Waves

• ‘a’ wave: rise in RA pressure during RA contraction.
• ‘x’ descent: atrial relaxation + RV contraction (pulls atrium downward).
• ‘c’ wave: bowing of tricuspid valve into RA during ventricular systole (not ordinarily visible to the naked eye).
• ‘v’ wave: right atrial filling, tricuspid valve closed, in late systole/early diastole.
• ‘y’ descent: emptying of RA after tricuspid valve opens.

Tips for Finding JVP

• Develop a systemic approach for scanning for the JVP, following the trajectory of the IJ vein. It starts at the cheek (just anterior to ear) and crosses the clavicle between the two heads of the sternocleidomastoid muscle.
• Tips to find the JVP:
  • Shine a light tangentially across the internal jugular vein, if needed.
  • Use at least two different patient angles to confirm that what you are looking at is the JVP. The JVP will lower 1) with elevation of the head of bed and 2) with inspiration.

• Tricks for differentiating JVP from carotid:

• Carotid upstroke is single, palpable, brisk, and timed with the radial pulse.
• Venous pulsations are diffuse with two distinct waves (if in sinus rhythm), positional (will fall when patient inclines and when patient inspires) and will rise with abdominojugular reflux (even in normal patients but only briefly).
• Pressure on skin just above the clavicle should result in disappearance of JVP pulsations but carotid pulsations will persist.
• Hepatojugular reflux: apply abdominal pressure or elevate the legs for 30 seconds. The JVP should rise but then fall immediately. Sustained rise in JVP (>3 cm for >10 sec) is abnormal.

• Once found, measure from top of sternal angle to highest point of JVP and add 5cm (height to RA). This will result in consistent measurements independent of head elevation. Normal JVP is <8 cm. When patient is sitting upright, the clavicle is ~10cm above the RA therefore the JVP is elevated if seen above the clavicle at 90 degrees.

Specific findings

• No ‘a’ wave in atrial fibrillation due to lack of coordinated atrial contraction.
• Increased ‘a’ with impaired atrial emptying: complete heart block, tricuspid stenosis/atresia, pulmonary valve stenosis, PAH, restrictive cardiomyopathy, carcinoid, right atrial myxoma.
• Large ‘v’ wave in tricuspid regurgitation due to increased RA filling during RV systole (Lancisi sign), atrial septal defect.
• ‘y’ descent diminished in tamponade, RA myxoma or thrombus, and constrictive pericarditis.
• Rapid ‘x’ and ‘y’ descent in constrictive pericarditis and restrictive cardiomyopathy.
• Kussmaul’s sign: increase in JVP with inspiration; typically seen in constrictive pericarditis, but can also be seen in restrictive cardiomyopathy and RV failure.