1. Definition Jugular Venous Pulse:
defined as the oscillating top of vertical column of blood in right IJV that reflects pressure changes in Right Atrium in cardiac cycle.
Jugular Venous Pressure:
Vertical height of oscillating column of blood.

2. Why Internal Jugular Vein?
IJV has a direct course to RA.
IJV is anatomically closer to RA.
IJV has no valves( Valves in EJV prevent transmission of RA pressure)
Vasoconstriction Secondary to hypotension ( in CCF) can make EJV small and barely visible.

3. Why Right Internal Jugular Vein?
Right jugular veins extend in an almost straight line to superior vena cava, thus favouring transmission of the haemodynamic changes from the right atrium.
The left innominate vein is not in a straight line and may be kinked or compressed between Aortic Arch and sternum, by a dilated aorta, or by an aneurysm.

4. R L
                                          

7. Difference from Carotid Pulse
Venous Pulse
Carotid Pulse
More lateral
Medial
Wavy, Undulant
Forceful, Brisk
Decrease with Inspiration
No change
Increase in supine position
^with abdominal pressure
Double Peaked
Single Peak
Obliterated with Pressure
Cannot be Obliterated
Better Visible
Better palpated
Better viewed from foot end of bed

8. Method Of Examination
The patient should lie comfortably during the examination.
Clothing should be removed from the neck and upper thorax.
Patient reclining with head elevated 45 °
Neck should not be sharply flexed.
Examined effectively by shining a light tangentially across the neck.
There should not be any tight bands around abdomen

9. Observations Made The level of venous pressure.
The type of venous wave pattern.

10. The level of venous pressure
Using a centimeter ruler, measure the vertical distance between the angle of Louis (manubrio sternal joint) and the highest level of jugular vein pulsation.
The upper limit of normal is 4 cm above the sternal angle,.
Add 5 cm to measure central venous pressure since right atrium is 5 cm below the sternal angle.
Normal CVP is < 9 cm H2O

12. Normal pattern of the jugular venous pulsex x`
The normal JVP reflects phasic pressure changes in the right atrium and consists of three positive waves and two negative troughs
Simultaneous palpation of the left carotid artery aids the examiner in relating the venous pulsations to the timing of the cardiac cycle.

13. a WAVE Venous distension due to RA contraction
Retrograde blood flow into SVC and IJV
Synchronous with S1, Follow P of ECG
Precede Carotid pulse

14. The x descent: is due to The c wave: X Atrial relaxation
X` Descent of the floor of the right atrium
during right ventricular systole.
Begins during systole and ends before S2
The c wave:
Occurs simultaneously with the carotid pulse

15. v WAVE
Rising right atrial pressure when blood flows into the right atrium during ventricular systole when the tricuspid valve is shut.
Synchronous with Carotid pulse
Begins in early systole, Peaks after S2 and ends in early diastole

16. y DESCENT
The decline in right atrial pressure when the tricuspid valve reopens
Following the bottom of the y descent and before beginning of the a wave is a period of relatively slow filling of the ventricle, the diastases period, a wave termed the h wave.

18. Identifying Wave Forms
The x descent occurs just prior to the second heart sound ( during systole), while the y descent occurs after the second heart sound (during diastole).
Normally X descent is more prominent than Y descent. Y descent is only sometimes seen during diastole. Descents are better seen than positive waves.
The a wave occurs just before the first sound or carotid pulse and has a sharp rise and fall.
The v wave occurs just after the arterial pulse and has a slower undulating pattern.
The c wave is never seen normally.

19. Abnormalities of jugular venous pulse
Low jugular venous pressure
1. Hypovolaemia.

20. B. Elevated jugular venous pressure
1. Intravascular volume overload conditions
Right ventricular infarction
Left heart failure
Myocardial infarction.
Valvular Heart Disease
Cardiomyopathy
2. Constrictive pericarditis.
3. Pericardial effusion with tamponade

21. Elevated “a” wave Increased Resistance to RV Filling.
Tricuspid stenosis
R Heart Failure PS
PAH

22. Cannon “a” wave Atrial-ventricular Dissociation
(atria contract against
a closed tricuspid valve)
Complete heart block
VPC
Ventricular tachycardia
Ventricular pacing
Junctional rhythm
Junctional tachycardia.

23. Absent “a” wave
1. Atrial fibrillation

24. Elevated “v” wave 1. Tricuspid regurgitation.
2. Right ventricular failure.
3. Restrictive cardiomyopathy.
4. Cor Pulmonale

25. Tricuspid regurgitation
Absent X Decsent
CV/ Regurgitant Wave
Has a rounded contour and a sustained peak
Followed by a rapid deep Y descent
Amplitude of V increases with inspiration.
Cause subtle motion of ear lobe with each heart beat c

26. “a” wave equal to “v” wave
ASD
Prominent X descent followed by a large V wave
M Configuration
Indicates a large L-R shunt
With PAH A wave becomes more prominent
If L JVP > R JVP indicates associated PAPVC

27. Prominent “x” descent Blunted “x” descent 1. Tricuspid regurgitation.
Cardiac tamponade.
Constrictive Pericarditis
RVMI
Restrictive Cardiomyopathy
Atrial septal defect
Blunted “x” descent
1. Tricuspid regurgitation.
2. Right atrial ischaemia

28. Prominent “y” descent Absent “y” descent Slow “y” descent
1. Constrictive pericarditis.
2. Tricuspid regurgitation.
3. Atrial septal defect.
Absent “y” descent
1. Cardiac tamponade.
2. Right ventricular infarction
3. Restrictive Cardiomyopathy
Slow “y” descent
1. Tricuspid stenosis.
2. Right atrial myxoma.

29. Constrictive pericarditis.
M shaped contour
Prominent X and Y descent (FRIEDREICH`SIGN)
Y descent is prominent as ventricular filling is unimpeded during early diastole.
This is interrupted by a rapid raise in pressure as the filling is impeded by constricting Pericardium
The Ventriclar pressure curve exhibit Square Root sign

31. Abdomino-jugular reflux
Is positive when JVP increase after 10 sec of abdominal pressure followed by a rapid drop in pressure of 4 cm on release of compression.
Most common cause of a positive test is RHF
Positive test in: Borderline elevation of JVP
Silent TR
Latent RHF
False positive: Fluid overload
False Negative: SVC/IVC obstruction
Budd Chiari syndrome
Positive Test imply SVC and IVC are patent

32. Kussmaul sign Failure of decline in JVP occur during inspiration.
Constrictive Pericarditis
Severe RHF
Restrictive Cardiomyopathy
Tricuspid Stenosis

33. Thank You