Clinical Assessment Of The Jugular Venous Pulse

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The foregoing principles of jugular physiology and pathophysiology can be simply and very easily brought to the bedside if certain points are kept in mind and applied when assessing a patient. Jugular pulse recordings obtained with electronically amplified transducers often cause artificial exaggeration of the a, c, and v waves. Recognition of the jugular pulse contours and interpretation become difficult only if the usual textbook description of the a, c, and v waves based on such jugular recordings are searched for at the bedside.

Points to remember are:

1. Descents in the jugular venous pulse are easy to see because they are fast movements down. Objects moving away from the eyes of the observer are better seen than ones moving towards the observer. The descents reflect flow acceleration. Normal jugular wave ascents are slow rises of pressure and therefore are hard to see. If the wave rises are prominent as well and easily seen, then they are abnormal and reflect retrograde flow in the jugulars.

2. Technique of recognition of the descents: Internal jugular pulsations are often transmitted to the skin overlying the sternomastoid and sometimes over a wide area of the skin adjacent to it and above the clavicle. One should not get too close to the neck of the patient. In fact, standing at the bedside with the patient properly positioned and feeling the radial artery pulse at the same time, one should look for any fast movement down overlying the jugulars, as mentioned. Rapid downward movements that synchronize with the radial arterial pulse upstroke will immediately be identified as the jugular X descent. Simultaneous palpation of the radial arterial pulse, even when one searches for the jugular pulse, must be encouraged because this way the normal X descent is quickly identified. Movements of the soft tissues of the neck related to respiration can easily be distinguished as well. Sometimes the descents may be observed to move even a chain or necklace that the patient may be wearing. Throwing shadows over the skin overlying the jugulars and the sternomastoid muscle using natural light or an artificial light source and watching the movement of the shadow also helps in identifying the movement. Occasionally descents may also be seen in the external jugulars because of inadequacy of the venous valves.

3. Arterial pulse has a fast rise, whereas the jugulars have a fast fall. That is the best way to distinguish the arterial pulsation in the neck from the jugular movement. External pressure applied below the pulsations over the sternomastoid will help to occlude the venous pulsations and not the carotid pulsation. When the venous pressure is high with marked tricuspid regurgitation, this technique will not work.

Arterial pulsation does not last long, whereas the v wave of tricuspid regurgitation lasts longer.

4. Once the descent or descents are noted, one should time them with the radial arterial pulse or the second heart sound (S2). Radial arterial pulse upstroke is the easiest and the simplest for timing. This timing with the radial pulse is not by any means like timing an Olympic photo finish or microsecond timing. In other words, one should be simply able to call each time a descent is seen as "down," " down" while feeling the pulse at the same time. This can be easily demonstrated even while teaching a group of several students at the bedside. One can be made to call the descent each time it is seen while another calls the pulse each time the upstroke is felt. The descent which is simultaneous with the pulse is the X descent, while the descent which is out of phase with the pulse is the y descent. The X descent falls onto the S2, while the y descent comes after the S2.

5. In most normal adults what one will see is simply one large downward movement or descent, which will be synchronous with the pulse. This jugular contour of the normal adult can be simply described as showing single X descent. It immediately implies a normal contour. In young subjects one may see a major descent in systole with the pulse and a much smaller descent slightly after the pulse, indicating the pattern of the X descent followed by a small y descent. This contour can be described as a dominant X descent. This description implies the presence of a small y descent. Occasionally there may be a slight hesitation in the systolic descent because of the presence of an X descent (caused by atrial relaxation) quickly followed by the X descent, which is of course caused by the descent of the base. The combined movement will still be synchronous with the pulse, indicating a normal contour.

6. The presence of the X descent in normal regular sinus rhythm implies the presence ofthe a wave before it, although not seen to rise prominently. The presence of even a small diastolic or y descent (as compared to the X or systolic descent) implies that there is a v wave, although not rising prominently. Therefore, one needs to simply describe the descent pattern alone when the wave rises are not prominent.

7. Single X descent or the dominant X descent patterns in the jugulars imply good right ventricular systolic function and in addition indicate the absence of significant tricuspid regurgitation.

8. If two descents are seen for each cardiac cycle, these will be generally because of a combination of the X and the y descents. Rarely it may be because of the combination of an X descent well separated from the X descent because of the presence of a long PR interval. This can only be diagnosed with the help of an ECG. This is usually not the common cause of the double descents in the jugular pulse. The more usual combination is because of the presence of both the X and the y descents. This is identified by the fact that the first of each pair will be systolic in timing, i.e., occurring with the radial pulse.

9. When two descents are seen to each cardiac cycle, then one must observe the relationship of the two to decide the relative dominance of the descents. If both descents are equally prominent, then the pattern is X = y. If one of them is less prominent than the other, the pattern will be either X > y or X < y.

10. Double descents are clearly abnormal in the adult, even when they are X >y. This could be normal in young subjects or pregnant women. However, in these situations the pattern has to be X > y.

11. In all cases of double descents one should consider causes of decreased X descent as well as factors that may exaggerate the y descent.

12. The X descent is decreased if there is right ventricular dysfunction in the presence of atrial fibrillation because of lack of atrial kick and in the presence of significant tricuspid regurgitation.

13. Exaggerated y descent requires an increased v wave pressure head with no restriction to ventricular filling in early diastole. This mechanism excludes cardiac tamponade in which filling restriction occurs throughout diastole.

14. Because double descents can occur with and without the context of pulmonary hypertension, they may be approached accordingly. These are discussed in detail in the text. Since jugular contour abnormalities are not specific for pulmonary hypertension, diagnosis of pulmonary hypertension must be made on the basis of other clinical findings, such as a loud or palpable pulmonic component of the second heart sound, sustained subxiphoid right ventricular impulse, and/or electrocardiographic evidence of right ventricular hypertrophy. Absence of these signs does not necessarily exclude the presence of pulmonary hypertension, and therefore further tests may have to be taken to exclude or confirm the presence of pulmonary hypertension. Two-dimensional echocardiogram, particularly with the Doppler assessment for tricuspid regurgitation jet, if identified, will often help in this respect. Peak tricuspid regurgitation velocity, if identified, can be related to the pressure difference between the right ventricle and the right atrium. The pressure difference is approximately four times the velocity squared (pressure gradient = 4 x v2 ).

15. In the presence of pulmonary hypertension, the relative dominance of the X vs the y descent reveals the adequacy or otherwise of the right ventricular systolic function. The X > y pattern is indicative of compensated right ventricular function. When it is X = y, it probably means beginning right ventricular dysfunction. The pattern X < y definitely is a late pattern indicating right ventricular decompensation.

16. In the absence of pulmonary hypertension X = y is usually normal for a post-cardiac-surgery patient. In the patient who has not had previous cardiac surgery, other conditions such as pericardial effusion with some restriction, constrictive pericarditis, cardiomyopathy, or mild or early right ventricular infarction in the context of acute inferior myocardial infarction need to be considered. Similar pattern can also be seen in some patients with atrial septal defect. If the pattern were X < y, it would in addition indicate significant right ventricular systolic dysfunction.

17. If the descent is single and is out of phase with the radial pulse, the pattern can be described as single y descent. It indicates significant right ventricular dysfunction. This is the common pattern seen in patients with chronic atrial fibrillation and heart failure with right ventricular dysfunction.

18. Prominent rises of either the a wave or the v wave in the jugulars imply flow reversal in the jugulars. If it is seen to precede the X descent, it must be the a wave, and if it precedes a y descent, then it must be the v wave of tricuspid regurgitation.

19. The a wave as opposed to the v wave has a shorter duration, like a flicker. They occur regularly in the context of resistance to ventricular filling with a strong atrial contraction causing end-diastolic flow reversal. They can occur irregularly because of simultaneous right atrial and right ventricular contraction in situations of atrioventricular dissociation. In this instance they are termed cannon waves.

20. The v wave, on the other hand, precedes the y descent. When a single y descent is noted, one must try to assess the prominence of the wave rise preceding it. If it were of large amplitude and rising actively as well, it would indicate the presence of tricuspid regurgitation. It will be seen to rise with the arterial pulse but will last longer than the arterial pulse in duration. The v wave of tricuspid regurgitation is often visible from a distance and may be seen well with the patient sitting up. It indicates quite clearly systolic flow reversal in the jugulars (see JVP Videofiles 1-11 on the Companion CD).

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