Examination of the jugular venous pulse

INTRODUCTION

Analysis of the jugular venous pressure and pulse provide information regarding hemodynamic changes in the right side of the heart. It is preferable to examine the internal rather than external jugular veins since the internal jugular veins are in a direct line with the superior vena cava and right atrium whereas the external jugular veins are not in a direct line with the superior vena cava and connect with it after negotiating two almost 90 degree angles [1]. There are valves between the superior vena cava and both internal and external jugular veins; however elevated venous pressure can be transmitted through the venous valves . The external jugular venous bulb is a site for thrombus formation, which can cause partial obstruction of the external jugular veins.

Partial compression of the left innominate vein is usually relieved during modest inspiration as the diaphragm and the aorta descend and the pressure in the two internal jugular veins becomes equal. However partial obstruction of the left innominate vein from compression by the aorta may persist, particularly in relatively elderly patients, impairing transmission of right atrial pressure to the left internal jugular vein; this is also the most common cause of unequal pressures between right and left internal jugular veins. There is better transmission of right atrial pressures and pulses to the right internal jugular vein since the right innominate and internal jugular veins are in a direct line with the superior vena cava. Thus, examination of the right internal jugular venous pulse is preferable for assessing the hemodynamic changes in the right side of the heart. (See "Cardiac catheterization techniques: Normal hemodynamics".)

JUGULAR PULSATIONS

The normal jugular venous pulse wave or right atrial pressure wave recordings usually consist of three positive waves, a, c and v, and two negative waves, x and y [2] (graph 1). (See "Cardiac catheterization techniques: Normal hemodynamics" and "Swan-Ganz catheterization: Interpretation of tracings".)

• The positive a wave is caused by the right atrial pressure transmitted to the jugular veins during right atrial systole, The a wave peaks just before or during the first heart sound (S1) and before the onset of ventricular ejection (carotid pulse upstroke).
• Atrial relaxation initiates the descent of the a wave and this is usually interrupted by the c wave. In the right atrial pressure tracing, the c wave is recognized with the onset of right ventricular systole and presumably occurs from bulging of the tricuspid valve into the right atrium as well as from transmission of the adjacent carotid artery pulsation. The c wave of the jugular venous pulse generally cannot be distinguished by clinical examination although it is usually apparent in the right atrial pressure tracing.
• Following the a and c waves, the x descent is a negative wave that occurs in late systole due to the delay in transmission of the pulse. Right atrial relaxation appears to be the primary mechanism for the x descent, although downward displacement of the tricuspid valve and right atrioventricular annulus during right ventricular ejection also contributes to the fall in right atrial pressure.
• Terminating the x descent is the v wave. The mechanism of the v wave is the rise in right atrial and jugular venous pressure due to continued inflow of blood to the venous system during late ventricular systole when the tricuspid valve is still closed. The peak of the normal v wave is immediately after ventricular systole; the normal v wave coincides with the downslope of the carotid pulse after the peak amplitude is felt.
• The descending limb of the v wave, termed the y descent, is caused by the opening of the tricuspid valve and the rapid inflow of blood to the right ventricle from the right atrium and the venous system. The initial y descent occurs during the rapid filling phase of the right ventricle, and the right ventricular third heart sound (S3) corresponds to the nadir of the y wave. The ascending limb of the y wave occurs during continued inflow of blood to the venous system and right ventricle after the rapid filling phase.

It is often difficult to distinguish a and v waves or x and y descents during tachycardia. Not infrequently, only one positive and one negative wave are recognized. Carotid massage may be necessary to slow the heart rate and allow better analysis of the jugular venous pulse. (See "Vagal maneuvers", section on 'Carotid sinus massage'.) In patients with atrial fibrillation, the jugular venous pulse is irregular and usually only v and y waves are appreciated. In atrial flutter, occasionally flutter waves are recognized, and the frequency of the flutter waves are higher than the arterial pulse rate.