................................................................................................................................................................................................................. ................................................................................................................................................................................................................. RESEARCH LETTERS doi:10.1002/ejhf.1111 Online publish-ahead-of-print 4 January 2018 How accurate is clinical assessment of neck veins in the estimation of central venous pressure in acute heart failure? Insights from a prospective study Medical history and physical examination are the primary diagnostic tools when assess- ing emergency department (ED) patients with suspected acute heart failure (AHF). Among physical signs, positive hepato-jugular refux (HJR) and jugular vein distention (JVD) are considered to indicate elevated central venous pressure (CVP). Both are major Fram- ingham heart failure criteria and evaluated with priority in dyspnoeic patients presenting to the ED. Unfortunately and in contrast to common perception, the accuracy of clinical neck vein assessment in estimating CVP in AHF patients presenting to the ED is largely unknown. This is a dilemma as treatment decisions are com- monly based on estimating CVP from assess- ing neck veins in AHF. The recent development and validation of a non-invasive forearm vein compression ultra- sound technique to reliably measure CVP 1,2 allowed us to address this gap in knowledge and to evaluate the diagnostic accuracy of clin- ical neck vein examination for the detection of elevated CVP in AHF patients at ED presen- tation. This sub-study of the Basics in Acute Short- ness of Breath Evaluation Study ( ClinicalTrials .gov identifer: NCT01831115) prospectively enrolled adult AHF patients at the time of ED presentation. Only patients with a fnal adjudi- cated diagnosis of AHF were included in this analysis. The study was approved by the local ethics committee, and patients gave written informed consent. At the time of presentation a physical examination was performed and doc- umented by the treating ED physician using the standardized case report form used universally at the University Hos- pital Basel. Findings of the examination of the jugular veins were categorized as: normal (HJR–/JVD–), distended Figure 1 Box plots displaying central venous pressure (CVP) levels according to clinical neck vein examination. Comparison between groups by Jonckheere–Terpstra test. HJR+, patients with distended neck veins after provocation with maintained abdominal pressure; JVD+, patients with distended neck veins without provocation; JVD–/HJR–, patients with normal neck veins. HJR, hepato-jugular refux; JVD, jugular vein distention. after provocation by HJR (HJR+), distended at rest (JVD+). Physicians were blinded to the measurements of CVP and were not aware of the research aim to compare their assessment to the actual measurement of CVP. Immediately after physical examination by the treating ED physician, CVP was mea- sured by a vascular specialist as described previously. 1,2 The vascular specialist perform- ing compression sonography was blinded to the clinician’s neck vein assessment and was not directly involved in routine patient care. Measurement of CVP was only recorded for the purpose of this study and the clinical care team remained blinded to its results. Overall, 217 patients were included in the analysis and CVP measurements were performed within a median of 2.8 h after ED presentation. The study population was elderly (median age: 80 years). At presen- tation, median B-type natriuretic peptide (BNP) blood concentration was 1150 pg/mL and median echocardiographic left ventric- ular ejection fraction was 39%, with 51% of patients suffering from heart failure with reduced ejection fraction. Tricuspid annu- lar plane systolic excursion in the overall population was mildly impaired [16 mm, interquartile range (IQR) 13–20]. ED physicians classifed neck veins as normal in 67 (31%), HJR+ in 26 (12%), and JVD+ in 124 (57%) patients. HJR+ and JVD+ patients differed only in the frequency of peripheral oedema (71% vs. 65%, P = 0.02). However, HJR+ or JVD+ patients more frequently presented with other clinical signs of AHF, tended to have higher BNP blood concentrations, and more frequently had already received outpatient diuretic therapy. In a logistic regression analysis, only AHF signs [peripheral oedema: odds ratio (OR) 3.48, P < 0.01; rales: OR 2.07, P = 0.02; con- gestion on X-ray: OR 2.06, P = 0.02; lgBNP: OR 2.29, P = 0.04; outpatient diuretics: OR 2.18, P = 0.02] and lower body weight (OR 0.98, P = 0.04) but not CVP (P = 0.71) were signifcantly associated with HJR+ or JVD+ documentation by the ED physician. Median CVP was 8.8 mmHg (IQR 5.9– 12.6). CVP values in the three groups were identical [HJR–/JVD–: median 8.8 (IQR 6.7– 13.3) mmHg; HJR+: 7.4 (IQR 5.0– 13.5) mmHg; JVD+: 9.6 (IQR 5.9-12.6) mmHg] (P = 0.65) (Figure 1). Sensitivity and specifcity of HJR+/JVD+ to detect elevated CVP was poor. HJR+/JVD+ achieved a sensitivity of 68.5% and a specifcity of 28.2% to detect CVP levels above 5 mmHg. Diagnostic accu- racies for HJR+ (sensitivity 11.2%, specifcity 84.6%) and JVD+ (sensitivity 57.3%, specifcity 43.6%) were similarly poor for the detection of CVP elevations above 5 mmHg. Sensitivity © 2018 The Authors European Journal of Heart Failure © 2018 European Society of Cardiology