Jugular Venous Pressure (from: http://en.wikipedia.

org/wiki/Jugular_vein_distension
The jugular venous pressure (JVP, sometimes referred to as jugular venous pulse) is the
indirectly observed pressure over the venous system via visualization of the internal jugular
vein. It can be useful in the differentiation of different forms of heart and lung disease.
Classically three upward deflections and two downward deflections have been described.

The upward deflections are the "a" (atrial contraction), "c" (ventricular contraction and
resulting bulging of tricuspid into the right atrium during isovolumetric systole) and "v" =
atrial venous filling.

The downward deflections of the wave are the "x" (the atrium relaxes and the tricuspid
valve moves downward) and the "y" descent (filling of ventricle after tricuspid opening).

Method
Visualization
The patient is positioned under 45, and the filling level of the jugular vein determined.
Visualize the internal jugular vein when looking for the pulsation. In healthy people, the filling
level of the jugular vein should be less than 3 centimetres vertical height above the sternal
angle. A pen-light can aid in discerning the jugular filling level by providing tangential light.
The JVP is easiest to observe if one looks along the surface of the sternocleidomastoid muscle,
as it is easier to appreciate the movement relative to the neck when looking from the side (as
opposed to looking at the surface at a 90 degree angle). Like judging the movement of an
automobile from a distance, it is easier to see the movement of an automobile when it is
crossing one's path at 90 degrees (i.e. moving left to right or right to left), as opposed to coming
toward one.
Pulses in the JVP are rather hard to observe, but trained cardiologists do try to discern these as
signs of the state of the right atrium.

Differentiation from the carotid pulse

The JVP and carotid pulse can be differentiated several ways:

multiphasic - the JVP "beats" twice (in quick succession) in the cardiac cycle. In other
words, there are two waves in the JVP for each contraction-relaxation cycle by the heart.
The first beat represents that atrial contraction (termed a) and second beat represents

venous filling of the right atrium against a closed tricuspid valve (termed v) and not the
commonly mistaken 'ventricular contraction'. These wave forms may be altered by certain
medical conditions; therefore, this is not always an accurate way to differentiate the JVP
from the carotid pulse. The carotid artery only has one beat in the cardiac cycle.

non-palpable - the JVP cannot be palpated. If one feels a pulse in the neck, it is
generally the common carotid artery.

occludable - the JVP can be stopped by occluding the internal jugular vein by lightly
pressing against the neck. It will fill from above.

varies with head-up-tilt (HUT) - the JVP varies with the angle of neck. If a person is
standing, his JVP appears to be lower on the neck (or may not be seen at all because it is
below the sternal angle). The carotid pulse's location does not vary with HUT.

varies with respiration - the JVP usually decreases with deep inspiration. Physiologically,
this is a consequence of the FrankStarling mechanism as inspiration decreases the
thoracic pressure and increases blood movement into the heart (venous return), which a
healthy heart moves into the pulmonary circulation.

JVP waveform
The jugular venous pulsation has a biphasic waveform.

The " a " wave corresponds to right Atrial contraction and ends synchronously with the
carotid artery pulse. The peak of the 'a' wave demarcates the end of atrial systole.

The " c " wave corresponds to right ventricular Contraction causing the triCuspid valve to
bulge towards the right atrium.

The " x " descent follows the 'a' wave and corresponds to atrial relaXation and rapid
atrial filling due to low pressure.

The " x' " (x prime) descent follows the 'c' wave and occurs as a result of the right
ventricle pulling the tricuspid valve downward during ventricular systole. The x' (x prime)
descent can be used as a measure of right ventricle contractility.

The " v " wave corresponds to Venous filling when the tricuspid valve is closed and
venous pressure increases from venous return - this occurs during and following the carotid
pulse.

The " y " descent corresponds to the rapid emptYing of the atrium into the ventricle
following the opening of the tricuspid valve.

Quantification
A classical method for quantifying the JVP was described by Borst & Molhuysen in 1952.[1] It has
since been modified in various ways. A venous arch may be used to measure the JVP more
accurately.

Abdominojugular test
The term hepatojugular reflux was previously used as it was thought that compression of the
liver resulted in "reflux" of blood out the hepatic sinusoids into the great veins thereby elevating
right atrial pressure and visualized as jugular venous distention. The exact physiologic
mechanism of jugular venous distention with a positive test is much more complex and the
commonly accepted term is now "Abdominojugular test."
In a prospective randomized study involving 86 patients who underwent right and left cardiac
catheterization, the abdominojugular test was shown to correlate best with the pulmonary
arterial wedge pressure. Furthermore, patients with a positive response had lower left
ventricular ejection fractions and stroke volumes, higher left ventricular filling pressure, higher
mean pulmonary arterial, and higher right atrial pressures.[2]
The abdominojugular test, when done in a standardized fashion, correlates best with the
pulmonary arterial wedge pressure, and therefore, is probably a reflection of an increased
central blood volume. In the absence of isolated right ventricular failure, seen in some patients
with right ventricular infarction, a positive abdominojugular test suggests a pulmonary artery
wedge pressure of 15 mm Hg or greater.

Interpretation
Certain wave form abnormalities, include Cannon a-waves, or increased amplitude 'a' waves,
are associated with AV dissociation (third degree heart block), when the atrium is contracting
against a closed tricuspid valve, or even in ventricular tachycardia. Another abnormality, "c-v
waves", can be a sign of tricuspid regurgitation. The absence of 'a' waves may be seen in atrial
fibrillation.[3]
An elevated JVP is the classic sign of venous hypertension (e.g. right-sided heart failure). JVP
elevation can be visualized as jugular venous distension, whereby the JVP is visualized at a
level of the neck that is higher than normal. The paradoxical increase of the JVP with inspiration
(instead of the expected decrease) is referred to as the Kussmaul sign, and indicates impaired
filling of the right ventricle. The differential diagnosis of Kussmaul's sign includes constrictive
pericarditis, restrictive cardiomyopathy, pericardial effusion, and severe right-sided heart failure.

Raised JVP, normal waveform

Bradycardia

Fluid overload

Heart Failure

Raised JVP, absent pulsation

Superior vena cava syndrome

Large 'a' wave (increased atrial contraction pressure)

tricuspid stenosis

Right heart failure

Pulmonary hypertension

Cannon 'a' wave (atria contracting against closed tricuspid valve)

Atrial flutter

Premature atrial rhythm (or tachycardia)

third degree heart block

Ventricular ectopics

Ventricular tachycardia

Absent 'a' wave (no unifocal atrial depolarisation)

atrial fibrillation
Large 'v' wave (c-v wave)

Tricuspid regurgitation
Slow 'y' descent

Tricuspid stenosis

Cardiac Tamponade

Prominent & Deep 'y' descent

Constrictive pericarditis
Parodoxical JVP (Kussmaul's sign: JVP rises with inspiration, drops with expiration)

Pericardial effusion

Constrictive pericarditis

Pericardial tamponade

An important use of the jugular venous pressure is to assess the central venous pressure in the
absence of invasive measurements (e.g. with a central venous catheter, which is a tube inserted
in the neck veins). A 1996 systematic review concluded that a high jugular venous pressure
makes a high central venous pressure more likely, but does not significantly help confirm a low
central venous pressure. The study also found that agreement between doctors on the jugular
venous pressure can be poor