OSCE Examining the Jugular Venous Pressure (JVP)

Related Subjects: |Examining the Arterial Pulse |Examining the Jugular Venous Pressure (JVP)

🩺 Introduction

• The Jugular Venous Pressure (JVP) is a key bedside marker of right atrial and central venous pressure.
• It provides insights into right heart function and overall hemodynamic status.
• The internal jugular vein is preferred since it connects directly to the right atrium with no valves, acting as a “manometer of the heart.”

🧠 Anatomy of the Internal Jugular Vein

• Runs deep to the sternocleidomastoid muscle, between its sternal and clavicular heads.
• Originates at the jugular foramen, descending within the carotid sheath beside the carotid arteries and vagus nerve.
• Absence of valves → right atrial pressure changes are transmitted directly.

🛠️ Technique of JVP Examination

• Patient Positioning: Recline at 45°, head slightly left, neck relaxed (pillow helps).
• Lighting: Use tangential light to highlight venous pulsations.
• Identification: Look for internal jugular pulsations (between SCM heads). External jugular is less reliable.
• Measurement: Measure vertical height above sternal angle (add 5 cm for RA level). 👉 Normal JVP ≤3 cm above sternal angle (≤8 cm above RA).

🔍 Differentiating JVP from Carotid Pulse

• ✋ JVP is not palpable vs carotid pulse which is palpable.
• 📈 JVP has a double waveform (a + v) vs carotid single upstroke.
• 🧍 JVP varies with posture (falls upright) vs carotid unchanged.
• 🌬️ JVP falls with inspiration vs carotid unaffected.
• 🤲 JVP occludable with gentle pressure vs carotid cannot be compressed.
• 🫁 Abdominojugular reflux raises JVP; carotid unaffected.

📉 Inspecting the Jugular Venous Pulse

• Height: Align a horizontal card/ruler with top of pulsation → measure against sternal angle.
• If absent: think hypovolemia (flat JVP) or SVC obstruction (distended, non-pulsatile veins, facial swelling).
• Respiratory changes: Normally falls with inspiration. Paradoxical rise (Kussmaul’s sign) → constrictive pericarditis or RV dysfunction.

📊 Understanding the JVP Waveform

• 🔺 a-wave: Atrial contraction → pushes blood into RV.
• 🔺 c-wave: Tricuspid bulges into RA during systole.
• ⬇️ x-descent: Atrial relaxation + downward tricuspid pull.
• 🔺 v-wave: RA fills against closed tricuspid (late systole).
• ⬇️ y-descent: Tricuspid opens → rapid ventricular filling.

⚠️ Pathological JVP Waveforms

• 💥 Cannon a-waves: Atria contract against closed tricuspid (e.g. complete heart block, VT, junctional rhythm).
• ❌ Absent a-waves: Atrial fibrillation (no atrial kick).
• 🌊 Prominent v-waves: Tricuspid regurgitation (backflow).
• ⏬ Steep y-descent: Constrictive pericarditis, severe RHF.
• ⏳ Slow y-descent: Tricuspid stenosis, RA myxoma.
• 🫁 Kussmaul’s sign: JVP rises on inspiration → constrictive pericarditis, restrictive cardiomyopathy, RV infarction.

📈 Causes of Abnormal JVP Height

• ⬆️ Raised JVP: Right heart failure, fluid overload, constrictive pericarditis, tamponade, tricuspid disease, pulmonary hypertension, SVC obstruction.
• ⬇️ Low/Flat JVP: Hypovolemia (bleeding, dehydration), septic shock, end-stage heart failure.

🧪 Additional Clinical Maneuvers

• Abdominojugular Reflux: Press RUQ 10s → sustained rise ≥3 cm = positive (right heart failure).
• Respiratory Variation: Normal = JVP falls with inspiration.

💡 Clinical Significance

• Assess volume status (hypovolemia vs overload).
• Detect right heart pathology (failure, tricuspid disease).
• Identify pericardial disease (constrictive pericarditis, tamponade).
• Recognise pulmonary hypertension.
• Diagnose SVC obstruction.

📚 References

• Bickley LS, Szilagyi PG. Bates' Guide to Physical Examination and History Taking. 12th ed. Wolters Kluwer; 2017.
• Kasper DL, Fauci AS, Hauser SL, et al. Harrison’s Principles of Internal Medicine. 20th ed. McGraw-Hill; 2018.
• Epstein O, Perkin GD, Cookson J, de Bono DP. Clinical Examination. Mosby; 2008.
• Seidel HM, Ball JW, Dains JE, Benedict GW. Mosby’s Guide to Physical Examination. Elsevier; 2011.
• McGee S. Evidence-Based Physical Diagnosis. Elsevier; 2018.
• Butman SM, Goldberg RJ. The Jugular Venous Pressure Revisited. Cleve Clin J Med. 2010;77(5):312-320.