Jugular Venous Pulsation

Aka: Jugular Venous Pulsation, Jugular Venous Distention, Jugular Venous Pulse, Jugular Venous Pressure, Kussmaul's Sign, JVD, JVP, Hepatojugular Reflux, Abdominojugular Test, HJR

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II. Physiology: Atrial Pressure Waves

  1. A Wave
    1. Rise in atrial pressure during late diastole with atrial contraction
    2. A Wave may be visible at Jugular Vein in neck on bedside exam
      1. Precedes carotid pulsation
    3. Large A Wave causes
      1. Pulmonary Artery Stenosis
      2. Third degree AV Block
        1. Atrium contracts against a closed tricuspid valve (simultaneous atrial and ventricular contraction)
  2. C Wave
    1. Atrioventricular valves close during the start of systole
  3. V Wave
    1. Atrial filling during systole
    2. Large V Wave Causes
      1. Large V waves may be visible in neck (coinciding with S1 Heart Sound)
      2. Tricuspid insufficiency

III. Technique: Jugular Venous Pressure measurement

  1. Examine position
    1. Head of bed elevated at 45 degree angle
    2. Head turned to right
  2. Identify top of venous pulsation in neck (JVP)
    1. Jugular Venous Pulsations are inward
    2. Contrast with outward Carotid Artery pulsations
  3. Identify the sternal angle (Angle of Louis)
    1. Located at superior edge or notch of Sternum
  4. Measure distance between top of pulsation and Sternum
    1. Measured in centimeters

IV. Interpretation: Distance between JVP and Sternum

  1. Normal: 4 cm or less
  2. Increased >4 cm (Jugular Venous Distention)
    1. Right-sided Heart Failure (most common)
      1. Increased Right Atrial Pressure
    2. Constrictive Pericarditis
    3. Tricuspid stenosis
    4. Superior Vena Cava Obstruction
    5. Valsalva phenomenon (laughing, coughing)
  3. Provocative: Hepatojugular Reflux
    1. Apply firm pressure to midabdomen for 30 seconds
      1. Apply 20-30 mmHg of pressure
    2. Positive test: >4 cm JVP rise for >10 seconds
      1. Suggests CHF (right or left sided failure)
      2. Falsely positive if Valsalva (abdominal guarding)
  4. Kussmaul's Sign
    1. Paradoxical rise in JVP with inspiration
      1. JVP normally falls with inspiration
    2. Causes
      1. Constrictive Pericarditis
      2. Cardiac Tamponade

V. Efficacy in CHF diagnosis

  1. Jugular Venous Distention (JVD) alone
    1. Test Sensitivity: 17%
    2. Test Specificity: 98%
  2. JVD with Hepatojugular reflex (provocative)
    1. Test Sensitivity: 33%
    2. Test Specificity: 94%

VI. References

  1. Bates (1991) Physical Exam, p. 287-8
  2. Timmis (1988) Cardiology, p. 12
  3. Degowin (1987) Bedside Exam, p. 409-15
  4. Dosh (2004) Am Fam Physician 70:2145-52 [PubMed]

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