Case Studies

Case 5: Jugular venous pressure up to the jaw

You are 2 weeks into your new job as a foundation year house officer in geriatric medicine. An 84-year-old woman has been transferred to your hospital for rehabilitation following a successful tissue aortic valve re-placement at a tertiary centre. On examination she is comfortable at rest, her hands are cool and her JVP is elevated to her jaw. Corneal arcus is present. Inspection of her precordium reveals a fresh midline sternotomy scar that is healing well. Her apex beat is located in the sixth intercostal space, mid-axillary line. Auscultation of her precordium reveals normal heart sounds. Her chest is notable for stony dullness at the left base and bibasal crepitations. She has pitting oedema to her thighs. ECG shows rate-controlled atrial fibrillation and her chest X-ray shows cardiomegaly, bilateral bat’s wing shadowing and bilateral pleural effusions (Case 5 figure). On the ward round, she complains of a poor night’s sleep and being ‘unable to catch my breath’. A recent echocardiogram showed an ejection fraction of 35%.

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AP erect film. Bilateral pleural effusions with adjacent lung atelectasis and generous cardiac silhouette. Sternotomy wires in situ. There is also separation of the left acromioclavicular joint.

• 1. What is the JVP a measure of?

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  The JVP is a clinical measure of pressure in the right atrium.

• 2. Which vessel are we looking at when we assess the JVP?

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  The internal jugular vein.

• 3. What is corneal arcus?

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  Corneal arcus is the name for white rings around the edge of the iris in the eye. They are caused by deposits of cholesterol-rich lipid particles that are thought to be trapped in the extracellular matrix in the stroma of the corneae. Unlike xanthelasmas, they do not indicate an increased risk of ischaemic heart disease or myocardial infarction.

• 4 .Is her apex beat displaced?

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  This woman’s apex beat is displaced. This is a result of cardiomegaly secondary to left ventricular failure. Normally, the apex beat is located in the fifth intercostal space, mid-clavicular line.

• 5. What is the diagnosis in this woman?

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  Her raised JVP and peripheral oedema are signs of right heart failure, while pleural effusions and pulmonary oedema are signs of left heart failure. The diagnosis is therefore congestive cardiac failure.

• 6. What do cardiomegaly, bibasal shadowing and the pleural effusion on her chest X-ray represent?

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  Cardiomegaly occurs as a result of cardiac dilatation in a compensatory attempt of the failing heart to maintain cardiac output. Bilateral bat’s wing shadowing represents pulmonary oedema (i.e. fluid in the air spaces) and parenchyma of the lungs causing impaired gas exchange and shortness of breath. The pleural effusions represent excess fluid that has accumulated between the parietal and visceral pleura as a result of increased capillary hydrostatic pressure.

• 7. How do you manage this patient?

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  This patient was grossly fluid-overloaded. She was started on diuretic therapy to offload the excess fluid, aiming for a weight loss of 0.5–1.0 kg/day. Initially she was started on intravenous frusemide at a dose of 80 mg/day. This was then switched to oral frusemide. She was advised not to drink excessive amounts of fluid. She had daily blood tests to monitor her kidney function, as over-aggressive diuresis can precipitate renal failure. Aggressive diuresis can also cause electrolyte imbalance (e.g. hypokalaemia). If this occurs, the potassium-sparing diuretic spironolactone can be considered. In view of her aortic valve replacement, she should have a repeat echocardiogram to assess the function of her left ventricle.

• 8. Do all patients with cardiac failure have a reduced ejection fraction on echocardiogram?

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  Many patients with cardiac failure have an ejection fraction within normal limits when estimated by echocardiography. This is partly because echocardiogram can only estimate ejection fraction. More importantly, in many patients the heart functions poorly because of problems with filling rather than ejecting out blood into the arterial circulation – this is often called diastolic cardiac failure.