Heart failure & cardiomyopathies
Does This Patient Have Volume Overload??: The Rational Clinical Examination
An erratum to this article was published (JAMA, 1 Sep 2026 ↗)
Authors' conclusion
A BNP level of 100 ng/mL or higher and presence of vascular congestion on chest radiography may be the most useful tests to identify patients with volume overload. Absence of pulmonary B-lines using point-of-care ultrasonography or BNP levels of less than 100 ng/mL may be most useful to exclude volume overload.
Study context
- Population
- Nonintubated, spontaneously breathing adults assessed for intravascular volume overload (33 studies in patients with dyspnea)
- Participants
- 11,490 participants40 studies
- Comparison
- Clinical examination, radiographic and laboratory findings for volume overload
- Outcome
- Diagnostic accuracy (sensitivity, specificity, likelihood ratios (LRs)) for volume overload
Methodological detailsMEDLINE searched 1946 to January 6, 2026, 2-level mixed logistic regression model to pool estimates
- MEDLINE searched 1946 to January 6, 2026
- 2-level mixed logistic regression model to pool estimates
Pooled result
As reported in the abstract
Volume overload
| Group | Positive LR | Specificity | Positive LR (bilateral B-lines) | Negative LR (absence of B-lines) | Sensitivity | LR (<50%) | LR (≥50%) | LR (>8 cm) | LR (≤8 cm) | LR (≥100 ng/mL) | LR (normal value) |
|---|---|---|---|---|---|---|---|---|---|---|---|
| JVD >3 cm | 4.1 (95% CI, 2.9-5.6) | 92% | |||||||||
| Lower extremity edema | 2.2 (95% CI, 1.5-3.1) | 80% | |||||||||
| Crackles | 2.7 (95% CI, 1.7-4.5) | 81% | |||||||||
| Vascular congestion on chest radiography | 5.9 (95% CI, 2.9-12.0) | 91% | |||||||||
| Pulmonary B-lines | 77% | 4.0 (95% CI, 2.6-6.1) | 0.09 (95% CI, 0.04-0.23) | 93% | |||||||
| IVC collapsibility index | 79% | 82% | 3.9 (95% CI, 2.5-6.1) | 0.22 (95% CI, 0.11-0.45) | |||||||
| Ultrasonographic jugular venous pressure (JVP) | 71% | 81% | 2.8 (95% CI, 2.2-3.5) | 0.26 (95% CI, 0.20-0.33) | |||||||
| BNP | 87% | 87% | 6.9 (95% CI, 2.4-20.4) | 0.14 (95% CI, 0.08-0.24) |
Positive LR
JVD >3 cm4.1 (95% CI, 2.9-5.6)
Lower extremity edema2.2 (95% CI, 1.5-3.1)
Crackles2.7 (95% CI, 1.7-4.5)
Vascular congestion on chest radiography5.9 (95% CI, 2.9-12.0)
Pulmonary B-lines— not stated in the abstract
IVC collapsibility index— not stated in the abstract
Ultrasonographic jugular venous pressure (JVP)— not stated in the abstract
BNP— not stated in the abstract
Specificity
JVD >3 cm92%
Lower extremity edema80%
Crackles81%
Vascular congestion on chest radiography91%
Pulmonary B-lines77%
IVC collapsibility index79%
Ultrasonographic jugular venous pressure (JVP)71%
BNP87%
Positive LR (bilateral B-lines)
JVD >3 cm— not stated in the abstract
Lower extremity edema— not stated in the abstract
Crackles— not stated in the abstract
Vascular congestion on chest radiography— not stated in the abstract
Pulmonary B-lines4.0 (95% CI, 2.6-6.1)
IVC collapsibility index— not stated in the abstract
Ultrasonographic jugular venous pressure (JVP)— not stated in the abstract
BNP— not stated in the abstract
Negative LR (absence of B-lines)
JVD >3 cm— not stated in the abstract
Lower extremity edema— not stated in the abstract
Crackles— not stated in the abstract
Vascular congestion on chest radiography— not stated in the abstract
Pulmonary B-lines0.09 (95% CI, 0.04-0.23)
IVC collapsibility index— not stated in the abstract
Ultrasonographic jugular venous pressure (JVP)— not stated in the abstract
BNP— not stated in the abstract
Sensitivity
JVD >3 cm— not stated in the abstract
Lower extremity edema— not stated in the abstract
Crackles— not stated in the abstract
Vascular congestion on chest radiography— not stated in the abstract
Pulmonary B-lines93%
IVC collapsibility index82%
Ultrasonographic jugular venous pressure (JVP)81%
BNP87%
LR (<50%)
JVD >3 cm— not stated in the abstract
Lower extremity edema— not stated in the abstract
Crackles— not stated in the abstract
Vascular congestion on chest radiography— not stated in the abstract
Pulmonary B-lines— not stated in the abstract
IVC collapsibility index3.9 (95% CI, 2.5-6.1)
Ultrasonographic jugular venous pressure (JVP)— not stated in the abstract
BNP— not stated in the abstract
LR (≥50%)
JVD >3 cm— not stated in the abstract
Lower extremity edema— not stated in the abstract
Crackles— not stated in the abstract
Vascular congestion on chest radiography— not stated in the abstract
Pulmonary B-lines— not stated in the abstract
IVC collapsibility index0.22 (95% CI, 0.11-0.45)
Ultrasonographic jugular venous pressure (JVP)— not stated in the abstract
BNP— not stated in the abstract
LR (>8 cm)
JVD >3 cm— not stated in the abstract
Lower extremity edema— not stated in the abstract
Crackles— not stated in the abstract
Vascular congestion on chest radiography— not stated in the abstract
Pulmonary B-lines— not stated in the abstract
IVC collapsibility index— not stated in the abstract
Ultrasonographic jugular venous pressure (JVP)2.8 (95% CI, 2.2-3.5)
BNP— not stated in the abstract
LR (≤8 cm)
JVD >3 cm— not stated in the abstract
Lower extremity edema— not stated in the abstract
Crackles— not stated in the abstract
Vascular congestion on chest radiography— not stated in the abstract
Pulmonary B-lines— not stated in the abstract
IVC collapsibility index— not stated in the abstract
Ultrasonographic jugular venous pressure (JVP)0.26 (95% CI, 0.20-0.33)
BNP— not stated in the abstract
LR (≥100 ng/mL)
JVD >3 cm— not stated in the abstract
Lower extremity edema— not stated in the abstract
Crackles— not stated in the abstract
Vascular congestion on chest radiography— not stated in the abstract
Pulmonary B-lines— not stated in the abstract
IVC collapsibility index— not stated in the abstract
Ultrasonographic jugular venous pressure (JVP)— not stated in the abstract
BNP6.9 (95% CI, 2.4-20.4)
LR (normal value)
JVD >3 cm— not stated in the abstract
Lower extremity edema— not stated in the abstract
Crackles— not stated in the abstract
Vascular congestion on chest radiography— not stated in the abstract
Pulmonary B-lines— not stated in the abstract
IVC collapsibility index— not stated in the abstract
Ultrasonographic jugular venous pressure (JVP)— not stated in the abstract
BNP0.14 (95% CI, 0.08-0.24)
- Prevalence of volume overload
- 35% to 69%
Original publication
Does This Patient Have Volume Overload??: The Rational Clinical Examination. JAMA. Published 7 April 2026. doi:10.
Composed by AI from the published abstract and checked against it. How Briefs are made →