Understanding Jugular venous pressure and various conditions affecting it

1. Jugular Venous Pressure
Dr. Lokesh Khandelwal
DM Cardiology
GB Pant Hospital, Delhi

2. JVP
• James Mackenzie first described JVP waves in 1870.
• Thomas Lewis described technique of bedside JVP assessment in
1930.*
*Montinari MR et al. The first 200 years of cardiac auscultation and future perspectives. J Multidiscip Healthc. 2019;12;183-9

3. Definition
• Oscillating top of column of blood in IJV.
• Reflects RA pressure at all stages of cardiac cycle.
• Reasonable estimate of CVP*
• Imparts prognostic information in patients with HF*
*Drazner MH, et al. Prognostic importance of elevated jugular venous pressure and a third heart sound in patients with heart
failure. N Engl J Med 2001; 345:574.

4. IJV or EJV
• IJV - In direct line with SVC and RA
• EJV has valves
• EJV passes through facial planes
• EJV not visible in increased sympathetic activity eg. Shock

5. Right IJV vs Left IJV
• Right IJV in direct line
• Compression of left innominate vein
• Left SVC draing into coronary sinus

6. Right IJV vs Left IJV

7. Technique of examination
Chua Chiaco JM, et al. The jugular venous pressure revisited. Cleve Clin J Med. 2013 Oct;80(10):638-44.

8. Technique of examination

9. Technique of examination

10. How to make JVP more obvious
• Inspiration – x descent becomes brisker
• Horizontal posture
• Leg elevation
• Abdominal compression
• IV fluids

11. Effect of respiration

12. JVP vs carotid pulse
Venous pulsation Arterial pulsation
Soft, diffuse and undulant Pulsatile
Better seen Better felt
Two crests and troughs One upstroke and decent
Collapse prominent Upstroke prominent
Pressure above clavicle obliterates Does not obliterates
Variation- Inspiration, posture,
abdominal compression
Does not vary
Laterally Medially

13. JVP vs carotid pulse

14. Normal wave patterns
Conn RD, O'Keefe JH. Simplified evaluation of the jugular venous pressure: significance of inspiratory collapse of jugular veins. Mo Med. 2012 Mar-Apr;109(2):150-2.

15. Timing of JVP
• a Wave – before carotid pulse and S1
• x Decent- ends just before S2,
Simultaneous with radial pulse
• v Wave – After carotid pulse and
peaks just after S2
• y Descent - after S2 in diastole

16. Normal JVP
• Should not exceed 3-4 cm above sternal angle at 30o
• At 45o – upper limit is 4.5 cm
• 1mmHg = 1.36 cm of water

17. Abrams J. Prim Cardiol. 1982

18. Seth R, et al. How far is the sternal angle from the mid-right atrium? J Gen Intern Med. 2002 Nov;17(11):852-6.
• Vertical distance between the sternal angle
and the level of the right atrium by CT scan in
160 patients
• SA-RA distance when supine – 5.4 cm
• SA-RA distance was calculated to be 8 cm, 9.7
cm and 9.8 cm at 30, 45 and 60 degrees
elevation respectively.

19. Seth R, et al. How far is the sternal angle from the mid-right atrium? J Gen Intern Med. 2002 Nov;17(11):852-6.

20. Variation with body habitus
• 52 consecutive patients underwent CT.
• The Angle of Louis and mid RA distance was accessed.
• There was a positive correlation between patients' weight or BMI and
the distance of the Angle of Louis to right atrium.
• Using the traditional 5 cm in an obese patient usually will result in an
underestimation of RA pressure.
Ramana RK, Sanagala T, Lichtenberg R. A new angle on the Angle of Louis. Congest Heart Fail. 2006 Jul-Aug;12(4):196-9.

21. Constant J. The X prime descent in jugular contour nomenclature and recognition. Am Heart J. 1974 Sep;88(3):372-9.

22. Carotid artifact
Constant J. The X prime descent in jugular contour nomenclature and recognition. Am Heart J. 1974 Sep;88(3):372-9.

23. h Wave

24. Abdominojugular reflux
• Hepatojugular reflux – first described by
Pasteur in TR.*
• Reflux not reflex
• Duration of pressure- 10 to 15 sec
• Amount of pressure – 20 to 35 mmHg
• Rise of at least 3 cm for 15 seconds**
*Pasteur W. Note on a new physical sigh of tricuspid regurgitation. Lancet. 1885;2:524
**Am J Medicine. 2000:109:59

25. Abdominojugular reflux
Am J Medicine. 2000;109:59

26. Abdominojugular reflux
• Constriction
• Restriction
• RVMI
• Incipient RHF
• PCWP more than 15mmHg
• False positive
• COPD
• Increased blood volume
Wiese J. The abdominojugular reflux sign. Am J Med. 2000 Jul;109(1):59-61.

27. Alterations of ‘a’ wave
Giant a wave
Severe pulmonary hypertension
Severe PS
Bernheim’s effect
Tricuspid stenosis

28. Alterations of ‘a’ wave
Regular cannon ‘a’ waves Irregular cannon ‘a’ waves
Junctional rhythm CHB
PSVT APC
Extremely prolonged PR
interval
VPC
VT

29. Alterations of ‘a’ wave
• Absent a waves – AF, Ebstein’s anomaly.

30. x Decent

31. x Decent
• Absent – AF, severe TR
• Small – RA myxoma, RA hypertrophy secondary to TS, absent
pericardium
• Prominent - Large a waves present
Increased RV contraction – PS, PAH, ASD, CP and cardiac
temponade.

32. v Wave
• Prominent – TR (Lancisi’s sign), ASD, CP, post RA surgery, PAPVC,
TAPVC

33. y Decent
• Slow – TS, Severe RVH
• Deep – CP ( Friedrich’s Sign), RCMP, TR, RV Failure

34. Kussmaul’s sign
• Failure to fall or increase in JVP during inspiration.
• Causes- CP, RVMI, RCMP, Massive pulmonary embolism, TS, RA or RV
tumors

35. ASD
• Wide a wave
• Deep x decent
• Tall v wave ≥ a wave
• Deep y decent

36. TR
• Large v wave
• Obliteration of x decent
• Ventricularization of RA pressure in severe TR

37. TS

38. Constrictive Pericarditis

39. Cardiac temponade

40. Chua Chiaco JM, et al. The jugular venous pressure revisited. Cleve Clin J Med. 2013 Oct;80(10):638-44.

41. Chua Chiaco JM, et al. The jugular venous pressure revisited. Cleve Clin J Med. 2013 Oct;80(10):638-44.

42. Chua Chiaco JM, et al. The jugular venous pressure revisited. Cleve Clin J Med. 2013 Oct;80(10):638-44.

43. Chua Chiaco JM, et al. The jugular venous pressure revisited. Cleve Clin J Med. 2013 Oct;80(10):638-44.

44. Chua Chiaco JM, et al. The jugular venous pressure revisited. Cleve Clin J Med. 2013 Oct;80(10):638-44.

45. THANK YOU