Jugular Venous Pressure

Its easier than it looks

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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' 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 & Kussmauls sign

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

JVP normally falls with inspiration Kussmauls sign

inspiratory in JVP constriction rarely tamponade RV infarction

Positive HJR correlates with LVEDP > 15

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Specific JVP patterns

Condition
Normal waveform Post CABG Atrial fibrillation

Pattern
X' deeper than Y X' shallower, now = Y CV wave

Tricuspid regurgitation
Complete heart block Tamponade Constriction RVContinuing Medical Implementation infarction

CV wave
Irregular cannon A waves JVP brisk X' > Y JVP brisk X' & Y descents X' less exaggerated than Y JVP low amplitudethe care gap ...bridging

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 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
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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

Kussmauls 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)

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 (Kussmauls 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) 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 Magder MD, Maurice McGregor MD Continuing Sheldon 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)
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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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