Jugular venous ultrasound for the assessment of congestion in the emergency setting

Background: Congestion is the leading cause of hospitalization in Acute Heart Failure (AHF). Its accurate identification in the emergency setting is crucial for early clinical management, but routinely used measures of congestion offer suboptimal diagnostic accuracy, particularly when applied as standalone tests. An ultrasound-based examination of the internal jugular vein (IJV) could serve as a point-of-care, easy additional tool for the multiparametric evaluation of volume status. Aim: The thesis aimed to investigate whether an ultrasound-based assessment of the internal jugular vein (IJV) is feasible and of value in the emergency department (ED). Specifically, the study intended to validate the use of a simplified qualitative definition of IJV distension assessed by ultrasound (JVDUS) versus established markers of congestion and relevant clinical outcomes. Methods: prospective, single-centre, observational study. All adult patients presenting to the ED of the Ospedale Sant’Antonio (Padova), triaged as dyspnoea or respiratory distress, underwent: a) IJV US, for measurement of the vertical height of the blood column as a surrogate of right atrial pressure (RAPUS), and for a simplified dichotomic definition of JVDUS, defined as an IJV dilated at least as much as the adjacent common carotid artery (CCA) and non-collapsible with respiration, assessed at the base of the neck in a semi-upright (45°±15°) position; b) inferior vena cava (IVC) and Lung US, for comparison with JVDUS; c) any additional test or intervention, including specific therapy and decisions regarding admission/discharge, as deemed appropriate by the attending physician blind to the results of JV US, for outcome analysis. Results: The IJV could be explored by US in almost all patients, unlike the IVC. A positive JVDUS result was significantly associated with higher RAPUS values, an independently validated diagnostic and prognostic tool; with elevated NT proBNP levels; with evidence of congestion on lung ultrasound and of dilated, non-collapsible IVC. A positive JVDUS predicted the need for IV diuretic use in the ED, a diagnosis of AHF, and hospital admission for heart failure. Overt congestion at JVDUS showed a remarkable positive predictive value (PPV=95%) for all-cause hospitalisations. Conclusions: JVDUS can be a universally feasible and rapid bedside tool for the assessment of congestion. It carries clinical information similar to other validated measures and predicts relevant short-term outcomes in patients presenting with dyspnoea or respiratory distress to the ED.