Jugular venous pressure

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Jugular venous pulse

The jugular venous pressure (JVP, sometimes referred to as jugular venous pulse) is the
indirectly observed pressure over the venous system. It can be useful in the differentiation of
different forms of heart and lung disease. Classically three upward deflections and two
downward deflections have been described.

 The upward deflections are the "a" (atrial contraction), "c" (ventricular contraction and
resulting bulging of tricuspid into the right atrium during isovolumic systole) and "v"=
atrial venous filling.
 The downward deflections of the wave are the "x"(the atrium relaxes and the tricuspid
valve moves downward) and the "y" descent (filling of ventricle after tricuspid opening).

Contents
[hide]

 1 Method
o 1.1 Visualization
o 1.2 Differentiation from the carotid pulse
o 1.3 JVP waveform
o 1.4 Quantification
o 1.5 Abdominojugular test
 2 Interpretation
 3 References
 4 External links

[edit] Method
[edit] Visualization

A gentleman with marked jugular venous distension. External jugular vein marked by an arrow.
N.B. The JVP is measured from the internal jugular vein that runs beneath the
sternocleidomastoid muscle.

The veins of the neck, viewed from in front.

The patient is positioned under 45°, and the filling level of the jugular vein determined. Visualize
the internal jugular vein when looking for the pulsation. In healthy people, the filling level of the
jugular vein should be a maximum of several (3-4) centimetres above the sternal angle. A pen-
light can aid in discerning the jugular filling level by providing tangential light.

The JVP is easiest to observe if one looks along the surface of the sternocleidomastoid muscle,
as it is easier to appreciate the movement relative the neck when looking from the side (as
opposed to looking at the surface at a 90 degree angle). Like judging the movement of an
automobile from a distance, it is easier to see the movement of an automobile when it is crossing
one's path at 90 degrees (i.e. moving left to right or right to left), as opposed to coming toward
one.
Pulses in the JVP are rather hard to observe, but trained cardiologists do try to discern these as
signs of the state of the right atrium.

[edit] Differentiation from the carotid pulse

The JVP and carotid pulse can be differentiated several ways:

 multiphasic - the JVP "beats" twice (in quick succession) in the cardiac cycle. In other
words, there are two waves in the JVP for each contraction-relaxation cycle by the heart.
The first beat represents that atrial contraction (termed a) and second beat represents
venous filling of the right atrium against a closed tricuspid valve (termed v) and not the
commonly mistaken 'ventricular contraction'. These wave forms may be altered by
certain medical conditions therefore this is not always an accurate way to differentiate the
JVP from the carotid pulse. The carotid artery only has one beat in the cardiac cycle.
 non-palpable - the JVP cannot be palpated. If one feels a pulse in the neck, it is generally
the common carotid artery.
 occludable - the JVP can be stopped by occluding the internal jugular vein by lightly
pressing against the neck. It will fill from above.
 varies with head-up-tilt (HUT) - the JVP varies with the angle of neck. If a person is
standing, his JVP appears to be lower on the neck (or may not be seen at all because it is
below the sternal angle). The carotid pulse's location does not vary with HUT.
 varies with respiration - the JVP usually decreases with deep inspiration. Physiologically,
this is a consequence of the Frank-Starling mechanism as inspiration decreases the
thoracic pressure and increases blood movement into the heart (venous return), which a
healthy heart moves into the pulmonary circulation.

[edit] JVP waveform

The jugular venous pulsation has a biphasic waveform.

 The ‘a’ wave corresponds to atrial contraction and ends synchronously with the carotid
artery pulse. The peak of the 'a' wave demarcates the end of atrial systole.
 The ‘c’ wave occurs when the ventricles begin to contract causing the atrioventricular
(AV) valves to bulge towards the atria.
 The 'x' descent follows the 'a' wave and represents atrial relaxation and rapid filling due
to low pressure. The 'x (x prime) descent follows the 'c' wave and occurs as a result of the
right ventricle pulling the tricuspid valve downward during ventricular systole. The 'x (x
prime) descent can be used as a measure of right ventricle contractility.
 The ‘v’ wave is seen when the tricuspid valve is closed and is caused by a pressure
increase in the atrium as the venous return fills the atria - this occurs during and
following the carotid pulse.
 The 'y' descent represents the rapid emptying of the atrium into the ventricle following
the opening of the tricuspid valve.

The absence of 'a' waves may be seen in atrial fibrillation.[1]

[edit] Quantification

A classical method for quantifying the JVP was described by Borst & Molhuysen in 1952.[2] It
has since been modified in various ways. A venous arc may be used to measure the JVP more
accurately.

[edit] Abdominojugular test

Main article: Abdominojugular test

The term hepatojugular reflux was previously used as it was thought that compression of the
liver resulted in "reflux" of blood out the hepatic sinusoids into the great veins thereby elevating
right atrial pressure and visualized as jugular venous distention. The exact physiologic
mechanism of jugular venous distention with a positive test is much more complex and the
commonly accepted term is now "Abdominojugular test."

In a prospective randomized study involving 86 patients who underwent right and left cardiac
catheterization, the abdominojugular test was shown to correlate best with the pulmonary arterial
wedge pressure. Furthermore, patients with a positive response had lower left ventricular ejection
fractions and stroke volumes, higher left ventricular filling pressure, higher mean pulmonary
arterial, and higher right atrial pressures.[3]

The abdominojugular test, when done in a standardized fashion, correlates best with the
pulmonary arterial wedge pressure, and therefore, is probably a reflection of an increased central
blood volume. In the absence of isolated right ventricular failure, seen in some patients with right
ventricular infarction, a positive abdominojugular test suggests a pulmonary artery wedge
pressure of 15 mm Hg or greater.[3]

[edit] Interpretation
Certain wave form abnormalities, include "Cannon a-waves", which result when the atrium
contracts against a closed tricuspid valve, due to complete heart block (3rd degree heart block),
or even in ventricular tachycardia. Another abnormality, "c-v waves", can be a sign of tricuspid
regurgitation.

An elevated JVP is the classic sign of venous hypertension (e.g. right-sided heart failure). JVP
elevation can be visualized as jugular venous distension, whereby the JVP is visualized at a
level of the neck that is higher than normal. The paradoxical increase of the JVP with inspiration
(instead of the expected decrease) is referred to as the Kussmaul sign, and indicates impaired
filling of the right ventricle. The differential diagnosis of Kussmaul's sign includes constrictive
pericarditis, restrictive cardiomyopathy, pericardial effusion, and severe right-sided heart failure.
  Raised JVP, normal waveform
o Bradycardia
o Fluid overload
o Heart Failure
 Raised JVP, absent pulsation
o Superior vena cava syndrome
 Large 'a' wave (increased atrial contraction pressure)
o tricuspid stenosis
o Right heart failure
o Pulmonary hypertension
 Cannon 'a' wave (atria contracting against closed tricuspid valve)
o Atrial flutter
o Premature atrial rhythm (or tachycardia)
o third degree heart block
o Ventricular ectopics
o Ventricular tachycardia
 Absent 'a' wave (no unifocal atrial depolarisation)
o atrial fibrillation
 Large 'v' wave (c-v wave)
o Tricuspid regurgitation
 Slow 'y' descent
o Tricuspid stenosis
 Parodoxical JVP (Kussmaul's sign: JVP rises with inspiration, drops with expiration)
o Pericardial effusion
o Constrictive pericarditis
o Pericardial tamponade

An important use of the jugular venous pressure is to assess the central venous pressure in the
absence of invasive measurements (e.g. with a central venous catheter, which is a tube inserted in
the neck veins). A 1996 systematic review concluded that a high jugular venous pressure makes
a high central venous pressure more likely, but does not significantly help confirm a low central
venous pressure. The study also found that agreement between doctors on the jugular venous
pressure can be poor.[4]

Apex beat
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The apex beat, also called the point of maximum impulse (PMI), is the furthermost point
outwards (laterally) and downwards (inferiorly) from the sternum at which the cardiac impulse
can be felt. The cardiac impulse is the result of the heart rotating, moving forward and striking
against the chest wall during systole.

[edit] Identification
The normal apex beat can be palpated in the precordium left 5th intercostal space, at the point of
intersection with the left midclavicular line. In children the apex beat occurs in the fourth rib
interspace medial to the nipple. The apex beat may also be found at abnormal locations; in many
cases of dextrocardia, the apex beat may be felt on the right side.

[edit] Interpretation

Algorithm for classification of the apex beat characters

Lateral and/or inferior displacement of the apex beat usually indicates enlargement of the heart,
called cardiomegaly. The apex beat may also be displaced by other conditions:

 Pleural or pulmonary diseases

Sometimes, the apex beat may not be palpable, either due to a thick chest wall, or conditions
where the stroke volume is reduced; such as during ventricular tachycardia or shock.

The character of the apex beat may provide vital diagnostic clues:

 A forceful impulse indicates pressure overload in the heart (as might occur in
hypertension)
 An uncoordinated (dyskinetic) apex beat involving a larger area than normal indicates
ventricular dysfunction; such as an aneurysm following myocardial infarction

An algorithm for the classification of some common apex beat characters is shown in the image
Examination of Cardiac Apex Beat
12 Comments
Apex beat is the palpable cardiac impulse. It is also defined as the lowermost and outermost
(most lateral and most inferior) prominent cardiac pulsation. Examination of this cardiac impulse
can give valuable inputs into the diagnosis of cardiac disease.

Synonyms: Apex impulse; Point of Maximal Impulse (PMI)

Normal location:

It is normally located in the left fifth intercostal space, about 1 centimeter medial to the mid-
clavicular line.
In children less than 7 years of age, the apex beat is located in the 4th intercostal space, lateral to
the mid-clavicular line.

How it is produced:

One of my students asked a very pertinent question. When the heart contracts, it expels blood
towards the great arteries, that are towards the base of the heart. Then why does the apex move
'outward' in the chest?

Heart is a spirally arranged muscle in syncytium. When this muscle contracts, the heart rotates
and the apex actually moves forward toward the chest wall and taps it.
Method of examination:

Position the flat of your hand so that the middle finger lies on the left 5th intercostal space of the
patient, covering the anterolateral ribcage. Other fingers are positioned on the spaces above and
below. If no pulsation is felt, move the hand in other directions, feeling for a pulsation.

Once the apex is felt, ascertain whether it is the most prominent pulsation. Then to identify the
position, palpate the sternal angle (angle of Louis). It is the angle between the manubrium and
the body of the sternum. The second rib corresponds to this angle. below the second rib is the
corresponding intercostal space. Starting from that space, count the intercostal spaces and reach
the palpable apex and identify the space in which it is located. Follow this by measuring the
distance between the pulsation and the mid-clavicular line. If the pulsation is nearer to any other
vertical landmark line, like the anterior or middle axillary lines, it is better to state the position in
relation to those lines rather than mid-clavicular line. For example, instead of mentioning that the
apex is 6 cm lateral to mid-clavicular line, it is better to document as 1 cm medial to mid-axillary
line.

Points to note in apex:

 Presence
 Location
 Size (is it localized or diffuse?)
 Amplitude (is it forceful?)
 Duration (is it abnormally sustained?)
 Type (assess based on above parameters, details are given below)
 Thrill

Causes for absence of apex beat:

Absent apex may be due to physiological and pathological causes.

Physiological causes:

 Dextrocardia. Though it will be absent at the 'usual' location on the left side, it will be
present on the right side.
 Apex behind a Rib. In this case it may not be palpable in an intercostal space. Just
turning the patient to the left lateral position will reveal the apex beat, confirming this
cause.

Pathological causes:

 Pericardial effusion
  Obesity and thick chest wall
 Pleural effusion (left sided)
 Emphysema

Causes for displaced apex beat:

This has to be assessed along with tracheal position. If trachea is also shifted along with the
displacement of apex beat, then it is due to mediastinal shift as a result of lung fibrosis, collapse,
pneumothorax etc.
If the trachea is central but the apex is displaced, the causes may be:

1. Left ventricular enlargement - the apex will be displaced downwards and laterally.
2. Right ventricular enlargement - the apex will displaced laterally.
3. Cardiomegaly due to significant enlargement of other chambers can also cause
displacement
4. Pectus excavatum
5. Situs inversus/ dextrocardia

Abnormal types (characters) of apex beat:

The normal apex beat is localized pulsation in the normal location as described above. Here are
some abnormal characters (please refer to the picture too):

1. Tapping Apex - This is an almost normal apex beat with a palpable first heart sound. This
is due to a loud first heart sound heard in mitral stenosis.
2. Hyperdynamic Apex - This is classically seen in volume overload conditions where there
is ventricular dilatation (aortic regurgitation, hyperdynamic circulation etc). This is a
forceful but ill-sustained apex that is palpable over a larger area than normal (diffuse).
3. Heaving Apex - Classically seen in pressure overload conditions that result in ventricular
hypertrophy (aortic stenosis, systemic hypertension etc). This is a forceful and sustained
apex that is usually localized.
4. Double Impulse Apex - Two impulses felt during systole rather than the normal single
upstroke. This is seen on HCM - hypertrophic cardiomyopathy).
5. Dyskinetic Apex - An apex that is uncoordinated, seen in myocardial infarction when
there are dyskinetic movements of the infarcted myocardium.