Jugular Venous Pressure (JVP)

  • Ask patient to lie down on the examination table with head of bed elevated to 30-45 degrees 
  • Ask patient to look to the left as much as possible
  • Landmark yourself between the two heads of the sternocleidomastoid.
  • The JVP is an occludable, non-palpable, biphasic waveform or pulsation.
    • If you cannot see the 2 heads of the SCM, have the patient push against your hand on the cheek
  • Use ruler to assess JVP height to sternal angle
    • Use ruler to measure it accurately 
    • Normal should be <5 cm above sternal angle 
  • Lookout for Kussmaul’s sign – JVP elevates with inspiration.
    • This is a sign of severe pericarditis or RHF
  • Lookout for beck’s triad – distended neck veins, low arterial BP, muffled heart sounds 
  • Press on liver to assess hepatojugular reflux (should return to normal within 10 seconds) 
  • Final Report: JVP is located and <5 cm above sternal angle 
JVPCarotid
Occludable and bounces back after occlusionNon-occludable
Non-palpablePalpable
Biphasic1-1 Pulse to heartbeat
Decreases with elevated position and with inspirationNo change with position or inspiration
Increases with hepatojugular refluxNo change with hepatojugular reflux
Differentiating the JVP from the Carotid

Pulsus paradoxus

  • Check BP in both arms as usual and mention that you will continue to measure BP
  • Listen for the first Korotkoff sound that appears then disappears with inspiration (recorded as SBP, as usual)
  • Listen for when the sound no longer disappears with inspiration (a pressure in between SBP and DBP)
  • Calculate the difference between these values; a difference of < 10 mmHg is normal – above this, is positive for pulsus paradoxus
  • Then listen for the last sounds in series (DBP, as usual), deflate cuff more quickly as normal
  • Final Report: The recorded drop in systemic blood pressure is <10mmHg, negative for pulsus paradoxus. 

Carotid upstroke

  • Rationale
    • Carotid upstroke is a special test used to assess aortic stenosis & regurgitation
    • Do if systolic murmurs are identified on auscultation
  • While auscultating the heart, mention than you will place the pads of fingers over the carotid artery on patient’s neck
  • As you listen for the murmur, there should be no delay between murmur onset (systole) and pulsation in the carotid
  • If carotid pulse is delayed and relatively diminished, this is pulsus parvis et tardus (sign of aortic stenosis)
  • If the carotid pulse is brisk, this may be a sign of aortic regurgitation
  • If the carotid pulse is biphasic (2 pulses per cardiac cycle), this is called pulsus bisferiens and may be a sign of coexisting aortic stenosis and regurgitation.