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Home , Cannon A waves, Jugular venous pressure, Right atrial pressure, Stroke volume, Systole, Ventricle (heart)

REVIEW CME EDUCATIONAL OBJECTIVE: Readers will measure and interpret the in their patients CREDIT with failure JOHN MICHAEL S. CHUA CHIACO, MD NISHA I. PARIKH, MD, MPH DAVID J. FERGUSSON, MD , John A. Burns School Assistant Professor, John A. Burns School Clinical Professor of Medicine, Department of Medicine, University of Hawaii, Honolulu of Medicine, University of Hawaii; of , John A. Burns School The Queen’s Medical Center, Honolulu of Medicine, University of Hawaii; The Queen’s Medical Center, Honolulu

The jugular venous pressure revisited

■■ ABSTRACT n this age of technological marvels, I it is easy to become so reliant on them as Assessment of the jugular venous pressure is often inad- to neglect the value of bedside physical signs. equately performed and undervalued. Here, we review Yet these signs provide information that adds the physiologic and anatomic basis for the jugular venous no cost, is immediately available, and can be pressure, including the discrepancy between right atrial repeated at will. and central venous pressures. We also describe the cor- Few physical findings are as useful but as rect method of evaluating this clinical finding and review undervalued as is the estimation of the jugular the clinical relevance of the jugular venous pressure, venous pressure. Unfortunately, many practi- especially its value in assessing the severity and response tioners at many levels of seniority and experi- to treatment of congestive . Waveforms ence do not measure it correctly, leading to a vicious circle of unreliable information, lack reflective of specific conditions are also discussed. of confidence, and underuse. Another reason ■■ KEY POINTS for its underuse is that the jugular venous pres- sure does not correlate precisely with the right If the jugular venous pressure differs from the true , as we will see below. atrial pressure, the jugular venous pressure is always the In this review, we will attempt to clarify lower value. physiologic principles and describe technical details. Much of this is simple but, as always, the devil is in the details. The jugular venous pressure is useful to observe when diagnosing congestive heart failure and when consider- ■■ ANATOMIC CONSIDERATIONS ing the need for or the adequacy of diuresis. Think of the systemic as a soft-walled The jugular venous wave form is more difficult to observe and mildly distensible reservoir with finger- than its elevation but can yield useful information in the like projections, analogous to a partially fluid- 1 assessment of certain , right-heart conditions, filled surgical glove. In a semi-upright posi- and pericardial disease. tion, the venous system is partially filled with and is collapsed above the level that this blood reaches up to. Blood is constantly flowing in and out of this reservoir, flowing in by venous return and flowing out by the pumping action of the right side of the heart. The volume in the venous reservoir and hence the pressure are normally maintained by the variability of right ventricular in accor- dance with the Frank-Starling law. Excess volume and pressure indicate failure of this homeostatic mechanism. The internal jugular veins, being con- doi:10.3949/ccjm.80a.13039 tinuous with the , provide

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a visible measure of the degree to which the lower venous pressures. systemic venous reservoir is filled, a manom- This indicates the following: eter that reflects the pressure in the right • In the presence of congestive heart failure, —at least in theory.2 Thus, the vertical the right atrial pressure is at least as high height above the right atrium to which they and perhaps higher than the jugular ve- are distended and above which they are in a nous pressure. Hence, if the jugular venous collapsed state should reflect the right atrial pressure is high, further treatment, espe- pressure. cially diuresis, is needed. (In fact, the jugular venous pressure may • A jugular venous pressure of zero implies a underestimate the right atrial pressure, for euvolemic state. reasons still not understood. This will be dis- Thus, the jugular venous pressure provides cussed below.) excellent guidance when administering diure- In a healthy person, the visible jugular sis in congestive heart failure. These deduc- veins are fully collapsed when the person is tions obviously require the clinical judgment standing and are often distended to a variable that the elevated right atrial pressure and degree when the person is supine. Selecting an jugular venous pressure do indeed reflect el- appropriate intermediate position permits the evation of pulmonary capillary wedge pressure top of the column (the meniscus) to become rather than other conditions discussed later in visible in the neck between the clavicle and this article. the mandible. ■■ WHICH REFERENCE POINT TO USE? ■■ DISCREPANCY BETWEEN JUGULAR VENOUS AND RIGHT ATRIAL PRESSURE The two points that can be used as refer- ences above which the jugular venous pres- Several reports have indicated that the jugu- sure is expressed are the center of the right lar venous pressure may underestimate the atrium and the sternal angle. While the right atrial pressure. Deol et al3 confirmed former may reflect physiology, the latter is this, while establishing an excellent correla- preferred, as it is always visible and has the The internal tion between the level of venous collapse (ob- added advantage of being close to the upper jugular veins served on ultrasonography) and the jugular limit of normal, which is about 3 cm above venous pressure. The difference between the this level. act as a right atrial pressure and the jugular venous The difference in height between these manometer, pressure tended to be greater at higher venous two reference points has often been quoted reflecting pressures.3 as 5 cm, but this is an underestimate in the Most people have a valve near the termi- body positions used in examination.5 Seth the pressure nation of the internal jugular , with vari- et al6 found a mean of 8 cm at 30° elevation, in the right able competence. Inhibition of reflux of blood 9.7 cm at 45°, and 9.8 cm at 60°. The dif- from the superior vena cava into the internal ference also varied between patients, being atrium— by this valve is the most plausible larger in association with smoking, older with a notable cause of this disparity.4 age, large body mass index, and large anteri- The failure of the jugular venous pressure or-posterior diameter. These factors should qualification to correlate with the right atrial pressure has be considered when trying to evaluate the been cited by some as a reason to doubt the significance of a particular jugular venous value of a sign that cardiologists have long pressure. relied on. How do we reconcile this apparent The junction of the midaxillary line and paradox? Careful review of the literature that the fourth left intercostal space (“the phlebo- has demonstrated this lack of correlation re- static point”) has been recommended as a ref- veals the following: erence point by some, as it is level with the • When unequal, the jugular venous pres- mid-right atrium. However, using the phlebo- sure always underestimates the right atrial static point as a reference position is cumber- pressure. some and results in a valid measurement only • The lack of correlation is less evident at with the patient in the supine position.7

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■■ The jugular venous pressure examination

The patient lies comfortably at an angle that brings the pulsating column into view. The head lies on the pillow with the shoulders on the mattress, relaxing the sternocleidomastoid.

The heel of the examiner’s left palm gently adjusts head rotation and angulation.

The flashlight held in the right Once the meniscus has been located, hand shines tangentially to its anatomic site is noted and its height the skin against a darkened above the sternal angle is measured background. using a ruler held vertically and a pen held horizontally to that site. CCF Medical Illustrator: Beth Halasz ©2013 FIGURE 1

■■ TECHNIQUE IS VITAL • Turning the head away and elevating the jaw, both slightly; this is often best achieved Close adherence to technical details is vital in by gentle pressure of the palm of the observ- reliably and reproducibly measuring the pres- er's hand on the patient's forehead. sure in the internal jugular veins (FIGURE 1). The right side is usually observed first, as Degree of head elevation it is the side on which the examiner usually Although the proper degree of head eleva- stands. Using the right side also avoids the tion is sometimes said to be between 30° rare occurrence of external compression of the and 60°, these numbers are approximate. left brachiocephalic vein. The correct angle is that which brings the venous meniscus into the window of vis- Head and shoulders ibility in the neck between the clavicle and The sternocleidomastoid muscle lies anterior mandible. to each .8 When tense, it impedes good observation. Shortening, and Lighting hence relaxing, this muscle permits the me- Shining a flashlight tangentially to the skin is niscus to be observed. Correct positioning is often helpful, casting shadows that improve achieved by: the visibility of vein motion. Dimming the • Placing a folded pillow behind the pa- room lighting may further enhance this effect. tient’s head Directing a light perpendicular to the skin is • Keeping the shoulders on the mattress not helpful.

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Also check the external jugular vein Jugular venous waveforms in various arrhythmias a Checking the external jugular vein can help establish that the jugular venous pres- Normal heart in sure is normal. If the vein is initially col- ECG lapsed, light finger pressure at the base of AS the neck will distend it. If the distention VS rapidly clears after release of this pressure, the jugular venous pressure is not elevated. Jugular venous However, if external jugular venous disten- wave tion persists, this does not prove true jugu- Premature ventricular beat coinciding with atrial b lar venous pressure elevation, since it may reflect external compression of the vein by ECG the cervical fascia or delayed blood flow AS caused by sclerotic venous valves.9 In these VS instances, the internal jugular pulsation Jugular level must be sought. venous wave Jugular venous collapse with inspiration Complete heart block b Collapse of the inferior vena cava with forced ECG inspiration is routinely evaluated during echo- cardiography as a way to estimate right atrial AS pressure. This finding has been extrapolated VS to the jugular veins, wherein the absence of Jugular venous venous collapse during vigorous inspiration wave or sniffing indicates elevated central venous b pressures.10 Atrioventricular dissociation ECG Distinguishing venous from arterial AS pulsation VS Features indicating venous rather than ar- terial pulsation were listed by Wood more Jugular 11 venous than 50 years ago and are still relevant to- wave day. These include internal jugular pulsation that: Atrioventricular junctional rhythm with repetitive giant a waves • Is soft, diffuse, undulant ECG • Is not palpable AS • Has two crests and two troughs per cardiac VS cycle • Has crests that do not coincide with the Jugular venous palpated carotid (exceptions may be wave seen with the systolic timing of the v wave with block showing regular fine oscillations c of tricuspid regurgitation) • Has higher pressure in expiration, lower in ECG inspiration (exceptions may be seen when Kussmaul physiology is present) VS • Has pressure that rises with abdominal Jugular venous pressure wave • Is obliterated by light pressure at the base a Not drawn to scale, but intended to illustrate the mechanisms involved. of the neck. b Produces occasional giant a waves. In addition to the above criteria, a wave c Not a true a wave, but fine oscillations of the waveform. whose movement is predominantly a descent AS = atrial systole; ECG = ; VS = ventricular systole is nearly always venous. FIGURE 2

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Abdominojugular reflex aspirated to bring blood into the transparent Firm, steady pressure over the abdomen will tubing. Leaving the proximal end open to the often result in a small rise in jugular venous air, and alternately raising and lowering it to pressure. In healthy people, this normalizes confirm free flow, the level to which the blood in a few seconds, even while manual pressure rises can be easily observed. Observing small is maintained. Persistence of jugular venous cardiac and respiratory variations of the me- pressure elevation beyond 10 seconds, fol- niscus confirms free communication with the lowed by an abrupt fall upon withdrawal of central veins. Attaching the line to a trans- manual pressure, is abnormal. This finding has ducer is another option, but this may be time- implications similar to those of an elevated consuming, and establishing an accurate zero baseline jugular venous pressure. point is often difficult. The previously described discrepancy ■■ SIGNIFICANCE OF JUGULAR VENOUS between jugular venous pressure and central PRESSURE ELEVATION venous pressure has to be considered when drawing conclusions from this measure- Elevated jugular venous pressure is a mani- ment. festation of abnormal right heart dynamics, mostly commonly reflecting elevated pulmo- Intrathoracic pressure elevators nary capillary wedge pressure from left heart Positive pressure ventilation will elevate in- failure.12 This usually implies fluid overload, trathoracic pressure (including right atrial indicating the need for diuresis. pressure) and hence the jugular venous pres- Exceptions to this therapeutic implication sure, making interpretation difficult.15 Large include the presence of a primary right heart pleural effusions or may have condition, pericardial disease, certain arrhyth- a similar effect.16 mias, and conditions that elevate intrathorac- ic pressure. These will be discussed below. One Superior vena cava syndrome important example is the acute jugular venous Markedly elevated jugular venous pressure is Pressure in the pressure elevation seen in right ventricular in- here associated with absent or very dimin- internal jugular farction, in which the high venous pressure is ished pulsation, as the caval obstruction has compensatory and its reduction can produce eliminated free communication with the right veins may and .13 atrium.17 Associated facial plethora and ede- underestimate, Primary right heart conditions also in- ma, papilledema, and superficial venous dis- but will not clude right-sided valvular disease, cor pul- tention over the chest wall will often confirm monale (including pulmonary and this diagnosis. overestimate, pulmonary ), and the compres- the pressure in sive effect of pericardial tamponade or con- ■■ THE WAVEFORM striction. A normal or near-normal jugular the right atrium venous pressure significantly decreases the While the main purpose of viewing the neck likelihood of significant constriction or of veins is to establish the mean pressure, useful tamponade of a degree necessitating urgent information can often be obtained by assess- .14 ing the waveform. Abnormalities reflect ar- rhythmias, right heart , or peri- ■■ SPECIAL CIRCUMSTANCES cardial disease.18 Changes may be subtle and difficult to detect, but some patterns can be Presence of an intravenous line in the neck quite readily appreciated (FIGURE 2). A limited An intravenous line in the neck will often pre- selection follows. vent observation of the jugular venous pres- sure. A simple measure can often compensate Arrhythmias for this. If the venous line can be temporar- . These intermittent sharp ily disconnected, the positive deflections in the venous pulse repre- can be measured directly. Using sterile tech- sent right atrial contraction against a closed nique, the line can be flushed with saline and . They are most commonly

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associated with premature ventricular com- Pericardial disease plexes, but they occur in other conditions in Kussmaul sign is the paradoxical increase which atrial and ventricular beating are dis- in jugular venous pressure with inspiration, sociated, including complete heart block, observed in conditions associated with lim- atrioventricular dissociation, and electronic ited filling of the right . It is typically ventricular pacing.19–21 associated with constrictive , al- Repetitive cannon waves. These may be though it occurs in only a minority of people seen with atrioventricular junctional tachycar- with this condition.24 It may also be seen in dia or ventricular with 1:1 retro- restrictive , massive pulmo- grade ventriculoatrial conduction in which the nary embolism, right ventricular infarction, tricuspid valve is closed to every atrial beat. and tricuspid stenosis.25 Fine rapid regular pulsation may be seen Diaphragmatic descent during inspiration in atrial flutter and may be a useful clue in dis- increases intra-abdominal pressure and de- tinguishing this from sinus rhythm when there creases intrathoracic pressure. The resulting is 4:1 atrioventricular conduction and a nor- increased gradient between the abdomen and mal ventricular rate. thorax enhances venous return from splanch- nic vessels, which in the setting of a noncom- Abnormal right heart hemodynamics pliant right ventricle may result in increased Large v waves (Lancisi sign). These surg- right atrial (and, hence, jugular venous) pres- es, replacing the usual x descent in systole, are sure.26 seen in tricuspid insufficiency when the right It is important to point out that the Kuss- atrium and its venous attachments are not maul sign does not occur with cardiac tam- protected from the right ventricular systolic ponade in the absence of associated pericar- pressure.22 High right ventricular pressure will dial constriction. obviously enhance this systolic surge. Exaggerated y descent is typically seen in Large a waves. These reflect resistance pericardial constriction, in which the high to right atrial outflow and may be seen when pressure of the v wave falls rapidly at the onset right ventricular compliance is reduced by hy- of , given initial minimal right ventric- Close adherence pertrophy from chronic pressure overload or ular resistance. Flow is abruptly stopped when to technical in tricuspid stenosis.23 the intrapericardial space is filled. ■ details is vital ■■ REFERENCES 9. Sankoff J, Zidulka A. Non-invasive method for the rapid assessment of central venous pressure: description and in measuring 1. Sherwood L. Physiology: From Cells to Systems. validation by a single examiner. West J Emerg Med 2008; the pressure 8th ed. Belmont, CA: Brooks/Cole; 2012. 9:201–205. 2. Constant J. Using internal jugular pulsations as a ma- 10. Conn RD, O’Keefe JH. Simplified evaluation of the jugu- in the internal nometer for right atrial pressure measurements. Cardiol- lar venous pressure: significance of inspiratory collapse ogy 2000; 93:26–30. of jugular veins. Mo Med 2012; 109:150–152. jugular veins 3. Deol GR, Collett N, Ashby A, Schmidt GA. Ultrasound 11. Wood PH. Diseases of the Heart and Circulation. 2nd ed. accurately reflects the jugular venous examination but Philadelphia, PA: Lippincott; 1956. underestimates central venous pressure. Chest 2011; 12. Drazner MH, Brown RN, Kaiser PA, et al. Relationship 139:95–100. of right- and left-sided filling pressures in patients with 4. Wu X, Studer W, Erb T, Skarvan K, Seeberger MD. Com- advanced heart failure: a 14-year multi-institutional petence of the internal jugular vein valve is damaged by analysis. J Heart Transplant 2012; 31:67–72. cannulation and catheterization of the internal jugular 13. Clark G, Strauss HD, Roberts R. Dobutamine vs furose- vein. Anesthesiology 2000; 93:319–324. mide in the treatment of cardiac failure due to right 5. Ramana RK, Sanagala T, Lichtenberg R. A new angle on ventricular infarction. Chest 1980; 77:220–223. the angle of Louis. Congest Heart Fail 2006; 12:196–199. 14. Roy CL, Minor MA, Brookhart MA, Choudhry NK. Does 6. Seth R, Magner P, Matzinger F, van Walraven C. How far this patient with a have cardiac is the sternal angle from the mid-right atrium? J Gen tamponade? JAMA 2007; 297:1810–1818. Intern Med 2002; 17:852–856. 15. Zhou Q, Xiao W, An E, Zhou H, Yan M. Effects of four dif- 7. Kee LL, Simonson JS, Stotts NA, Skov P, Schiller NB. ferent positive airway pressures on right internal jugular Echocardiographic determination of valid zero reference vein catheterisation. Eur J Anaesthesiol 2012; 29:223–228. levels in supine and lateral positions. Am J Crit Care 1993; 16. Jolobe OM. Disproportionate elevation of jugular venous 2:72–80. pressure in . Br J Hosp Med (Lond) 2011; 8. Park SY, Kim MJ, Kim MG, et al. Changes in the relation- 72:582–585. ship between the right internal jugular vein and an 17. Seo M, Shin WJ, Jun IG. -related anatomical landmark after head rotation. Korean J superior vena cava syndrome following renal trans- Anesthesiol 2011; 61:107–111. plantation—a case report. Korean J Anesthesiol 2012;

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63:550–554. Circulation 1986; 73:799–808. 18. Applefeld MM. The jugular venous pressure and pulse 23. Wooley CF, Fontana ME, Kilman JW, Ryan JM. Tricus- contour. In: Walker HK, Hall WD, Hurst JW, editors. pid stenosis. Atrial systolic murmur, tricuspid opening Clinical Methods: The History, Physical, and Laboratory snap, and right atrial pressure pulse. Am J Med 1985; Examinations. 3rd ed. Boston, MA: Butterworths; 1990. 78:375–384. 19. El Gamal MI, Van Gelder LM. Chronic ventricular pacing 24. McGee SR. Evidence-Based Physical Diagnosis. 3rd ed. with ventriculo-atrial conduction versus atrial pacing in Philadelphia, PA: Elsevier/Saunders; 2012. three patients with symptomatic sinus . Pac- 25. Mittal SR, Garg S, Lalgarhia M. Jugular venous pressure ing Clin Electrophysiol 1981; 4:100–105. and pulse wave form in the diagnosis of right ventricular infarction. Int J Cardiol 1996; 53:253–256. 20. Berman ND, Waxman MB. Cannon waves with A-V as- 26. Bilchick KC, Wise RA. Paradoxical physical findings sociation. Am Heart J 1976; 91:643–644. described by Kussmaul: and Kussmaul’s 21. Luisada AA, Singhal A, Kim K. The jugular and hepatic sign. Lancet 2002; 359:1940–1942. tracings in normal subjects and in conduction defects. Acta Cardiol 1983; 38:405–424. ADDRESS: David John Fergusson, MD, 550 South Beretania 22. Miller MJ, McKay RG, Ferguson JJ, et al. Right atrial Street, Unit 601, Honolulu, HI 96813; e-mail: dfergusson@ pressure-volume relationships in tricuspid regurgitation. queens.org

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