Jugular Venous
Pressure
It’s easier than it looks
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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' descentand JVP waveform is normal
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JVP Inspection
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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.
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Normal JVP Waveform
• Consists of 3
positive waves
– a,c & v
• And 3 descents
– x, x'(x prime)
and y
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Normal JVP Waveform
• a wave - atrial systole • x' (prime) descent !!!
– occurs during systole due
• x descent – onset of
to RV contraction pulling
down the TV valve ring
atrial relaxation
“descent of the base”
• c wave - small
– a measure of RV
contractility
positive notch in the 'x'
descent due to bulging • v wave - after the x'
descent - slow positive
of the AV ring into the
wave due to right atrial
atria in ventricular
filling from venous return
contraction.
• y descent - rapid
emptying of the RA into
RV due to TV opening
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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
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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
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• 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
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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
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• JVP normally falls
with inspiration
• Kussmaul’s sign
–
–
–
–
inspiratory  in JVP
constriction
rarely tamponade
RV infarction
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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
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Medical Implementation
 JVP –low amplitude
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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
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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
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Pulsus Paradoxus
An exaggerated drop in SBP (>10mmHg) with inspiration
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Tamponade versus
Constriction
• Tamponade
– 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
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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)
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Pulsus without tamponade
–
–
–
–
COPD
RV infarct
pulmonary embolism
effusive constrictive
pericarditis
– restrictive
cardiomyopathy
– extreme obesity
– tense ascites
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Central Venous Pressure
Cardiac Tamponade
Constrictive Pericarditis
presence of a rapid Y-descent argues against cardiac tamponade
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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
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Phono-echocardiography
Pericardial Knock (early diastolic sound)
Venous Pulse
(X- and Y-descend)
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M-Mode Echo
(thickened pericardium)
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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)
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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
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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
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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
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Implementation
(Am J Cardiol
1983;52:1299-1303)
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the care gap
The Abdominojugular Test:
Technique and Hemodynamic
Correlates
Gordon A. Ewy MD
(Annals Int Med 1988;109:456-460)
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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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