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• a wave never prominent • v and x wave is normal • y descent is diminished or absent • Kussmaul's sign usually negative 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 Endomyocardial fibrosis • JVP is usually elevated • a wave is prominent • v wave is prominent due to TR • x descent is obliterated due to TR • Rapid y descent is due to TR • Kussmaul's sign is negative Primary Pulmonary Hypertension • Normal RV compliance :normal JVP • Early RV decompensation : JVP may be elevated a wave is prominent and larger than v wave x and y descent seen and equal Decompensated RVF: JVP is always elevated a and v wave prominent , v wave larger than a wave x descent is diminished or absent rapid y descent due to TR JVP in ASD • JVP is normal and equal a and v waves. x descent is more prominent . • Elevated JVP may seen in severe PAH and in RVF • Prominent a wave with PS and MS • Prominent v wave with PAH and in RVF with TR • Rapid y descent with RVF or TRJVP in VSD • Prominent a wave with severe PS • Elevated JVP with CHF • Prominent v wave with Gerbode's shunt • In Eisenmenger complex : JVPressure usually normal Normal a and v waves CHF and TR is rare Ebstein Anomaly • JVP is usually normal • Prominent a waves are seen only occasionally • Attenuated x descent and systolic v wave are not reflected in jugular pulse despite appreciable TR • Unimpressive JVP is attributed to damping effect of large capacitance RA and thin, toneless atrialized RV (Hypokinetic TR) • Prominent a and v / elevated JVP with advent of right ventricular failure . Cyanosis with prominent a wave • It usually indicates intact IVS • Severe PS with intact IVS and Right to Left shunt

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Patient should lie comfortably and trunk is inclined by 45 degree position • Elevate chin and slightly rotate head to the left • Inclination angle should be subtended between trunk and bed , while neck and trunk should be in same line • When neck muscles are relaxed ,shining the light tangentially over the skin and see pulsations • In patients with low jugular pressure , a lesser (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 precedes the next a wave Normal JVP Waveform • Consists of 3 positive waves • a,c & v • And 3 descents • x, x'(x prime) and ya Wave • First positive presystolic a wave is due to right atrial contraction results in retrograde blood flow in to svc and jugulars • 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 x Descent • Systolic x descent (systolic collapse) 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 c WAVE • Second positive wave recorded in JVP which interrupts the x descent • Produced by carotid artery impact on JVP upward bulging of closed TV into RA during isovolumic contraction 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 by contracting RV v Wave • Third positive wave in JVP which begins in late systole and ends in early diastole • Rise in RA pressure due to

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IJV and see the top of oscillating venous column Measurement of JVP • Two scale method is commonly used • 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 • Normally JV pressure does not exceed 4 cm above the sternal angle • Since RA is approximately 5 cm below the sternal angle , the jugular venous pressure (RA mean pressure) is corresponds to 9 cm • By way of conversion , normal mean JV pressure does not exceed 7 mm Hg (9 cm column of water / 1.3 =6.9) • Elevated JVP : JVP of >4 cm above sternal angle . 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 Elevated JVP • Circulatory overload : Renal failure Cirrhosis liver Excessive fluid administration • SVC obstruction • COPD Kussmual's sign • Mean jugular venous pressure increases during inspiration as a result of impaired RV compliance. • Constrictive pericarditis • Severe right heart failure • RV infarction • Restrictive cardiomyopathy Abdominal -Jugular Reflux • Hepatojugular reflux – Rondot (1898) • Apply firm pressure to periumbilical region for 10 -30 sec with patient lying comfortably and breathing quietly while observe JVP • Normally JV pressure rises transiently(15 sec) to Positive AJR • Incipient and or compensated RVF • LVF with volume overload • Tricuspid regurgitation • False Positive AJR ( without CCF) COPD Systemic vasoconstriction Increased sympathetic tone Severe anaemia 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 Cardiac tamponade • JVP is usually elevated

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Jugular Venous Pulse Dr .Latchumanadhas Madras medical missionHistory of JVP • Lancis : Venous pulse of EJV • Chauvea,marey :Graphic recording of JVP • Pontain :Wave pattern in JVP • James Mackenzie :Nomenclature of JVP • Paul wood : Hemodynamics of JVP Jugular Venous System • Venous system contains 70-80% of the circulating blood volumes . • Right atrial and right ventricular filling produce pulsations in the central veins that are transmitted to jugular veins . • An accurate assessment of the jugular venous pulse reflects the hemodynamics of the right sided heart . • Right atrial pressure during systole and right ventricular filling pressure during diastole are producing pulsations and pressure waves in jugular veins .JVP InspectionExam of JVP • Right IJV is usually assessed both for waveform and estimation of CVP • Internal jugular venous pulsation located between two heads of sternocleidomastoid muscle are transmitted to overlying skin . • Right IJV is in direct continuity with SVC and right atrium • Left IJV drains into left innominate vein, which is not in straight line from RA • Right IJV and innominate vein is not compressed by adjacent structures Right IJV Preferred :Why? • Direct continuation of right atrium • Straight line course through innominate vein to the svc and right atrium • IJV is less likely affected by extrinsic compression from other structures in neck • There are no or less numbers of valves in IJV than EJV • Less impact of vasoconstriction on IJV due to sympathetic activity than EJV 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 Mean jugular venous pressure falls during standing 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 Carotid pulse do not change when standing . Differences between IJV and Carotid pulsesPosition of Patient •

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