JVP

MANPREETH A
Roll No 61
Jugular Venous Pulse:
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.
• In systole: Right atrial pressure
• In diastole: RVEDP
 Advantages of IJV vs EJV
•  IJV has a direct course to &anatomically closer
to RA.
• IJV has no valves & pulsations can be seen
(Valves in EJV prevent transmission of RA
pressure)
• EJV can become small and barely visible when
there is vasoconstriction secondary to
hypotension(CCF)
• EJV is superficial & prone to kinking
 Importance of Right IJV
• 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 by other
structures in neck
 How to measure JVP?
• Position: Patient should be lying inclined at 45⁰.
• Assure good lighting( use tangential beam of light
through torch)
• The head & thorax should be in a straight line without
flexing the neck.
• Keep one scale horizontally at the upper limit of
venous column & then measure the vertical height
from sternal angle with another scale
• Normally, the center of right atrium is 5cm below the
sternal angle at any position of the patient
• Not in sitting posture: Upper level of venous
column is below the clavicle
• Not in supine posture: Because the whole venous
column moves beyond the angle of jaw into
intracranial cavity.
• Note the upper level of pulsation, waveform, and
respiratory variation
• Normal level: 3.5-4 cm from sternal angle
• 7cm H2O
Elevated JVP:
• Increased RV filling & reduced compliance:
– Right ventricular failure
– Right ventricular hypertrophy
– Pulmonary stenosis
• RV inflow obstruction(Increased RAP):
– RA myxoma
– Tricuspid stenosis
• Fluid overload states:
– Cirrhosis, renal failure, Excessive fluid overload
• SVC obstruction
 NORMAL WAVE PATTERN
• 3 ascents : a, c & v
• 2 descents: x,x’ & y
• a wave: Due to active atrial contraction leading to
retrograde blood flow to neck veins
• Corresponds to S1
• Follows P wave in ECG
• Sharper & prominent than v wave

• x descent: Due to continued atrial relaxation

• Follows S1; less prominent than y descent
• c wave:
• It is produced by right ventricular systole & the bulging
of tricuspid valve into right atrium
• Due to transmitted Carotid artery pulsations
• Occurs simultaneously with carotid pulse
• Not usually visible
• x’ wave: Due to descent of tricuspid valve during
right ventricular systole & continued atrial relaxation
• Fall in RA pressure
• v wave: Due to passive venous filling
• Coincides with S2; less prominent than a ascent
• Y descent: Due to opening of tricuspid valve &
subsequent rapid inflow of blood from right atrium
into the right ventricle leading to a sudden fall in right
atrial pressure.
• Follows S2
• More prominent than x descent
• h wave: small positive wave between y descent & a
wave during the period of diastasis (relatively slow
ventricular filling)
ABNORMALITIES :
• Prominent a wave: Due to resistance to atrial
emptying at
Tricuspid level : Tricuspid stenosis, right atrial
tumours
Right ventricular level: Concentric hypertrophy due
to pulmonary HTN, right ventricular
cardiomyopathy, severe AS, acute pulmonary
embolism
• Cannon waves: due to atrial contraction
 Regular: Junctional rhythm, isorhythmic AV
dissociation
Irregular: Complete heart block, ventricular
tachycardia, classic AV dissociation
• Absent a wave: AF
• Single wave:
a & v wave merge: Heart rate>120/min
Early v wave with obliterated x wave: a/c tricuspid
regurgitation
• Absent x wave:
– Failure of atrial pressure to fall
– AF, tricuspid regurgitation, constrictive pericarditis
• Prominent x wave: cardiac tamponade
• Prominent v wave: Right ventricular failure, tricuspid
regurgitation, ASD
• Diminished v wave: hypovolemia
• Rapid y descent: constrictive pericarditis (Frederich’s
sign)
• Slow y descent: tricuspid stenosis, pericardial
tamponade, tension pneumothorax
• c-v wave prominent with prominent y descent:
– tricuspid regurgitation (lateral ear lobe pulsations-
Lancisi’s sign)
• Equal a & v wave(M Pattern): ASD
 Respiratory Variation of JVP

• Normal: Venous column in IJV rises during

expiration and falls during inspiration.
• During Inspiration, venous return to the right side
of the heart increases due to increased negative
thoracic pressure.
• However, this is accommodated by the inspiratory
decrease in pulmonary vascular resistance.
• As a result, pulmonary artery, right ventricle, and
right atrial pressures fall in spite of increased
venous return.
• During expiration, due to increased positive
intrathoracic pressure, pulmonary circulation is
compressed by the thoracic cage resulting in increased
pulmonary resistance and pressure.
 Kussmaul's sign
• Paradoxical rise in JVP during inspiration
• Causes: Constrictive pericarditis, right ventricular
infarction, restrictive cardiomyopathy
• Increased venous return in inspiration cannot be
accommodated by the heart leading to a increase in
the venous blood flow back through the SVC and
presents as distended jugular veins even during
inspiration.
 Abdominojugular/hepatojugular reflux
• When pressure is applied over the liver by pressing firmly
(40 mm Hg) over the abdomen for around 30sec, the
venous pressure gets exaggerated initially due to
increased venous return. Later the myocardium
accomodates the extra venous return & the level falls
(within 2-3 cardiac cycles)
• Normal response: Upper level of jugular venous pulsation
moves upwards by <3 cm and then falls down within 5
seconds even when the pressure is continued
• Positive test: Rise in JVP (>3 cm) for 10 seconds
Early cardiac failure: 1st sign of right heart failure,
TR
False positive: Valsalva, fluid overload,COPD
• False negative: SVC/IVC obstruction, Budd Chiari
syndrome
• Also helps to differentiate venous pulsation from the
arterial pulsation
THANK YOU…