A 65-year-old woman has had dyspnea for 2 months. She has had to give up her hobby of hiking and is now short of breath after climbing even 1 flight of stairs. Her dyspnea is sometimes worse at night. She has no chest pain, cough, or sputum, and the result of systems review is otherwise negative. On physical examination, her blood pressure is 135/90 mm Hg, and she has a regular cardiac rhythm at 72/min. You turn your attention to the jugular veins and next ask yourself, “Does this patient have abnormal central venous pressure (CVP)?”
Why Is This Question Important?
Evaluation of the jugular venous pulse provides important information about pressure and other hemodynamic events in the right atrium.1-3 The jugular venous pulse provides a useful estimate of CVP and thus the patient's intravascular volume status. Inspection of the waveforms can assist the diagnosis of several tricuspid and pulmonic valvular abnormalities. Moreover, accurate assessment of CVP by physical examination may obviate the necessity for invasive hemodynamic monitoring.
Accordingly, the clinical evaluation of jugular venous pressure (JVP) and waveforms is useful whenever intravascular volume status, ventricular function, valvular disease, or pericardial constriction is in question. Proficiency in this examination is especially important, given that it may be difficult, if not impossible, to identify venous pulsation in patients with low CVP,4 in patients receiving mechanical ventilation,4, 5 in patients with short or fat necks, and in some patients who have conditions causing wide swings in CVP during the respiratory cycle (eg, during acute asthma).
Anatomic and Physiologic Origins of the Jugular Venous Pressure
Because the jugular veins act as manometer tubes for the right atrium, they display changes in blood flow and pressure caused by right atrial filling, contraction, and emptying. In general, the jugular vein with the most distinct, undamped waveform is likely to most accurately reflect right atrial pressure. Because the right internal jugular vein is directly in line with the right atrium, thereby favoring an unimpeded transmission of atrial pulsations and pressure, it is the preferred site for examining the jugular venous pulse.
Direct measurements of CVP according to the left jugular veins tend to be higher than those on the right, but the correlation between the 2 is high.6 The discrepancy may reflect the fact that both the innominate vein and the left internal jugular vein can be compressed by a variety of normal or abnormal structures.
Although the internal jugular vein lies deep to the sternocleidomastoid muscle and may not always be visible as a discrete structure, its pulsation usually is transmitted to the overlying skin. Normally, the CVP pulsation moves toward the heart during inspiration because of a sudden increase in venous return to the right side of the heart.
The external jugular veins, although sometimes easier to see, may be constricted as they pass through the fascial planes of the neck and thus may not accurately reflect right atrial pressures. However, in one study, venous pressures measured in the external jugular vein accurately reflected right atrial pressures during anesthesia and with controlled or spontaneous ventilation.7 Positive-pressure ventilation caused regular, periodic changes to occur in venous return, which resulted in similar phasic changes in right atrial and external jugular pressures. The only significant difference was the greater right atrial pressure variation during mechanical ventilation, although the maximal venous pressures at the 2 sites were nearly identical.7
Among critically ill patients, one group of investigators found jugular venous pulsations sufficiently obvious for examination only 20% of the time,8 whereas another group was able to estimate CVP in 84% of critically ill patients.4 In the former study, although external jugular pulsations were visible in all patients, clinicians’ estimates of venous pressure according to physical examination were within 2 cm of CVP determined by central venous catheter only 47% of the time.
The evaluation of individual components of the venous pulse in health and disease lies outside the focus of this overview but can be summarized as follows.
Analysis of the Venous Waveform
The normal JVP reflects phasic pressure changes in the right atrium and consists of 3 positive waves and 3 negative troughs (Figure 11-1). Although these pressure changes can be recorded with pressure monitors, they are not always appreciable on clinical examination of the jugular pulse. Auscultation of the heart or simultaneous palpation of the left carotid artery may aid the examiner in relating the pattern of venous pulsations to the cardiac cycle.
Venous Pulsation in the Neck Corresponds With the Electrocardiogram
Simultaneous recording of an electrocardiogram (top tracing) and jugular venous pressure waves (lower tracing). The a wave reflects right atrial contraction just before the first heart sound and carotid pulse; atrial relaxation is reflected by the x descent; c wave reflects the bulging of the tricuspid valve into the right atrium during ventricular isovolumetric contraction; x1 descent reflects subsequent atrial relaxation; v wave reflects the closure of tricuspid valve and subsequent distention of the right atrium; and y descent reflects the right atrium emptying after the opening of the tricuspid valve.
Taken in sequence, right atrial contraction is reflected by the dominant positive a wave and occurs just before the first heart sound and carotid pulse. Atrial relaxation is reflected by the first negative trough, the x descent. The second positive wave is produced by the bulging of the tricuspid valve into the right atrium during ventricular isovolumetric contraction; this is called the c wave. Subsequent atrial relaxation creates the most dominant descent, the x 1 descent. When the tricuspid valve closes, subsequent distention of the right atrium creates the v wave, which occurs just after the arterial pulse. Finally, after the opening of the tricuspid valve, the right atrium empties, resulting in the y descent.
Various cardiac conditions are associated with waveform abnormalities. A few of the most common include the absence of a waves in atrial fibrillation, large cv waves in tricuspid regurgitation, the slow y descent of tricuspid stenosis, and the brisk y descent seen in constrictive pericarditis. Table 11-1 shows a summary of abnormal venous waveforms and the conditions in which they occur. Remember, it is not always possible to see each of these waves and descents.
Table 11-1Abnormalities of the Venous Waveforms |Favorite Table|Download (.pdf) Table 11-1 Abnormalities of the Venous Waveforms
|Waveform ||Cardiac Condition |
|Absent a wave ||Atrial fibrillation, sinus tachycardia |
|Flutter waves ||Atrial flutter |
|Prominent a waves ||First-degree atrioventricular block |
|Large a waves ||Tricuspid stenosis, right atrial myxoma, pulmonary hypertension, pulmonic stenosis |
|Cannon a waves ||Atrioventricular dissociation, ventricular tachycardia |
|Absent x descent ||Tricuspid regurgitation |
|Prominent x descent ||Conditions causing enlarged a waves |
|Large cv waves ||Tricuspid regurgitation, constrictive pericarditis |
|Slow y descent ||Tricuspid stenosis, right atrial myxoma |
|Rapid y descent ||Constrictive pericarditis, severe right heart failure, tricuspid regurgitation, atrial septal defect |
|Absent y descent ||Cardiac tamponade |
How to Examine the Neck Veins
The right internal jugular vein should be used to assess CVP for several reasons. It is in direct line with the right atrium, thereby favoring unimpeded transmission of atrial pulsations and pressure. Clinical assessment of CVP on the left may be marginally higher than that on the right. Finally, constricted or tortuous external jugular veins may introduce inaccuracy.
Proper positioning is crucial for examination of the neck veins. The patient's head is supported to relax the neck muscles, and the trunk is inclined at an angle that brings the top of the column of blood in the internal jugular vein to a level above the clavicle but below the angle of the jaw; in normal subjects, this positioning is accomplished at 30 to 45 degrees above the horizontal. In patients with elevated venous pressure, it often is necessary to elevate the trunk beyond 45 degrees, and patients with severe venous congestion may have to stand up and inspire deeply to bring the meniscus down into view. In some cases, the level of venous pulsation will be seen behind the angle of the jaw or will appear to move the earlobes. If the pressure in the internal jugular vein is high, venous pulsations will be lost in the completely full vein, and the high venous pressure may be overlooked.
Conversely, patients with low CVP may have to be positioned at 0 to 30 degrees. When CVP is low, the neck veins will be empty, and pulsations may not be visible even when the patient is horizontal.
Tangential light often improves the detection of the venous pulse. When ambient light is insufficient for this purpose, a penlight, directed away from the examiner's eyes, may be useful.
Distinguishing Arterial (Carotid) From Venous (Jugular) Pulsation
Difficulty in distinguishing between the carotid arterial pulse and jugular venous pulse may be overcome by noting several differentiating features (Table 11-2).9 First, the venous pulsation is diffuse, usually has 2 waves, and the upward deflection is slow. In contrast, the carotid pulse is a fast, well-localized, single, outward deflection. Second, venous pulsations (unless the venous pressure is extremely high) diminish toward the clavicle or disappear beneath it as the patient sits up or stands and advance toward the angle of the jaw as the patient reclines; carotid pulses generally do not vary with position. Third, in the absence of intrathoracic disease, the top of the venous wave descends during inspiration (because of increasingly negative intrathoracic pressure). However, the visible carotid pulse does not vary with the respiratory cycle, except during pulsus paradoxus. Fourth, the JVP is nonpalpable, and gentle pressure applied by the examiner's finger to the root of the neck above the clavicle will obstruct the vein, fill its distal segment, and obliterate the venous pulse. However, the carotid pulse is almost always palpable, usually striking the examining finger with considerable force. Finally, sustained pressure on the abdomen (the abdominojugular reflux test, to be described later) usually will cause even a normal venous pulse to increase briefly but will have no effect on the carotid pulse.
Table 11-2Distinguishing the Carotid Arterial From Jugular Venous Pulsation |Favorite Table|Download (.pdf) Table 11-2 Distinguishing the Carotid Arterial From Jugular Venous Pulsation
|Characteristic ||Venous Pulse ||Carotid Pulse |
|Waveform ||Diffuse biphasic ||Single sharp |
|Positional change ||Varies with position ||No variation |
|Respiratory variation ||Height falls on inspiration ||No variation |
|Effect of palpation ||Wave nonpalpable, pressure obliterates pulse, vein fills ||Pulse palpable, not compressible |
|Abdominal pressure ||Displaces pulse upward ||Pulse unchanged |
Estimation of Central Venous Pressure
The level of venous pressure is estimated by identifying the highest point of oscillation of the internal jugular vein (which usually occurs during the expiratory phase of respiration). This level must then be related to the middle of the right atrium, where venous pressure is, by convention, zero. Because the latter site is inaccessible on clinical examination, an accessible, reliable landmark is substituted: the sternal angle of Louis. This easily palpated landmark, found at the junction of the manubrium with the body of the sternum, lies 5 cm above the middle of the right atrium (for all practical purposes) in reclining patients of normal size and shape, regardless of the angle at which they are reclining.
Using the sternal angle as the reference point, the vertical distance (in centimeters) to the top of the jugular venous wave can be determined (Figure 11-2) and reported as the JVP; thus, JVP is 5 cm less than CVP.
Estimation of Central Venous Pressure From the Jugular Venous Pulse
At any patient position, the top of the jugular vein meniscus is identified. The jugular venous pulse measurement is sighted from the height read from a ruler placed vertically over the sternal notch. The traditional assumption has been that the CVP is the JVP + 5 cm. However, the Update for this article showed that physicians tend to underestimate the CVP and the assumption of a 5-cm depth from the sternal notch to the right atrium is probably not valid. Thus, this figure has been updated to reflect current recommendations that a JVP ≥ 3 cm suggests an elevated CVP. Abbreviations: CVP, central venous pressure; JVP, jugular venous pressure.
When the patient is positioned at 45 degrees above the horizontal, the clavicle lies a vertical distance of about 2 cm above the sternal angle, and only CVPs of at least 7 cm will be observed.10 Because the normal CVP in adults is 5 cm, the top of their venous pressure column lies at their sternal angle, 2 cm below their lowest visible point in a patient at 45 degrees, and will only appear as the patient reclines toward the horizontal. The upper limit of normal for CVP is 9 cm H2O, which produces a JVP extending 4 cm above the sternal angle.1 (Note: The Update that follows this section revealed that physicians underestimate the value of the central venous pressure from the jugular vein meniscus. Part of the underestimate may result from variability in the depth measured from the sternal notch to the mid-right atrium. This can be partially corrected by accepting a JVP of 3 cm or more as elevated.)
Estimating CVP may be done as follows: Identify the highest point of pulsation in the internal jugular vein; find the sternal angle of Louis; from the sternal angle, measure the vertical distance to the top of the pulsation in centimeters; and report as “the JVP is xx cm.”
Alternative methods of assessing CVP exist but have not been validated. For example, with a reclining patient, the clinician can inspect the veins of the back of the hand as the arm is slowly, passively raised; the level at which the veins collapse can then be related to the angle of Louis. This method may give false high readings with local obstruction and peripheral venous constriction, so it is not recommended.
Abnormal Central Venous Pressure
Elevated JVP reflects an increase in CVP. This increase can be due to increased right ventricular diastolic pressure (eg, right ventricular failure or infarction, pulmonary hypertension, or pulmonic stenosis), obstruction to right ventricular inflow (eg, tricuspid stenosis, right atrial myxoma, or constrictive pericarditis), hypervolemia, or superior vena cava obstruction.
Decreased JVP reflects a decreased or a low CVP. Low CVP may be due to intravascular volume depletion from gastrointestinal losses (vomiting or diarrhea), urinary losses (diuretics, uncontrolled diabetes mellitus, or diabetes insipidus), third-space fluid losses, and hypovolemic shock.
Abdominojugular Reflux Test (Hepatojugular Reflux)
The abdominojugular reflux test consists of observing JVP before, during, and after abdominal compression. The increase in jugular pressure that follows abdominal compression is believed to be a consequence of blood shifting from abdominal veins into the right atrium. Pasteur first described the hepatojugular reflux in 1885.11 Now, this bedside test is used to confirm the presence of right ventricular failure or reduced right ventricular compliance. Like all clinical tests, it is most reliable when performed in a standardized fashion.
The patient is instructed to relax and breathe normally through an open mouth (to avoid the false-positive increase in jugular pressure that accompanies the Valsalva maneuver). Firm pressure is then applied with the palm of the hand to the midabdomen for 15 to 30 seconds (abdominal compression for 1 minute, as has previously been described, is not required).10, 12, 13 This pressure should approximate 20 to 35 mm Hg when an unrolled bladder of a standard adult blood pressure cuff, partially inflated with 6 full bulb compressions, is placed between the examiner's hand and the patient's abdomen.10, 13 Pressure directly over the liver, as was originally described,1, 2, 12, 14 appears to be unnecessary.13, 15 Therefore, designation of the test as abdominojugular reflux, rather than hepatojugular reflux is more appropriate. If pain is produced by this maneuver, or if the patient strains (Valsalva), the test becomes falsely positive. Either instruct the patient to open his or her mouth and breathe slowly or try a trial run, which is sometimes useful to demonstrate to the patient the force that will be applied over the abdomen.
Healthy individuals may exhibit one of 3 responses to abdominal compression: no change in JVP; a transient (few seconds) increase of more than 4 cm that returns to its former level or near the baseline before 10 seconds, with little or no decrease when abdominal pressure is released; or an increase of more than 3 cm sustained throughout compression.10, 13 A positive abdominojugular test result occurs when abdominal compression causes a sustained increase in JVP of greater than or equal to 4 cm.
The JVP normally decreases during inspiration. The Kussmaul sign is the paradoxic increase in the height of JVP that occurs during inspiration. It can be explained by a heart that is unable to accommodate the increased venous return that accompanies the inspiratory decrease in intrathoracic pressure. Although classically described in constrictive pericarditis, the most common contemporary cause of the Kussmaul sign is severe right-sided heart failure, regardless of etiology. Other causes include myocardial restrictive disease such as amyloidosis, tricuspid stenosis, and superior vena cava syndrome.
Precision of the Clinical Assessment of Central Venous Pressure
When 2 clinicians examine the same patient once (interobserver variation), and even when 1 clinician examines the same patient twice (intraobserver variation), estimates of CVP commonly vary by up to 7 cm.4 Final-year medical students, first- and second-year medical residents, and attending physicians examined the same 50 intensive care unit patients (but were blinded to simultaneous CVP manometry) and estimated these patients’ CVPs as low (<5 cm), normal (5-10 cm), or high (>10 cm).4 Agreement between students and residents was substantial (κ, a measure of chance-corrected agreement, was 0.65), agreement between students and attending physicians was moderate (κ = 0.56), and agreement between residents and attending physicians was modest (κ = 0.30).
Suggested causes for disagreement include variations in the positioning of patients, poor ambient lighting, difficulty in distinguishing carotid from venous pulsations, biological variation in CVP with the phases of respiration, and the effects of vasoactive medication and diuretics.
The precision of the abdominojugular reflux test has not been reported, but its results will vary with the force of abdominal compression. Different investigators suggest different forces: Ducas et al10 compressed a semi-inflated blood pressure cuff placed in the middle of the abdomen to 35 mm Hg (equivalent to a weight of approximately 8 kg), whereas Ewy13 applied a pressure of approximately 20 mm Hg.
Although no validated methods for improving precision in determining JVP have been reported, it seems prudent to standardize the procedure as described herein, encourage normal breathing, rehearse abdominal compression until the Valsalva maneuver is avoided, and gradually increase abdominal compression during a few seconds.16 Even when the Valsalva maneuver is avoided, there is still a small variation in JVP with the phases of breathing.17
Accuracy of the Clinical Assessment of Central Venous Pressure
We describe 3 studies that have reported the relation between clinical assessments of CVP and the gold standard of simultaneous pressure measurements through an indwelling central venous catheter.4, 5, 18 When the clinical assessment was reported as low, normal, or high, the pooled overall accuracy was 56%. In one study,4 venous pressure was assessed in each of 50 intensive care unit patients by one of 3 intensive care unit attending physicians, one of 6 medical residents, and one of 6 medical students. Although all groups tended to underestimate venous pressure, only the residents did so to a statistically significant degree. The correlation coefficient between clinical assessment and central line measured CVP was highest for medical students (0.74), slightly lower for residents (0.71), and lowest for staff physicians (0.65), and these correlations improved slightly when patients receiving mechanical ventilation were excluded. The students’ data from this study4 (Table 11-3) display the results for 2 clinical questions: “Is the patient's true CVP low?” and “Is the patient's true CVP high?”2 Despite small numbers of participants, it is apparent that a clinically assessed low CVP increases the likelihood by about 3-fold that the measured CVP will be low; no patient clinically assessed as having a high CVP had a low measured CVP. Similar results hold when the clinician considers whether the patient has increased CVP. Clinical assessments of a high CVP increase the likelihood by about 4-fold that the measured CVP will be high; conversely, clinical assessments of a low CVP make the probability of finding a high measured CVP extremely unlikely (likelihood ratio [LR], 0.2). The data demonstrate that clinical assessments of a normal CVP are truly indeterminate, with LRs approaching 1; such estimates provide no information because they neither increase nor decrease the probability of an abnormal CVP.19 Aside from less observer variation, the data suggest that CVP estimates achieve greater accuracy among patients breathing spontaneously. However, the relatively small patient population creates an opportunity for further studies on how mechanical ventilatory assistance affects clinical assessment of CVP.
Table 11-3Measured Central Venous Pressurea |Favorite Table|Download (.pdf) Table 11-3 Measured Central Venous Pressurea
|Is the CVP Low? |
|Clinical Assessment ||Low, CVP <5 cm ||Normal or High, CVP >5 cm || |
|CVP low ||3 ||5 ||3.4 (1.0-11) |
|CVP normal ||4 ||22 ||1.0 (0.5-2.1) |
|CVP high ||0 ||13 ||0 (0-1.5) |
|Is the CVP High? |
|Clinical Assessment ||High, CVP >10 cm ||Normal or Low, CVP <5 cm ||LR That CVP Is High (95% CI) |
|CVP high ||10 ||3 ||4.1 (1.3-13) |
|CVP normal ||10 ||16 ||0.8 (0.5-1.3) |
|CVP low ||1 ||7 ||0.2 (0.02-1.3) |
In a study of 62 patients undergoing right-sided heart catheterization,5 an attending physician, a critical care fellow, a medical resident, an intern, and a student each predicted whether 4 hemodynamic variables, including CVP, were low, normal, high, or very high. The sensitivity of the clinical examination for identifying low (<0 mm Hg), normal (0-7 mm Hg), or high (>7 mm Hg) CVP was 0.33, 0.33, and 0.49, respectively (10 cm of H2O is equivalent to 7.5 mm Hg). The specificity of the clinical examination for identifying low, normal, or high CVP was 0.73, 0.62, and 0.76, respectively. Predictions of right atrial pressure (CVP) were more accurate in patients with low cardiac indexes (<2.2 L/min) and high pulmonary artery wedge pressures (>18 mm Hg) and less accurate among patients in coma or receiving mechanical ventilation. Accuracy was not improved in cases in which precision (interobserver agreement) among the examiners was high.
In a third study, Eisenberg et al18 compared clinical assessments with pulmonary artery catheter readings in 97 critically ill patients. The physicians caring for these patients were asked to predict whether CVP was less than 2, 2 through 6, or greater than 6 mm Hg; whether cardiac output was less than 4.5, 4.5 through 7.5, or greater than 7.5 L/min; whether systemic vascular resistance was 1100, 1100 through 1300, or greater than 1300 (dyn × s)/cm5; and whether pulmonary artery wedge pressure was less than 10, 10 through 14, 15 through 19, or greater than or equal to 20 mm Hg. Physicians correctly predicted the patients’ CVP only 55% of the time and cardiac index, systemic vascular resistance, and pulmonary artery wedge pressure only 51%, 44%, and 30% of the time, respectively. CVP was more frequently underestimated (27%) than overestimated (17%).
Although the abdominojugular reflux test is an insensitive way to diagnose congestive heart failure, the specificity of this test is high.20, 21 Moreover, the positive LRs (6.4 when the strict criteria are used and 6.0 when emergency physician judgment is used) indicate that this is a useful bedside test (Table 11-4).
Table 11-4Sensitivity and Specificity of the Abdominojugular Reflux in Diagnosing Congestive Heart Failurea |Favorite Table|Download (.pdf) Table 11-4 Sensitivity and Specificity of the Abdominojugular Reflux in Diagnosing Congestive Heart Failurea
|Abdominojugular Reflux ||CHF ||No CHF ||Total |
|By Explicit Criteria for the Abdominojugular Reflux Response |
|Present ||5 ||1 ||6 |
|Absent ||16 ||26 ||42 |
|Total ||21 ||27 ||48 |
|By Emergency Physician's Judgment of the Abdominojugular Reflux Response |
|Present ||4 ||2 ||6 |
|Absent ||8 ||34 ||42 |
|Total ||12 ||36 ||48 |
Improving Clinical Examination of the Jugular Veins
Examining patients with indwelling central venous catheters provides the clinician with an opportunity for calibrating and periodically testing clinical skills for evaluating CVP. Of course, the examination should be performed blind to the catheter reading. If the examination is also conducted blind to other patient data, interpretation of waveforms can be compared to electrocardiograms and other data from cardiac investigations. Learning aids such as pocket cards displaying the normal jugular pulsations may also be helpful. Assessment of JVP in patients with tachycardia, irregular cardiac rhythms, and rapid and deep respirations and those requiring mechanical ventilation provide a challenge for even seasoned clinicians.22
According to the results of this overview, the following recommendations apply to the clinical assessment of JVP. First, in a well-lit room, position the patient at an angle such that the meniscus of blood in the right jugular vein is brought into vision (usually an angle of 30 to 45 degrees from the horizontal). To identify the top of the meniscus, it may be necessary to raise or lower this angle. Second, distinguish the jugular venous waveform from the carotid pulsation by remembering the following: The venous waveform is diffuse and biphasic, varies with position and respiration, is nonpalpable, and may be displaced upward during abdominal pressure. In contrast, the carotid pulsation is single, sharp, and palpable; does not vary with position or respiration; and is unchanged with abdominal pressure. Third, measure the vertical distance in centimeters from the sternal angle of Louis to the top of the column of blood in the jugular vein. The upper limit of normal is approximately 4 cm (Note: The Update to this article recommends that the clinician consider a value of 3 cm or more as elevated). Armed with evidence about how to examine and interpret the clinical assessment of CVP, you can now answer the question of whether the patient presented at the beginning of this article, and subsequent patients you care for, have abnormal CVP.
Author Affiliations at the Time of the Original Publication
Departments of Medicine and Clinical Epidemiology and Biostatistics, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada, and the Ontario Ministry of Health, Toronto, Ontario, Canada (Dr Cook); The Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Duke University Medical Center, Durham, North Carolina (Dr Simel).
The authors thank Ernest Fallen, MD, FRCPC, and David Sackett, MD, FRCPC, for their thoughtful review and helpful comments on the manuscript.
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