jugular venous pressure,waves in jugular venous pulse and abnormalities waves in jugular venous pulse

1. JUGULAR VENOUS PRESSURE &
JUGULAR VENOUS PULSE
Dr.G.VENKATA RAMANA
MBBS DNB FAMILY MEDICINE

2. DEFINITION
• 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 column of
blood

3. • WHY INTERNAL JUGULAR VEIN?
• IJV has a direct course to right atrium
• IJV is anatomically closer to right atrium
• IJV is larger, straighter and has no valves
• Vasoconstriction secondary to hypotension can make EJV
small and barely visible
• WHY RIGHT INTERNALJUGULAR VEIN?
• Right jugular veins extend in an almost straight line to
superior vena cava,thus favouring transmission of the
haemodynamic changes from the right atrium
• The left innominate vein is not in a straight line and may be
kinked or compressed between aortic arch and sternum,by
a dilated aorta,or by an aneurysm

5. METHOD OF EXAMINATION
• The patient should lie comfortably during the
examination
• Clothing should be removed from the neck and
upper thorax
• Patient reclining with head elevated 45 degree
• Neck should not be sharply flexed
• Examined effectively by shining a light
tangentially across the neck
• There should not be any tight bands around
abdomen

6. • JVP as Indicator of Mean Right Atrial Pressure
• The overall height of the pulsating column is an
indicator of mean right atrial pressure, which can be
estimated based on a simple anatomic fact, that in
most individuals, the centre of the right atrium is
approximately 5 cm from the sternal angle of Louis.
• This relation is maintained in every position between
supine and upright posture
• Thus, the vertical height of the column of blood in the
neck can be estimated from the sternal angle, to which
5 cm is added to obtain an estimate of mean right
atrial pressure in centimeters of blood
• This amount can be converted to millimetres of
mercury by multiplying by 0.736
• Normal values are less than 8 cm of blood or less than
6 mm Hg
• This estimation may be erroneous in patients with
deformed chest walls or malpositioning of the heart

8. • Causes of Elevated Jugular venous pressure
• 1. Unilateral non-pulsatile
• Innominate vein thrombosis
• 2. Bilateral non-pulsatile
• SVC obstruction, Massive right sided pleural
effusion
• 3. Bilateral pulsatile
• a.Cardiac
• Cardiac failure
• Tricuspid stenosis
• Tricuspid regurgitation
• Constrictive pericarditis
• Cardiac tamponade

9. • b. Pulmonary
• COPD/ Cor pulmonale
• c. Abdominal
• Ascites
• Pregnancy
• d. Iatrogenic
• Excess IV fluids
• Causes of Fall in JVP
• Hypovolemia
• Shock
• Addison’s disease

10. JUGULAR VENOUS PULSE
• Method
• Subject performs valsalva manoeuvre (deep
inspiration followed by forceful expiration
against closed glottis),internal jugular vein will
be prominent
• Choose position on the IJV away from carotid
artery
• Place pulse transducer over the vein and
kept it in position with self adhesive plaster
• Connect to recorder

12. Waves in JVP Cardiac event
‘a’ wave (atrial wave) Right atrial contraction
‘c’ wave (closure wave) Carotid artery impact
Tricuspid valve ascends
‘x’ wave Right atrial relaxation
‘x’-wave Tricuspid valve descends
‘v’ wave (ventricular wave) Venous filling into atrium
‘y’ wave Tricuspid valve opens

17. Absent “a” wave
• Atrial fibrillation

18. Elevated “a” wave
• Increased resistance to RV
filling
• Tricuspid stenosis
• Right heart failure
• Pulmonary stenosis
• Pulmonary hypertension

19. Cannon “a” wave
• Atrial ventricular
dissociation
• Complete heart block
• VPC
• Ventricular tachycardia
• Ventricular pacing
• Junctional rhythm
• Junctional tachycardia

20. Elevated “v “wave
 Tricuspid regurgitation
 Right ventricular failure
 Restrictive cardiomyopathy
 Cor Pulmonale

21.  Prominent “x “descent
 Cardiac tamponade
 RVMI
 Restrictive cardiomyopathy
 Atrial septal defect
 Blunted “x” descent
 Tricuspid regurgitation
 Right atrial ischemia

22. Constrictive pericarditis
• M shaped contour
• Prominent x and y descent
(Friedreich sign)
• y descent is prominent as
ventricular filling is unimpeded
during early diastole
• This is interrupted by a rapid rise
in pressure as the filling is
impeded by constricting
pericardium
• The ventricular pressure curve
exhibit square root sign

23. “a” wave equal to “v “ wave
• ASD
• Prominent x descent
followed by a large v wave
• M configuration
• Indicates a large L-R shunt
• With PAH a wave becomes
more prominent
• If L JVP>R JVP indicates
associated PAPVC

24. Tricuspid regurgitation
• Absent x descent
• CV/Regurgitant wave
• Has a rounded contour
and a sustained peak
• Followed by a rapid deep
y descent
• Amplitude of v increases
with inspiration
• Cause subtle motion of
ear lobe with each heart
beat

25.  Slow ‘y’ descent
 Tricuspid stenosis
 Right atrial myxoma
 Prominent ‘y’ descent
 Tricuspid regurgitation
 Atrial septal defect
 Constrictive pericarditis
 Absent ‘y’ descent
 Cardiac tamponade
 Right ventricular infarction
 Restrictive cardiomyopathy

26. • Kussmaul’s sign is an inspiratory
increase in JVP
• Causes of Kussmaul’s sign
• Constrictive pericarditis
• Restrictive cardiomyopathy
• Right ventricle infarct
• Right ventricle failure
• Tricuspid stenosis

27. Abdomino-jugular reflex
• Is positive when JVP increase after 10sec of abdominal
pressure followed by a rapid drop in pressure of 4cm
on release of compression
• Most common cause of a positive test is right heart
failure
• Positive test in :borderline elevation of JVP
Silent TR
Latent RHF
• False positive –Fluid overload
• False negative –SVC/IVC obstruction
• Budd Chiari syndrome
• Positive test imply SVC and IVC are patent