Jugular Venous Pressure Its easier than it looks

Jugular Venous Pressure It’s easier than it looks © Continuing Medical Implementation …. . . bridging the care gap

JVP 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' descentand JVP waveform is normal © Continuing Medical Implementation …. . . bridging the care gap

JVP Inspection © Continuing Medical Implementation …. . . bridging the care gap

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. © Continuing Medical Implementation …. . . bridging the care gap

© Continuing Medical Implementation …. . . bridging the care gap

Normal 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

Normal JVP Waveform • a wave - atrial systole • x' (prime) descent !!! – occurs during systole due • x descent – onset of to RV contraction pulling down the TV valve ring atrial relaxation “descent of the base” • c wave - small positive – a measure of RV contractility notch in the 'x' descent • v wave - after the x' due to bulging of the descent - slow positive AV ring into the atria wave due to right atrial in ventricular filling from venous return contraction. • y descent - rapid emptying of the RA into RV due to TV opening © Continuing Medical Implementation …. . . bridging the care gap

JVP Inspection • Look at the JVP and simultaneously feel the carotid or auscultate to identify systole • Say “systole”, “down”, 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 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 © Continuing Medical Implementation • 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 1 o heart block …. . . bridging the care gap

JVP- 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 © Continuing Medical Implementation • JVP normally falls with inspiration • Kussmaul’s sign – – inspiratory in JVP constriction rarely tamponade RV infarction …. . . bridging the care gap

Specific JVP patterns Condition Pattern Normal 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 J VP brisk X' & Y descents X' less exaggerated than Y JVP –low amplitude …. . . bridging the care gap RV infarction © Continuing Medical Implementation

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 – 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 • 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 Paradoxus An exaggerated drop in SBP (>10 mm. Hg) with inspiration © Continuing Medical Implementation …. . . bridging the care gap

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 Paradoxus Tamponade without pulsus – – – atrial septal defect severe aortic stenosis aortic insufficiency LVH with LVEDP left ventricular dysfunction – decreased intravascular volume (low-pressure tamponade) © Continuing Medical Implementation Pulsus without tamponade – – COPD RV infarct pulmonary embolism effusive constrictive pericarditis – restrictive cardiomyopathy – extreme obesity – tense ascites …. . . bridging the care gap

Central 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 • 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-echocardiography Pericardial Knock (early diastolic sound) Venous Pulse (X- and Y-descend) © Continuing Medical Implementation M-Mode Echo (thickened pericardium) …. . . bridging the care gap

Validity of the Hepato-jugular Reflux as a Clinical Test for Congestive Heart Failure John Ducas MD, Sheldon Magder MD, Maurice Mc. Gregor MD (Am J Cardiol 1983; 52: 1299 -1303) © Continuing Medical Implementation …. . . bridging the care gap

Normal JVP • Normal JVP < SA at 45 o • 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: • 25 patients studied – 6 with normal resting LV function – 16 with potential bi-ventricular dysfunction – 3 with RV dysfunction • Abdominal pressure 35 mm 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 • In patients with normal LV function abdominal compression did not increase > 2 mm Hg (2. 7 cm H 2 O ) • In 16/19 patients with impaired ventricular function CVP increased by > 3 mm Hg (4 cm H 2 O) • CVP stabilized over 12 seconds and did not change over subsequent 60 seconds • An increase of 3 cm H 2 O (2. 2 mm Hg) in the height of the neck veins is a reasonable upper limit of normal for HJR John Ducas MD, Medical Sheldon Magder MD, Maurice Mc. Gregor MD © Continuing Implementation (Am J Cardiol 1983; 52: 1299 -1303) …. . . bridging the care gap

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: • 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 © Continuing Medical Implementation …. . . bridging the care gap