CLINICAL MEDICINE

Jugular Venous Pulse : An Appraisal

Naveen Garg*, Nitish Garg**

Abstract
Physical examination of jugular venous pulse (JVP) which is an integral part of cardiovascular examination is a commonly
neglected part of physical examination. Precise bedside analysis of JVP is not only possible but highly desirable. The
normal JVP reflects phasic pressure changes in the right atrium and consists of three positive waves and two negative
troughs. Clinicians can identify the jugular vein in a majority of patients with fair to moderate inter-observer variability.
There are several studies of external and internal reference points and phlebostatic axis in human beings. The method
of Lewis which states that “the CVP equals to the vertical distance between a point 5 cm below the sternal angle and
the top of the neck veins”, is the most accepted one. There are specific reasons for different changes in the normal
jugular waveforms; sometimes characteristic wave patterns are diagnostic of few clinical conditions. Careful examination
of JVP not only provides insight into cardiac haemodynamics and filling pressures but also provide electrophysiological
information that can be helpful to reach a final diagnosis. Regular careful examination of JVP is essential to monitor
therapy of congestive cardiac failure. Abdomino-jugular reflux and Kussmaul’s sign are two additional physical signs
which can be further helpful in making a final diagnosis. So we have enough reasons to believe that we can restore
the art of jugular vein assessment.

“The trouble with doctors is not that they don’t venous pressure can be reliably assessed at
know enough, but that they don’t see enough.” the bedside.
- Sir Dominic J. Corrigan (1802-1880)
Although clinicians began to associate
Physical examination of jugular venous pulse conspicuous neck veins with heart disease
(JVP) is an integral part of cardiovascular almost 3 centuries ago 1,2 , the practice of
examination and provides valuable a c t u a l l y m e a s u r i n g a pa t i e n t ’s v e n o u s
information to reach diagnosis and monitor pressure during physical examination is only
therapy for many cardiac illnesses. This part several decades old. Even Sir James
of examination is often neglected by Mackenzie, who in the late 1800s described
clinicians. During clinical teaching it should most of what we now know about bedside
be emphasised that precise bedside analysis diagnosis of the jugular venous pulse – the
of jugular venous pulse and pressure is not a, c, and v waves, venous sounds, cannon a
only possible but also highly desirable. waves, venous waveforms in heart disease,
and bedside diagnosis of atrial fibrillation (by
Failure to identify the height of the jugular
examination only of the pulse and neck veins,
venous pulsation most commonly results from
before the era of electrocardiography) 3,4 –
failure to look for it. Once a cardinal aspect
totally ignored the concept of measuring
of the clinical cardiovascular examination,
venous pressure.
jugular venous pulsations are unlikely to be
sought by contemporary physicians unless we Venous pressure became more important to
can convince them of three principles: (1) JVP clinicians in the twentieth century after direct
is important to assess cardiac filling cannulation of the antecubital vein allowed
pressures, (2) jugular venous pressure often clinicians to measure pressure directly by
reflects cardiac filling pressure, (3) jugular manometry 5 and after Ernest Starling’s
investigations between 1912 and 1914 that
* Assistant Professor, linked venous pressure to cardiac output 6-9 .
** Senior Resident, In his book “The Failure of Circulation,”
Department of Cardiology, Tinsley Harrison further endorsed Starling’s
Sanjay Gandhi PGIMS, Lucknow (India). ideas 10 and, along with others, encouraged
clinicians to regard the elevated venous on the phlebostatic axis, (a line representing
pressure as an early and essential finding of intersection of the cross-section plane
heart failure 11,12 . The treatment of heart through the fourth intercostal space at the
failure became less empirical and more sternum and the coronal plane midway
rational, and venous pressure became the between back and xiphoid; a line that
objective end point that clinicians monitored traverses the posterior right atrium of most
frequently, often on graph paper, after individuals) the venous pressure of healthy
administration of digitalis, phlebotomy, or adults changes less than 1-2 cm H 2 O
diuretics 13-15 . whether the individual is supine, prone, or
in various positions between supine and
The main focus of the current review is
upright 16 -18. Whether the right atrium is the
whether and how jugular venous pulse can
actual zero point, however, is uncertain
accurately be assessed by the clinician at the
because the zero point should logically lie
bedside and its examination as a source of
in the patient’s midline to minimise the
anatomic, haemodynamic, and electro-
hydrostatic pressure changes that would
physiologic information from right side of the
occur when any individual rolls from side-
heart.
to-side19 most of right atrium, of course, lies
Central venous pressure in the right chest.

The central venous pressure (CVP) refers to (b) The external reference point
the mean vena caval or right atrial pressure,
which is equivalent to right ventricle end Over the last century, investigators have
diastolic pressure in the absence of tricuspid proposed numerous landmarks to help
stenosis. CVP is expressed in millimetres of clinicians to locate the level of the right atrium,
mercury (mm Hg) or centimetres of water (cm most as reference point for directly measuring
H 2O) above atmospheric pressure (this article the supine antecubital venous pressure with a
uses cm H 2O; 1.36 cm H 2O = 1.0 mm Hg). catheter (Table I). The evidence for these
reference points varies, resting in some cases
Reference point on anatomic dissection5,20, in others on a trial
and error search for the zero point16,17, but in
(a) Physiological reference point
most, unfortunately, on no data; the landmark
The physiological reference point is the location simply representing a convenient point14,21-26.
in the cardiovascular system where the CVP is
Sir Thomas Lewis, a pupil of Mackenzie,
tightly regulated, changing little (if at all) during
proposed in 1930 a simple bedside
the volume shifts that occur when the patient
method for measuring venous pressure
stands or sits. To obtain reproducible
designed to replace the manometer, which
measurements that are independent of
he found too burdensome for general use.
position, the “zero” mark of the manometer
He observed that the top of the jugular
or electronic system used to measure venous
veins of normal individuals (and the top
pressure should lie at the same vertical height
of the fluid in the manometer) always
of this point.
came to lie within 1 to 2 cm of vertical
There are few studies of reference point (zero distance from the sternal angle, whether
point) in human beings, if it even exists, the individual’s position was supine,
although most clinicians assume that it lies semiupright, or upright. If neck veins were
in the right atrium. In investigations where higher than this, Lewis concluded the
the zero mark of the manometer was kept patient had elevated venous pressure. A

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October-December 2000 261
 modification of this technique, commonly When the various landmarks in table I
cited in textbooks 27 and review articles 28 were compared with the position of a right
and sometimes called the “method of atrial catheter on lateral chest
Lewis” states that the CVP equals the radiographs of patients in supine position,
vertical distance between a point 5 cm the method of Lewis identified a point
below the sternal angle and the top of the consistently 1-2 cm anterior to the catheter
neck veins 13,26,29,30, although Lewis did not whereas the phlebostatic axis identified a
make such a claim. point consistently 2-3 cm posterior 31 .

Table I : Proposed external reference points for measurement of venous pressure

Author Suggested reference point* Evidence
Von Recklinghausen21 (1906) Midway between xiphoid and back # No data offered
Moritz (1910)
5
5 cm below thoracic surface at fourth In cadavers with varying chest
costal cartilage # dimensions, a needle inserted at this
point parallel to the anterior thoracic
surface usually pierces the junction of
vena cava and right atrium
Young22 (1923) 8 cm posterior to sternum # No data offered
Harris (1928)
22
Anterior axillary line # No data offered
Eyster24 (1929) Junction of anterior and middle thirds No data offered
of anterior posterior dimension at fourth
intercostal space #
Taylor14 (1930) Midaxillary line # No data offered
Griffith25 (1934) 21/2 inches below sternal angle # No data offered
Lyons20 (1938) 10 cm anterior to skin of the back $ Usual location of right atrium in
dissections of frozen cadavers, and
author’s experience that reference to
posterior body wall minimised variation
in pressure measurements in patients
with widely divergent chest dimensions
Holt16 (1940) 10 cm anterior to skin of the back Point minimising variation of venous
pressure in 10 individuals with varying
chest dimension who were positioned
supine and then prone
Winsor17 (1945) Phlebostatic axis – (intersection of plane Point minimising variation of venous
parallel to anterior surface midway pressure in 90 individuals with varying
between back and xiphoid and chest dimension who were placed in
cross-sectional plane through fourth various positions from supine to 90
intercostal space at sternum) degrees upright
Borst26 (1952) 5 cm below sternal angle $ No data offered
* Identification of reference points assumes the patient in supine.
# Reference point “accurate” only when patient in supine position.
$ Reference point “ accurate” in any position.

262 Journal, Indian Academy of Clinical Medicine
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October-December 2000
 Obviously, the measurement of venous catheterization (which tends to select unstable
pressure is only as good as the reference patients or those with confusing examinations
point used. because they have not responded to initial therapy)
34,35
or patients who already had an internal jugular
Bedside examination versus direct catheter in place (which may obscure the neck
measurement of venous pressure veins during examination)33,36,37. Nonetheless,
these studies are relevant because the patients
Clinicians can identify the jugular veins in 72-94%
recruited are among those with the most pressing
of patients22,33 and measure the CVP with fair to
need for accurate measurements of CVP.
moderate inter-observer agreement33. Table II
presents data from the five clinical studies that Four of the five studies concluded that bedside
compared direct measurements of CVP to diagnosis was inaccurate and unreliable 33-36.
clinicians’ estimates from physical diagnosis. Results were similar whether the clinicians had

Table II : Venous pressure bedside examination versus direct measurement.

External reference point
Reference (A) For the clinician (B) For catheter measurement Findings
Clinician’s estimate vs
catheter measurement
Division36 (1974) Method of Lewis 5cm below sternal angle Difference in measurements#
(n=39) in supine patients < 2cm = 57%
< 3cm = 93%
< 4cm = 100%
Ducas37 (1983) Method of Lewis 5cm below sternal angle Difference in measurements$
(n=25) in supine patient < 5.4cm = 86%
Cook33 (1990) Not stated Not stated Correlation coefficient of
(n=50) bedside vs catheter value
0.65 to 0.74
Clinician’s accuracy
predicting venous
pressures §
34
Connors (1983) Not stated Not stated 42.7% predictions within
(n=62) measured range
Eisenberg35 (1984) Not stated Midaxillary line 55% predictions within
(n=103) 2.7 cm H2O of measured
range
# Only data from right internal jugular shown. Results from right and left internal and external jugular veins were similar.
$ Neck veins were not seen in 40% of patients positioned at 45 degrees; all these patients had measured values < 7cm or >
26cm, too low or too high to be visualized in this position.
§ Defined as low, normal and high; < 0cm, 0 to 9.5cm and > 9.5cm (Connors et al), respectively, and < 2.7cm, 2.7-8.2cm,
and > 8.2cm (Eisenberg et al), respectively.

Importantly, the patients in these studies were examined the external or internal jugular vein.
probably the most difficult to examine. Over 90% Accuracy improved when mechanically ventilated
were in the intensive care unit, and many were on patients were excluded 33,34. In studies when
mechanical ventilators. Entry criteria included clinicians were asked to assess the CVP as either
either the clinical need for right atrial low, normal, or high, they were accurate only

Journal, Indian Academy of Clinical Medicine
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about half of the time, although more so if the sternocleidomastoid muscle and is therefore not
venous pressure was predicted to be high (77- usually visible as a discrete structure, except in the
80% accuracy) than low (3- 38% accuracy)28,34. presence of severe systemic venous hypertension.
Accuracy improved when mechanically ventilated However, its pulsations are transmitted to the skin
patients were excluded33,34. of the neck, where they are usually easily visible.
Sometimes difficulty may be experienced in
Jugular venous pulse examination differentiating between the carotid and jugular
Important information concerning the dynamics venous pulses in the neck, particularly when the
of the right side of the heart can be obtained by latter exhibits prominent v waves, as occurs in
observation of the jugular venous pulse.38-41 The patients with tricuspid regurgitation in whom the
internal jugular vein is ordinarily employed in the valves in the internal jugular veins may be
examination. The venous pulse can usually be incompetent. However, there are several helpful
analysed more readily on the right than on the clues42 : (1) The arterial pulse is a sharply localised
left side of the neck, because the right innominate rapid movement that may not be readily visible
and jugular veins extend in an almost straight line but that strikes the palpating fingers with
cephalad to the superior vena cava (Figue 1), thus considerable force, in contrast the venous pulse,
favouring transmission of the haemodynamic while more readily visible, often disappears when
changes from the right atrium, while the left the palpating finger is placed lightly on or below
innominate vein is not in a straight line and may the pulsation area; (2) The arterial pulse usually
be kinked or compressed by a variety of normal exhibits a single upstroke while the venous pulse
structures, by a dilated aorta, or by an aneurysm. has two peaks and two troughs per cardiac cycle
in sinus rhythm; (3) The arterial pulsations do not
The internal jugular vein is located deep within change with change in the patient’s position or
the neck, where it is covered by the during respiration, whereas venous pulsations
usually disappear or diminish greatly in the upright
position and during inspiration, unless the venous
pressure is greatly elevated; (4) Compression of
the root of the neck does not affect the arterial
pulse but usually abolishes venous pulsation,
except in the presence of extreme venous
hypertension.
The patient should lie comfortably during the
examination: clothing should be removed from
the neck and upper thorax; although the head
should rest on a pillow, it must not be elevated at
a sharp angle from the trunk. The jugular venous
pulse may be examined effectively by shining a
light tangentially across the neck. Most patients
with heart disease are examined most effectively
in the 45O position, but in patients in whom venous
pressure is high, a greater inclination (60O or even
90O) is required to obtain visible pulsations, while
in those in whom jugular venous pressure is low,
Fig. 1 : Spatial relationships of jugular veins, superior vena cava and
right atrium. Note that right internal jugular vein is in more direct line a lesser inclination (30O) is desirable. In order to
with superior vena cava than external jugulars. amplify the pulsations of the jugular veins, it may

264 Journal, Indian Academy of Clinical Medicine
Vol. 1, No. 3
October-December 2000
be helpful to place the patient in the supine position the heart. Changes in flow and pressure caused
and try to increase venous return by elevating the by right atrial and ventricular filling, however,
patient’s legs. Simultaneous palpation of the left produce pulsation in the central veins that are
carotid artery aids the examiner in relating the transmitted towards the peripheral veins, opposite
venous pulsations to the timing of the cardiac cycle. to the direction of blood flow. With the possible
exception of the c wave, the pulsations observed
Venous pressure may also be estimated by
in the neck are produced by right atrial and
examining the veins in the dorsum of the hand.
ventricular activity. Factors influencing the CVP
With the patient sitting or lying at a 30O elevation
include the total blood volume and its distribution,
or greater, the arm is slowly and passively raised
and right atrial contraction.
from dependent position. When the venous
pressure is normal, the veins collapse when the The normal JVP reflects phasic pressure changes
dorsum of the hand reaches the level of the sternal in the right atrium and consists of three positive
angle of Lewis. Unfortunately, local venous waves and two negative troughs (Figure 2). The
obstruction or augmented peripheral venous events of the cardiac cycle, shown in figure 2,
constriction may diminish the accuracy of provide an explanation for the details of the jugular
estimating CVP by this method. This method is venous waveform. The a wave in the venous pulse
especially useful in patients with markedly elevated results from venous distention due to right atrial
CVP when upper level is above angle of mandible systole, while the x descent is due to atrial
in sitting position. relaxation and descent of the floor of the right
atrium during right ventricular systole; the latter,
Two principal observations can usually be made
sometimes called the x‘ descent, interrupts the x
from examination of the neck veins, the level of
descent. The c wave, which occurs simultaneously
venous pressure and the type of venous wave
with the carotid arterial pulse, is an inconstant
pattern. In order to estimate jugular venous
pressure, the height of the oscillating top of the
distended proximal portion of the internal jugular
vein, which reflects right atrial pressure, should
be determined. The upper limit of normal is 4 cm
above the sternal angle, which corresponds to a
central venous pressure of approximately 9 cm
H2O, since the right atrium is approximately 5 cm
below the sternal angle. When the veins in the
neck collapse in a subject breathing normally in
the horizontal position, it is likely that the central
venous pressure is subnormal. When obstruction
of veins in the lower extremities is responsible for
oedema, pressure in the neck veins is not elevated
and the abdomino-jugular reflux is negative.

Normal pattern of the jugular venous

pulse
Venous blood returning from the systemic
capillaries is non-pulsatile; changes in volume flow
created by skeletal muscles and respiratory pump Fig. 2 : Normal and few diagnostic abnormal venous pulse wave
patterns.
are non-synchronous with the pulsatile activity of

Journal, Indian Academy of Clinical Medicine
Vol. 1, No. 3
October-December 2000 265
wave in the jugular venous pulse and/or 5. Obstructive atrial myxoma.
interruption of the descent following the peak of 6. Superior vena caval obstruction.
the a wave (many investigators refer to this wave
C. Elevated “a” wave
as the x‘ descent). The v wave results from the rise
in right atrial pressure when blood flows into the 1. Tricuspid stenosis
right atrium during ventricular systole when the 2. Decreased ventricular compliance due to
tricuspid valve is shut, and the y descent, i.e., the ventricular failure, pulmonic valve stenosis, or
downslope of the v wave, is related to the decline pulmonary hypertension.
in right atrial pressure when the tricuspid valve D. Cannon “a” wave
reopens. Following the bottom of the y descent
1. Atrial-ventricular asynchrony (atria contract
(the y trough) and before beginning of the a wave
against a closed tricuspid valve – as during
is a period of relatively slow filling of the atrium
complete heart block, premature ventricular
or ventricle, the diastases period, a wave termed
contraction, during ventricular tachycardia,
the h wave.
ventricular pacing and during junctional
While all or most of these events can usually be rhythm and tachycardia).
recorded, they may not be readily distinguishable
E. Absent “a” wave
on inspection. The descents or downward
collapsing movements of the jugular veins are 1. Atrial fibrillation or atrial standstill.
more rapid, produce larger excursions, and are F. Elevated “v” wave
therefore more prominent. The x descent occurs 1. Tricuspid regurgitation.
just prior to the second heart sound, while the y 2. Right ventricular failure.
descent ends after the second heart sound. The a
3. Reduced atrial compliance (restrictive
wave occurs just before the first sound or carotid
cardiomyopathy).
pulse and has a sharp rise and fall. The v wave
occurs just after the arterial pulse and has a slower G. “a” wave equal to “v” wave
undulating pattern. 1. Cardiac tamponade.
2. Constrictive pericarditis.
Abnormalities of jugular venous pulse 3. Hypervolaemia.
(Figure 2)
4. Atrial septal defect.
A. Low jugular venous pressure
H. Prominent “x” descent
1. Hypovolaemia. 1. Cardiac tamponade.
B. Elevated jugular venous pressure 2. Subacute constriction and possibly chronic
1. Intravascular volume overload conditions due constriction.
to valvular disease (tricuspid or pulmonic 3. Right ventricular ischaemia with preservation
stenosis or regurgitation), right ventricular of atrial contractility.
ischaemia or infarction, cardiomyopathy or 4. Atrial septal defect.
secondary to left heart failure (mitral stenosis/
I. Prominent “y” descent
regurgitation, aortic stenosis/regurgitation,
1. Constrictive pericarditis.
cardiomyopathy, myocardial ischaemia/
2. Restrictive cardiomyopathies.
infarction).
3. Tricuspid regurgitation.
2. Right ventricular failure.
4. Atrial septal defect.
3. Constrictive pericarditis.
4. Pericardial effusion with tamponade J. Blunted “x” descent
physiology. 1. Tricuspid regurgitation.

266 Journal, Indian Academy of Clinical Medicine
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2. Atril fibrillation. right heart failure46,47, pulmonary embolism48 and
3. Right atrial ischaemia. right ventricular infarction49-51.
K. Blunted “y” descent Perhaps the fixed right ventricular distention in
1. Cardiac tamponade. these patients eliminates the normal regulatory
role of CVP on the Starling cardiac function curves:
2. Right ventricular ischaemia.
instead of augmenting ventricular distention and
3. Tricuspid stenosis.
output, any increase in venous return only
4. Right atrial myxoma.
exaggerates the increment in CVP.
Abdomino-jugular reflux 42,43
Conclusion
In patients suspected of right ventricular failure
In the current era of modern medicine,
but having normal resting venous pressure, the
examination of JVP, which is an integral part of
abdomino-jugular reflux (also known as hepato-
CVS examination, has become a neglected part
jugular test) is useful.
of physical examination. It not only provides
This can be tested by applying firm pressure to indirect assessment about cardiac haemodynamics
the peri-umbilical region for 10-30 seconds with and cardiac filling pressures, sometimes
the patient breathing quietly while the jugular veins characteristic wave patterns are diagnostic and
are observed; increased respiratory excursions or pathognomic of a few clinical conditions. So we
straining should be avoided. In normal subjects, have enough reasons to believe that we must
jugular venous pressure either does not alter restore the art of jugular venous pulse assessment.
significantly or rises less than 3 cm H2O and only
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 in compressive cardiac disorders: Constrictive 49. Lorell B, Leinbach RC, Pohost GM et al. Right ventricular
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rig e

30
av red
al
O Th

N ble d P
in

%
ai u

ow a r
Flavedon 20
la ce

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3 TABLETS DAILY

e
A major antianginal for all patients
As first line treatment
l

l Uncontrolled on conventional drugs

l To replace a poorly tolerated antianginal

l At risk (elderly, diabetic CAD patients)

When it comes to the heart do not compromise on quality

Journal, Indian Academy of Clinical Medicine
Vol. 1, No. 3
October-December 2000 269