Physical examination
JVP
Measure Jugular Venous Pressure (JVP)
1. Encourage the patient to relax and elevate the bed about 45 degrees.
2. Remove the pillow, as waveforms are usually more visible, with the head resting directly on the examining table.
3. Adjust the neck position for the best visibility.
4. Ensure the room is well-lit, removing the need for a flashlight or direct light source.
5. Your initial goal should be to observe a pulsation. Determine whether it is arterial or venous by using the following criteria to identify venous waves:
- Venous waves appear bifid.
- Pulsation increases when the head of the bed is lowered and decreases when it is raised.
- Pulsation changes with respiration, sinking into the chest during inspiration.
- It is not palpable.
Using an external jugular vein is acceptable if you can see the waveforms. It is important to differentiate between the prominent pulsations from the carotid artery and the JVP.
The JVP can be assessed on either side; if it is not visible on the right internal jugular due to factors like musculoskeletal anatomy or venous clots, examine the left side instead.
Once you have confirmed the venous waves, measure the jugular venous pressure by identifying the JVP at the highest pulsation point. Extend a card or ruler horizontally from this peak and cross it with a ruler at the sternal angle (Angle of Louis).
For example, if it measures 4 cm, add 5 cm to account for the distance to the center of the atrium, and report the JVP as "the jugular venous pressure was 9 cm of water" (not mercury).
"A" wave: Atrial contraction (ABSENT in atrial fibrillation)
"C" wave: ventricular Contraction (tricuspid bulges).
"X" descent: atrial relaXation
"V" wave: atrial Venous filling (occurs at the same time as ventricular contraction)
"Y" descent: atrial emptYing (tricuspid opens)
The A wave occurs during right atrial contraction and appears before the S1 heart sound on auscultation. However, in patients with atrial fibrillation, the A wave is absent.
In situations where the right atrium contracts but blood cannot flow adequately into the right ventricle, the A wave becomes more prominent, such as in tricuspid stenosis or A-V dissociation (when the right atrium contracts but the right ventricle is not relaxed enough to receive blood).
In patients experiencing palpitations due to AV nodal reentrant tachycardia (AVNRT), where the atria and ventricles contract almost simultaneously, blood is pushed back into the jugular veins. This results in a noticeably high A wave each time the heart contracts, known as the “Frog sign.”
The X descent is the downward slope following the peak of the A wave, caused by the relaxation of the right atrium, which pulls blood downward. Midway through, a C wave is produced when the proper ventricle contracts and pushes the tricuspid valve upward. (tricuspid bulges). If you palpate the carotid pulse, it will coincide with the C wave.
The V wave arises from the accumulation of blood in the right atrium and appears after the S2 heart sound. The height of the V wave depends on right atrial compliance and the blood volume entering the right atrium. If the right atrium can accommodate a large volume of blood, the V wave will not be very high.
In cases of tricuspid regurgitation, the C wave and V wave appear simultaneously because, during ventricular systole, blood regurgitates through the incompetent tricuspid valve.
The Y descent follows the peak of the V wave and occurs when the tricuspid valve opens, allowing blood to flow into the right ventricle. In conditions where blood cannot adequately enter the right ventricle—such as tricuspid stenosis or when the right ventricle’s compliance is reduced (e.g., in cardiac tamponade)—the Y descent is diminished. Conversely, a deep Y descent may be observed when the right ventricle relaxes rapidly, such as in constrictive pericarditis.
Hepatojugular reflux
The patient should be positioned so the jugular venous pressure can be easily seen. Classically, the patient is placed in a semi-recumbent position with the head of the bed elevated to 30 to 45 degrees. At least a 3 cm margin should exist from the baseline JVP's upper margin to the mandible's angle. Apply gentle pressure (30-40 mm Hg) over the right upper quadrant or middle abdomen for at least 10 seconds.
The location of abdominal compression does not significantly impact the test. Applying pressure directly on the liver is not mandatory, as midline pressure also increases intra-abdominal pressure.
Sustained elevation of JVP > 3 cm, sustained for over 15 seconds, is considered a positive hepatojugular reflux.
An elevation of 1 to 3 cm is considered normal. However, one should avoid breath-holding or performing the Valsalva maneuver because it can result in a false positive.