1. Jugular venous pressure and waveforms
Dr Bijilesh

2. Jugular venous pulse is the oscillating top of the the distended proximal portion of the internal jugular vein and represents volumetric changes that faithfully reflect the pressure cahnges in the right heart

3. Right atrial pressure during systole and right ventricular filling pressure during diastole
Window into the right heart, providing critical information regarding its hemodynamics.
Right atrial pressure during systole and right ventricular filling pressure during diastole are producing pulsations and pressure waves in jugular veins .
Evaluation of the jugular venous pulse offers a window into the right heart, providing critical information regarding its hemodynamics.

4. “In the study of venous pulse we have often the direct means of observing the effects of systole and diastole of right auricle and systole and diastole of right ventricle.”
James Mackenzie
Ging back to a little bit of history.In 1902 james mc established jvp as an important part of cvs examination. According to him jvp provides a good opportunity to observe the effects of systole and diastole of right auricle and systole and diastole of right ventricle.”

5. “Precise analysis of the cervical venous pulse and measurement of the height of each wave is not only possible at the bedside but highly desirable”
Paulwood
Despite this ,analysis of jvp was lacking in the examination till 1950 wen paulwood reawakened the interest eplaining the hemodynamics

6. Anatomy
JV pressure measurement
Causes of elevated JVP
Normal wave pattern
Abnormal wave pattern
Kussmaul s sign and hepatojugular reflux
Specific conditions

7. Jugular veins Internal jugular vein External jugular vein
Two jugular veins int and ext can be used 4 assessing jv pulse and pressure, though internal one is the preffered one

8. The internal jugular vein begins just medial to the mastoid process at the base of the skull. The internal jugular vein runs directly inferior from the mastoid process,.  it joins the subclavian vein, to form r innominate which continue as superior vena cava and then into the right atrium.

9. Lateral to carotid artery & deep to sternomastoid muscle.
External jugular is superficial to sternomastoid
The internal jugular vein is

10. Shows the vertical course of the ijv which psses inbetween the two heads of the st mastoid under the medial end of clavicle

11. Examination of JVP
Right IJV is usually assessed both for waveform and estimation of venous pressure
Transmitted pulsations to overlying skin between two heads of sternocleidomastoid
Unlike ejv pulsations it is not possible to see ijv pulsations directly as it is deep. We actually see the transmitted pulsations to the overlying skin b/w the two heads of st mast.

12. Right IJV Preferred :Why?
Straight line course through innominate vein to the svc and right atrium
Less likely extrinsic compression from other structures in neck
Why not EJV
No or less numbers of valves in IJV than EJV
Usually rijv s pref 4 jvp examination. RIJV is less likely affected by extrinsic compression from other structures in neck. Left inno compresssed by arch f aorta and presence of left svc can falsely elevate the jvp on left side. So in conditions with increased symp tone ejv pulsations less visible. Left IJV drains into left innominate vein, which is not in straight line from RA

13. Differences between IJV and Carotid pulses
Superficial and lateral in the neck
Better seen than felt
Has two peaks and two troughs
Descents >obvious than crests
Digital compression abolishes venous pulse
Jugular venous pressure falls during inspiration
Abdominal compression elevates jugular pressure
Deeper and medial in the neck
Better felt than seen
Has single upstroke only
Upstroke brisker and visible
Digital compression has no effect
Do not change with respiration
Abdominal compression has no effect on carotid pulse

14. Estimation of Venous Pressure
Measuring jugular venous pressure
Hepatojugular reflux
Examining the veins on the dorsum of the hand
Assessment of jugular venous pressure at bed side reflect mean right atrial pressure
Venous pressure can be roughly assessed

15. Measurement of JV Pressure
Sternal angle or angle of Louis - reference point
Found approximately 5 cm above the center of the right atrium
Sternal angle – RA Fixed relationship
Sternal angle or angle of Louis is a surface anatomical mark reference point used for JVP measurement
Distance between sternal angle and center of right atrium remains relatively constant regardless of position of the thorax

16. In an adult with anatomically normal chestthe sternal angle is found to be 5 cm above the centre of ra in siiting supine or varios reclining angle inbetween. Since tha angle of louis has a fixed relationship with the centre of ra this landmark is used for measuresment os jvp.

17. Position of Patient
Patient should lie comfortably and trunk is inclined by an angle
Elevate chin and slightly rotate head to the left
Neck and trunk should be in same line
When neck muscles are relaxed ,shine the light tangentially over the skin and see pulsations
Simultaneous palpation of the left carotid artery or apical impulse aids in timing of the venous pulsations in cardiac cycle .
Or at an angle which permits best view of the upperlevel of the venouspulsations

18. Iclination is required as level go below mandible in high jvp or below clavi in low pr. So start with 45 then tilt pt appropriately up or down . In patients with low jugular pressure , a lesser (<30‘) inclination is desirable
In patients with high jugular pressure ,a greater (60-90‘) inclination is required to obtain visible pulsations

19. Measurement of JVP Two scale method is commonly used
Normally JV pressure does not exceed 3- 4 cm above the sternal angle
Since RA is approximately 5 cm below the sternal angle , the jugular venous pressure corresponds to 9 cm =7mmhg
Elevated JVP : JVP of >4 cm above sternal angle .
(9 cm column of water / 1.3 =6.9)

20. .A horizontal scale at the top of the oscillating venous column in IJV cuts the vertical scale at the sternal angle gives JV pressure in cm of water
Add 5 cm to measurement since right atrium is 5 cm below the sternal angle

21. Elevated JVP Increased RVP and reduced compliance: Pulmonary stenosis
Pulmonary hypertension
Right ventricular failure
RV infarction
RV inflow impedance:
Tricuspid stenosis / atresia
RA myxoma
Constrictive pericarditis

22. Elevated JVP Circulatory overload : Renal failure Cirrhosis liver
Excessive fluid administration
SVC obstruction

23. Kussmaul's sign
Mean jugular venous pressure increases during inspiration
Constrictive pericarditis
Severe right heart failure
RV infarction
Restrictive cardiomyopathy
Impaired RV compliance.
Normally mean jvp falls during insp ..as a result of impaired RV compliance, so the increased venous return cannot be accomodated by the rv, resulting in an elevated jvp

24. Abdominal -Jugular Reflux
Hepatojugular reflux – Rondot (1898)
Apply firm pressure to periumbilical region sec
Normally JV pressure rises transiently to < 1cm while abdominal pressure is continued
If JV pressure remains elevated >1cm until abdominal pressure is continued: Positive AJR.
Apply firm pressure to periumbilical region for sec with patient lying comfortably and breathing quietly while observe JVP ABRAMS

25. Abdominal compression forces venous blood into thorax.
A failing/dilated RV not able to receive venous return without rise in mean venous pressure.
Positive AJR
Incipient and or compensated RVF
Tricuspid regurgitation
COPD
Copd sudden disproportionate increase in intrathoracic pr due to altered intrathoracic pr relation ships in copd

26. Hepatojugular reflux

27. Gaertner's method
Measurement of JVP by examining the veins on the dorsum of the hand
When patient sitting or lying at a 45‘ elevation , arm slowly and passively raised from dependant position until the vein collapses
Height of the limb above the level of sternal angle at which vein collapses represents the venous pressure
When venous pressure is normal , veins of hand collapse at the level of sternal angle

28. Normal JVP
Normal JVP reflects phasic pressure changes in RA during systole and RV during diastole
Two visible positive waves ( a and v) and two negative troughs ( x and y)
Two additional positive waves can be recorded C wave interrupts x descent and h wave
and h wave precedes the next a wave

29. Normal JVP Waveform Consists of 3 positive waves a,c & v
And 3 descents
x, x'(x prime) and y

30. a Wave
First positive presystolic a wave is due to right atrial contraction
Effective RA contraction is needed for visible a wave
Dominant wave in JVP and larger than v
It precedes upstroke of the carotid pulse and S1, but follow the P wave in ECG
First positive presystolic a wave is due to right atrial contraction results in retrograde blood flow in to svc and jugulars

31. x Descent
Systolic x descent is due to atrial relaxation during atrial diastole
X descent is most prominent motion of normal JVP which begins during systole and ends just before S2
It is larger than y descent
X descent more prominent during inspiration

32. C Wave Not usually visible. Two different causes
- Transmitted carotid artery pulsations.
- Upward bulge of closed Tricuspid valve in
isovolumic systole
Second positive wave recorded in JVP which interrupts the x descent

33. x` Descent x`descent is systolic trough after c wave Due to
Fall of right atrial pressure during early RV systole
Downward pulling of the TV by contracting right ventricle
Descent of RA floor

34. v Wave Begins in late systole ends in early diastole
Rise in RA pressure due to continued RA filling during ventricular systole when tricuspid valve closed
Roughly synchronous with carotid upstroke and corresponds S2 .
Third positive wave in JVP which begins in late systole and ends in early diastole

35. y Descent Diastolic collapse wave (down slope v wave)
It begins and ends during
diastole well after S2
Decline of RA pressure due to RA emptying during early diastole when tricuspid valve opens

36. h wave
Small brief positive wave following y descent just prior to a wave
Described by Hieschfelder in 1907
It usually seen when diastole is long
With increasing heart rate, y descent immediately followed by next a wave .
Small brief positive wave following y descent just prior to a wave during period of diastasis
It usually seen when diastole is long (as in slow heart rates)

37. Prominent a Wave
Forceful atrial contraction when there is resistance to RA emptying or increased resistance to ventricular filling
RV inflow obstruction:
Tricuspid stenosis or atresia
RA mxyoma
Decreased ventricular compliance:
Pulmonary stenosis
Pulmonary hypertension of any cause
RV infarction
RV cardiomyopathy (HOCM)
Acute pulmonary embolism
3. Increased RVEDP.
RV infarction , Acute pulmonary embolism

38. Large a wave

39. Cannon Waves
Whenever RA contracts against closed TV valve during RV systole
Regular cannon waves:
Junctional rhythm
VT with 1:1 retrograde conduction
Isorhythmic AV dissociation
Irregular cannon waves :
Complete heart block
Ventricular tachycardia
Ventricular pacing or ventricular ectopics .
Venous corrigan by paul wood

40. Rgular cannon waves

41. Absent a Wave When no effective atrial
contraction as in atrial fibrillation
In sinus tachycardia , when a wave may fuse with preceding v wave , especially when the PR interval is prolonged .

42. Prominent x descent
Presence of atrial relaxation with intact tricuspid valve and good RV contraction
Causes :
Cardiac tamponade
Constrictive pericarditis
is needed for prominent x descent.

43. Reduced x descent Moderate to severe TR: early sign
Atrial fibriillation
Obliteration of x descent with early large systolic wave

44. Prominent v wave Increased RA volume during ventricular
systole produce prominent v wave
Severe TR : giant v wave
Giant v wave sometimes causes :
systolic movement of ear lobe
head bobbing with each systole
systolic pulsation of liver
pulsatile exophthalmos
(Lanci sign) – ventricularization of atrial / jugular pressure

45. cv wave

46. PROMINENT V WAVE ASD with mitral regurgitation
VSD of LV to RA shunt (Gerbode's defect)
RV failure

47. Rapid y Descent Severe TR
C .Pericarditis (Friedreich's sign): Early rapid ventricular filling
Severe RV failure
ASD with mitral regurgitation
Elevated venous pressure from any cause.
Constrictive pericarditis,(Friedreich’s sign)
Severe TR, Severe RVF Severe RV infarction

49. Slow y Descent
When RA emptying and RV filling are impaired y descent is slow and gradual
Tricuspid stenosis
Right atrial tumours
Pericardial tamponade( y descent may even be absent).

50. Respiratory influences
Inspiration – increased visibility of venous pulse.
Mean venous pressure falls , but the wave forms are accentuated during inspiration.

51. Waves more prominent during inspiration
X descent more brisk
Increased venous return augment RA contraction and hence relaxation >> brisk x
Also increased venous return augment RV volume and contraction > increased systolic descent of floor of RA>>brisk x’

52. JUGULAR VENOUS PULSE IN ARRHYTHMIAS
‘a’ & ‘v’/c (carotid pulse correlates with P & QRS complex in ECG.
Normal sinus rhythm is characterized by sequential a & v waves.
Any disturbance in this wave form indicates rhythm abnormality.
A wave occurring along 1st heart sound – normal PR interval.

53. Rhythm Cannon waves Sinus a - v regular Absent I AV block
Pr0longed AC interval
Wenckebach’s
Gradual prolongation of A-C interval
Mobitz II block
Constant AC interval followed by sudden skipping of carotid pulse
CHB
Variable
Present & irregular
VPC JPC
Early cycle
Present
APC VT
Atrial tachycardia
Normal

54. Cardiac tamponade JVP is usually elevated
y descent is diminished or absent
x wave is normal
Kussmaul's sign
usually negative

55. Constrictive pericarditis
JVP is elevated
a wave is usually normal
v wave is usually equal to a wave
x descent –prominent
y descent – rapid descent
Kussmauls sign is usually positive

56. Restrictive cardiomyopathy
JVP is usually elevated
Both a and v wave equal
Kussmaul s may be positive

57. Pulmonary Hypertension
Early RV decompensation :
JVP may be elevated
a wave is prominent
Decompensated RVF:
a and v wave prominent ,
v wave larger than a wave
x descent is diminished or absent
Rapid y descent due to TR

58. JVP in ASD JVP is normal and equal a and v waves
Elevated JVP may seen in severe PAH and in RVF
Prominent a wave with PS and MS
Prominent v wave with PAH and RVF with TR
Rapid y descent with RVF or TR

59. JVP in VSD Elevated JVP with CHF Prominent v wave with Gerbode's shunt
In Eisenmenger complex :
JV Pressure usually normal
Normal a and v waves

60. Ebstein Anomaly JVP is usually normal
Attenuated x descent and systolic v wave are not reflected in jugular pulse despite appreciable TR
Damping effect of large capacitance RA and thin, toneless atrialized RV
Unimpressive JVP is attributed to

61. Thank you………