This document discusses jugular venous pulse (JVP) examination and provides information on three related signs: hepatojugular reflex, Kussmaul's sign, and pulsus paradoxus. It defines each sign and explains their pathophysiology and clinical significance. The hepatojugular reflex test evaluates right heart function by observing changes in JVP during abdominal compression. Kussmaul's sign and pulsus paradoxus involve paradoxical increases or decreases in JVP and blood pressure with inspiration, respectively, and indicate conditions that restrict right ventricular filling. The document also covers techniques for evaluating these physical exam findings.

1. DR MANISH RUHELA
Department of Cardiology
Sawai Man Singh Medical College, jaipur

2. Hepatojugular reflex
Kussmaul’s sign
Pulsus Paradoxus

3. Some points about JVP :-
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 changes in the right heart.

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

5. 1. Anatomy
2. JV pressure measurement
3. Normal wave pattern

6. Jugular veins
Internal jugular vein
External jugular vein

8. Lateral to
carotid artery &
deep to
sternomastoid
muscle.
External jugular
is superficial to
sternomastoid

10. Examination of JVP
Right IJV is usually assessed both for waveform
and estimation of venous pressure
Unlike EJV pulsation, it is not possible to see IJV
pulsation directly as it is deep.
We actually see the transmitted pulsations to
overlying skin between two heads of
sternocleidomastoid.

11. Right IJV Preferred :Why?
Right IJV have straight line course through innominate vein
to the svc and right atrium
Less likely extrinsic compression from other structures in
neck.
Left innominate vein compressed by arch of Aorta and
Presence of Left SVC can falsely elevate the JVP on Left
side.
Left IJV drains into Lt innominate vein, which is not in
straight line from RA.
Why not EJV
No or less numbers of valves in IJV than EJV

12. 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

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. Jugular venous pressure
Level of sternal angle is about 5 cm above the level of
mid right atrium IN ANY POSITION.
JVP is measured in ANY position in which top of the
column is seen easily.
Usually JVP is less than 8 cm water
< 3 cm column above level of sternal angle.

15. 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 .

18. 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 .

20. Normal waveform
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)
one additional positive wave can be recorded C
wave interrupts x descent.

21. Normal JVP Waveform
a wave - atrial systole
x descent – onset of
atrial relaxation
c wave - small positive
notch in the 'x' descent
due to bulging of the AV
ring into the atria in
ventricular contraction.
x' (prime) descent !!!
occurs during systole due
to RV contraction pulling
down the TV valve ring
“descent of the base”
a measure of RV
contractility
v wave - after the x'
descent - slow positive wave
due to right atrial filling
from venous return
y descent - rapid
emptying of the RA into RV
due to TV opening

22. 1.Hepatojuglar reflux
The Original Description in 1885:
The Lancet. September 19, 1885
Note on a
NEW PHYSICAL SIGN OF TRICUSPID
REGURGITATION
By W. Pasteur, M.D. Lond., M.R.C.P.,
Medical Registrar to the Middlesex Hospital, Etc.

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

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

26. What happened in Normal
Subjects:-
JV pressure rises transiently (<15 sec.) to <3cm while
abdominal pressure is continued, because Normal RV
is able to receive the augmented venous return to Rt
heart without a rise in mean venous Pressure.

27. 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.

28. Mechanism
The test probably works by displacing splanchnic
venous blood towards the heart.
It has been suggested that in congestive cardiac failure
(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).

29. Abdominal compression forces venous blood into
thorax.
A failing/dilated RV not able to receive venous return
without rise in mean venous pressure.

30. 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.
Hence only if the IVC is already distended will
compressing the abdomen create a pressure wave and raise
the JVP, so some would say that abdomino-jugular reflux
is per se a sign of pathology.
In fact as the physiology is still not completely understood
it is probably safer to call this the abdomino-jugular test,
and altogether omit the word reflux.

31. Positive AJR Suggests:-
Elevated CVP or PAWP and occurs in-
1. Incipient or actual RVF
2. LVF with Hypervolemia or fluid overload
3. TR

32. False Positive AJR:-
1. COPD – sudden disproportionate increase in
intrathoracic pressure impedes venous return,which
elevates JVP .
2. Increased generalised Sympathetic tone
(pain,nervousness,IV catecholamines)-
causes decreased distensibility of venous bed and
false positive AJR

33. How should the Abdomen is compressed in order to prevent false
elevations of venous pressure due to sympathetic overactivity ?
1) Compress with warm hands or with a sheet between
our hand and abdomen.
2) Spread the fingers apart,to avoid localised pressure.
3) Strat by pressing gently , and gradually increases the
pressure to just below the point of discomfort.

34. 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.

35. The abdominojugular test: technique and hemodynamic correlates
Ann Intern Med 1988 Dec 15;109(12):997
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

36. Hepatojugular reflux

37. 2.Kussmaul’s sign and Pulsus
Paradoxus
Increased 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.

38. Adolf Kussmaul (1822–1902)

39. Kussmaul’s sign
Normally, JVP decreases with inspiration ,but if the
venous pressure increases during inspiration , it is
known as Kussmaul’s sign.

40. Physiologically, in healthy individuals, Inspiration creates
negative intrathoracic pressure, and enhances the pressure
gradient and translocation of blood volume between the
positive abdominal pressure and negative intrathoracic
pressure within the thorax and superior vena cavae.
increasing right ventricular pressure and volume, and
decreasing right atrial pressure.
Furthermore, the increase in negative intrathoracic
pressure causes decreased left-atrial and left ventricular
filling from the pulmonary venous system due to increased
pulmonary pooling of blood volume which in turn causes a
slight drop in systolic blood pressure.

41. pathophysiological mechanisms
Kussmaul’s sign explained by conditions which cause right
ventricular dysfunction, impair right ventricular filling, and raise
atrial pressure .
The inability for cardiac chambers to expand due to-
(1) hypoelasticity or inelasticity of the myocardium caused by
conditions such as infection and fibrosis (restrictive
cardiomyopathy)
2) mechanical compartmentalization by constrictive pericardial
diseases (constrictive pericarditis)
(3) impaired right ventricular function resulting from RVMI,
impede effective RV filling and cause a paradoxical increase in
jugular venous pressure during inspiration.

42. Mechanism of Kussmaul’s sign

43. Thus, Kussmaul’s sign is seen in conditions that
restrict right ventricular 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

44. The presence of Kussmaul’s sign in patients with
constrictive pericarditis and/or restrictive
cardiomyopathy and not cardiac tamponade can be
accounted for by the physiological differences in filling
patterns and thus provides a physician with useful
bedside information for diagnostic decision making.

45. Kussmaul’sign not seen in Cardiac
Temponade
Kussmaul’s sign is not seen in patients with cardiac
tamponade because
the increase in pericardial pressure exerts an inward
force compressing the entire heart during inspiration,
the increase in negative intrathoracic pressure is still
able to be transmitted to the right side of the heart and
subsequent increase in blood flow to the right atrium
ensues

46. the restriction to diastolic filling of the right ventricle
in constrictive pericarditis and restrictive
cardiomyopathy by the fixed, less compliant
constricting pericardium or myocardium respectively
at higher chamber volumes, results in the paradoxical
increase in jugular venous pressure referred to as
Kussmaul’s sign.

47. 3.Pulsus Paradoxus
Term coined by Kussmaul in 1873.
Defined as apparent paradox of disappearance of pulse
during inspiration despite the presence of heart beat.
It is an exaggeration of normal inspiratory decline in
systolic arterial pressure of >10 mmhg .

48. Normally, Systolic BP slightly decreases with
inspiration –
- lung capacity increases and Pulmonary vascular bed
expands
- Less blood moves from Lung in to Left Heart

49. Mechanism
There is no consensus on the underlying mechanism
of pulsus paradoxus.
The major theories proposed for the mechanism in
cardiac tamponade have included:-
1. Pooling of blood in the pulmonary vasculature
during inspiration as a result of increased pulmonary
venous compliance, leading to decreased left
ventricular filling (“pulmonary venous pooling”)

50. 2.Impaired filling of the left ventricle due to inspiratory filling of the
right heart in a constricted pericardial space (“ventricular diastolic
interdependence”)
RV distends due to increased venous return, the interventricular
septum bulges into the left ventricle reducing its size and increased
pooling on blood in the expanded lungs decreases return to the left
ventricle, decreasing the stroke volume of the left ventricle.

51. Increased respiratory variability in systemic venous
return in cardiac tamponade (“systemic venous return
variation”).
Ventricular septal flattening causes impaired left
ventricular systolic function (“ventricular systolic
interdependence”).

52. In exacerbations of asthma and COPD, the
exaggerated swings in pleural pressure may enhance
the normal respiratory variation in venous return
through the mechanisms discussed. In addition,
hyperinflation of the lungs in these conditions may
also impede right ventricular ejection causing
decreased filling of the left ventricle (“pulmonary
afterload”).

53. Mechanism of Pulsus Paradoxus

56. MEASUREMENT OF PULSUS
PARADOXUS —
- With a sphygmomanometer, the blood pressure is
measured in the standard fashion except that the cuff
is deflated more slowly than usual.
During deflation, the first Korotkoff sound is audible
only during expiration, but with further deflation
additional Korotkoff sounds are clearly heard
throughout the respiratory cycle.
The difference between the systolic pressure at which
the first beats are heard and the pressure at which all
beats are heard is the size of the pulsus.

58. Tachycardia , AF , and Tachypnea make its assessment
difficult.
Pulsus Paradoxus may be palpable when pressure
difference exceeds 15 -20 mmhg.

60. Limitations of Pulsus Paradoxus
Although pulsus paradoxus is a valuable physical sign, it has its
limitations.
The use of the term is not uniform and as it is an exaggeration of
a normal phenomenon, a cut-off value is difficult to provide.
In patients of cardiac tamponade, studies have shown that when
right ventricular diastolic collapse on echocardiography and
pulsus paradoxus were compared, right ventricular diastolic
collapse was more sensitive and more specific than pulsus
paradoxus in detecting increases in intrapericardial pressure
during euvolaemia and hypervolemia whereas the two tests were
equally valuable in hypovolaemic states

61. Contd…….
As with other clinical signs, pulsus paradoxus must not
be considered in isolation but in conjunction with the
patient's clinical state and with other indices of the
severity of asthma.
Finally, the absence of pulsus paradoxus does not rule
out the presence of a significant pericardial effusion.
However, this important bedside sign must be elicited
in indicated patients, foregoing which life threatening
and potentially treatable causes are likely to be missed
by the examining physician.

62. Reverse pulsus Paradoxus
A rise in systolic blood pressure during inspiration,
first described by Massumi et al, in patients with
idiopathic hypertrophic subaortic stenosis
isorhythmic ventricular rhythm
left ventricular failure on positive pressure ventilation.
A rise in peak systolic pressure on inspiration by more
than 15 mm Hg is considered significant.

63. In a mechanically ventilated patient, positive pressure
ventilation displaces the ventricle wall inward during
systole to assist in ventricular emptying causing a
slight rise in the systolic pressure during mechanical
inspiration.
A reverse pulsus paradoxus in mechanically ventilated
patients is a sensitive indicator of hypovolaemia

64. Absent Pulsus Paradoxus in
Cardiac Tamponade
Aortic regurgitation (AR): In the presence of AR, the
left ventricle can fill from the aorta during inspiration.
Therefore, if aortic dissection produces both AR and
tamponade, pulsus paradoxus may be absent.
Large atrial septal defect: The normal increase in
systemic venous return on inspiration is balanced by a
decrease in the left to right shunt, resulting in minimal
change in the right ventricular volume.

65. Contd….
Isolated right heart tamponade: This entity has been
described in patients of chronic renal failure on
hemodialysis
Elevated left ventricular diastolic pressures
Severe rheumatoid spondylitis or disease of the bony
thorax: Wide changes in intrathoracic pressure
prevented by the relative immobility of the chest wall.
Coexistent condition producing "reversed pulsus
paradoxus

66. THANKS