JVP

PowerPoint PresentationJugular Venous
© Continuing Medical Implementation …...bridging the care gap
JVP Summary
Just never taught properly
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
JVP Inspection
Jugular 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.
Jugular venous pressure -
IJV acts as a barometer - direct transmission of the pressure of RA seen as a blood column.
IJV - medial to sternomastoid - not seen but the pulsations seen - top of the pulsating column indicates JVP
EJV - not used because tortuous course in the thoracic cavity - subject to compression - not very accurate.
Level of sternal angle is about 5 cm above the level of mid right atrium IN ANY POSITION. JVP 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.
Normal JVP Waveform
a,c & v
Normal JVP Waveform
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
JUGULAR VENOUS PULSE
Consists of 3 positive waves & 2 troughs.
'a' wave - corresponds to atrial systole - occurs just before the systole / S1
'x' descent - d.t. relaxation of atria while the ventricles start contracting.
'c' wave - small positive notch in the 'x' descent - d.t. bulging of the AV ring into the atria in ventricular contraction.
'v' wave - after the 'x' descent - slow positive wave d.t. atrial filling from the veins. Corresponds to the S2
'y' descent - d.t. rapid emptying of the atria into ventricles - 1st rapid filling.
Jugular venous pressure -
IJV acts as a barometer - direct transmission of the pressure of RA seen as a blood column.
IJV - medial to sternomastoid - not seen but the pulsations seen - top of the pulsating column indicates JVP
EJV - not used because tortuous course in the thoracic cavity - subject to compression - not very accurate.
Level of sternal angle is about 5 cm above the level of mid right atrium IN ANY POSITION. JVP 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.
Abnormalities in JVP -
TS
RVH
PS
PHT
'Cannon' 'a' waves - atria contract against a closed tricuspid valve.
Complete heart block - Grade III.
Paroxysmal nodal tachycardia with retrograde atrial conduction.
V-tach with retrograde atrial conduction or A-V dissociation.
Absent 'a' wave - AF
'x' descent -
Absent - Atrial fibrillation - no 'a' wave
'y' descent -
Reduced - TS, RA myxoma (obstruction to 1st rapid filling).
JVP 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
Identifying 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
JVP- HJR & Kussmaul’s sign
Hepato-jugular reflux (various definitions)
venous tone & SVR
JVP normally falls with inspiration
Kussmaul’s sign
inspiratory in JVP
and R. Gunnar
Inspect for internal jugular vein pulsations in the neck, in supine position and with neck and trunk raised to approximate angle of 45o. Internal jugular vein pulsation are visible at the root of the neck between clavicular and sternal heads of sternoclidomastoid muscle. Internal jugular vein corresponds to a line drawn from this point to infra auricular region.
Inspection with simultaneous palpation of the carotid and/or auscultation of the heart will assist in identification and timing of the waves.
Inspect the vein from different angles. Apply light tangentially and observe for venous pulsations in the shadow of neck on the pillow.
At 0o jugular veins should be filled. An impulse visible just prior to S1 or the upstroke of the carotid is the "a-wave". This will be followed by a x-descent. The 'c' wave is usually not visible. The 'v' wave occurs after the start of the carotid upstroke and during ventricular systole (which is atrial diastole). When the tricuspid valve opens there is a brisk descent (y-descent).
Observe the venous pressure changes with respiration. There is normally a drop in intrathoracic pressure with inspiration. This decrease is also reflected on the intracardiac pressures. Therefore, an increase in the pressure difference between the SVC/IVC and the RA increases cardiac filling.
Normal: Neck veins are not visible at 45 o inclination.
Neck veins should be visible in supine position. JVP should decrease with inspiration.
Specific JVP patterns
JVP brisk X' & Y descents X' less exaggerated than Y
RV infarction
Pulsus 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
The phase lag between right and left sided events
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
Pulsus Paradoxus
Tamponade versus
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
Pulsus Paradoxus
Pulsus without tamponade
Central Venous Pressure
Constrictive Physiology - Hemodynamics
RV pressure
LV and RV pressures
Phono-echocardiography
Venous Pulse
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)
Normal 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
Methods:
16 with potential bi-ventricular dysfunction
3 with RV dysfunction
Patient instructed to breath normally
JVP estimated 12 seconds after compression
Hemodynamics, esophageal and gastric pressure recordings obtained simultaneously
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)
The Abdominojugular Test: Technique and Hemodynamic Correlates
Gordon A. Ewy MD
(Annals Int Med 1988;109:456-460)
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

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JVP