Correspondence

A Sailor's Heartbreak

N Engl J Med 2005; 353:2408-2409December 1, 2005

Article

To the Editor:

In the article by Pinto et al. (Sept. 1 issue),1 the examination of the sailor presenting with dyspnea and weight gain revealed that his “jugular venous pressure was not elevated,” leading the discussant to dismiss a cardiac cause. In fact, the jugular venous pressure should have been elevated in this patient, who had a pericardial effusion severe enough to cause peripheral edema, ascites, pleural effusions, and hepatic congestion with transaminitis and coagulopathy.

When reclining patients are examined, a markedly elevated jugular venous pressure can be misinterpreted as “not elevated” because of obstruction by the ear or jaw. Borst and Molhuysen described the proper technique for measuring jugular venous pressure as follows2: “The position of the patient must be adapted so that the pulsations are visible preferably midway between the clavicle and the jaw. Patients with normal or low central venous pressure have to be positioned horizontally.”

This case highlights the importance of reporting the exact measurement of jugular venous pressure, rather than simply stating whether it is elevated.3 We wonder whether the inferior vena cava was dilated on the initial echocardiogram, since this would favor an elevated jugular venous pressure that perhaps was not recognized owing to improper positioning of the patient.

Lori B. Daniels, M.D.
David Krummen, M.D.
University of California, San Diego, San Diego, CA 92103
loridaniels@ucsd.edu

3 References

1. 1

   Pinto DS, Blair BM, Schwartzstein RM, Smith CC. A sailor's heartbreak. N Engl J Med 2005;353:934-939
   Full Text | Web of Science | Medline

2. 2

   Borst JG, Molhuysen JA. Exact determination of the central venous pressure by a simple clinical method. Lancet 1952;2:304-309
   CrossRef | Medline

3. 3

   van't Laar A. Why is the measurement of jugular venous pressure discredited? Neth J Med 2003;61:268-272
   Web of Science | Medline

Author/Editor Response

We agree with Drs. Daniels and Krummen that, barring a process such as hepatic-vein thrombosis with an incidental, hemodynamically insignificant pericardial effusion, elevation of jugular venous pressure should have been detected. Considerable variation exists in expertise in the measurement of jugular venous pressure, and studies indicate poor reliability of such assessments in critically ill patients.1 This patient subsequently was found to have plethora of the inferior vena cava on echocardiography, reflecting elevated right atrial pressure2 and signifying that the initial interpretation of the jugular venous pressure was probably incorrect.

Though one may be tempted to ensure complete agreement of all historical and physical findings with the patient's subsequent diagnosis, we chose to present details as they unfolded and as they were documented by the clinicians. We recognize that clinicians often consider broad differential diagnoses and commonly are faced with incongruent elements of a case. Consequently, one challenge is the integration of data and the determination of whether to discount or question inconsistencies. We hope that presenting the case in this manner accurately portrays the complex decision making that is necessary in routine practice, especially when conflicting or imprecise information exists.

Duane S. Pinto, M.D.
Barbra M. Blair, M.D.
C. Christopher Smith, M.D.
Beth Israel Deaconess Medical Center, Boston, MA 02215
dpinto@bidmc.harvard.edu

2 References

1. 1

   Connors AF Jr, McCaffree DR, Gray BA. Evaluation of right-heart catheterization in the critically ill patient without acute myocardial infarction. N Engl J Med 1983;308:263-267
   Full Text | Web of Science | Medline

2. 2

   Otto CM. Textbook of clinical echocardiography. 2nd ed. Philadelphia: W.B. Saunders, 2000:220.