The Jugular Venous Pressure (JVP)

Draping and Positioning:

• Patient lying at 30-45 degrees
• Neck gently extended and rotated ~ 45 degrees to the left
• Tangential lighting

Locate the JVP and differentiate from carotid

• Look for the JVP along the line coursing between the two heads of the sternocleidomastoid towards the earlobe
• JVP usually has double waveform
• JVP varies with respiration (should decrease with inspiration, if increases this is called Kussmaul's sign seen in constrictive pericarditis, restrictive cardiomyopathy, RV failure/overload)
• JVP can be occluded and is non palpable
  
• JVP varies with position of the bed
  
• JVP will change position with abdominal pressure

Estimate the height of the JVP by measuring the height of the top of the wave above the sternal angle (in centimetres)

• Low <0>
• "Normal" 0-5cm
  
• High >5cm

There is a high degree of intra-observer variability in the JVP.

In general, a "low JVP" has a LR+ for low CVP of ~ 3.4 and a LR- for a high CVP of 0.2
A "high JVP" has a LR+ of 4.1 for a high CVP.

Comment on any abnormalities of the waveforms

Some notable abnormalities (there is a long list, these are but some):

• Large a waves seen in tricuspid stenosis, pulmonary hypertension, RA/RV masses
  
• Absent a waves (or flutter waves) seen in atrial fibrillation or flutter
• Canon a waves seen in AV dissociation
• large v waves (or c-v waves) seen in RV failure, severe TR, ASD

Abdominojugular reflux:

• With a semi-inflated BP cuff apply 20-30mmHg pressure to the central abdomen for 15-30 seconds while observing the JVP. An increase of more than 4cm which does not return to normal within 10 seconds in "positive".
• Indicated inability of right heart to accommodate increased venous return seen in constrictive pericarditis, restrictive cardiomyopathy, RV failure.

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From the JVP alone you can learn many things that will make the remainder of your exam more fruitful. For example if you go in knowing to listen specifically for the murmur of TR or perhaps a loud P2 or S3/S4 you may be more successful in hearing them.

Also, note that there is some evidence that the external jugular vein is also useful for estimating CVP and may, in fact be easier.