© continuing medical implementation …...bridging the care gap jugular venous pressure it’s...

© Continuing Medical Implementation …...bridging the care gap

Jugular Venous Pressure

Jugular Venous Pressure

It’s easier than it looks


JVP SummaryJVP 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


JVP InspectionJVP Inspection


Jugular venous pressureJugular 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.


Normal JVP WaveformNormal JVP Waveform

• Consists of 3 positive waves

– a,c & v

• And 3 descents

– x, x'(x prime) and y


• 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

Normal JVP WaveformNormal JVP Waveform


JVP InspectionJVP 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


Identifying the WaveformIdentifying 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


JVP- HJR & Kussmaul’s signJVP- 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


Specific JVP patternsSpecific JVP patterns

Condition PatternNormal 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 JVP –low amplitude


Pulsus ParadoxusPulsus 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


How to measure Pulsus Paradoxus

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



An exaggerated drop in SBP (>10mmHg) with inspiration


Tamponade versus Constriction

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



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


Central Venous PressureCentral Venous Pressure

Cardiac Tamponade Constrictive Pericarditis

presence of a rapid Y-descent argues against cardiac tamponade


Constrictive Physiology - Hemodynamics

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


Phono-echocardiographyPericardial Knock (early diastolic sound)

Phono-echocardiographyPericardial Knock (early diastolic sound)

Venous Pulse(X- and Y-descend)

M-Mode Echo(thickened pericardium)


Validity of the Hepato-jugular Reflux as a Clinical Test for

Congestive Heart Failure

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)


Normal JVPNormal 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


Methods: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


Validity of the HJR as a Clinical Test for CHF

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;52:1299-1303)John Ducas MD, Sheldon Magder MD, Maurice McGregor MD (Am J Cardiol 1983;52:1299-1303)


The Abdominojugular Test: Technique and Hemodynamic

Correlates

The Abdominojugular Test: Technique and Hemodynamic

Correlates

Gordon A. Ewy MD

(Annals Int Med 1988;109:456-460)


Results: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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