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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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StatPearls [Internet].

Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

Physiology, Jugular Venous Pulsation

Saranyan Senthelal ; Manish Maingi .

Authors

Saranyan Senthelal 1 ; Manish Maingi 2 .

Affiliations

1 St. George's University 2 Trillium Health, University of Toronto

Last Update: January 30, 2023 .

Introduction

Running along the sternocleidomastoid muscle, the internal jugular vein (IJV) provides deoxygenated blood directly to the right atrium (RA). Although there is a functional valve bordering the superior vena cava (SVC) and RA, this valve does not appear to hinder the phasic flow of blood to the RA. Therefore, the pulsations that can be observed at the level of the IJV can provide valuable insight into the hemodynamics of blood at the level of the RA.[1] The importance of the relationship between the IJV and RA provides healthcare professionals with an invaluable physical examination tool. The bedside examination of the jugular venous pulse (JVP) can be used to determine the central venous pressure (CVP), venous pulse contour, and many cardiac pathologies.[2]

Issues of Concern

The examination of the JVP is a frequently overlooked physical examination technique due to the plethora of advancing technologies.[3] However, the importance that healthcare practitioners understand this examination remains important because it is not only resourceful but is also diagnostically valuable and can be easily repeatable.[3]

Function

The JVP tracing is a measurement of the right atrial pressure (RAP) that can provide the status of a patient’s intravascular volume. The JVP tracing can be obtained from inserting a central line into the superior vena cava or, less invasively, can be observed from the bedside.[4] At the bedside, the JVP is often observed at the right side of the patient’s neck, more specifically it can be seen passing diagonally over the top of the sternocleidomastoid muscle. Next, once the patient is in a comfortable reclined position, a penlight can be pointed at a 45-degree angle towards the midline of the neck. The examiner should now be able to observe and measure the venous pulsations. The height of the JVP can be measured by intersecting 2 rulers perpendicularly, one ruler extending horizontally from the observed JVP and the other ruler extending vertically from the sternal angle of Louis.[5][6] The distance from the sternal angle to the intersection is then measured. Finally, the height of JVP is simply calculating by adding the distance measured, plus the constant distance from the midpoint of the RA to the sternal angle (5 cm HO).[7][8] The midpoint of the RA is added because the JVP is defined as the vertical distance above this point. Normally, the JVP is between 6 to 8 cm H2O.

Mechanism

The tracings of the jugular venous pulse wave, which can be observed using cardiac catheterization, are said to be biphasic due to the presence of alternating peaks and troughs.[1][9] The tracing begins with an "A" wave peak that corresponds to the contracting right atrium (atrial systole), next there is a "C" wave peak that represents the contracting right ventricle (ventricular systole) causing the tricuspid valve to bulge towards the right atrium during RV isovolumetric contraction. Following the “C” wave there is an "X" (X prime) descent result of the right ventricle pulling the tricuspid valve downward during ventricular systole. [10] Additionally, there is also an “X” descent that follows the "A" wave which represents atrial relaxation and the resulting rapid atrial filling that ensues (atrial systole).[11] The "V" wave represents venous filling when the tricuspid valve is closed and venous pressure increases from venous return. Finally, as the tricuspid valve opens and the blood in the right atrium empties into the right ventricle (ventricular diastole), this is the final trough, known as the “Y descent” on the pressure tracing.[11]

Pathophysiology

The first peak observed in a normal jugular venous pulse wave tracing, the "A" wave, represents the contraction of the atria (atrial systole). Therefore, in patients with atrial fibrillation, the "A" wave is often attenuated due to the absence of atrial contraction.[10][11][12] Furthermore, the absence of contraction in atrial fibrillation additionally means atrial relaxation must also not be occurring, causing an attenuation of the "X" descent.[12] On the contrary, the "A" wave can be more pronounced, and the "Y" descent can be slightly attenuated when there is an increased resistance of blood flow traveling through the right atrium. Increased resistance across the tricuspid valve is often seen in patients with pulmonary hypertension, tricuspid stenosis, and pulmonic stenosis.[13][14][15][16][17]

The chronological sequence of the atria contracting before the ventricles is important for the shuttling of blood through the circulatory system. When this sequence becomes asynchronous, such as what is seen with third-degree atrioventricular heart block, this can cause the atria and ventricles to contract at the same time.[18][19][1] This can, unfortunately, prevent the shuttling of blood through the tricuspid valve due to the force of ventricular contraction. As a result, the easily discernible "Cannon A wave" can be seen on the jugular venous pulse wave tracing and even on physical exam.[20][21]

Tricuspid regurgitation occurs during systole, as a portion of blood is inadvertently sent back to the atrium through an incompetent tricuspid valve, rather than through the pulmonary arteries.[22] This is also quite noticeable in pulse tracings, as there can be a very prominent attenuation of the "X" descent or even the formation of a "CV" wave. A "CV" wave, which occurs when the "X" descent diminishes, can be observed in severe cases of tricuspid regurgitation.[20][23]

The "Y" descent can also be significantly attenuated because of the inability of the right atrium to relax during ventricular diastole.[24] The fixed perimeter of the fluid-filled pericardial sac results in increased pressure on the right atrium during its emptying of blood into the right ventricle. Although there is blood leaving the atrium potentially relieving pressure on the atrium, this relief is immediately negated by the pressure from the upward shift of fluid within the pericardial sac as a result of the expansion of the right ventricle.[25][26][27] This phenomenon is known as cardiac tamponade. Cardiac tamponade can be characterized on a JVP tracing as a severely attenuated or absent "Y" descent. On the contrary, one can observe a very prominent "Y descent' (Friedreich's sign) with constrictive pericarditis due to the limited ability of the right ventricle to expand during ventricular diastole.[28][29]

Clinical Significance

Critical bedside examination of the jugular venous pulse (JVP) provides an invaluable amount of information relating to both disease process and medication management. Using the method above to examine the height of the JVP, clinicians are able to interpret the volume status of patients. Simply stated, an elevated JVP of greater than 9 cm H2O (venous hypertension) along with other symptoms can help distinguish between left and right heart failure, suggest pericardial disease, and suggest some specific types of arrhythmias.[4] Conversely, a low JVP of less than 5 cm H2O can reflect either hypovolemia or the use of diuretics. The JVP assessment used alongside other diagnostic cardiac testing can help the clinician to make the proper diagnosis and guide treatment decisions.[4]

Review Questions

References

Applefeld MM. The Jugular Venous Pressure and Pulse Contour. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd ed. Butterworths; Boston: 1990. [PubMed : 21250143 ]

McGee SR. Physical examination of venous pressure: a critical review. Am Heart J. 1998 Jul; 136 (1):10-8. [PubMed : 9665212 ]

Metkus TS, Kim BS. Bedside Diagnosis in the Intensive Care Unit. Is Looking Overlooked? Ann Am Thorac Soc. 2015 Oct; 12 (10):1447-50. [PMC free article : PMC4627420 ] [PubMed : 26389653 ]

Chua Chiaco JM, Parikh NI, Fergusson DJ. The jugular venous pressure revisited. Cleve Clin J Med. 2013 Oct; 80 (10):638-44. [PMC free article : PMC4865399 ] [PubMed : 24085809 ]

Economides E, Stevenson LW. The jugular veins: knowing enough to look. Am Heart J. 1998 Jul; 136 (1):6-9. [PubMed : 9665211 ]

Cook DJ, Simel DL. The Rational Clinical Examination. Does this patient have abnormal central venous pressure? JAMA. 1996 Feb 28; 275 (8):630-4. [PubMed : 8594245 ]

Ewy GA. Bedside evaluation of the jugular venous pulse in the acute care setting. 1983-1984 Acute Care. 10 (3-4):194-9. [PubMed : 6545501 ]

Seth R, Magner P, Matzinger F, van Walraven C. How far is the sternal angle from the mid-right atrium? J Gen Intern Med. 2002 Nov; 17 (11):852-6. [PMC free article : PMC1495124 ] [PubMed : 12406357 ]

Pyhel HJ, Stewart J, Tavel ME. Clinical assessment of calibrated jugular pulse recording. Br Heart J. 1978 Mar; 40 (3):297-302. [PMC free article : PMC481996 ] [PubMed : 637984 ]

Fukuda N, Oki T, Iuchi A, Tabata T, Yamada H, Takeichi N, Shinohara H, Soeki T, Yui Y, Tamura Y. Right heart flow dynamics after tricuspid valve annuloplasty. Characteristics and time course. Jpn Heart J. 1998 May; 39 (3):339-46. [PubMed : 9711185 ]

Lee CH, Xiao HB, Gibson DG. Jugular venous 'a' wave in dilated cardiomyopathy: sign of abbreviated right ventricular filling time. Br Heart J. 1991 Jun; 65 (6):342-5. [PMC free article : PMC1024679 ] [PubMed : 2054245 ]

Silverman ME. From rebellious palpitations to the discovery of auricular fibrillation: contributions of Mackenzie, Lewis and Einthoven. Am J Cardiol. 1994 Feb 15; 73 (5):384-9. [PubMed : 8109554 ]

Devine PJ, Sullenberger LE, Bellin DA, Atwood JE. Jugular venous pulse: window into the right heart. South Med J. 2007 Oct; 100 (10):1022-7; quiz 1004. [PubMed : 17943049 ]

Chen JP. Back to basics: editorial review of "jugular venous pulse: window into the right heart". South Med J. 2007 Oct; 100 (10):968. [PubMed : 17943035 ]

Ma TS, Paniagua D, Denktas AE, Jneid H, Kar B, Chan W, Bozkurt B. Usefulness of the Sum of Pulmonary Capillary Wedge Pressure and Right Atrial Pressure as a Congestion Index that Prognosticates Heart Failure Survival (from the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness Trial). Am J Cardiol. 2016 Sep 15; 118 (6):854-859. [PubMed : 27474338 ]

Stojnic BB, Brecker SJ, Xiao HB, Gibson DG. Jugular venous 'a' wave in pulmonary hypertension: new insights from a Doppler echocardiographic study. Br Heart J. 1992 Aug; 68 (2):187-91. [PMC free article : PMC1025012 ] [PubMed : 1389735 ]

Ranganathan N, Sivaciyan V. Abnormalities in jugular venous flow velocity in pulmonary hypertension. Am J Cardiol. 1989 Mar 15; 63 (11):719-24. [PubMed : 2646897 ]

Vigo V, Lisi P, Galgano G, Lomonte C. Lancisi's sign and central venous catheter tip position: a case report. J Vasc Access. 2018 Jan; 19 (1):92-93. [PubMed : 28731490 ]

Hosoi K, Fukuda N, Iuchi A, Ogawa S, Hayashi M, Fujimoto T, Kiyoshige K, Fukuda K, Oki T. [Characteristics of jugular venous pulse and its genesis in Ebstein's anomaly]. J Cardiol. 1992; 22 (2-3):475-85. [PubMed : 1339806 ]

Morgan DE, Norman R, West RO, Burggraf G. Echocardiographic assessment of tricuspid regurgitation during ventricular demand pacing. Am J Cardiol. 1986 Nov 01; 58 (10):1025-9. [PubMed : 3776842 ]

Luisada AA, Singhal A, Kim K. The jugular and hepatic tracings in normal subjects and in conduction defects. Acta Cardiol. 1983; 38 (5):405-24. [PubMed : 6606920 ]

Mulla S, Asuka E, Bora V, Siddiqui WJ. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Nov 17, 2022. Tricuspid Regurgitation. [PubMed : 30252377 ]

ur Rehman H. Images in clinical medicine: Giant C-v waves of tricuspid regurgitation. N Engl J Med. 2013 Nov 14; 369 (20):e27. [PubMed : 24224640 ]

Zhang S, Kerins DM, Byrd BF. Doppler echocardiography in cardiac tamponade and constrictive pericarditis. Echocardiography. 1994 Sep; 11 (5):507-21. [PubMed : 10150627 ]

Kearns MJ, Walley KR. Tamponade: Hemodynamic and Echocardiographic Diagnosis. Chest. 2018 May; 153 (5):1266-1275. [PubMed : 29137910 ]

Sivaciyan V, Ranganathan N. Transcutaneous doppler jugular venous flow velocity recording. Circulation. 1978 May; 57 (5):930-9. [PubMed : 639215 ]

Stashko E, Meer JM. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Aug 7, 2023. Cardiac Tamponade. [PubMed : 28613742 ]

Yacoub M, Quintanilla Rodriguez BS, Mahajan K. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jul 24, 2023. Constrictive-Effusive Pericarditis. [PMC free article : PMC519579 ] [PubMed : 30137863 ]

Yadav NK, Siddique MS. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Feb 13, 2023. Constrictive Pericarditis. [PubMed : 29083701 ]

Disclosure: Saranyan Senthelal declares no relevant financial relationships with ineligible companies.

Disclosure: Manish Maingi declares no relevant financial relationships with ineligible companies.