Clinical and Prognostic Significance of Positive Hepatojugular Reflux on Discharge in Acute Heart Failure: Insights from the ESCAPE Trial

Abstract

Background. There has been a decline in emphasis of the value of physical examination in heart failure (HF) with increased reliance on cardiac imaging. We aim to study the clinical and prognostic significance of positive hepatojugular reflux (HJR) on discharge in patients hospitalized with HF. Methods. Using the ESCAPE trial data, patients were compared according to the presence or absence of a positive HJR on discharge. The primary study endpoints were all-cause mortality and a composite endpoint of death, rehospitalization, and cardiac transplant during the first 6 months after discharge. Results. Among 392 patients (age: 56 years, 74% men), the HJR correlated well with clinical and objective hemodynamic markers of volume overload including right atrial pressure (RAP, P = 0.002), pulmonary capillary wedge pressure (PCWP, P = 0.006), and inferior vena cava size during inspiration (P = 0.005) and expiration (P = 0.003). The RAP had the highest AUC for predicting a positive HJR on admission (AUC: 0.655, P = 0.004) and discharge (AUC: 0.672, P = 0.001). Cox's proportional hazards analysis revealed that a positive HJR on discharge is an independent predictor of 6-month mortality (estimated hazard ratio: 1.689; 95% CI: 1.032-2.764; P = 0.037) after adjusting for age, baseline creatinine, baseline hematocrit, baseline NYHA class, chronic obstructive pulmonary disease, and the presence of tricuspid regurgitation. Conclusion. The HJR should be routinely checked in patients admitted with acute HF throughout hospitalization and especially on discharge as it serves as an important prognostic marker for postdischarge outcomes.

Figure 1

Forest plot showing results of Cox's proportional hazards analysis of 6-month mortality for ESCAPE trial patients admitted with acute systolic heart failure. HJR: hepatojugular reflux; TR: tricuspid regurgitation; COPD: chronic obstructive pulmonary disease; NYHA: New York Heart Association class.

Figure 2

Kaplan-Meier cumulative survival curves in ESCAPE trial patients hospitalized with acute systolic heart failure showing a significant difference in survival between those who have either positive or negative hepatojugular reflux on discharge.