1. Jugular Venous Pressure
It’s easier than it looks

2. JVP Summary It’s 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

3. JVP Inspection

4. 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.
Jugular venous pressure -
IJV acts as a barometer - direct transmission of the pressure of RA seen as a blood column.
IJV - medial to sternomastoid - not seen but the pulsations seen - top of the pulsating column indicates JVP
EJV - not used because tortuous course in the thoracic cavity - subject to compression - not very accurate.
Level of sternal angle is about 5 cm above the level of mid right atrium IN ANY POSITION. JVP 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.

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

7. Normal JVP Waveform a wave - atrial systole
x descent – onset of atrial relaxation
c wave - small positive notch in the 'x' descent due to bulging of the AV ring into the atria in ventricular contraction.
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
v wave - after the x' descent - slow positive wave due to right atrial filling from venous return
y descent - rapid emptying of the RA into RV due to TV opening
JUGULAR VENOUS PULSE
Character of the JVP -
Consists of 3 positive waves & 2 troughs.
'a' wave - corresponds to atrial systole - occurs just before the systole / S1
'x' descent - d.t. relaxation of atria while the ventricles start contracting.
'c' wave - small positive notch in the 'x' descent - d.t. bulging of the AV ring into the atria in ventricular contraction.
'v' wave - after the 'x' descent - slow positive wave d.t. atrial filling from the veins. Corresponds to the S2
'y' descent - d.t. rapid emptying of the atria into ventricles - 1st rapid filling.
Jugular venous pressure -
IJV acts as a barometer - direct transmission of the pressure of RA seen as a blood column.
IJV - medial to sternomastoid - not seen but the pulsations seen - top of the pulsating column indicates JVP
EJV - not used because tortuous course in the thoracic cavity - subject to compression - not very accurate.
Level of sternal angle is about 5 cm above the level of mid right atrium IN ANY POSITION. JVP 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.
Abnormalities in JVP -
Elevated JVP (raised CVP)
RVF
Pericardial effusion
Constrictive pericarditis
SVC obstruction (thrombosis/compression)
Fluid overload
Hyperdynamic circulation
TR / TS
Giant 'a' waves - partial obstruction to atrial emptying. TS
RVH PS
PHT
'Cannon' 'a' waves - atria contract against a closed tricuspid valve.
Complete heart block - Grade III.
Paroxysmal nodal tachycardia with retrograde atrial conduction.
V-tach with retrograde atrial conduction or A-V dissociation.
Absent 'a' wave - AF
Giant 'v' wave -
TR - 'c-v' complexes seen - correspond to the ventricular systole.
'x' descent -
Exaggerated - Cardiac tamponade / constrictive pericarditis - low volume state.
Absent - Atrial fibrillation - no 'a' wave
'y' descent -
Exaggerated - Constrictive pericarditis, TR - low volume
Reduced - TS, RA myxoma (obstruction to 1st rapid filling).

8. 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

9. 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

10. JVP- HJR & Kussmaul’s 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
Kussmaul’s sign
inspiratory  in JVP
constriction
rarely tamponade
RV infarction
Method Of Exam
Author: A. ChandrasekharConsultant: R. Lichtenberg and R. Gunnar
Inspect for internal jugular vein pulsations in the neck, in supine position and with neck and trunk raised to approximate angle of 45o. Internal jugular vein pulsation are visible at the root of the neck between clavicular and sternal heads of sternoclidomastoid muscle. Internal jugular vein corresponds to a line drawn from this point to infra auricular region. Inspection with simultaneous palpation of the carotid and/or auscultation of the heart will assist in identification and timing of the waves. Inspect the vein from different angles. Apply light tangentially and observe for venous pulsations in the shadow of neck on the pillow.
At 0o jugular veins should be filled. An impulse visible just prior to S1 or the upstroke of the carotid is the "a-wave". This will be followed by a x-descent. The 'c' wave is usually not visible. The 'v' wave occurs after the start of the carotid upstroke and during ventricular systole (which is atrial diastole). When the tricuspid valve opens there is a brisk descent (y-descent).
Observe the venous pressure changes with respiration. There is normally a drop in intrathoracic pressure with inspiration. This decrease is also reflected on the intracardiac pressures. Therefore, an increase in the pressure difference between the SVC/IVC and the RA increases cardiac filling.
Normal: Neck veins are not visible at 45 o inclination. Neck veins should be visible in supine position. JVP should decrease with inspiration.

11. Specific JVP patterns Condition Pattern Normal waveform
X' deeper than Y
Post CABG
X' shallower, now = Y
Atrial fibrillation
CV wave
Tricuspid regurgitation
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
 JVP –low amplitude

12. 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

13. How to measure Pulsus Paradoxus
Pulsus paradoxus is an exaggerated inspiratory fall in BP
Ask the subject to breath normally
Auscultate Korotkoff’s 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. Korotkoff’s sounds seem to double at this point.
The difference is the measured pulsus paradoxus

14. Pulsus Paradoxus
An exaggerated drop in SBP (>10mmHg) with inspiration

15. Tamponade versus Constriction
in tamponade, filling is restricted throughout diastole
Constriction
in constrictive pericarditis, filling is truncated in early to mid diastole
Kussmaul’s Sign
in constriction, venous return increases with inspiration and a high right atrial pressure resists filling resulting in an increased JVP

16. Pulsus Paradoxus Tamponade without pulsus Pulsus without tamponade
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

17. Central Venous Pressure
Cardiac Tamponade
Constrictive Pericarditis
presence of a rapid Y-descent argues against cardiac tamponade

18. 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 (Kussmaul’s sign)
RV pressure
RVEDP > 1/3 of RVSP
dip and plateau configuration of RVDP (square root sign)
LV and RV pressures
discordant changes

19. Phono-echocardiography Pericardial Knock (early diastolic sound)
Venous Pulse (X- and Y-descend)
M-Mode Echo (thickened pericardium)

20. John Ducas MD, Sheldon Magder MD, Maurice McGregor MD
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: )

21. 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

22. 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

23. 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, Sheldon Magder MD, Maurice McGregor MD (Am J Cardiol 1983;52: )

24. The Abdominojugular Test: Technique and Hemodynamic Correlates
Gordon A. Ewy MD
(Annals Int Med 1988;109: )

25. 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