State-of-the-Art Review Article
Noninvasive Evaluation of Right Atrial Pressure

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In current practice, right atrial pressure (RAP) is an essential component in the hemodynamic assessment of patients and a requisite for the noninvasive estimation of the pulmonary artery pressures. RAP provides an estimation of intravascular volume, which is a critical component for optimal patient care and management. Increased RAP is associated with adverse outcomes and is independently related to all-cause mortality in patients with cardiovascular disease. Although the gold standard for RAP evaluation is invasive monitoring, various techniques are available for the noninvasive evaluation of RAP. Various echocardiographic methods have been suggested for the evaluation of RAP, consisting of indices obtained from the inferior vena cava, systemic and hepatic veins, tissue Doppler parameters, and right atrial dimensions. Because the noninvasive evaluation of RAP involves indirect measurements, multiple factors must be taken into account to provide the most accurate estimate of RAP. The authors review the data supporting current guidelines, identifying areas of agreement, conflict, limitation, and uncertainty.

Section snippets

Jugular Venous Pressure (JVP)

Sir Thomas Lewis, in 1930, first proposed the determination of a patient's venous pressure during the physical examination.11 Lewis observed that the top of the jugular veins of normal individuals and the vertical distance from the top of the fluid in the manometer (which was used at that time to measure CVP) always came to lie within 1 to 2 cm of the sternal angle. Currently, examination of JVP is the mainstay of the bedside estimation of CVP.5, 12, 13

Evaluation of CVP using the jugular veins

Conclusions

Currently, there is no single ideal parameter for noninvasive RAP estimation. Using the most recent ASE criteria43 based on IVC parameters, it is most appropriate to categorize RAP into low (0–5 mm Hg), normal (6–10 mm Hg), or elevated (11–20 mm Hg). We believe additional information from some of the methods discussed in this review should aid in the better quantification of RAP. As noninvasive evaluation of RAP involves indirect measurements, multiple factors must be taken into account to

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    Dr. Beigel is a recipient of a fellowship grant from American Physicians and Friends for Medicine in Israel (Boston, MA).

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