Jugular Venous Distention Workup

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Definition:

Jugular venous distention (JVD) or jugular venous pressure (JVP) focuses on the right atrium and not any other part of the heart because the right subclavian vein and the right internal jugular vein are directly connected to the right atrium. JVP and JVD are stated as "JVD is 10 cm above the right clavicle." We always look for JVD on the right side of the neck with the patient sitting at an angle of 45 degrees.

Internal vs external jugular venous pressure

Now, we don't look for distention in the external jugular vein because internal jugular vein is very superficial and the external jugular vein has valves in it, hence, doesn't accurately reflect the pressure of the right atrium.

How to measure jugular venous distention:

The distance between the right atrium and the sternum is about 5 cm and normal pressure of the right atrium is somewhere between 5-8 cm of water. This means that the right internal jugular venous distention 3 cm above the right clavicle is normal and anything beyond 3 cm is abnormal.

Jugular venous distention waveforms:

We need to look for certain wave forms in internal jugular venous distention; these waveforms only represent pressure in the right atrium and nothing else. When the right atrium contracts, it produces the first positive wave known as the a-wave. As the right atrium contracts, blood moves from right atrium into the right ventricle and the pressure in right atrium decreases producing a negative waveform called the x-wave. As pressure in the right atrium becomes less than pressure in the right ventricle, the tricuspid valve cusp closes and pushes into the right atrium producing a positive wave called the c-wave. Now, the right atrium is empty and sucks in venous blood from IVC and SVC producing the positive v-wave. Now, the pressure in the right atrium increases and blood spills into the right ventricle producing a y-wave.

JVD Waveform:

JVD wave

Summary of JVD waveforms:

• +a-wave: atrial contraction.

• -x-wave: atrial relaxation and tricuspid closure.

• +c-wave: atrial cusps pushing into the right atrium due to right ventricular contraction.

• +v-wave: venous return into the right atrium due to maximal atrial filling.

• -y-wave: passive emptying of right atrium into right ventricle.

Abnormal JVD waveforms:

• No +a-wave: atrial fibrillation.

• Cannon +a-wave: complete heart block.

• Prominent +a-wave: tricuspid stenosis.

• Prominent +v-wave: tricuspid regurgitation and atrial stenosis accompanied with pulsatile liver.

• Low +v-wave: hypotension.

• Low -x-wave: constrictive pericarditis.

• Low -y-wave: constrictive pericarditis and cardiac temponade.

Kussmaul Sign:

Kussmaul sign is indicative of constrictive pericarditis. When a patient sitting at an angle of 45 degrees takes a deep breath, take a look at the upper limit of the JVD; if it increases, it is indicative of constrictive pericarditis.

Abdominojugular Reflux:

Abdominojugular reflux, also known as hepato-jugular reflux, is one of the signs used to diagnose right-sided heart failure when other CHF signs and symptoms are in the grey zone. Suppose a patient presents with normal CVP, paroxysmal nocturnal dyspnea, suspicious pedal edema, and JVD of 2 cm above the clavicle (which may be normal) and you're determined that the patient has congestive heart failure. Now, the first symptom of CHF is paroxysmal nocturnal dyspnea but the first sign of CHF is abdominojugular reflux. In the abdominojugular reflux test, you place your palm on the patient's abdomen and apply pressure for about 10 seconds. In normal individuals, this maneuver doesn't change the jugular venous pressure, however, can increase upper venous pulsation in individuals with right heart dysfunction. So, as soon as you remove your palm, jugular venous pressure drops by 4 cm. The most common cause of a positive abdominojugular reflux test is right heart failure secondary to elevated left heart filling pressures. Right ventricular infarction, constrictive pericarditis, and restrictive cardiomyopathy are also common causes of a positive abdominojugular reflux.

Additional Reading:

Random USMLE Facts

1. Random USMLE Facts volume 1-1
2. Random USMLE Facts volume 2-1
3. Random USMLE Facts volume 3-1
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5. Random USMLE Facts volume 5-1
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1. General Examination for Internal Medicine
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3. ER Chest Pain Workup
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