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Rapid Review·Cardiovascular

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Foundations

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Jugular Venous Pressure

Focus on

Read the JVP in two steps: estimate right atrial pressure from the column height, then match the abnormal wave to its mechanical event — cannon a waves mean AV dissociation, giant v waves mean tricuspid regurgitation, and the y descent separates constriction from tamponade.

Key takeaways

Estimating central venous pressure

Measure the vertical venous column above the sternal angle and add the approximate distance to the right atrium. Normal central venous pressure is 6 to 8 cm H2O (a column 1 to 3 cm above the sternal angle); a column more than 3 cm above it means an elevated pressure.
What this shows
Measure the vertical venous column above the sternal angle and add the approximate distance to the right atrium. Normal central venous pressure is 6 to 8 cm H2O (a column 1 to 3 cm above the sternal angle); a column more than 3 cm above it means an elevated pressure.

Find the internal jugular pulsation

recline the patient 30 to 45°.
  • It is biphasic and non-palpable.
  • It falls with inspiration and rises with abdominal pressure.
  • A carotid pulse does none of these things.

Measure, then add 5

the vertical height of the top of the column above the sternal angle, plus ~5 cm for the distance to the right atrium (RA).
  • Normal is ≤ 8 to 9 cm H2O; a column more than 3 cm above the sternal angle is elevated.
  • See the JVP pressure estimation figure.

An elevated jugular venous pressure (JVP) means raised right-sided filling pressure

right or biventricular heart failure, tricuspid disease, pericardial constriction or tamponade, pulmonary hypertension, volume overload, superior vena cava (SVC) obstruction.

The normal waveform

Central venous pressure through one cardiac cycle: the a wave at the end of diastole, the c wave at the start of systole, the x descent during systole, the v wave late in systole, and the y descent in early diastole as the tricuspid valve opens.
What this shows
Central venous pressure through one cardiac cycle: the a wave at the end of diastole, the c wave at the start of systole, the x descent during systole, the v wave late in systole, and the y descent in early diastole as the tricuspid valve opens.

Five parts, each a mechanical event

see the normal waveform.

a wave

right atrial contraction (late diastole).

c wave

tricuspid valve bulging into the RA at the start of systole.

x descent

atrial relaxation and downward movement of the tricuspid annulus during systole.

v wave

venous filling of the atrium against a closed tricuspid valve (late systole).

y descent

the tricuspid valve opens and the atrium empties (early diastole).

Abnormal waveforms

Abnormal jugular venous waveforms beside the normal one: severe tricuspid regurgitation (giant v wave), constrictive pericarditis (prominent x and y descents), tricuspid stenosis (large a wave), complete AV block (intermittent cannon a waves), pericardial tamponade (blunted y descent), atrial septal defect (v wave as large as the a wave) and atrial fibrillation (no a wave).
What this shows
Abnormal jugular venous waveforms beside the normal one: severe tricuspid regurgitation (giant v wave), constrictive pericarditis (prominent x and y descents), tricuspid stenosis (large a wave), complete AV block (intermittent cannon a waves), pericardial tamponade (blunted y descent), atrial septal defect (v wave as large as the a wave) and atrial fibrillation (no a wave).
Abnormal JVP patterns
PatternMechanismDiagnosis
Absent a wavesNo organized atrial contractionAtrial Fibrillation
Cannon a waves (intermittent, giant)Atrium contracts against a closed tricuspid valve, atrioventricular (AV) dissociationAtrioventricular Block, Ventricular Tachycardia, frequent premature ventricular contractions (PVCs)
Large regular a wavesHigh resistance to right ventricular fillingTricuspid stenosis, pulmonary hypertension, pulmonic stenosis
Giant v waves, absent x descentSystolic regurgitation into the RATricuspid Regurgitation
v wave ≥ a waveLeft-to-right shunt volumeAtrial Septal Defect
Prominent x and y descentsRapid early filling then abrupt haltConstrictive Pericarditis
Prominent x, blunted or absent yFilling impaired throughout diastoleCardiac Tamponade

Constriction and tamponade share a high JVP

in both the pressure outside the atria is raised.
  • The y descent separates them: sharp in constriction, blunted or absent in tamponade.

Cannon a waves can be felt

patients sometimes report a pulsing sensation in the neck.

Respiration and the Kussmaul sign

Normal JVP falls with inspiration

a JVP that rises or fails to fall on inspiration is Kussmaul sign.
  • Causes: constrictive pericarditis, restrictive cardiomyopathy, right ventricular infarction, severe right heart failure, massive pulmonary embolism (PE).

Abdominojugular (hepatojugular) reflux

Sustained abdominal pressure that keeps the JVP elevated indicates limited right-ventricular reserve. Right ventricular failure (left): pressure over the right upper quadrant for 10 seconds raises the jugular venous distension (reflux present). Liver cirrhosis (right): the same pressure does not raise it (reflux absent); the edema there comes from low albumin and ascites compressing the iliac veins.
What this shows
Sustained abdominal pressure that keeps the JVP elevated indicates limited right-ventricular reserve. Right ventricular failure (left): pressure over the right upper quadrant for 10 seconds raises the jugular venous distension (reflux present). Liver cirrhosis (right): the same pressure does not raise it (reflux absent); the edema there comes from low albumin and ascites compressing the iliac veins.

The test

firm pressure over the abdomen for 10 to 15 s while watching the neck.
  • A sustained rise ≥ 3 cm means the right heart cannot accommodate the extra venous return: heart failure or high filling pressures.
  • A brief rise that fades is normal.

It separates cardiac from hepatic edema

the bedside maneuver for edema and ascites.
  • Positive in heart failure.
  • Negative in uncomplicated cirrhosis.
A patient with a heart rate of 38 has intermittent giant pulsations in the neck. Name the wave, the mechanism and the likely rhythm.

Cannon a waves. The atrium contracts against a closed tricuspid valve because atria and ventricles beat independently (AV dissociation). With a rate of 38 the likely rhythm is complete heart block.

How it's tested

A patient with a heart rate of 38 and intermittent giant pulsations in the neck: cannon a waves from complete heart block — atria contracting against a closed tricuspid valve.

Holosystolic murmur louder on inspiration with prominent neck-vein pulsations and a pulsatile liver: tricuspid regurgitation; the v wave is the regurgitant jet.

Elevated JVP that rises on inspiration in a patient with prior chest radiation, ascites and pericardial calcification: constrictive pericarditis with Kussmaul sign — expect a sharp y descent.

Leg edema and ascites; the resting JVP looks borderline: press on the abdomen — a sustained ≥ 3 cm rise points to the heart, not the liver.

Go deeper

Related Step 2 pages: Heart Sounds & Murmurs, Constrictive Pericarditis, Cardiac Tamponade, Tricuspid Regurgitation, Cor Pulmonale, Cardiac Tamponade

High-yield images6
Measure the vertical venous column above the sternal angle and add the approximate distance to the right atrium. Normal central venous pressure is 6 to 8 cm H2O (a column 1 to 3 cm above the sternal angle); a column more than 3 cm above it means an elevated pressure.
Sustained abdominal pressure that keeps the JVP elevated indicates limited right-ventricular reserve. Right ventricular failure (left): pressure over the right upper quadrant for 10 seconds raises the jugular venous distension (reflux present). Liver cirrhosis (right): the same pressure does not raise it (reflux absent); the edema there comes from low albumin and ascites compressing the iliac veins.
The normal jugular venous waveform: a wave, c wave, x descent, v wave, y descent.
Abnormal jugular venous waveforms beside the normal one: severe tricuspid regurgitation (giant v wave), constrictive pericarditis (prominent x and y descents), tricuspid stenosis (large a wave), complete AV block (intermittent cannon a waves), pericardial tamponade (blunted y descent), atrial septal defect (v wave as large as the a wave) and atrial fibrillation (no a wave).
Jugular venous waveform, normal (top) and with intermittent cannon a waves (bottom, arrows) from atrial contraction against a closed tricuspid valve.
Central venous pressure through one cardiac cycle: the a wave at the end of diastole, the c wave at the start of systole, the x descent during systole, the v wave late in systole, and the y descent in early diastole as the tricuspid valve opens.

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# What physical exam manuever is useful for distinguishing between cardiac- and liver disease-related causes of lower extremity edema? 

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