Expired CME Article

Jugular Venous Pulse: Window into the Right Heart

Authors: Patrick J. Devine, MD, Lance E. Sullenberger, MD, Daniel A. Bellin, MD, J Edwin Atwood, MD

Abstract

Although physicians began associating conspicuous neck veins with heart disease almost three centuries ago, the jugular venous pulse remains an often ignored component of the physical examination. Many physicians have not invested in the necessary understanding of the technique, and there is a misconception that its examination is difficult and of limited clinical value. When performed properly, evaluation of the jugular venous pulse can be extremely useful in distinguishing the cause of dyspnea and edema.


The normal jugular venous pulse is reviewed, and pulse wave abnormalities are described, including ways in which they can provide clues to the diagnosis of certain disease states, ranging from pericardial disease to conduction disturbances. The jugular venous pulse provides a window into the right heart and an occasional glimpse of left heart hemodynamics. By peering through this window, clinicians can gain valuable information in the diagnostic evaluation of the cardiovascular patient.


Key Points


* In patients with atrial fibrillation and severe tricuspid regurgitation, the jugular venous pulse can be easily mistaken for carotid pulsation.


* Cannon a waves result when there is loss of atrioventricular synchrony, a feature of several different types of arrhythmias.


* The presence of the y descent on physical examination can serve as a useful clue for excluding pericardial tamponade in a patient presenting with hypotension and distended neck veins.


* In contrast to traditional teaching, when the thorax is elevated to 30° or more, 10 cm should be added to the height of the venous column from the sternal angle to best obtain an estimate of the jugular venous pressure.


* In the absence of isolated right ventricular failure, a positive hepatojugular reflux suggests a pulmonary artery wedge pressure of 15 mm Hg or greater.

This content is limited to qualifying members.

Existing members, please login first

If you have an existing account please login now to access this article or view purchase options.

Purchase only this article ($25)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

1. Warner AL, Ewy GA. Using the cardiovascular exam to full advantage. Contemp Intern Med 1992;51–76.
 
2. Economides E, Stevenson LW. The jugular veins: knowing enough to look. Am Heart J 1998;136:6–9.
 
3. Stoelting RK. Evaluation of external jugular venous pressure as a reflection of right atrial pressure. Anesthesiology 1973;38:291–294.
 
4. Ryan GM, Howland WS. An evaluation of central venous pressure monitoring. Anesth Analg 1966;45:754–759.
 
5. Connors AF, McCaffree DR, Gray BA. Evaluation of right heart catheterization in the critically ill patient without acute infarction. N Engl J Med 1983;308:263–267.
 
6. Bates B, Bickley LS, Hoekelman RA. The cardiovascular system. In: Bates B, ed. A Guide to Physical Examination and History Taking, 6th ed. Philadelphia, J B Lippincott, 1995, pp 259–312.
 
7. Matthews MB. The cardiovascular system. In: MacLeod J, ed. Clinical Examination. Edinburgh, Churchill Livingstone, 1982, pp 99–146.
 
8. Hartman H. The jugular venous tracing. Am Heart J 1960;59:698–717.
 
9. Feder W, Cherry RA. External jugular phlobogram as reflecting venous and right atrial hemodynamics. Am J Cardiol 1963;12:383–393.
 
10. Ewy GA. Evaluation of the neck veins. Hosp Pract 1987;73–81.
 
11. Hurst JW, Schlant RC. Examination of the veins. In: Hurst JW, Louge RB (eds). The Heart, 1st ed. New York, McGraw Hil, 1966, pp 88–91.
 
12. Garratt CJ, Griffith MJ, Young G, et al. Value of physical signs in the diagnosis of ventricular tachycardia. Circulation 1994;90:3103–3107.
 
13. Berman ND, Waxman MB. Canon waves with AV association. Am Heart J 1976;91:643–644.
 
14. Dimond EG, Benchimol A. Phonocardiography in pulmonary stenosis: special correlation between hemodynamics and phonocardiographic findings. Ann Intern Med 1960;52:145–162.
 
15. Benchimol A, Tippit HC. The clinical value of the jugular and hepatic pulses. Prog Cardiovasc Dis 1967;10:159–186.
 
16. Maisel AS, Atwood JE, Goldberger AL. Hepatojugular reflux: useful in the bedside diagnosis of tricuspid regurgitation. Ann Intern Med 1984;101:781–782.
 
17. Tavel ME, Bard RA, Franks LC, et al. The jugular venous pulse in atrial septal defect. Arch Intern Med 1968;121:524–529.
 
18. Friedreich N. Zur Diagnose der Herzbeutelverwachsungen. Virchows Arch Pathol Anat 1864;29:296.
 
19. Braunwald E. The physical examination. In: Braunwald E (ed). Heart Disease: A Textbook of Cardiovascular Medicine. Philadelphia, WB Saunders, 1988, pp 13–40.
 
20. O’Rourke RA. The measurement of systemic blood pressure, normal and abnormal pulsations of the arteries and veins. In: Hurst JW, Schlant RC (eds). The Heart, Arteries and Veins. New York, McGraw Hill, 1989, pp 157–162.
 
21. Davison R, Cannon R. Estimation of central venous pressure by examination of the jugular veins. Am Heart J 1974;87:279–282.
 
22. Lewis T. Early signs of cardiac failure of the congestive type. BMJ 1930;1:849–852.
 
23. Seth R, Magner P, Matzinger F, et al. How far is the sternal angle from the mid-right atrium? J Gen Intern Med 2002;17:852–856.
 
24. Abrams J. The Jugular Venous Pulse. In: Synopsis of Cardiac Physical Diagnosis, 2nd ed. Woburn, Butterworth-Heinemann, 2001, p 28.
 
25. Butman SM, Ewy GA, Standen JR, et al. Bedside cardiovascular examination in patients with severe chronic heart failure: importance of rest or inducible jugular venous distention. J Am Coll Cardiol 1993;22:968–974.
 
26. Drazner MH, Rame JE, Dries DL. Third heart sound and elevated jugular venous pressure as markers of the subsequent development of heart failure in patients with asymptomatic left ventricular dysfunction. Am J Med 114:431–437.
 
27. Drazner MH, Rame JE, Stevenson LW. Prognostic importance of elevated jugular venous pressure and a third heart sound in patients with heart failure. N Engl J Med 2001;23:574–581.
 
28. Pasteur W. Note on a new physical sign of tricuspid regurgitation. Lancet 1885;2:524.
 
29. Hitzig WM. On mechanisms of inspiratory filling of the cervical veins and pulsus paradoxus in venous hypertension. J Mount Sinai Hosp NY 1942;8:625–644.
 
30. Ducas J, Magder S, McGregor M. Validity of the hepatojugular reflux as a clinical test for congestive heart failure. Am J Cardiol 1983;52:1299–1303.
 
31. Ewy GA. The abdominojugular test: technique and hemodynamic correlates. Ann Intern Med 1988;109:456–460.
 
32. Kussmaul A, Stern MT. Pericarditis and the paradox pulse. Berl Klin Wochenschr 1873:38.
 
33. Meyer TE, Sareli P, Marcus RH, et al. Mechanism underlying Kussmaul’s sign in chronic constrictive pericarditis. Am J Cardiol 1989;64:1069–1072.
 
34. Cook D, Simel D. Does this patient have abnormal central venous pressure? JAMA 1996;275:630–634.
 
35. Dell’Italia LJ, Starling MR, O’Rourk RA. Physical examination for exclusion of hemodynamically important right ventricular infarction. Ann Intern Med 1983;99:608–611.
 
36. Lange RL, Botticelli JT, Tsagaris TJ, et al. Diagnostic signs in compressive cardiac disorders: constrictive pericarditis, pericardial effusion, and tamponade. Circulation 1966;33:763–777.