Mahwash saeed jacques rizkallah megan jack leigh anne s hafer james tam
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Mahwash Saeed, Jacques Rizkallah , Megan Jack , Leigh Anne S hafer, James Tam PowerPoint PPT Presentation

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Non Invasive Bedside Assessment of Right Atrial Pressure; Scanning into the Future. Mahwash Saeed, Jacques Rizkallah , Megan Jack , Leigh Anne S hafer, James Tam. disclosures. None. Right Atrial Pressure.

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Mahwash Saeed, Jacques Rizkallah , Megan Jack , Leigh Anne S hafer, James Tam

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Non Invasive Bedside Assessment of Right Atrial Pressure;

Scanning into the Future

Mahwash Saeed, Jacques Rizkallah,

Megan Jack, Leigh Anne Shafer, James Tam


  • None.

Right Atrial Pressure

  • Noninvasive bedside physical examination of volume status is a common clinical skill taught to medical students early in their training

  • Right atrial pressure (RAP) is used as a surrogate for central venous pressure and overall volume status

RAP: Evaluation

  • Noninvasive evaluation of RAP can be achieved by the following techniques:

    • Jugular Venous Pressure (JVP)

    • Peripheral Venous Collapse (PVC)

    • Ultrasound visualization of the inferior vena cava (IVC)

JVP: Limitations

  • The JVP examination is a practical clinical tool, however it can be very difficult to assess in certain individuals

    • obesity

    • anomalous venous anatomy

    • connective tissue diseases

    • venous scarring from catheter insertion

  • In such patients, alternative methods may be helpful, although not systematically validated

RAP Estimation: Alternative Techniques

  • PVC, IVC collapse

    • The relative accuracy of these techniques, compared to one another, and their application by trainees of varying experience remains uncertain


  • We compared the utility of the JVP, PVC, and bedside mini echo (BME) as non-invasive RAP clinical predictive tools amongst trainees of varying experience


  • A 2nd year medical student, 2nd year medical resident, and 2nd year cardiology fellow examined patients presenting for outpatient and inpatient echocardiogram at a tertiary care hospital


  • Inclusion Criteria

    • Patients receiving scheduled echo at

      St Boniface Hospital in Winnipeg, MB

    • Patient able to give informed consent


  • Exclusion Criteria

    • Patients with intravenous catheters (IV) or recent IV insertions within the last 2 weeks in the right arm or neck veins

    • Patients with a history of intravenous drug use

    • Patients who could not give informed consent, including those with language barrier


  • Patients were examined for JVP and PVC by all three examiners

  • BME (without JVP/PVC) was utilized (after 10 hours of instruction) by the student in another group of patients

  • Bedside RAP estimates were then compared to measurements from a complete echo study by a trained sonographer read by a level 3 echocardiologist


Peripheral Vein Collapse

Anthem Sign



  • All patients underwent their regularly scheduled two dimensional echocardiographic examination

  • The echo technologist and staff echocardiographer interpreting the study were not involved in the clinical assessment of the patients

  • Assessment of the IVC by the echocardiographer was used as the gold standard for RAP estimates

Overall Patient Characteristics

Overall Patient Characteristics


PPV and NPV of Specific Exam Techniques

PPV and NPV of Specific Exam Techniques in Obese Patients (BMI >30)


  • Of the physical exam maneuvers for detecting elevated RAP, the JVP was the most sensitive at 86%

    • This improved with clinical experience


  • The PVC/anthem sign more useful for the early learner who has not mastered the JVP yet

  • There was consistency in the sensitivity of the anthem sign which hints towards ease of use and reproducibility


  • The BME showed 100% sensitivity for detecting increased RAP


  • The JVP was the most sensitive physical exam technique

  • There may be an adjunctive role for the PVC and Anthem sign

    • Helpful for early learner and in obese patients


  • BME estimate of CVP is at least comparable to physical examination assessment and may require less instruction

  • The use of BME in medical training should be further evaluated and encouraged



St Boniface Echo staff

Photo models:

  • Rosalie Grant

  • DrAnjalaChelvanathan

  • Dr Ali Bagherli

  • D Shelley Zieroth


  • Dr Jacques Rizkallah

  • Dr James Tam

  • Megan Jack

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