1. JVP
2. Distinguishing JVP from carotid
3. Examination of JVP
4. Exam: Kussmal's sign
5. Exam: hepatojugular reflex
6. Causes of elevated JVP
7. Causes of abnormal waveform

JVP

• Manometer of right atrial pressure.
• Function at waveform points: ASK ME:
  • Atrial filling
  • Systole
  • Klosed tricuspid
  • Maximal atrial filling
  • Emptying of atrium
• S1 occurs with 'a' and 'c' wave, S2 occur with 'v' wave. 

Distinguishing JVP from carotid

• Fills from above.
• Complex, double pulsation for each arterial pulse [if pt has normal sinus rhythm].
• Usually visible, but not palpable.
• Changes with posture.
• Moves on inspiration [decreases in healthy].
• Hepatojugular reflex.

Examination of JVP

• Pt. must be at 45°. Pt's head tilted upwards and facing slightly away from Dr.
• Use the internal jugular, not external jugular. External jugular is lateral to SCM and easier to see. Internal jugular is medial/behind the clavicular head of SCM. Distinguish from carotid pulse.
• Shine a torch [light] on internal jugular vein at an oblique angle.
• Extend torch out horizontally from highest point of JVP pulsations, use ruler to measure vertical height from sternal notch to torch.
• Height >3cm above sternal angle is pathologic (raised ventricular filling pressure or volume overload often from RHF).
• In normal person, usu. can't see the JVP when pt is at 45°, but can see when pt is at 90°.
• Optionally: auscultate heart or feel carotid pulse to help identify JVP by its complex waveform.

Exam: Kussmaul's sign

• Place Pt. sitting up at 90°.
• JVP becomes more distended during inspiration (classically constrictive pericarditis, currently severe RHF). This is opposite of what happens in normal pt.
• Usually negative in cardiac tamponade.

Exam: hepatojugular reflex

• Exert pressure on liver for 15 sec.
• Venous return to right atrium increases.
• JVP will rise transiently in normal person.
• Check if remains elevated (RVF).

Causes of elevated JVP

• Bradycardia
• Fluid overload [esp. IV infusion]
• RVF
• Constrictive pericarditis
• Pericardial effusion
• SVC obstruction
• Tricuspid stenosis or regurgitation
• Hyperdynamic circulation

Abnormal waveform causes

• Dominant a wave
  • Pulmonary stenosis
  • Pulmonary hypertension
  • Tricuspid stenosis
• Cannon a wave
  • Complete heart block
  • Paroxysmal nodal tachycardia
  • Ventricular tachycardia
• Dominant v wave [easily heard].
  • Tricuspid regurgitation
• Absent x descent
  • Atrial fibrillation
• Exaggerated x descent
  • Cardiac tamponade
  • Constrictive pericarditis
• Sharp y descent
  • Constrictive pericarditis
  • Tricuspid regurgitation
• Slow y descent
  • Right atrial myxoma