Accurate assessment of the jugular venous pressure (JVP) and right atrial pressure (RAP) has relied on the same bedside examination method since 1930. While this technique provides a rough estimate of right-sided pressures, it is limited by poor sensitivity and overall diagnostic inaccuracy. The internal jugular vein (IJV) is difficult to visualize in many patients and relies on an incorrect assumption that the right atrium lies 5 centimeters below the sternum. Point-of-care ultrasound (POCUS) offers an alternative method for more precisely estimating JVP and RAP. We propose a novel method of measuring the right atrial depth (RAD) using a sonographic measurement of the depth of the posterior left ventricular outflow tract as a surrogate landmark to the center of the right atrium when viewed in the parasternal long axis view. This is combined with determination if JVD was present at the supraclavicular point. Sensitivity, specificity, PPV, NPV of JVD at the supraclavicular point was 70%, 76%, 59%, 91% respectively. These values were confounded by the lack of standardization of zero reference landmarks (ZRLs) used during the right heart catheterizations. When the RAD estimate was adjusted to account for measurement error the sensitivity of JVD at supraclavicular point for elevated RAP improved to 90% with negative predictive value of 96%. This may offer a rapid and reliable method for ruling out elevated RAP and increase objectivity in our volume status assessment.

Acute bacterial endocarditis is an acute febrile illness that spreads hematogenously and can be fatal if it is not treated in a timely fashion. A traditional physical examination has very limited sensitivity and specificity when diagnosing bacterial endocarditis. Point-of-care ultrasound (POCUS) during the physical exam can assist with the diagnosis by evaluating for valvular regurgitation or visible vegetation. In this case, a patient presented to the hospital with a cough and shortness of breath and was diagnosed with pneumonia. She did not improve with intravenous antibiotics and a POCUS exam revealed the diagnosis was in fact bacterial endocarditis and not pneumonia. This led to further imaging, which revealed an abdominal abscess. This highlights the importance of incorporating POCUS into the physical exam of any patient presenting with cardiopulmonary symptoms.

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Current noninvasive estimation of right atrial pressure (RAP) by either bedside jugular venous pressure (JVP) exam or inferior vena cava (IVC) measurement during a formal echocardiogram offer imprecise estimates of actual RAP. We enrolled 41 patients in a prospective, blinded study to validate a novel point-of-care ultrasound method to estimate RAP. Two subjects were excluded and 39 were included in the final analysis. The ultrasound estimate of RAP (RAPU) was compared to the RAP measurement during right heart catheterization (RAPi) both as measured and corrected for the mid-AP diameter. The correlation coefficient between RAPi and corrected RAPU measurements was +0.72, regression R2 0.52, bias −0.60 mmHg (95% confidence interval [CI], −1.60 to +0.39 mmHg) with the limits of agreement −5.56 to +7.24 mmHg, and 3 mmHg accuracy of 26 (67%). Similarly, for the uncorrected RAPU measurement, the correlation coefficient was +0.75, regression R2 0.56, bias −0.49 mmHg (95% CI, −1.42 to +0.43 mmHg) with the limits of agreement −5.56 to +7.24 mmHg, and 3 mmHg accuracy of 29 (74%). This simple bedside evaluation of right atrial depth and the right jugular vein correlates with actual right atrial pressure better than traditional IVC parameters, and can accurately estimate RAP within 3mmHg in most patients.

Mitral regurgitation is a common valvular disorder found in the general population with varying degrees of severity. The symptoms of this disorder correspond to the severity of regurgitation as well as its associated complications such as arrhythmias. Suspicion of mitral regurgitation is based on physical exam findings with diagnosis generally requiring confirmatory findings on transthoracic echocardiogram. However, asymptomatic patients with mitral regurgitation and limited sensitivity of cardiac auscultation to detect a murmur confound the diagnosis. In this case, a patient presented with nonspecific symptoms of shortness of breath and abdominal pain in which a bedside point-of-care ultrasound (POCUS) in initial examination demonstrated severe mitral regurgitation and pulmonary edema. These findings expedited an intervention on the regurgitation, which highlights the importance of incorporation and early use of POCUS during physical examination.