Examination, visualization, measurement, waveforms, quantification, abnormalities, hepatojugular reflux, Kussmaul's sign

1. By:- Dr. Ankur Gupta

2. Introduction
 Oscillating top of the distended proximal portion of the
internal jugular vein (IJV).
 Represents volumetric changes that faithfully reflect the
pressure changes in the right side of heart.
 Useful in the differentiation of different forms
of heart and lung disease.
 Classically three upward deflections and two downward
deflections:
 Upward deflections: a, c and v.
 Downward deflections: x and y.

3.  Pulsations and pressure waves in jugular veins:
 Right atrial pressure during systole.
 Right ventricular filling pressure during diastole.
 Evaluation of JVP offers a window into the right heart, providing
critical information regarding its hemodynamics.

4. Jugular veins
Internal jugular vein
External jugular vein

6.  Lateral to
carotid artery &
deep to SCM.
 External jugular
is superficial to
SCM.

7. Examination of JVP
 Done bedside to assess CVP and waveform.
 Right IJV – for waveform and estimation of
venous pressure.
 Unlike EJV pulsations, it is not possible to see IJV
pulsations directly as it is deep within the neck and
covered by SCM.
 Actually seen are the transmitted pulsations to
overlying skin and soft tissues.

9. IJV preferred to EJV
 Anatomically, IJVs are closer to RA.
 Take a direct course (‘straight line’) to SVC
and RA.
 More accurately reflect the dynamics of the
Right Heart.
 Transmission of RA pulsations prevented by
prominent valves at the proximal EJV.
 Other structures of neck and upper thorax
causes extrinsic compression of EJV.
 Sympathetic activity (as in CCF) 
vasoconstriction of EJV  Pulsations are
barely visible.

10. Right IJV Preferred to Left IJV
 Rt. IJV
 Straight line course through innominate vein to the SCV
and RA.
 Less likely extrinsic compression from other structures
in neck.
 Lt. IJV
 Left innominate vein may be compressed by dilated
aorta or an aneurysm.
 Drains into left innominate vein, which is not in straight
line from SVC and RA.

11. Differences between JVP and Carotid pulsations
JVP Carotid Pulsations
Superficial and lateral in the neck. Deeper and medial in neck.
Better seen than felt. Better felt than seen.
Two peaks and troughs per cardiac
cycle.
Single upstroke.
Descents more prominent than crests. Upstroke brisker and visible than
descent.
x and y more prominent during
inspiration.
No effect.
a and v transiently during
expiration.
No effect.
JVP falls during inspiration. No effect.
Digital compression at the root of neck
abolishes JVP.
No effect.

12.  multiphasic - the JVP "beats" twice (in quick
succession) in the cardiac cycle
 There are two waves in the JVP for each contraction-
relaxation cycle by the heart.
 The first beat represents that atrial contraction
(termed a).
 The second beat represents venous filling of the right
atrium against a closed tricuspid valve (termed v).
 The carotid artery only has one beat in the cardiac cycle.

13. 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.

14.  Level of sternal angle is about 5 cm above the level of
mid right atrium IN ANY POSITION.
 Examined in ANY position in which top of the column is
seen easily.
 <30⁰ in most normal subjects.
 Most patients with heart disease - 45⁰.
 In patients with high venous pressure, a greater (60-90⁰)
inclination is required to obtain visible venous
pulsations.
 Usually JVP is less than 8 cm water
< 3 cm column above level of sternal angle.

15. Visualization
 Patient should lie comfortably.
 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 a beam of light
tangentially across the skin overlying the IJV to see its
pulsations.
 Simultaneous palpations of the left carotid artery or cardiac
ausculation aids in timing of the JVP in cardiac cycle.

18. Measurement of JVP
 Commonly used - two scale method.
 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: >4 cm above sternal angle.

21. JVP waveform
The JVP has a biphasic waveform.
 The "a" wave: First positive presystolic wave.
 Right Atrial contraction.
 Precedes the upstroke of carotid pulse, synchronously with S1,
follows P wave of ECG.
 Peak of the 'a' wave demarcates
the end of atrial systole.
 Dominant wave in JVP during
inspiration.
 Larger than “v” wave.

22.  The "x" descent: (Systolic collapse)
 Follows the 'a' wave
 Corresponds to atrial relaXation and rapid atrial filling due to low
pressure.
 Most prominent motion of normal JVP.
 Begins during systole and ends just before S2.
 Larger than “y” descent.

23.  The " x' " (x prime) descent
 Follows the 'c' wave
 Occurs as a result of the right ventricle pulling the tricuspid
valve downward during ventricular systole.
 As stroke volume is ejected, the ventricle takes up less space
in pericardium, allowing relaXed atrium to enlarge.
 Can be used as a measure of right ventricle contractility.
 The "c" wave
 2nd positive venous wave.
 Right ventricular (isovolumic) Contraction  triCuspid valve to bulge
towards the right atrium.

24.  The "v" wave
 3rd positive wave.
 Begins in late systole and ends in early diastole.
 Corresponds to Venous filling when the tricuspid valve is closed and
venous pressure increases from venous return.
 Occurs during and following the carotid pulse and peaks after S2.
 The "y" descent:
 Downslope of v wave.
 Decline in RA pressure –
rapid emptYing of the RA into
the RV following the opening of
the tricuspid valve in early diastole.

28. Quantification
 A classical method for quantifying the JVP was
described by Borst & Molhuysen in 1952.
 It has since been modified in various ways. A venous
arch may be used to measure the JVP more accurately.
 Moodley's Sign - Determine which waveform you are
viewing.
 Feel the radial pulse while simultaneously watching the
JVP.
 Waveform seen immediately after the arterial pulsation
is felt is the 'v wave' of the JVP.

31. a wave abnormalities
Prominent or Large a waves
 Increased resistance to RA emptying  Increased RA
contraction. (e.g. TS, RA myxomas, Tricuspid atresia).
 Increased RVedp  RVH  Decreased RV
compliance. (e.g. PS, PAH as in MS, Acute PE, RV
infarction.)

32. Giant a Waves or Cannon Waves
 RA contracts against closed TV during RV systole.
 Paul Wood – Venous Corrigan.
 Most prominent during arrhythmias.
 Regular seen in:
 Junctional rhythm
 VT 1:1 retrograde conduction
 Irregular seen in:
 CHB
 Classic AV dissociation
 VT
 VPCs

33. Absent a Waves
 Seen when there is no effective atrial contraction.
 AF
 Sinus tachycardia – a wave may fuse with preceding v
wave.

34. Abnormalities of x descent
Absent x descent
 TR
 Blunting of x descent – early sign of TR.
Prominent x descent
 Vigorous RV contraction.
 Cardiac tamponade.
 Constrictive pericarditis.
 RV overload – ASD.

35. Abnormalities of v wave
Prominent v wave
 Increased RA blood volume during ventricular systole
when normally TV is closed in TR.
 It can sometimes cause:
 Systolic movement of earlobe.
 R  L head throbbing with each ventricular systole.
 Pistol shots heard over IJV.
 Pulsatile exophthalmos.

36. Prominent v wave in absence of TR
 Large ASD.
 VSD of LV to RA shunt (Gerbode’s defect).
 Severe CHF.
 AF.
 Cor Pulmonale.

37. Prominent a and v wave
 Non restricted ASD with normal venous pressure.
 CP with increased venous pressure.

38. Abnormalities of y descent
Rapid (Diastolic Collapse) y descent
 Elevated venous pressure, myocardial dysfunction or
severe ventricular dilatation.
 Severe TR.
 CP. (Friedrich’s sign) Usually accompanied by
pericardial knock.
 Severe RVF.
 ASD with MR.

39. Slow y descent
 Impeded RA emptying and RV filling.
 TS.
 RA myxoma.
 Cardiac tamponade (y descent may even be absent).

41. Hepatojugular reflux (HJR)
 Rondot (1898) coined the term ‘hepatojugular reflux’.
 Useful diagnostic maneuver when –
1. JVP is borderline elevated
2. Latent RVF
3. Silent TR is suspected

42. Maneuver:-
 Gently apply firm pressure to the periumblical region
for 10 – 30 sec with patient lying comfortably and
breathing quietly.
 JVP is observed.
 Pressure shouldn’t applied over the Liver in Rt.
hypochondrium region, as it may be painful in
presence of hepatic congestion.

44. Observations:
 Normal subjects:
 JV pressure rises transiently (<15 sec.) to <3cm while
abdominal pressure is continued.
 Normal RV is able to receive the augmented venous
return to Rt. heart without a rise in mean venous
pressure.
 Positive HJR:
 Elevated CVP or PAWP.
 Acute RVF.
 LVF with hypervolemia or fluid overload.
 TR
 COPD (false positive AJR).

45. Positive Response
 A Sustained rise of >3cm in venous pressure for at least
15 sec after resumption of spontaneous respiration is a
positive response.
 A positive test result indicates the inability of the right
heart to handle an increased venous return.

46. Mechanism
 Displacing splanchnic venous blood towards the heart.
 In CCF systemic venous hypertension makes the
venous system inelastic, tight, and non-compliant.
 In any such hydraulic system, pressure exerted upon
smaller vessels (e.g. splanchnic) will be transmitted to
larger vessels (e.g. cervical veins).

47.  Abdominal compression forces venous blood into
thorax.
 A failing/dilated RV is not able to receive venous
return without rise in mean venous pressure.
 A challenging alternative view is that in a normal
patient the IVC is a flaccid tube, which is compressed
by abdominal pressure, thereby reducing venous
return to the heart.

48.  As with all tests of physical signs there is inevitable
inter-observer variability.
 Nonetheless this test – performed correctly – has a
66% sensitivity and up to 100% specificity for
distinguishing tricuspid from mitral incompetence.
 It has again a high specificity for diagnosing heart
failure.

49.  When done in a standardized fashion, correlates
best with the PAWP.
 Reflection of an increased central blood volume.
 In the absence of isolated RVF, seen in some
patients with RV infarction, a positive
abdominojugular test suggests a PAWP of
≥15 mm Hg.

50. Hepatojugular reflux

51. Kussmaul’s sign and Pulsus Paradoxus
 Increase in jugular venous pressure with inspiration is
commonly referred to as Kussmaul’s sign.
 Disappearance of the radial pulse or a drop in systolic
blood pressure of 10 mmHg or greater with inspiration
is recognized as pulsus paradoxus.
 Both Kussmaul’s sign and pulsus paradoxus are
commonly attributed to the discoveries of Dr. Adolf
Kussmaul.

52. Kussmaul’s sign
 Normally, JVP decreases with inspiration.
 Kussmaul’s sign – Increase in venous pressure during
inspiration.

53. Inspiration  negative intrathoracic pressure
Enhances the pressure gradient between the positive
abdominal pressure and negative intrathoracic
pressure within the thorax and superior vena cavae.
Translocation of blood volume.
Increasing right ventricular pressure and volume, and
decreasing right atrial pressure.

54. Increase in negative
intrathoracic pressure.
Increased pulmonary pooling of
blood volume.
Decreased LA and LV filling from
the pulmonary venous system.
Slight drop in systolic blood
pressure.

55. Pathophysiological mechanisms
 Kussmaul’s sign explained by conditions which cause RV
dysfunction, impair RV filling, and raise atrial pressure .
 The inability for cardiac chambers to expand due to-
(1) hypoelasticity or inelasticity of the myocardium:
infection and fibrosis (RCM)
2) mechanical compartmentalization by constrictive
pericardial diseases (constrictive pericarditis)
(3) impaired RV function resulting from RVMI, impede
effective RV filling and cause a paradoxical increase in JVP
during inspiration.

56. Mechanism of Kussmaul’s sign

57.  Thus, Kussmaul’s sign is seen in conditions that
restrict RV filling such as
 Constrictive pericarditis
 RVF
 RVMI
 Tricuspid stenosis
 Therefore, conditions that raise right atrial and venous
pressure are a prerequisite to cause Kussmaul’s sign.

58. Kussmaul’sign not seen in Cardiac Temponade
 Increase in pericardial pressure  inward force 
compressing the entire heart during inspiration.
 Increase in negative intra-thoracic pressure is still able
to be transmitted to the right side of the heart and
subsequent increase in blood flow to the RA ensues.

59. JVP DCM RCM EMF Cardiac
Tamponade
CP
JV pressure May be
elevated
May be
elevated
Usually
elevated
Elevated Elevated
a waves Normal Prominent Prominent Never
prominent
Normal or
may be
prominent
v waves May be
prominent
Normal Prominent
due to TR
Normal Usually
equal to a
waves
x descent Normal Normal Obliterated
with TR
Normal Prominent
y descent May be
rapid
descent
Normal Rapid
descent due
to TR
or absent Rapid
Kussmaul’s
sign
Negative May be
positive
Negative Negative.
May be
positive
Usually
positive

60. JVP Cardiac Tamponade Constricitve Pericarditis
JV pressure Elevated Eleavted
a waves Never prominent. Normal, may be prominent
v waves Normal Usually equal to a waves
x descent Normal Prominent
y descent or absent Rapid
Kussmaul’s sign Negative, may be positive Usually positive
JVP in Pericardial Diseases

61. ASD with R  L shunt VSD with R  L PDA with R  L shunt
JV pressure may be
elevated.
Usually normal. May be elevated.
Normal a waves, but
absent with AF
Normal a waves a waves may be
prominent
Prominent v waves with
CHF or TR
Normal v waves.
CHF and TR rare
Prominent v waves with
CHF or TR
JVP in Eisenmenger complex and syndrome

62. Take message
 An accurate assessment of the venous pulse, JVP reflects the dynamics
of the right side of the heart.
 Therefore, a careful examination of the neck veins in various
conditions is helpful.