Elevated Jugular Venous Pressure/Central Venous Pressure

I. Problem/Condition.

The physical examination finding of elevated jugular venous pressure (JVP) can provide pivotal information to the bedside clinician. The degree of elevation directly reflects the central venous pressure (CVP) or right atrial pressure, in turn reflecting potential pulmonary hypertension and/or elevated left sided filling pressures. Less common subtleties include prominent ventricular waves (V waves) reflecting tricuspid regurgitation and canon atrial waves (A waves), which occur in the setting of complete heart block and instances of atrial systole against a closed tricuspid valve. The crux of successful interpretation of this critical physical examination finding is to develop an accurate and reliable method and to communicate the findings clearly.

II. Diagnostic Approach.

A. What is the differential diagnosis for this problem?

Acute decompensated heart failure (ADHF), whether with reduced or preserved left ventricular ejection fraction, represents the most common element in the differential diagnosis. The elevated right sided cardiac pressures that are directly responsible for this finding may be due to right and/or left sided ADHF, which in turn have broad differential diagnoses. Other less common considerations are constrictive pericarditis, cardiac tamponade, tension pneumothorax and pulmonary hypertension without clinical features of left heart failure.

B. Describe a diagnostic approach/method to the patient with this problem.

The clinical history may vary substantially in patients with this finding and in the extent of its abnormality. For ADHF, the key is to determine whether there is left heart failure, right heart failure, or both.

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1. Historical information important in the diagnosis of this problem.

The history should focus on the presence or absence of dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and edema. The time course of these changes and severity must be noted, as therapies for ADHF are tightly linked to severity as determined by New York Heart Association (NYHA) functional class. In the absence of these symptoms, features of pulmonary disease should be pursued, such as cough, occupational exposures, and symptoms of connective tissue disease.

2. Physical Examination maneuvers that are likely to be useful in diagnosing the cause of this problem.

The absolute key to assessing jugular venous pressure is to change the patient’s position until venous pulsations are seen in the neck. Either internal or external jugular veins may be used for inspection, provided there is the characteristic two-component wave (A and V wave) to ensure valves or other obstructive lesions are not present. If the precise location of the vein is in question, have the patient perform the Valsalva maneuver, which in many instances will engorge the jugular venous system and bring them into view.

Proper lighting is important, although a flashlight is often not as helpful as overall ambient light – lighting from near the head of the bed will cast shadows down the neck and makes assessment simple. Some patients may have venous pulsations visible only when completely supine, others only when sitting upright. The degree of elevation of the patient is immaterial to the measurement itself but is indispensable to the process of seeing the pulsation in order to perform the measurement.

In some instances, it may be difficult to differentiate venous from arterial pulsation. By placing the ulnar side of the hand gently against the base of the neck with enough pressure to occlude the veins, this will block venous pulsations and what remains will be arterial. Releasing the hand will then allow venous pulsation to resume and the examiner can determine whether what was visible was indeed venous. If not, the patient likely needs to be repositioned up or down. Again, performing the Valsalva maneuver at this point can be extremely helpful: seeing the veins engorge and rise will tell the examiner that the patient needs to be positioned lower.

The pulsation should vary with respiration, dropping during inspiration. Measurement is performed at end expiration. To estimate the CVP, determine the VERTICAL (as opposed to linear) distance between the jugular venous pulsation and the sternal angle and add 5 cm. The “Cardiologist’s Constant” is 5 cm – that the distance between the sterna angle and the right atrium remains approximately 5 cm and constant throughout patient positioning from supine to upright (also known as the method of Lewis). The sum of the vertical distance plus 5 is the CVP in centimeters of water above atmospheric pressure by this method. Normal CVP is 4-6 cm H2O. By this method, an estimated CVP >8 cm H2O has a positive likelihood ratio of 9.7 for detecting elevated CVP by invasive catheterization, and a positive likelihood ratio of 6.3 for detecting reduced LV ejection fraction as measured by transthoracic echocardiography.

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. Especially for patients in whom body habitus makes accurate assessment difficult, the examiner is encouraged to communicate that jugular venous distension was “inapparent”, rather than stating is was negative or not present.

3. Laboratory, radiographic and other tests that are likely to be useful in diagnosing the cause of this problem.

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.

C. Criteria for Diagnosing Each Diagnosis in the Method Above.

There are no specific criteria for diagnosing heart failure, as it is a clinical syndrome of volume overload due to cardiac and/or pulmonary 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.

D. Over-utilized or “wasted” diagnostic tests associated with the evaluation of this problem.

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.

III. Management while the Diagnostic Process is Proceeding.

A. Management of Clinical Problem Elevated Jugular Venous Pressure.

Will depend on the suspected etiology of elevated CVP.

B. Common Pitfalls and Side-Effects of Management of this Clinical Problem.

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.

IV. What's the evidence?

Sapira, JD. “The Art and Science of Bedside Diagnosis”. 1990.

McGee, S. “Evidence-Based Physical Diagnosis”. 2012.

Vinayak, AG, Levitt, J, Gehlback, B. “Usefulness of the external jugular vein examination in detecting elevated central venous pressure in critically ill patients”. Arch Intern Med. vol. 166. 2006. pp. 2132-2137.

Wang, CS, FitzGerald, JM, Schulzer, M. “Does this dyspneic patient in the emergency department have congestive heart failure”. JAMA. vol. 294. 2005. pp. 1944-1956.