Jugular Venous Pressure: It's Easier Than It Looks

Jugular Venous
Pressure
Its easier than it looks
Continuing Medical Implementation
...bridging the care gap
JVP Summary
Its easier than it looks !!!

Just never taught properly
Look for descents not waves
Time deepest descent with systole
This is the x' (prime) descent !!!
Occurs during systole due to RV contraction pulling down
the TV valve ring descent of the base
A measure of RV contractility
If the dominant descent is systolic-this is the x' descent-and
JVP waveform is normal
JVP Inspection
Jugular venous pressure

Level of sternal angle is about 5 cm above
the level of mid right atrium IN ANY
POSITION.
JVP is measured in ANY position in which
top of the column is seen easily.
Usually JVP is less than 8 cm water
< 3 cm column above level of sternal angle.
Normal JVP Waveform

Consists of 3
positive waves
a,c & v
And 3 descents
x, x'(x prime)
and y
Normal JVP Waveform

a wave - atrial systole x' (prime) descent !!!
occurs during systole due to
x descent onset of
RV contraction pulling
down the TV valve ring
atrial relaxation
descent of the base
a measure of RV contractility
c wave - small
positive notch in the 'x' v wave - after the x'
descent - slow positive wave
descent due to bulging
due to right atrial filling
from venous return
of the AV ring into the
y descent - rapid emptying
atria in ventricular
of the RA into RV due to TV
contraction.
opening
JVP Inspection
Look at the JVP and
simultaneously feel the
carotid or auscultate to
identify systole
Say systole, systole,
systole, down,
down, down, X', X',
X' and look for systolic
descent
Descents are easier to see
due to greater amplitude
and frequency
Identifying the Waveform

If the dominant descent
is systolic-this is the x'
descent-and JVP
waveform is normal
The a wave is inferred as
the positive wave before
the dominant descent
The y descent is
sometimes seen but is
not as deep as x' descent
The c wave never seen

The y descent sometimes
seen
Diastolic descent
Shallower than X'
The v wave is inferred as

the positive wave between
x' and y
The x descent rarely seen
visible in 1o heart block
JVP- HJR & Kussmauls sign

Hepato-jugular reflux
(various
definitions)
sustained rise 1 cm for
30 sec.
venous tone & SVR
RV compliance
Positive HJR correlates

with LVEDP > 15
JVP normally falls

with inspiration
Kussmauls sign
inspiratory in JVP
constriction
rarely tamponade
RV infarction
Specific JVP patterns

Condition
Pattern
Normal waveform
X' deeper than Y
Post CABG
X' shallower, now = Y
Atrial fibrillation
CV wave
Tricuspid regurgitation
CV wave
Complete heart block
Irregular cannon A waves
Tamponade
JVP brisk X' > Y
Constriction
JVP brisk X' & Y descents

X' less exaggerated than Y
RV
infarction
Continuing
Medical Implementation
JVP low amplitude

Pulsus Paradoxus
Venous return normally increases with inspiration
Despite this, BP normally decreases by up to 8
mm Hg on inspiration
This paradoxical response is due to:
Increased pulmonary capacitance
Increased negative intra-thoracic pressure with
inspiration and
The phase lag between right and left sided events
How to measure Pulsus

Paradoxus
Pulsus paradoxus is an exaggerated inspiratory fall
in BP
Ask the subject to breath normally
Auscultate Korotkoffs sounds as the BP cuff is slowly
lowered. Time respiration simultaneously
Mark when BP sounds are heard only in expiration
Mark when BP sounds are heard both in expiration &
inspiration. Korotkoffs sounds seem to double at this
point.
The difference is the measured pulsus paradoxus
Pulsus Paradoxus
An exaggerated drop in SBP (>10mmHg) with inspiration
Tamponade versus
Constriction
Tamponade
in tamponade, filling
is restricted
throughout diastole
Constriction
in constrictive
pericarditis, filling is
truncated in early to mid
diastole
Kussmauls Sign
in constriction, venous
return increases with
inspiration and a high
right atrial pressure
resists filling resulting in
an increased JVP
Pulsus Paradoxus
Tamponade without
pulsus
atrial septal defect

severe aortic stenosis
aortic insufficiency
LVH with LVEDP
left ventricular
dysfunction
decreased intravascular
volume (low-pressure
tamponade)
Pulsus without tamponade
COPD
RV infarct
pulmonary embolism
effusive constrictive
pericarditis
restrictive
cardiomyopathy
extreme obesity
tense ascites
Central Venous Pressure

Cardiac Tamponade
Constrictive Pericarditis
presence of a rapid Y-descent argues against cardiac tamponade

Constrictive Physiology Hemodynamics
End-diastolic pressures
elevated and equalized
(<5 mm Hg difference)
RA pressure tracing
rapid X- and Y-descent, W or
M pattern
failure to decrease with
inspiration (Kussmauls sign)
RV pressure
RVEDP > 1/3 of RVSP
dip and plateau configuration of
RVDP (square root sign)
LV and RV pressures
discordant changes
Phono-echocardiography
Pericardial Knock (early diastolic sound)
Venous Pulse
(X- and Y-descend)
M-Mode Echo
(thickened pericardium)
Validity of the Hepato-jugular

Reflux as a Clinical Test for
Congestive Heart Failure
John Ducas MD, Sheldon Magder
MD, Maurice McGregor MD
(Am J Cardiol 1983;52:1299-1303)
Normal JVP
Normal JVP < SA at 45o
Visible when exceeds 7 cm above reference
point in RA = 5 cm < SA
Visible to height 20 cm > SA (25 cm >
reference point)
Correlate with CVP 5-19 mm Hg
Methods:
25 patients studied
6 with normal resting LV function
16 with potential bi-ventricular dysfunction
3 with RV dysfunction
Abdominal pressure 35mm Hg applied with rolled up
manometer
Patient instructed to breath normally
JVP estimated 12 seconds after compression
Hemodynamics, esophageal and gastric pressure
recordings obtained simultaneously
Validity of the HJR as a

Clinical Test for CHF
In patients with normal LV function abdominal
compression did not increase > 2 mm Hg (2.7 cm H2O )
In 16/19 patients with impaired ventricular function
CVP increased by > 3 mm Hg (4 cm H2O)
CVP stabilized over 12 seconds and did not change
over subsequent 60 seconds
An increase of 3 cm H2O (2.2 mm Hg) in the height of
the neck veins is a reasonable upper limit of normal for
HJR
John
Ducas MD,Medical
Sheldon Magder
MD, Maurice McGregor MD
Continuing
Implementation
(Am J Cardiol
1983;52:1299-1303)
...bridging
the care gap
The Abdominojugular Test:

Technique and Hemodynamic
Correlates
Gordon A. Ewy MD
(Annals Int Med 1988;109:456-460)
Results:
PCW mean 10.5 +/- 1 mm Hg in patients
with negative HJR
PCW mean 19 +/- 3 mm Hg in patients with
positive HJR
Positive HJR correlated with PCW > 15 mm
Hg

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Jugular Venous

Continuing Medical Implementation

...bridging the care gap

Its easier than it looks !!!

...bridging the care gap

Continuing Medical Implementation

...bridging the care gap