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© Continuing Medical Implementation …...bridging the care gap
Jugular Venous Pressure
Jugular Venous Pressure
It’s easier than it looks
© Continuing Medical Implementation …...bridging the care gap
JVP SummaryJVP Summary
• It’s easier than it looks !!!• Just never taught properly• Look for descents not waves• Time deepest descent with systole• This is the x' (prime) descent !!!
– Occurs during systole due to RV contraction pulling down the TV valve ring “descent of the base”
– A measure of RV contractility– If the dominant descent is systolic-this is the x'
descent-and JVP waveform is normal
© Continuing Medical Implementation …...bridging the care gap
JVP InspectionJVP Inspection
© Continuing Medical Implementation …...bridging the care gap
Jugular venous pressureJugular venous pressure
• Level of sternal angle is about 5 cm above the level of mid right atrium IN ANY POSITION.
• JVP is measured in ANY position in which top of the column is seen easily.
• Usually JVP is less than 8 cm water< 3 cm column above level of sternal angle.
© Continuing Medical Implementation …...bridging the care gap
© Continuing Medical Implementation …...bridging the care gap
Normal JVP WaveformNormal JVP Waveform
• Consists of 3 positive waves
– a,c & v
• And 3 descents
– x, x'(x prime) and y
© Continuing Medical Implementation …...bridging the care gap
• a wave - atrial systole • x descent – onset of
atrial relaxation • c wave - small positive
notch in the 'x' descent due to bulging of the AV ring into the atria in ventricular contraction.
• x' (prime) descent !!! – occurs during systole due to
RV contraction pulling down the TV valve ring “descent of the base”
– a measure of RV contractility
• v wave - after the x' descent - slow positive wave due to right atrial filling from venous return
• y descent - rapid emptying of the RA into RV due to TV opening
Normal JVP WaveformNormal JVP Waveform
© Continuing Medical Implementation …...bridging the care gap
JVP InspectionJVP Inspection
• Look at the JVP and simultaneously feel the carotid or auscultate to identify systole
• Say “systole”, “systole”, “systole”, “down”, “down”, “down”, X', X', X' and look for systolic descent
• Descents are easier to see due to greater amplitude and frequency
© Continuing Medical Implementation …...bridging the care gap
Identifying the WaveformIdentifying the Waveform
• If the dominant descent is systolic-this is the x' descent-and JVP waveform is normal
• The a wave is inferred as the positive wave before the dominant descent
• The y descent is sometimes seen but is not as deep as x' descent
• The c wave never seen
• The y descent sometimes seen– Diastolic descent
– Shallower than X'
• The v wave is inferred as the positive wave between x' and y
• The x descent rarely seen– visible in 1o heart block
© Continuing Medical Implementation …...bridging the care gap
JVP- HJR & Kussmaul’s signJVP- HJR & Kussmaul’s sign
• Hepato-jugular reflux (various definitions)– sustained rise 1 cm for
30 sec. venous tone & SVR RV compliance
• Positive HJR correlates with LVEDP > 15
• JVP normally falls with inspiration
• Kussmaul’s sign– inspiratory in JVP
– constriction
– rarely tamponade
– RV infarction
© Continuing Medical Implementation …...bridging the care gap
Specific JVP patternsSpecific JVP patterns
Condition PatternNormal waveform X' deeper than Y
Post CABG X' shallower, now = Y
Atrial fibrillation CV wave
Tricuspid regurgitation CV wave
Complete heart block Irregular cannon A waves
Tamponade JVP brisk X' > Y
Constriction JVP brisk X' & Y descents
X' less exaggerated than Y
RV infarction JVP –low amplitude
© Continuing Medical Implementation …...bridging the care gap
Pulsus ParadoxusPulsus Paradoxus
• Venous return normally increases with inspiration• Despite this, BP normally decreases by up to 8
mm Hg on inspiration• This paradoxical response is due to:
– Increased pulmonary capacitance
– Increased negative intra-thoracic pressure with inspiration and
– The phase lag between right and left sided events
© Continuing Medical Implementation …...bridging the care gap
How to measure Pulsus Paradoxus
How to measure Pulsus Paradoxus
• Pulsus paradoxus is an exaggerated inspiratory fall in BP– Ask the subject to breath normally– Auscultate Korotkoff’s sounds as the BP cuff is slowly
lowered. Time respiration simultaneously– Mark when BP sounds are heard only in expiration– Mark when BP sounds are heard both in expiration &
inspiration. Korotkoff’s sounds seem to double at this point.
– The difference is the measured pulsus paradoxus
© Continuing Medical Implementation …...bridging the care gap
Pulsus ParadoxusPulsus Paradoxus
An exaggerated drop in SBP (>10mmHg) with inspiration
© Continuing Medical Implementation …...bridging the care gap
Tamponade versus Constriction
Tamponade versus Constriction
• Tamponade– in tamponade, filling
is restricted throughout diastole
• Constriction– in constrictive
pericarditis, filling is truncated in early to mid diastole
• Kussmaul’s Sign– in constriction, venous
return increases with inspiration and a high right atrial pressure resists filling resulting in an increased JVP
© Continuing Medical Implementation …...bridging the care gap
Pulsus ParadoxusPulsus Paradoxus
Tamponade without pulsus– atrial septal defect– severe aortic stenosis– aortic insufficiency– LVH with LVEDP– left ventricular
dysfunction– decreased intravascular
volume (low-pressure tamponade)
Pulsus without tamponade– COPD
– RV infarct
– pulmonary embolism
– effusive constrictive pericarditis
– restrictive cardiomyopathy
– extreme obesity
– tense ascites
© Continuing Medical Implementation …...bridging the care gap
Central Venous PressureCentral Venous Pressure
Cardiac Tamponade Constrictive Pericarditis
presence of a rapid Y-descent argues against cardiac tamponade
© Continuing Medical Implementation …...bridging the care gap
Constrictive Physiology - Hemodynamics
Constrictive Physiology - Hemodynamics
• End-diastolic pressures– elevated and equalized
(<5 mm Hg difference)
• RA pressure tracing– rapid X- and Y-descent, “W” or
“M” pattern – failure to decrease with
inspiration (Kussmaul’s sign)
• RV pressure– RVEDP > 1/3 of RVSP– dip and plateau configuration of
RVDP (square root sign)
• LV and RV pressures– discordant changes
© Continuing Medical Implementation …...bridging the care gap
Phono-echocardiographyPericardial Knock (early diastolic sound)
Phono-echocardiographyPericardial Knock (early diastolic sound)
Venous Pulse(X- and Y-descend)
M-Mode Echo(thickened pericardium)
© Continuing Medical Implementation …...bridging the care gap
Validity of the Hepato-jugular Reflux as a Clinical Test for
Congestive Heart Failure
Validity of the Hepato-jugular Reflux as a Clinical Test for
Congestive Heart Failure
John Ducas MD, Sheldon Magder MD, Maurice McGregor MD
(Am J Cardiol 1983;52:1299-1303)
© Continuing Medical Implementation …...bridging the care gap
Normal JVPNormal JVP
• Normal JVP < SA at 45o
• Visible when exceeds 7 cm above reference point in RA = 5 cm < SA
• Visible to height 20 cm > SA (25 cm > reference point)
• Correlate with CVP 5-19 mm Hg
© Continuing Medical Implementation …...bridging the care gap
Methods:Methods:
• 25 patients studied– 6 with normal resting LV function– 16 with potential bi-ventricular dysfunction– 3 with RV dysfunction
• Abdominal pressure 35mm Hg applied with rolled up manometer
• Patient instructed to breath normally• JVP estimated 12 seconds after compression• Hemodynamics, esophageal and gastric pressure
recordings obtained simultaneously
© Continuing Medical Implementation …...bridging the care gap
Validity of the HJR as a Clinical Test for CHF
Validity of the HJR as a Clinical Test for CHF
• In patients with normal LV function abdominal compression did not increase > 2 mm Hg (2.7 cm H2O )
• In 16/19 patients with impaired ventricular function CVP increased by > 3 mm Hg (4 cm H2O)
• CVP stabilized over 12 seconds and did not change over subsequent 60 seconds
• An increase of 3 cm H2O (2.2 mm Hg) in the height of the neck veins is a reasonable upper limit of normal for HJR
John Ducas MD, Sheldon Magder MD, Maurice McGregor MD (Am J Cardiol 1983;52:1299-1303)John Ducas MD, Sheldon Magder MD, Maurice McGregor MD (Am J Cardiol 1983;52:1299-1303)
© Continuing Medical Implementation …...bridging the care gap
The Abdominojugular Test: Technique and Hemodynamic
Correlates
The Abdominojugular Test: Technique and Hemodynamic
Correlates
Gordon A. Ewy MD
(Annals Int Med 1988;109:456-460)
© Continuing Medical Implementation …...bridging the care gap
Results:Results:
• PCW mean 10.5 +/- 1 mm Hg in patients with negative HJR
• PCW mean 19 +/- 3 mm Hg in patients with positive HJR
• Positive HJR correlated with PCW > 15 mm Hg