Detection of elevated right atrial pressure using a simple bedside ultrasound measure
Received 21 July 2009; accepted 6 January 2010.
Aims
Accurate assessment of right atrial pressure (RAP) often requires invasive measurement. With normal RAP, Valsalva increases right internal jugular vein (RIJV) cross sectional area (CSA) 20% to 30%. With high RAP, when venous compliance is low, we hypothesized that the increase in CSA would be blunted and could be detected non-invasively with bedside ultrasound.
Methods and Results
RIJV ultrasound images were obtained in 67 patients undergoing right heart catheterization. The median RAP at end-expiration was 7 mm Hg (interquartile range [IQR] 5-9 mm Hg) in patients with normal RAP (n = 47) versus 15 mm Hg (IQR 12-22 mm Hg) in patients with elevated RAP (n = 20). With Valsalva, the median percent change in RIJV CSA was 35% (IQR 19%-79%) versus 5% (IQR 3%-14%) for normal and high RAP, respectively. By receiver operating curve analysis, a <17% increase in RIJV CSA with Valsalva predicted elevated RAP (≥12 mmHg) with 90% sensitivity, 74% specificity, 94% negative predictive value, and 60% positive predictive value (area under the curve 0.86, P < .001).
Conclusions
An increase in RIJV CSA >17% during Valsalva effectively rules out elevated RAP. This simple bedside technique may be useful to assess central venous pressure and reduce the need for invasive pressure measurement.
Center for Ultrasound Molecular Imaging and Therapeutics, Cardiovascular Institute, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
Reprint requests: John J. Pacella, MS, MD, FACC, University of Pittsburgh, Cardiovascular Institute, Suite A350 Scaife Hall, 200 Lothrop Street, Pittsburgh, PA 15213.
ABSTRACT