Definition

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Definition

• Jugular Venous Pulse
• defined as the oscillating top of
  vertical column of blood in right IJV that
  reflects pressure changes in Right Atrium in
  cardiac cycle.
• Jugular Venous Pressure
• Vertical height of oscillating
  column of blood.

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Why Internal Jugular Vein?

• IJV has a direct course to RA.
• IJV is anatomically closer to RA.
• IJV has no valves( Valves in EJV prevent
  transmission of RA pressure)
• Vasoconstriction Secondary to hypotension (
  in CCF) can make EJV small and barely visible.

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Why Right Internal Jugular Vein?

• Right jugular veins extend in an almost straight
  line to superior vena cava, thus favouring
  transmission of the haemodynamic changes from the
  right atrium.
• The left innominate vein is not in a straight
  line and may be kinked or compressed between
  Aortic Arch and sternum, by a dilated aorta, or
  by an aneurysm.

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L
R
                                          
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Difference from Carotid Pulse
Venous Pulse Carotid Pulse
More lateral Medial
Wavy, Undulant Forceful, Brisk
Decrease with Inspiration No change
Increase in supine position No change
with abdominal pressure No change
Double Peaked Single Peak
Obliterated with Pressure Cannot be Obliterated
Better Visible Better palpated
Better viewed from foot end of bed
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Method Of Examination

• The patient should lie comfortably during the
  examination.
• Clothing should be removed from the neck and
  upper thorax.
• Patient reclining with head elevated 45
• Neck should not be sharply flexed.
• Examined effectively by shining a light
  tangentially across the neck.
• There should not be any tight bands around abdomen

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Observations Made

• the level of venous pressure.
• the type of venous wave pattern.

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The level of venous pressure

• Using a centimeter ruler, measure the vertical
  distance between the angle of Louis (manubrio
  sternal joint) and the highest level of jugular
  vein pulsation.
• The upper limit of normal is 4 cm above the
  sternal angle,.
• Add 5 cm to measure central venous pressure since
  right atrium is 5 cm below the sternal angle.
• Normal CVP is lt 9 cm H2O

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Normal pattern of the jugular venous pulse
x
x

• The normal JVP reflects phasic pressure changes
  in the right atrium and consists of three
  positive waves and two negative troughs
• Simultaneous palpation of the left carotid artery
  aids the examiner in relating the venous
  pulsations to the timing of the cardiac cycle.

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a WAVE

• Venous distension due to RA contraction
• Retrograde blood flow into SVC and IJV
• Synchronous with S1, Follow P of ECG
• Precede Carotid pulse

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• The x descent is due to
• X Atrial relaxation
• X Descent of the floor of the right
  atrium
• during right ventricular systole.
• Begins during systole and ends before S2
• The c wave
• Occurs simultaneously with the carotid pulse
• Artifact by Carotid pulsation
• Bulging of TV into RA during ICP

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v WAVE

• Rising right atrial pressure when blood flows
  into the right atrium during ventricular systole
  when the tricuspid valve is shut.
• Synchronous with Carotid pulse
• Begins in early systole, Peaks after S2 and ends
  in early diastole

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y DESCENT

• The decline in right atrial pressure when the
  tricuspid valve reopens
• Following the bottom of the y descent and before
  beginning of the a wave is a period of relatively
  slow filling of the ventricle, the diastases
  period, a wave termed the h wave.

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Identifying Wave Forms

• The x descent occurs just prior to the second
  heart sound ( during systole), while the y
  descent occurs after the second heart sound
  (during diastole).
• Normally X descent is more prominent than Y
  descent. Y descent is only sometimes seen during
  diastole. Descents are better seen than positive
  waves.
• The a wave occurs just before the first sound or
  carotid pulse and has a sharp rise and fall.
• The v wave occurs just after the arterial pulse
  and has a slower undulating pattern.
• The c wave is never seen normally.

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Abnormalities of jugular venous pulse

• Low jugular venous pressure
• 1. Hypovolaemia.

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B. Elevated jugular venous pressure

• 1. Intravascular volume overload conditions
• Right ventricular
  infarction
• Left heart failure
• Myocardial infarction.
• Valvular Heart Disease
• Cardiomyopathy
• 2. Constrictive pericarditis.
• 3. Pericardial effusion with tamponade

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Elevated a wave

• Increased Resistance to RV Filling.
• Tricuspid stenosis
• R Heart Failure
• PS
• PAH

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Cannon a wave

• Atrial-ventricular Dissociation
• (atria contract against
• a closed tricuspid valve)
• Complete heart block
• VPC
• Ventricular tachycardia
• Ventricular pacing
• Junctional rhythm
• Junctional tachycardia.

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Absent a wave

• 1. Atrial fibrillation

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Elevated v wave

• 1. Tricuspid regurgitation.
• 2. Right ventricular failure.
• 3. Restrictive cardiomyopathy.
• 4. Cor Pulmonale

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Tricuspid regurgitation

• Absent X Decsent
• CV/ Regurgitant Wave
• Has a rounded contour and a sustained peak
• Followed by a rapid deep Y descent
• Amplitude of V increases with inspiration.
• Cause subtle motion of ear lobe with each heart
  beat

c
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a wave equal to v wave

• ASD
• Prominent X descent followed by a large V wave
• M Configuration
• Indicates a large L-R shunt
• With PAH A wave becomes more prominent
• If L JVP gt R JVP indicates associated PAPVC

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Prominent x descent

• Cardiac tamponade.
• Constrictive Pericarditis
• RVMI
• Restrictive Cardiomyopathy
• Atrial septal defect

Blunted x descent
1. Tricuspid regurgitation. 2. Right atrial
ischaemia
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Prominent y descent

• 1. Constrictive pericarditis.
• 2. Tricuspid regurgitation.
• 3. Atrial septal defect.

Absent y descent
1. Cardiac tamponade. 2. Right ventricular
infarction 3. Restrictive Cardiomyopathy
Slow y descent
1. Tricuspid stenosis. 2. Right atrial myxoma.
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Constrictive pericarditis.

• M shaped contour
• Prominent X and Y descent (FRIEDREICHSIGN)
• Y descent is prominent as ventricular filling is
  unimpeded during early diastole.
• This is interrupted by a rapid raise in pressure
  as the filling is impeded by constricting
  Pericardium
• The Ventriclar pressure curve exhibit Square Root
  sign

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Abdomino-jugular reflux

• Is positive when JVP increase after 10 sec of
  abdominal pressure followed by a rapid drop in
  pressure of 4 cm on release of compression.
• Most common cause of a positive test is RHF
• Positive test in Borderline elevation of JVP
• Silent TR
• Latent RHF
• False positive Fluid overload
• False Negative SVC/IVC obstruction
• Budd Chiari syndrome
• Positive Test imply SVC and IVC are patent

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Kussmaul sign

• Failure of decline in JVP occur during
  inspiration.
• Constrictive Pericarditis
• Severe RHF
• Restrictive Cardiomyopathy
• Tricuspid Stenosis

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