2. “INTRODUCTION”
JVP- reflects Rt side of heart , Rt atrial
pressure during systole and Rt ventricular
filling pressure during diastole.
Bedside examination is done-
to estimate CVP
assess the waveform
3. JUGULAR VENOUS PULSE:
DEFINED AS THE OSCILLATING TOP OF
VERTICAL COLUMN OF BLOOD IN RIGHT
IJV THAT REFLECTS PRESSURE
CHANGES IN RIGHT ATRIUM IN
CARDIAC CYCLE.
JUGULAR VENOUS PRESSURE:
VERTICAL HEIGHT OF OSCILLATING
COLOUMN OF BLOOD.
4. Why IJV over EJV ?
IJV are close to RA, direct course from
innominate vein to SVC & RA.
Valves at prox part of EJV are more than IJV.
EJV passes through more fascial plane,
hence, affected by extrinsic compression.
symp activity(CHF) vasoconstriction of
EJV pulsations barely visible.
5. Rt IJV preferred than Lf IJV..
Rt IJV & IV – in straight line from SVC & RA
Lf IJV & IV – not in straight line
Lf IJV may get compressed by variety of
normal structures, dilated aorta or aneurysm.
If difficulty on Rt side , look for Lf side also.
6. DIFFN BETWEEN JVP & CAROTID
JVP PULSATION CAROTID PULSATION
Superficial & Lateral in neck Deeper & Medial in neck
Better seen > felt Better felt > seen
Has 2 peaks & 2 troughs/ cardiac cycle Has single upstroke
Descents > crests Upstroke brisker & visible than
descent.
X & Y > prominent in inspiration No effect
a decreses, v increase in expiration No effect
JVP falls during inspiration No effect
Digital compression at root of neck
abolishes JVP
No effect.
7. “JVP measurement”
Sternal angle/ angle of Louis- approx 5 cm from centre of
RA, constant regardless of position.Hence, refernce point.
30-90 ^ recline, relaxed neck muscles, beam of light
tangentially across skin over IJV exposes top of oscillating
venous column.
1 horizontal line at top level & other at sternal angle.
Vertical distance between 2 lines is to be added to 5.
ex: 4+ 5=9 cm. 1.3 cm of water= 1 mm Hg.
Normal RAMP doesn’t exced 7 mm Hg ( 9 cm of JVP
/1.3=6.92)
9. AJR/HJR? When jvp is borderline elevated/
when latent RVF or silent TR is suspected
Method : firm pressure to periumbilical area(10-
30 sec),with quite breath , avoid valsalva,
Normally- JVP rises transiently (<15 sec)to <3cm
when abd is compressed.
In positive AJR, JVP remains elevated
-----why--- as failing RV may not be able to
receive augmented venous return to Rt
heart without a rise in mean venous
pressure.
11. “KUSSMAUL’S SIGN”
Normally, JV Pulsations rises during Inspiration
while, mean JVP decrease bcz of raised filling of
Rt side a/c decreased ITP.
But if JVP increases during inspration....known as
MECHANISM-
when myo/pericardium stiff Neg ITP not
transmit to heart Heart cant accomodate
inspiratory raised blood flow Hence, Raised
JVP
H
12. KUSSMAUL’S SIGN seen in
1. CONSTRICTIVE PERICARDITIS
2. SEVERE RIGHT HEART FAILURE
3. RIGHT VENTRICULAR INFARCTION
4.RESTRICTIVE CARDIOMYOPATHY
13. “GAERTNER’S METHOD”
METHOD: Patient sitting/lying at >30^
elevation, arm is slowly, passively raised from
dependent position until vein collapses.
Height of the limb above the level of sternal
angle at which vein collapses represents venous
pressure.
When venous pressure is normal, veins of hand
collapse at level of sternal angle.
14. “MAY’S SIGN “
In sitting posture, visible engorged veins
on undersurface of tongue also indicates
elevated venous pressure
16. “a”wave
First positive presystolic wave.
D/t RAC which results in retrograde blood
flow into SVC & JV during RA systole.
Normally, it is dominant during inspiration,
larger than v wave.
Synchronous with S1 , follows P wave of ECG.
17. “x” descent( systolic collapse)
a is followed by x
d/t RA relaxation during atrial diastole
often, it is the most prominent motion of normal
JVP which begins during systole, ends just before
S2.
larger than y descent.
18. “c wave”
2nd positive venous wave.
produced d/t- impact of carotid artery
which is adjacent to the IJV
- -upward bulging of the closed
TV into RA during RV Isovolumetric
contraction.
19. “ x’ descent “
It is x descent below the c wave .
more often, it is interrupted by 2nd positive
wave.
it is d/t-fall in RAP during early RV systole
- descent of the floor of RA
- downward pulling of TV by contracting
RV.
20. “v wave”
3rd positive wave , begins in late systole and
ends in early diastole.
d/t RAP d/t continued RA filling during
ventricular systole when TV is closed.
synchronous with carotid upstroke.
peaks after S2.
21. “y descent ( diastolic collapse)”
its downslope of v wave.
d/t decline in RAP d/t RA emptying and RV
filling when TV opens in early diastole.
22. “h wave”
when diastole is long (as in slow heart rate),
ascending limb of the y wave is often
followed by a small, brief, positive wave
known as h wave.
It occurs prior to next a wave during the
period of diastasis.
23. Prominent/ large ‘a’ wave
RA emptying resist Decreased RV compliance Bernheim effect: severe LVH
with thickened ventricular
septum.
1. TS 1. PS 1. severe AS
2. RA Myxoma 2. P HTN d/t any cause 2. HCM.
3. Tricuspid atresia 3. RV cardiomyopathy
4. Acute P. Emb.
5. RVMI with IWMI.
24. Giant a waves/ Cannon
waves/venous corrigan.
occur when RA contracts against the closed TV
during RV systole
Regular cannon wave irregular cannon wave
1.junctional rhythm 1. CHB
2.VT 1:1 retrograde conduction 2. Classic AV dissociation
3.Isorhythmic AV dissociation 3.VT
4.VT pacing
5.Ventricular ectopics
25. absent a wave
AF- a wave absent as there is no effective
atrial contraction
Sinus Tachycardia- when a wave may fuse
with preceding v wave, especially when PR
interval is prolonged.
26. Abnormal x descent
Prominent x descent Absent x descent
1. const. pericarditis 1. TR.
2. cardiac tamponade
3.ASD
27. Abnormalities of v wave
Prominent v wave- d/t increased RA blood volm
during vent systole when normally TV is closed
as in TR.
Prominent v waves Diminished v wave
1. TR 1. Hypovolemia
2. Large ASD 2. Use of Nitrates.
3. Gerbode’s effect
4. severe CHF
5. AF
6. Cor pulmonale
28. abmormalities of y descent
Rapid y descent- occurs in conditions with
elevated venous pressure, myocardial
dysfunction or severe vent. dilatation.
Slow y descent-when RA emptying & RV filling
impeded.
Rapid y descent Slow y descent
1. severe TR 1. TS
2. const. pericarditis 2. RA Myxoma
3. Severe RVF 3. Pericardial Tamponade.
4. ASD with MR
29. JVP in valvular lesion
JVP in MS.
JVP elevated with RVF/when a/c TS/ASD.
Prominent a wave with PH, TR.
Absent a wave with AF
Absent x descent with AF, TR.
Prominent v wave with RVF, TR.
Rapid y descent with TR , RVF.
Slow y descent with TS.
30. JVP in MR
Elevated JVP with RVF, a/c ASD or TS, in
secondary MR d/t cardiomyopathy or CAD.
Prominent a wave with PH or MR d/t HOCM.
Prominent v waves with RVF or a/c TR or ASD.
Rapid y decent : with RVF and TR.
31. JVP in TS
Elevated JVP
Prominent a wave a/c presystolic hepatic
pulsations
Slow y descent
32. JVP in TR
Elevated JVP with RVF or PH
Prominent v waves : with obliteration of x
descent , forms a prominent s wave i.e.,
Lanci’s sign and ventricularization of RAP.
Rapid y descent, but slow descent when a/c
TS.
33. JVP in AS
Elevated JVP with RVF or when a/c MS
and PH, or TS.
Prominent a waves in severe AS, HOCM or
when a/c MS and PH or TS.
34. JVP in AR
Elevated JVP with RVF, with CRF and
fluid overload.
Prominent a waves with TS, MS and PH.
Prominent v waves and rapid y descent
with RVF
35. JVP in PS
Elevated JVP with RVF .
Prominent a waves in severe PS.
Prominent v waves and rapid y descent:
with RVF or TR.
36. JVP in ASD
Elevated JVP with RVF, when a/c MS/MR,
or severe PH
Prominent a wave with PS or MS and PH.
Equal a and v waves, v more with TR
Rapid y descent with TR or RVF.
37. JVP in VSD
Elevated JVP in CHF, in AV canal defect (VSD
with MR/TR), VSD with LV to RA
shunt(Gerbode’s)
Prominent a waves with severe PS.
Prominent v waves and rapid y descent with
CHF,TR and in Gerbode’s defect.
Absent x descent with TR and in Gerbode’s.
38. JVP in Eisenmenger complex
In VSD with Rt to Lf shunt, JVP is usually
normal with normal a and v waves.
In Eisenmenger synd with ASD and PDA,
JVP may be elevated with prominent v
waves.
39. JVP in TOF
JVP- normal, may be elevated in TOF
when a/c PDA, AR, after shunt operation,
adult TOF.
Normal a wave.
Normal v wave.
40. JVP in TGA/TAPVC with increased
pulm blood flow.
Elevated JVP
May be prominent a waves
Normal v waves, but prominent with HF or
TR
41. JVP in DCM
JVP elevated.
a wave- normal.
v wave-may be prominent.
x descent – normal.
y descent- may be rapid decent.
Kussmaul’s sign- negative.
42. JVP in RCMP.
JVP may be elevated.
a wave- prominet.
v, x descent, y descent- normal.
Kussmaul’s sign- may be positive.
43. JVP in Const. Pericarditis
JVP elevated
a wave- normal , may be prominent.
v wave- usually equal to a waves.
x descent- Prominent.
y descent- rapid.
Kussmaul’s sign- positive.
44. JVP in Cardiac Tamponade
JVP elevated
a wave- never prominent
v wave – normal
x decent – normal
y descent- reduced/absent
Kussmaul’s sign-negative, may be positive.
45. JVP in Arrhytmias
Sinus Brady: slow normal regular sequence
of a & v waves maintained.
AF : JVP simulates TR as v wave is prominent
d/t absenceof a wave & diminution of x
descent.
APC : normal sequence of a wave, carotid
pulse and v wave is maintained.
46. SVT : with HR > 160, a & v waves merge into
a single venous crest which resemble cannon
wave of JT.
VT, JT : cannon waves are characteristic.
47. JVP in Conduction defect
PR interval can be estimated- interval between
a wave & carotid pulse(C).
Increased a-C, indicates prolonged PR.
1 ^ AV Block, complete LBBB : a-C prolongs.
Mobitz type I: gradual lengthening of a-C ,
ending with an a wave i.e., not follwed by a
carotid.
48. Mobitz type II block: a-C doesnt vary,
but suddenly interrupted by isolated a
waves that are not followed by a carotid
pulse.
2:1 AV Block: 2 a waves for every one
carotid.
CHB: intermittent cannon waves.
Editor's Notes
copd- sudden disproportionate increase in ITP, impedes venous return, elevates venous pressure. false positive.
condition with increased sympathatic tone, syst vasoconstriction, results in decreased distensibility of venous bed may also show positive AJR.