DefinitionDefinition

Jugular Venous Pulse:Jugular Venous Pulse:

defined as the oscillating top of vertical defined as the oscillating top of vertical column of blood in right IJV that reflects column of blood in right IJV that reflects pressure changes in Right Atrium in cardiac pressure changes in Right Atrium in cardiac cycle.cycle.

Jugular Venous Pressure:Jugular Venous Pressure:

Vertical height of oscillating column of Vertical height of oscillating column of blood.blood.

Why Internal Jugular Vein?Why Internal Jugular Vein?

IJV has a direct course to RA.IJV has a direct course to RA. IJV is anatomically closer to RA.IJV is anatomically closer to RA. IJV has no valves( Valves in EJV prevent IJV has no valves( Valves in EJV prevent

transmission of RA pressure)transmission of RA pressure) Vasoconstriction Secondary to hypotension Vasoconstriction Secondary to hypotension

( in CCF) can make EJV small and barely ( in CCF) can make EJV small and barely visible.visible.

Why Right Internal Jugular Vein?Why Right Internal Jugular 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.

                                          

Difference from Carotid PulseDifference from Carotid PulseVenous PulseVenous Pulse Carotid PulseCarotid Pulse

More lateralMore lateral MedialMedial

Wavy, UndulantWavy, Undulant Forceful, BriskForceful, Brisk

Decrease with InspirationDecrease with Inspiration No changeNo change

Increase in supine positionIncrease in supine position No changeNo change

^with abdominal pressure^with abdominal pressure No changeNo change

Double PeakedDouble Peaked Single PeakSingle Peak

Obliterated with PressureObliterated with Pressure Cannot be ObliteratedCannot be Obliterated

Better VisibleBetter Visible Better palpatedBetter palpated

Better viewed from foot Better viewed from foot end of bedend of bed

Method Of ExaminationMethod 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 °

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

Observations MadeObservations Made

the level of venous pressure.

the type of venous wave pattern.

The level of venous pressure

Using a centimeter ruler, measure the vertical distance between the angle of Louis (manubrio sternal joint) and the highest level of jugular vein pulsation.

The upper limit of normal is 4 cm above the sternal angle,.

Add 5 cm to measure central venous pressure since right atrium is 5 cm below the sternal angle.

Normal CVP is < 9 cm H2O

Normal pattern of the jugular venous pulse

The normal JVP reflects phasic pressure changes in the right atrium and consists of three positive waves and two negative troughs

Simultaneous palpation of the left carotid artery aids the examiner in relating the venous pulsations to the timing of the cardiac cycle.

Venous distension due to RA contractionVenous distension due to RA contraction Retrograde blood flow into SVC and IJVRetrograde blood flow into SVC and IJV Synchronous with S1, Follow P of ECGSynchronous with S1, Follow P of ECG Precede Carotid pulsePrecede Carotid pulse

a WAVEa WAVE

The x descent: is due to X Atrial relaxation X` Descent of the floor of the right atrium during right ventricular systole. Begins during systole and ends before S2

The c wave: Occurs simultaneously with the carotid pulse Artifact by Carotid pulsation Bulging of TV into RA during ICP

v WAVEv WAVE

Rising right atrial pressure when blood flows into the right atrium during ventricular systole when the tricuspid valve is shut.

Synchronous with Carotid pulse Begins in early systole, Peaks after S2 and ends in early

diastole

y DESCENTy DESCENT

The decline in right atrial pressure when the tricuspid valve reopens

Following the bottom of the y descent and before beginning of the a wave is a period of relatively slow filling of the ventricle, the diastases period, a wave termed the h wave.

The x descent occurs just prior to the second heart sound ( during systole), while the y descent occurs after the second heart sound (during diastole).

Normally X descent is more prominent than Y descent. Y descent is only sometimes seen during diastole. Descents are better seen than positive waves.

The a wave occurs just before the first sound or carotid pulse and has a sharp rise and fall.

The v wave occurs just after the arterial pulse and has a slower undulating pattern.

The c wave is never seen normally.The c wave is never seen normally.

Identifying Wave FormsIdentifying Wave Forms

Abnormalities of jugular venous pulse

A. Low jugular venous pressure

1. Hypovolaemia.

B. Elevated jugular venous pressure

1. Intravascular volume overload conditions Right ventricular infarction Left heart failure Myocardial infarction. Valvular Heart Disease Cardiomyopathy 2. Constrictive pericarditis.3. Pericardial effusion with tamponade

Elevated “a” wave

Increased Resistance to RV Filling.

Tricuspid stenosis

R Heart Failure

PS

PAH

Cannon “a” wave Atrial-

ventricular Dissociation

(atria contract against a closed tricuspid

valve) Complete heart block VPCVentricular

tachycardiaVentricular pacingJunctional rhythmJunctional

tachycardia.

Absent “a” wave

1. Atrial fibrillation

Elevated “v” wave

1. Tricuspid regurgitation.

2. Right ventricular failure.

3. Restrictive cardiomyopathy.

4. Cor Pulmonale

Tricuspid regurgitation Absent X DecsentAbsent X Decsent CV/ Regurgitant WaveCV/ Regurgitant Wave Has a rounded contour Has a rounded contour

and a sustained peakand a sustained peak Followed by a rapid deep Followed by a rapid deep

Y descentY descent Amplitude of V increases Amplitude of V increases

with inspiration.with inspiration. Cause subtle motion of Cause subtle motion of

ear lobe with each heart ear lobe with each heart beatbeat

“a” wave equal to “v” wave

ASDProminent X descent

followed by a large V wave

M ConfigurationIndicates a large L-R

shuntWith PAH A wave

becomes more prominent

If L JVP > R JVP indicates associated PAPVC

1. Cardiac tamponade.2. Constrictive Pericarditis3. RVMI4. Restrictive Cardiomyopathy5. Atrial septal defect

Prominent “x” descent

Blunted “x” descent

1. Tricuspid regurgitation.2. Right atrial ischaemia

Prominent “y” descent

1. Constrictive pericarditis.

2. Tricuspid regurgitation.

3. Atrial septal defect.

1. Cardiac tamponade.2. Right ventricular infarction3. Restrictive Cardiomyopathy

Absent “y” descent

Slow “y” descent

1. Tricuspid stenosis.2. Right atrial myxoma.

Constrictive pericarditis.

M shaped contourM shaped contour Prominent X and Y descent (FRIEDREICH`SIGN)Prominent X and Y descent (FRIEDREICH`SIGN) Y descent is prominent as ventricular filling is Y descent is prominent as ventricular filling is

unimpeded during early diastole.unimpeded during early diastole. This is interrupted by a rapid raise in pressure as the This is interrupted by a rapid raise in pressure as the

filling is impeded by constricting Pericardiumfilling is impeded by constricting Pericardium The Ventriclar pressure curve exhibit Square Root signThe Ventriclar pressure curve exhibit Square Root sign

Abdomino-jugular reflux Is positive when JVP increase after 10 sec of abdominal Is positive when JVP increase after 10 sec of abdominal

pressure followed by a rapid drop in pressure of 4 cm on pressure followed by a rapid drop in pressure of 4 cm on release of compression.release of compression.

Most common cause of a positive test is RHFMost common cause of a positive test is RHF Positive test in: Borderline elevation of JVPPositive test in: Borderline elevation of JVP Silent TRSilent TR Latent RHFLatent RHF

False positive: Fluid overloadFalse positive: Fluid overload False Negative: SVC/IVC obstructionFalse Negative: SVC/IVC obstruction Budd Chiari syndromeBudd Chiari syndrome

Positive Test imply SVC and IVC are patentPositive Test imply SVC and IVC are patent

Kussmaul sign

Failure of decline in JVP occur during inspiration.Failure of decline in JVP occur during inspiration.

Constrictive PericarditisConstrictive Pericarditis Severe RHFSevere RHF Restrictive CardiomyopathyRestrictive Cardiomyopathy Tricuspid StenosisTricuspid Stenosis