When is jvp raised

Look For The pulsation of the jugular vein, between the sternal and clavicular heads of the sternocleidomastoid. Position the patient at 45 degrees and ask them to turn their head to the left. Hold a flashlight tangentially to the skin of the neck and inspect for the highest level of the jugular venous pulsation. Measure the vertical distance between the sternal angle and this level.

White : clavicle Black : sternocleidomastoid muscle Blue : internal jugular vein Red : external carotid artery. Interpretation The JVP is elevated if the vertical distance between the sternal angle and the highest point of the pulse is greater than 4cm. The pulsation should vary with respiration, dropping during inspiration. Measurement is performed at end expiration.

The sum of the vertical distance plus 5 is the CVP in centimeters of water above atmospheric pressure by this method. Not only can accurate estimation of CVP assist in diagnosis, it can be tremendously useful in monitoring therapy, for example in response to diuresis from day to day. Careful communication of bedside clinical findings is essential to avoid confusion. Transthoracic echocardiography can reliably determine whether cardiac dysfunction is present, and, if so, to what extent.

Some very obese patients or those with poor ultrasound windows for other reasons may need multiple gated acquisition MUGA scans to more accurately assess left ventricular ejection fraction. If the echocardiogram suggests normal left sided function, but elevated right sided pressures are consistent with pulmonary hypertension, chest imaging and pulmonary function tests can help determine whether a primary pulmonary process may be present.

Lastly, polysomnography is the gold standard test for diagnosing obstructive sleep apnea. Brain natriuretic peptide BNP levels or pro-N-terminal BNP levels can be used to rule in or rule out heart failure, although depending on the specific assay may be elevated in non-cardiac conditions such as pulmonary embolism and severe obstructive lung disease.

Useful constructs are to consider whether there is volume overload on the left, right, or both, and if there is a cardiac abnormality, whether that is systolic or diastolic in nature.

Serial measurement of BNP is unlikely to be of net value. One-time measurements, though, especially if highly elevated or very low, can be tremendously useful in the differential diagnosis. Patients with significant pulmonary hypertension along with left sided cardiac disease present an especially difficult clinical challenge.

Their JVP will likely always be elevated and may not reflect elevated left sided filling pressures. Excess preload reduction in these patients can lead to poor right ventricular cardiac output, poor left sided filling, and systemic hypoperfusion. This low cardiac output state can manifest clinically as hypotension, syncope, and renal failure.

There are internal and external branches. The internal jugular vein lies deep in the root of the neck, medial to the sternomastoid muscle Fig 1. It is joined to the superior vena cava and the right atrium, without any intervening valves Epstein et al, The external jugular vein lies lateral to the sternomastoid muscle and is more superficial than the internal jugular vein, so is therefore easier to see.

Pressure in the right atrium is an important indicator of cardiac or pulmonary disease; as the right atrium communicates directly with the right internal jugular vein, the pressure within the vein provides an accurate indication of right atrial pressure Cox and Roper, When the pressure in the right atrium is sufficiently high, blood flows back into the internal jugular vein.

Therefore, in a healthy patient with normal right atrial pressure:. These occur at irregular intervals because sometimes the tricuspid valve will be shut and sometimes it will be open Cox and Roper, This will transiently increase venous pressure resulting in a more prominent internal jugular vein.