tively; p [ 0.02), 1-year (33% vs 28%, respectively; p <0.001), and greater 10-year mortality
(91.8% vs 87.2%, respectively; p <0.001). Consistently, interaction term analysis demon-
strated that the presence of JVD at the time of the index HF hospitalization was inde-
pendently associated with a significant increased risk for 10-year mortality, with a more
pronounced effect among younger patients, patients with reduced LVEF, preserved renal
function, and chronic HF. In conclusion, in patients admitted with HF, JVD is associated
with specific risk factors and is independently associated with increased risk of both short-
and long-term mortality. These findings can be used for improved risk assessment and
management of this high-risk population. Ó 2016 Elsevier Inc. All rights reserved. (Am J
Cardiol 2016;118:226e231)

Heart failure (HF) is a common clinical syndrome and a are more likely to be hospitalized and have pump fail-
major cause of morbidity and mortality.1 Despite significant ureerelated death.6 In an attempt to predict the prognosis
improvement in the management of patients with HF, rates of patients admitted to the hospital with the diagnosis of
of readmission and in-hospital mortality remain high.2e5 acute decompensated HF, many models and scores have
Therefore, a simple clinical marker may be useful for emerged.7,8 However, data regarding the prognostic impli-
improved risk stratification in patients hospitalized with HF. cations of physical examination findings in this population
Acute decompensated HF often presents as an acute eleva- are limited and conflicting.9,10 We hypothesized that
tion of cardiac filling pressures. Jugular venous distension elevated jugular venous pressure on physical examination,
(JVD) is an easy and simple test to perform during the as manifested by JVD, can provide incremental short- and
physical examination, without the costs and difficulty of long-term prognostic information in patients admitted with
interpretation of more complex methods. Patients with JVD acute HF.

a
Leviev Heart Center and bInternal Medicine D, Sheba Medical Center, Methods
Tel Hashomer, Israel; cLeviev Heart Center, Sheba Medical Center, Sackler
School of Medicine, Tel Aviv University, Tel Hashomer, Israel; dCardiac Baseline characteristics and admission data of patients
Rehabilitation Institute, Leviev Heart Center, Sheba Medical Center and admitted with acute HF were obtained from the Heart
e
Department of Cardiology, Tel Aviv Medical Center, Sackler School of Failure Survey in Israel (HFSIS 2003) survey database. The
Medicine, Tel Aviv University, Tel Aviv, Israel; and fDepartment of design and methods of the HFSIS have been described
Medicine, Meir Medical Center, Kfar Saba, Israel. Manuscript received previously.11,12 Briefly, the survey was conducted during
December 12, 2015; revised manuscript received and accepted April 11, March 2013 to April 2003 in all 25 public hospitals in Israel.
2016.
The study included 93 of the 98 internal medicine and 24 of
Drs. Chernomordik, Berkovitch, and Klempfner contributed equally to
the 25 cardiology departments in Israel at that time.
the work.
See page 230 for disclosure information.
The survey enrolled 4,102 patients of which 2,302 with an
*Corresponding author: Tel: (þ972) 54-719-4564; fax: (þ972) acute HF event, defined as: de novo HF or, an acute exac-
3-5302472. erbation of chronic HF. After excluding patients without a
E-mail address: [email protected] valid JVD result (n ¼ 90), the final analysis cohort for this
(F. Chernomordik). study included 2,212 patients (96% of the acute HF cohort).

0002-9149/16/$ - see front matter Ó 2016 Elsevier Inc. All rights reserved. www.ajconline.org
http://dx.doi.org/10.1016/j.amjcard.2016.04.035
 Heart Failure/Prognostic Implications of JVD in HF 227

HF was diagnosed by the local survey physicians ac- included the following prespecified covariates: acute de
cording to the following prespecified criteria: (1) clinical novo HF (vs chronic HF exacerbation), hyponatremia,
presentation (symptoms/physical examination), (2) chest anemia, reduced LVEF, ischemic etiology of HF (vs other
x-ray, (3) echocardiography, (4) radionuclide study, and causes), NYHA functional class (III to IV), age >75 years,
(5) cardiac catheterization. Results of echocardiography, reduced admission systolic BP, obesity, and previous diag-
radionuclide scintigraphy, and catheterization findings were nosis of diabetes mellitus, chronic obstructive pulmonary
obtained either during or within the 6 months before the disease, and hypertension.
index hospitalization, unless the patient had a recent cardiac We evaluated prespecified events in a binary logistic
insult. regression model adjusted for age, sex, eGFR, NYHA
functional class, and the presence (vs absence) of JVD
JVD assessment: Recording JVD was a prespecified
funding to explore the independent association of JVD
survey objective and was assessed in most subjects (96%).
finding with in-hospital adverse events. The events included
Physical examination was performed only by physicians
were stroke, pneumonia, renal function worsening (defined
according to recommendations, while patients laid supine
as 0.3 mg/dl increase in serum creatinine levels),
with a 30-degree angle. The definition of positive JVD was
new-onset atrial fibrillation or flutter, and life-threatening
right internal jugular vein distension or right external jugular
arrhythmia (defined as events of cardiopulmonary resusci-
vein when the internal jugular vein cannot be determined,
tation or sustained ventricular tachycardia or ventricular
>9 cm of water above the right atrium (or 4 cm from the fibrillation).
sternal angle).
Independent predictors of the 30-day, 1-, and 10-year
Anemia was defined as hemoglobin <11 g/dl and sig-
all-cause mortality outcome were evaluated using binary
nificant hyponatremia as serum sodium 130 mmol/dl13 on
logistic regression modeling including the following cova-
admission. Diabetes mellitus was defined by one of the
riates: age, NYHA functional class, sex, and JVD presence.
following criteria: a history of diabetes mellitus obtained
We applied multivariate Cox proportional hazards anal-
from medical records, admission blood glucose
ysis to evaluate long-term mortality predictors. The
200 mg/dl, or the use of antidiabetic agents (on admission
following prespecified covariates, of established prognostic
or discharge). New York Heart Association (NYHA) func-
significance, were introduced using the best subset method:
tional class was determined according to functional status
sex, reduced systolic BP, hyponatremia, JVD presence, third
and symptoms before index hospitalization. Left ventricular heart sound, anemia, age >75 years, renal dysfunction (GFR
ejection fraction (LVEF) was determined by echocardiog-
<60 ml/min/1.73 m2), obesity, NYHA functional class III to
raphy and defined as reduced when <50% or preserved
IV, diabetes mellitus, decreased LV function, and acute HF.
50%. Obesity was defined as a body mass index >30 In a secondary analysis, we evaluated the association be-
measured on admission. De novo (new-onset) HF was
tween JVD and 10-year mortality in patients’ subgroups
defined as the absence of previous diagnosis of HF, or ad-
categorized by age (younger and older than 75 years), HF
missions due to HF in the past. Renal function was cate-
with preserved EF (HFpEF) versus HF with reduced EF, de
gorized using the Modification of Diet in Renal Disease
novo HF versus acute exacerbation of chronic HF, eGFR
formula for estimated glomerular filtration rate (eGFR).
over and below 60 ml/min/1.73 m2, and hemoglobin over
Systolic blood pressure (BP) was defined as reduced when
and below 11 g/dl, using interaction term subgroup analysis.
admission values were below 140 mm Hg.
Ethics committee at each of the participating hospitals
The end points of this study were 30-day, 1-, and 10-year
approved the study protocol.
all-cause mortality, obtained during follow-up, either from
All p values calculations were 2-tailed and were
the database itself (hospital charts) or by matching patient considered statistically significant if their value was 0.05.
identification numbers with the Israeli National Population
The statistical analyses were performed with IBM SPSS,
Registry. Every effort was made to ensure accurate and
version 20.
reliable profiling data, which included standardizing HF and
data validation definitions. Survey forms were completed by
Results
physicians, and data accuracy and consistency was checked
by dedicated software. The HFSIS survey included 2,212 hospitalized patients
For the univariate analysis, percentages were calculated for congestive HF, of whom 1,395 (63%) had JVD on
for categorical variables and means with SD for continuous admission. The baseline demographic, clinical characteris-
variables. The chi-square test in case of categorical vari- tics and hospitalization data of study patients are presented
ables, with continuity correction for 2  2 tables in case of in Table 1. The mean age of total survey population was 75
dichotomous variables, and the Student t test, in case of T10 years. Sex and cardiovascular risk factors were similar
continuous variables, was used for measuring the signifi- between the 2 groups. However, patients with JVD dis-
cance of differences between the patients with and without played several important differences in their clinical char-
JVD across the baseline characteristics. The cumulative acteristics compared with those without JVD at the time of
probability of 30-day and 10-year all-cause mortality in hospital admission, including older age, higher serum
patients with and without JVD was graphically displayed creatinine value, higher rates of anemia, increased frequency
according to the method of Kaplan and Meier, with com- of a third heart sound, worse NYHA functional class, and a
parison of cumulative events by the log-rank test. higher frequency of previous myocardial infarction.
Logistic regression modeling was used to identify Consistently, these patients were more often treated with
important predictors for the detection of JVD. The model furosemide and digoxin (Table 1).
228 The American Journal of Cardiology (www.ajconline.org)

Table 1 Table 2
Subjects’ characteristics according to the presence or absence of JVD Independent predictors of jugular venous distension finding on admission*
Variable Jugular venous distension p-value OR 95% CI p-value

Absent Present Exacerbation of chronic vs. “de novo” HF 1.5 1.1-1.9 < 0.01
(n¼ 817) (n¼1,395) Male 0.92 0.76-1.12 0.4
Serum Sodium < 130 mmol/dl 1.48 1.03-2.12 0.03
Age > 75 years 50.8% 56.2% 0.015 Left ventricle ejection fraction < 50% 1.24 1.02-1.51 0.03
Male 54.3% 55.9% 0.41 Hemoglobin < 11 mg/dl 1.31 1.07-1.59 0.01
Left ventricle ejection fraction % 3914 3715 0.007 New York Heart Association functional 1.34 1.11-1.61 < 0.01
Ischemic etiology of HF 72.1% 70.5% 0.43 class III-IV
Diabetes mellitus 43.9% 43.2% 0.75 Ischemic etiology of HF 0.97 0.78-1.19 0.75
Chronic obstructive pulmonary 19% 20.1% 0.54 Age > 75 years 1.32 1.09-1.6 0.01
disease Body mass index > 30 kg/m2 1.15 0.92-1.43 0.22
Body mass index > 30 kg/m2 22.9% 24.2% 0.46 Hypertension 0.99 0.78-1.24 0.9
Serum sodium < 130 mmol/dl 5.1% 7.9% 0.01 Chronic obstructive pulmonary disease 0.88 0.70-1.12 0.31
Hemoglobin < 11 g/dl 27.2% 33.1% 0.004 Diabetes mellitus 0.94 0.75-1.18 0.61
Estimated glomerular filtration 46.3% 56.9% < 0.001 Admission SBP < 140 mm Hg 1.01 0.84-1.22 0.88
rate  50 ml/min/1.73m2
De novo HF 32.5% 21.7% < 0.001 HF ¼ heart failure; SBP ¼ systolic blood pressure.
Third heart sound 3.9% 8.4% < 0.001 * Logistic regression model was further adjusted for additional HF eti-
New York Heart Association 41.4% 52.5% < 0.001 ology (ischemic vs nonischemic).
functional class III-IV
Beta-blockers 47.3% 48.7% 0.5
ACEI/ARB 56.8% 58.4% 0.5 were not significantly associated with short-term outcomes.
Loop diuretics 60.6% 74.1% < 0.001 Long-term outcomes demonstrated that patients with JVD
Aldosterone antagonists 17% 27% < 0.01
finding had a 15% (hazards ratio [HR] 1.15, 95% CI 1.05 to
Digoxin 12.5% 18.5% 0.02
1.27; p <0.01) increased risk of all-cause 10-year mortality.
ACEI ¼ angiotensin-converting enzyme inhibitor; ARB ¼ angiotensin Additional significant predictors of worse outcomes were:
receptor blocker; HF ¼ heart failure. hyponatremia, exacerbation of chronic HF (compared with
de novo HF), renal dysfunction, lower systolic BP, anemia,
Multivariate logistic regression analysis identified several worse NYHA functional class, and age older than 75 years
independent predictors of JVD finding on physical exami- (Table 4). Interestingly, the presence of a third heart sound
nation at the index hospitalization, including: exacerbation was not associated with adverse outcomes.
of chronic HF versus a de novo event, hyponatremia, Interaction term analysis (Figure 3) showed that the as-
reduced LV function, anemia, higher NYHA functional sociation between JVD and risk for 10-year mortality was
class, and age >75 years. Conversely, ischemic etiology of more pronounced in prespecified subgroups of patients,
HF, reduced systolic BP at admission, diabetes mellitus, including: age <75 years (HR 1.45, 95% CI 1.35 to 1.62),
chronic obstructive pulmonary disease, and hypertension reduced systolic function (HR 1.51, 95% CI 1.35 to 1.68),
were not identified as independent predictors of JVD preserved renal function (HR 1.46, 95% CI 1.29 to 1.65)
(Table 2). Notably, obesity was not associated with the and chronic HF compared with de novo HF (HR 1.59, 95%
absence of JVD finding on physical examination. Patients CI 1.41 to 1.78).
with JVD finding were 28% more likely to have acute
worsening of renal function (odds ratio 1.28, 95% CI 1.08 to
Discussion
1.53) and acute events of atrial fibrillation or flutter (odds
ratio 1.29, 95% CI 1.11 to 1.50) after adjustment for age, The present study demonstrates that assessment of JVD
baseline eGFR, sex, and NYHA functional class. Finding of in patients admitted to the hospital with acute HF has
JVD was not associated with increased risk of in-hospital important short- and long-term prognostic implications. We
stroke, pneumonia, and ventricular arrhythmia or resuscita- have shown that JVD finding is associated with increased
tion (Figure 1). The KaplaneMeier survival analysis for 30- likelihood of in-hospital adverse events, increased 30-day
day all-cause mortality demonstrated significantly worse and 1-year all-cause mortality, as well as being indepen-
outcomes in patients with JVD, including worse short-term, dently associated with long-term, 10-year, all-cause mor-
30-day mortality (7.2% vs 4.9%; log-rank p value ¼ 0.02), tality after adjustment for multiple factors known to
1-year (28% vs 33%, respectively; log-rank p value significantly associated with outcomes.
<0.001), and a significantly higher cumulative probability Although recent studies14,15 have addressed the value of
of mortality at 10-year follow-up (91.8% vs 87.2%, JVD as a prognostic factor, we believe our research is
respectively; log-rank p value <0.001 [Figure 2]). unique in that it includes a nationwide, multicenter “real-
Consistent with the unadjusted results, multivariate world” population with long-term follow-up. It should also
analysis demonstrated that JVD finding was independently be noted that our population not only included patients with
associated with a significant adjusted 40% (p ¼ 0.04) HF with reduced EF but also HFpEF from numerous large
increased 30-day all-cause mortality risk (Table 3). Addi- and small hospitals across the country. Research published
tional significant predictors of worse outcomes were: older during the recent years by Drazner et al15 concluded that
age and worse NYHA functional class. HF etiology and sex right-sided filling pressures often reflect left-sided filling
 Heart Failure/Prognostic Implications of JVD in HF 229

Figure 1. Adjusted OR of in-hospital adverse events in patients with JVD (vs subjects without JVD). Model adjusted for age, sex, eGFR, and NYHA functional
class. p Value 0.01. AF ¼ atrial fibrillation; AFL ¼ atrial flutter; ARF ¼ acute renal failure; CPR ¼ cardiopulmonary resuscitation; VF ¼ ventricular
fibrillation; VT ¼ ventricular tachycardia.

Table 4
Cox regression model for all-cause 10-year mortality outcome*
HR 95% CI p-value

Jugular venous distension finding 1.15 1.05-1.27 < 0.01

Admission systolic blood 1.68 1.07-1.28 < 0.01
pressure < 140 mmHg
Serum sodium < 130 mmol/dl 1.40 1.71-1.28 < 0.01
Third heart sound 1.1 0.83-1.43 0.12
Hemoglobin < 11 mg/dl 1.30 1.17-1.45 < 0.01
Age > 75 years 1.30 1.17-1.85 < 0.01
Renal dysfunction (estimated glomerular 1.43 1.29-1.59 < 0.01
filtration rate <60 ml/min/1.73 m2)
Body mass index > 30 kg/m2 0.93 0.83-1.05 < 0.01
New York Heart Association functional 1.26 1.18-1.38 < 0.01
class III-IV
Figure 2. The 10-year cumulative survival probability of patients who were Left ventricular ejection fraction < 50% 0.97 0.85-1.66 0.64
hospitalized with and without JVD. De novo acute HF 0.82 0.72-0.92 < 0.01
Diabetes mellitus 1.08 0.98-1.20 0.13

Table 3 CI ¼ confidence interval; HF ¼ heart failure; HR ¼ hazards ratio.

Multivariate independent predictors for the 30-day all-cause mortality * Cox regression model was further adjusted for sex and HF etiology
outcome* (ischemic vs other).

Predictor OR 95% CI p-value

pressure in patients with HF is an important risk factor for
Jugular venous distension finding 1.4 1.01-2.0 0.04 decreased renal function and for all-cause mortality,
Age (per 1-year increment) 1.04 1.02-1.06 < 0.001
regardless of cardiac function. The mechanism by which
NYHA functional class III-IV 2.1 1.5-3.1 < 0.002
renal impairment occurs can partially be explained by the
CI ¼ confidence interval; NYHA ¼ New York Heart Association; elevated renal vein pressure leading to direct renal insuffi-
OR ¼ odds ratio. ciency independent of renal blood flow or cardiac
* Model was further adjusted for HF etiology (ischemic vs nonischemic) output.21,22 As right-sided cardiac catheterization is an
and sex. invasive technique and is no longer a routine part of eval-
uation,23 finding of JVD, as shown in this study, may help
pressures in HFpEF, supporting the role of estimation of clinicians identify patients that are prone to renal dysfunc-
jugular venous pressure in this group of patients. It is well tion and evaluate their clinical and laboratory values more
known that worsening renal function during treatment of often. Indeed, we found that patients with JVD finding had
patients with acute decompensated HF is a strong inde- significantly lower values of eGFR, nevertheless JVD was
pendent predictor of adverse outcomes.16e18 Previous independently associated with 10-year all-cause mortality
studies19,20 have concluded that increased central venous after adjustment for eGFR values.
230 The American Journal of Cardiology (www.ajconline.org)

Figure 3. Long-term mortality risk associated with JVD finding in prespecified subgroups of patients admitted with HF. Hb ¼ hemoglobin; HFpEF ¼ heart
failure with preserved ejection fraction; HFrEF ¼ heart failure with reduced ejection fraction.

Assessing this finding has practical implications as Although the HFSIS database is more relevant than older
modern HF management recognizes that some patients do databases to today’s patients in terms of contemporary
not need to be hospitalized, yet others need more specialized clinical practice, it does have some limitations. First, we
care and tight monitoring. A selected group of patients with have no knowledge as to the treatment these patients
acute HF can be safely managed in the emergency depart- received after discharge nor do we know whether they have
ment or outpatient clinic without exposing them to the risks been adherent to medical treatment. Second, utilization of
of hospitalization and without unnecessarily increasing device-based therapy including cardiac defibrillators or
medical expenses.24 Thus, our study supports the notion that biventricular pacemakers was very limited at the time the
JVD presence should be one of the selected criteria when survey was carried out. Third, natriuretic peptides were not
contemplating management decisions. This information available in Israel at the time of the survey; thus, we were
should guide clinicians to identify patient with JVD and not able to compare positive JVD to peptide levels or
provide them with closer medical supervision and possibly included peptide levels in the multivariate analysis. No
more aggressive management. attempt was made to serially record JVD changes and
We acknowledge that there is a significant difference no predischarge value is available. Furthermore, we have no
between physicians with regard to the JVD examination. data regarding the cause of death. However, despite these
However, Drazner et al25 suggested that clinicians should limitations, we believe that our study is unique since it
determine only whether the venous pressure is increased, represents “real-life” patients receiving contemporary
and forego attempts to determine actual values. For these guideline-recommended medications.
reasons, we have decided to record JVD as a dichotomic
value (present vs absent) and not assess the actual value.
Based on this approach, JVD is an easy and simple test to Disclosures
perform during the physical examination and comprise no The authors have no conflicts of interest to disclose.
additional expenses, inherent to other risk markers, such as
biomarkers. Nonetheless, assessment of JVD can be at time 1. Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats
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