Cardiovascular system

1. Approach To A Patient With
Elevated JVP

2. Definition
 Oscillating top of vertical column of blood in
the right internal jugular vein that reflects
the pressure changes in the right atrium in
cardiac cycle

3. Why Internal Jugular Vein instead
of External Jugular Vein?
 The internal jugular vein, SVC and RA are in
continuity
(height of jugular venous pulsation = right atrial
pressure)
Normally,right atria pressure < 7mmHg
 External jugular vein :
- has valve & not directly align with SVC and
RA
- passes through fascial planes = extrinsic
compression can alter the blood flow

4. Jugular Vein Carotid Artery
Palpable pulsation No Yes
Pulsation obliterated by
pressure above the
clavicle
Yes No
Level of pulse wave Decreased on inspiration,
increased on expiration
No effects
Pulsations per systole 2 (x and y descents) 1
Prominent descents yes no
Effect of abdominal
pressure on pulsations
Pulsations sometimes
more prominent
No effect

5. Common cases of elevated JVP
CARDIAC CAUSES NON CARDIAC CAUSES
Congestive heart failure Superior vena caval obstruction
Right ventricular infarction Massive ascites
Pericardial effusion Pleural effusion
Constrictive pericarditis Iatrogenic fluid overload (
surgical and renal patients )
Pulmonary embolism
Tricuspid valve disease ( tricuspid
regurgitation and tricuspid
stenosis )
Cardiac tamponade
Restrictive/hypertrophic
cardiomyopathy
Cor pulmonale

6. HISTORY TAKING

7. Patient profile
• Name
• Age
• Gender
• Occupation
• Address
• Date of Admission

8. Chief complaints
1) Breathlessness
2) Palpitation
3) Pitting edema
4) Abdominal distension
5) Syncope (transient loss of consciousness
with postural collapse due to hypoperfusion
of brain)
6) Fatigue

9. History of presenting illness
Breathlessness
- Paroxysmal nocturnal
dyspnoea (PND),
Exertional dyspnoea,
Orthopnea
• Onset
• Duration
• Description
• Progression
• Aggravating factor:
sleep, exertion, posture
• Relieving factor: Drugs
• Associated symptoms:
Nausea, Vomiting,
Dizziness
Palpitation
- Onset : -sudden
(cardiac
arrhythmias)
- gradual (sinus
tachycardia)
Pitting Edema
- usually symmetrical
- worse in the evenings
with improvement
during the night
- may be symptom of
biventricular failure/RVF
secondary to other
causes

10. Past history:
Hypertension, diabetes mellitus, heart problems, fits,
collapses, angina, cardiac procedures/surgeries (type and
date of intervention and outcome), RF or heart problems
as a child, cardiac tamponade, constrictive pericarditis
Personal history:
Smoking (pack years), alcohol intake, obesity, weight loss,
diet, bowel and micturition habits
Family history:
Genetic disorders, cardiomyopathy, congenital heart
diseases, MI, mitral valve prolapse, relative with similar
problems, death among relatives
Social history:
Economic status, income, type of house, travel history,
sanitary facilities

11. Drug history :
 Diuretics
 Anti- hypertensive
 Sublingual medications
 Aspirin
 Anti-coagulants
 Beta-blockers
 Digoxin

12. Abnormalities in patient with
elevated JVP on physical
examination

13. Examination of JVP
 Position the patient supine, reclined at 45° with
the head on a pillow to relax sternocleidomastoid
muscles
 Look across the patient’s neck from the right side.
Use oblique lighting if the JVP is difficult to see.
 Identify the jugular vein pulsation in the
suprasternal notch/behind the
sternocleidomastoid muscle
 Use the abdomino-jugular test /occlusion to
confirm the JVP
 The JVP is the vertical height in cm between the
upper limit of pulsation and sternal angle
 Identify the timing and waveform of the pulsation
and note any abnormality.

15. - ‘a’ wave- atrial systole
- ‘c’ wave- closure of tricuspid valve
- ‘x’ wave- atrial relaxation and due to
downward movement of tricuspid valve
during early right ventricular systole
- ‘v’ wave- venous filling right atrium and
when tricuspid valve is closed
- ‘y’ wave- tricuspid valve opening with right
atrial pressure decrease

16. JVP is elevated in states of fluid overload-
heart failure & in conditions with right heart
dilatation :eg- acute pulmonary embolism,
cor pulmonale
 Extreme, non pulsatile elevation of JVP-
mechanical obstruction of superior vena
cava-lung cancer
 Kussmaul’s sign: paradoxical rise of JVP
on inspiration- Pericardial constriction or
tamponade, congestive cardiac failure
 Prominent ‘a’ wave: delayed or restricted
right ventricular filling - tricuspid stenosis,
pulmonary hypertension

17.  Cannon waves : giant ‘a’ waves – right
atrium contracts against a closed tricuspid
valve.
a)Irregular canon waves are seen in
complete heart block and are due to
atrio-ventricular dissociation.
b) Regular cannon waves
- during junctional rhythm
- ventricular and supraventricular
tachycardia
• ‘cv’ wave -fusion of the ‘c’ and ‘v’ wave-
- Seen in tricuspid regurgitation

18. Abnormalities of the jugular venous pulse
Condition Abnormalities
Heart failure Elevation, sustained
abdominojugular reflux > 10
seconds
Pulmonary embolism Elevation
Pericardial effusion Elevation, prominent ‘y’ descent
Pericardial constriction Elevation, Kussmaul’s sign
Superior vena cava obstruction Elevation, loss of pulsation
Atrial fibrillation Absent ‘a’ waves
Tricuspid stenosis Giant ‘a’ waves
Tricuspid regurgitation Giant ‘v’ waves
Complete heart block Cannon waves

19. Differential diagnosis in a
patient with elevated JVP

20. Elevated JVP seen in
Cardiac causes: -Right ventricular failure
-Pericardial effusion
-Constrictive pericarditis
-Superior vena cava obstruction
 Congested states: -Volume overload conditions
 Non cardiac cause: -Massive ascites
-Pleural effusion
 Infective endocarditis
 Rheumatic fever
 Chronic aortic regurgitation

21. Right ventricular failure
 Increased JVP (pulsating elevation)
 Congestive hepatomegaly
 Ascites
 Cardiac cachexia
 Pedal edema

22. Pericardial Effusion
 Increased JVP (pulsating)
 Apex beat not palpable
 Cardiac dullness increases outside
apex
 Heart sounds muffled
 Ewart’s sign

23. Constrictive Pericarditis
 Increased JVP (pulsating)
 Kussmaul’s sign
 Failure in the appropriate fall of JVP
with inspiration indicates limited right
ventricular filling
 Pericardial knock (early diastolic
sound)
 Pericardial rub

24. SVC obstruction
 Increased JVP (NON pulsating)
 Difficulty in breathing
 Edema of face and upper limb
 Edema of neck (Collar of Stokes)
 Distended veins in neck, upper chest
and arms
 Pemberton’s sign

25. Endocarditis
1) Fever
2) Pallor
3) Clubbing
4) Petechial hemorrhages
5) Splinter hemorrhage
6) Osler’s nodes
7) Janeway lesion
8) Roth spots
9) Splenomegaly

26. Rheumatic Fever
- Arthritis
- Erythema marginatum
- Subcutaneous nodules
- Jaccoud’s arthritis (in repeated
attacks)

27. CHRONIC SEVERE AORTIC
REGURGITATION
 Collapsing pulse
(Watson’s water
hammer pulse)
 Corrigan’s sign
 De Musset’s sign
 Quincke’s sign
 Traube’s sign (pistol
shot sound)
 Duroziez’s sign
 Hill’s sign
 Less prominent signs
 Muller’s sign (uvula)
 Becker’s sign (retinal
artery)
 Lighthouse sign (face)
 Rosenbach’s sign
(liver)
 Gerhardt’s sign
(spleen)

28. Plan initial investigations and basic
management based on the differential
diagnosis

29. NON-PULSATILE ELEVATION
OF JVP
Diagnosis of venous obstruction can be confirmed
by :
 Doppler ultrasound
 Venography
 Chest X-ray supplemented by CT-scan or MRI

30. PULSATILE ELEVATION OF JVP
Analysis of the venous waveform

31. 1. Heart failure (right-sided)
 Biomarkers - BNP
 ECG-abnormal, often shows Q wave
 Echocardiograph
 Serum urea, creatinine, electrolytes
 Thyroid function
 Chest X-ray - left ventricular dilatation
with regional or global contractile
impairment

32. MANAGEMENT
1. General Measure
 Diet - good general nutrition and weight reduction for
the obese. Avoidance of high-salt foods and added salt,
especially for patients with severe congestive heart
failure
 Alcohol - moderation or elimination of consumption.
Alcohol induced cardiomyopathy requires abstinence
 Smoking – cessation
 Exercise - regular moderate aerobic exercise within
limits of symptoms
2. Drug therapy
 Diuretic, ACEI, ARB, Vasodilators, Beta-blocker, Digoxin,
Amiodarone
3. Implantable cardiac defibrillator and resynchronization
therapy
4. Coronary revascularization

33. 2.Tricuspid stenosis
-Raised JVP with prominent ‘a’ wave, and slow ‘y’
descent due to lost of normal rapid ventricular filling.
-Doppler echocardiography - the valve has similar
appearances to those of rheumatic mitral stenosis
-Raised JVP with ‘giant’ ‘v’ wave (a ‘cv’ wave replaces
the normal ‘x’ descent)
-Echocardiography may reveal dilatation of the RV.
3. Tricuspid regurgitation

34. MANAGEMENT:
 Valvotomy
 Replacing the valve
 Balloon valvuloplasty
 Diuretic
 Vasodilator
 Valve repair with annuloplasty
 Valve replacement

35. 4. Pericardial effusion(Cardiac
Tamponade)
INVESTIGATIONS:
 Echocardiograph for confirmation
 ECG - low voltage QRS complexes with alternating
electrical axis
 Tests for etiological diagnosis - Serology in SLE or
tuberculous disease
MANAGEMENT:
 Pericardiocentesis (pericardial aspiration)
 Surgical drainage

36. 5. Constrictive
Pericarditis
INVESTIGATION:
 Chest X-ray - pericardial calcification on lateral film
 Echocardiography
 CT-scan or MRI - imaging the increased pericardial
thickness/calcification
 Cardiac catheterization - equalization of diastolic
pressures in 4 cardiac chambers
 Echo-Doppler studies
MANAGEMENT:
 Surgical resection of the diseased pericardium (morbidity
50%)

37. 6.Pulmonary embolism
INVESTIGATION:
 D-dimer
 ECG - sinus tachycardia
 Chest X-ray - wedge-shaped peripheral opacification, absent of pulmonary
vascular marking
 Echocardiogram - dilated right heart in some cases of central PE
 CT pulmonary angiogram
MANAGEMENT:
 General measures - Oxygen, IV fluid or plasma expander, opiates, external
cardiac massage
 Anticoagulants
 Thrombolytic and surgical therapy
 Caval filter - for those contraindicated in using anticoagulant

38. 7. Massive Ascites
INVESTIGATIONS:
 Ultrasonography - in obese or those with small
volume of fluid
 Paracentesis - for analysis
 Serum-ascites albumin gradient (SAAG)
MANAGEMENTS:
 Sodium and water restriction
 Diuretics
 Paracentesis
 Transjugular intrahepatic portosystemic stent
shunt
 Peritoneo-venous shunt

39. THANK YOU