Lecture Slides Presented at SIMS by Medical Unit SIMS Hospital

1. The Jugular Venous
Pressure and Pulse
Dr Nighat Majeed
Assistant Professor
Medical Unit II
SIMS/SHL Lahore

2. Introduction
 It provides indirect measure of central venous
pressure.
 The normal mean jugular venous pressure,
determined as the vertical distance above the
midpoint of the right atrium, is 6 to 8 cm H2
O.
 Deviations from this normal range reflect
Hypovolemia ( less than 5 cm H2
O).
Impaired cardiac filling(greater than9cm).

3. Introduction
 The peripheral venous pressure is measured
accurately with manometry.
 For clinical purposes, approximation of
venous pressure can be obtained by
inspection of jugular pulsations.
 An elevated JVP is the classic sign of venous
hypertension (e.g. right-sided heart failure).

4. Introduction
 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.
 Reference point for bed side evaluation is
sternal angle.

5. Basic Physiology
 The right internal jugular vein communicates
directly with the right atrium via the superior
vena cava.
 There is a functional valve at the junction of
the internal jugular vein and the superior vena
cava.
 This valve does not impede the phasic flow of
blood to the right atrium. Thus the wave form
generated by phasic flow to the right atrium is
accurately reflected in the internal jugular
vein.

6. Basic Physiology
 The external jugular vein possesses valves.
 The relatively direct line between the right
external and internal jugular veins, as
compared to the left external and internal
jugular veins, make the right jugular vein the
preferred system for assessing the venous
pressure and pulse contour.

7. Basic Physiology
 In determining mean jugular venous
pressure, one assumes that the filling
pressure of the right atrium and right ventricle
are the mirror that of the left atrium and
left ventricle.
 This relationship is usually correct.

8. Exceptions
 correlate with history and physical
examination
 Acute left ventricular failure may significantly
raise the pulmonary capillary wedge pressure
without raising the mean right atrial and
jugular venous pressures.
 pulmonary hypertension, tricuspid
insufficiency, or stenosis may be associated
with elevated mean right atrial and jugular
venous pressures while leaving the left heart
pressures unaffected.

9. Clinical Examination
 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 a maximum of (3-4)
centimeters above the sternal angle.

10. Visualization
 Height of jugular pulsations varies with the
position of chest.
 The upper limits for normal venous pressures are
recumbent,2cm
30 degrees,3cm
45 degrees,4.5cm
Upright at the level of suprasternal notch.
these values are less than those obtained by
manometry because the true zero is at the level of
right atrium.

11. 

12. Characteristics of JVP
Multiphasic
 The JVP "beats" twice (in quick succession)
in the cardiac cycle.
 The first beat represents that atrial
contraction (termed a).
 second beat represents venous filling of the
right atrium against a closed tricuspid valve
(termed v) and not the commonly mistaken
'ventricular contraction'.
 The carotid artery only has one beat in the
cardiac cycle

13. Characteristics of JVP
 Non-palpable - the JVP cannot be palpated.
 If one feels a pulse in the neck, it is generally
the common carotid artery.

14. Characteristics of JVP
 Occludable
The JVP can be stopped by occluding the
internal jugular vein by lightly pressing
against the neck.
 varies with head-up-tilt (HUT)
The JVP varies with the angle of neck. The
carotid pulse's location does not vary with
HUT.

15. Characteristics of JVP
 varies with respiration - the JVP usually
decreases with deep inspiration.
Physiologically, this is a consequence of the
Frank-Starling mechanism as inspiration
decreases the thoracic pressure and venous
return.

16. The jugular venous pressure
(JVP)

18. Waveforms of the JVP
 a - presystolic; produced by right atrial
contraction.
 c - bulging of tricuspid valve into the right
atrium during ventricular systole (isovolumic
contraction phase).
 v - occurs in late systole; (atrial venous
filling)increased blood in right atrium from
venous return.

19. Descents(occur during
diastole)
 x - combination of atrial relaxation, downward
movement of the tricuspid valve and
ventricular systole Deeper than the y descent).
 y - tricuspid valve opens and blood flows in to
the right ventricle.

20. Descents(occur during
diastole)
 Usually, the descents in the jugular venous pulse
are brisk but not excessively rapid.
 The descents or troughs of the jugular venous
pulse occur between the "a" and "c" wave ("x"
descent), between the "c" and "v" wave ("x"
descent), and between the "v" and "a" wave ("y"
descent).

24. How to examine the JVP
• Use the right internal jugular vein.
• Neck should not be sharply flexed.
• Patient should be at a 45° angle.
• Head turned slightly to the left.
• If possible have a tangential light source
that shines obliquely from the left.

25. How to examine the
JVP(contd)
• Locate the surface markings of the
internal jugular vein runs from medial end
of clavicle to the ear lobe under medial
aspect of the sternocleidomastoid.
• Locate the JVP - look for the double
waveform pulsation (palpating the
contralateral carotid pulse will help).

26. How to examine the JVP
 Measure elevation of neck veins above the
sternal angle (Lewis Method).
 Using a centimeter ruler, measure the
vertical distance between the angle of Louis
(manubrio sternal joint) and the highest
level of jugular vein pulsation. A straight
edge intersecting the ruler at a right angle
may be helpful.

27. How to examine the
JVP(contd)
• Measure the level of the JVP by measuring
the vertical distance between the sternal
angle and the top of the JVP. Measure the
height - usually less than 3cm

28. How to examine the
JVP(contd)
 Add 5 cm to measurement since right atrium is
5 cm below the sternal angle.
 Normal CVP <= 8 cm H2
O

29. How to examine the
JVP(contd)
If the internal jugular vein is not
detectable, use the external jugular
vein. The internal jugular vein is the
preferred site.
Thus, either the external or internal
jugular vein may be useful in the
assessment of mean venous pressure
and pulse contour.

32. 

33. Wave Form
 The a and v wave can be identified by timing
the double waveform with the opposite carotid
pulse.
 The a wave will occur just before the pulse
and the v wave occurs towards the end of the
pulse.

34. Wave Form
 Distinguishing the c wave, x and y descents is an
almost impossible task.

35. Differentiate a jugular venous
pulse from the carotid pulse
The JVP pulse is
 Not palpable.
 Obliterated by pressure.
 Characterised by a double waveform.
 Varies with respiration - decreases with
inspiration.
 Enhanced by the hepatojugular reflux.

36. Jugular Vein Carotid Artery
No pulsations palpable Palpable pulsations
Pulsations obliterated by
pressure above the clavicle.
Pulsations not obliterated by
pressure above the clavicle.
Level of pulse wave decreased
on inspiration; increased on
expiration
No effects of respiration on
pulse.
Usually two pulsations per
systole (x and y descents).
One pulsation per systole.
Prominent descents Descents not prominent.
Pulsations sometimes more
prominent with abdominal
pressure.
No effect of abdominal
pressure on pulsations.

37. Hepatojugular reflux
(abdominojugular reflux sign)
 This can help confirm that the pulsation is
caused by the JVP.
 Firm pressure is applied to the right upper
quadrant using the palm of the hand.
 A transient increase in the JVP will be seen in
normal patients.
 There may be a delayed recovery back to
baseline which is more marked in right
ventricular failure.

38. Causes of a raised JVP
 Heart failure.
 In constrictive pericarditis.
 restrictive cardiomyopathy.
 pericardial effusion.
 Right-sided heart failure.
JVP increases on inspiration called
Kussmaul's sign
 Cardiac tamponade.
 Fluid overload e.g. renal disease.
 Superior vena cava obstruction (no
pulsation).

39. Abnormalities of the JVP
Abnormalities of the a wave
 Disappears in atrial fibrillation.
 Large a waves
Right ventricular hypertrophy (pulmonary
hypertension and pulmonary stenosis)
Decreased right ventricular compliance as in
restrictive cardiomyopathy.
Tricuspid stenosis.
 Extra large a waves (called cannon
waves) complete heart block
ventricular tachycardia.

40. Prominent v waves
 Tricuspid regurgitation
called cv or V waves and occur at the same
time as systole (combination of v wave and
loss of x descent), there may be ear lobe
movement.

41. Slow y descent
 Tricuspid stenosis.
 Right atrial myxoma.

42. Steep y descent
 Right ventricular failure.
 Constrictive pericarditis.
 Tricuspid regurgitation.
 (The last two conditions have a rapid rise and
fall of the JVP called Friedreich's sign).

44. Prognostic use of the JVP
 An elevated JVP in patients with heart failure
is associated with an increased risk of
hospital admission, death and subsequent
hospitalization for heart failure. Therefore
appreciation of this sign can be clinically
helpful.

45. THANKYOU