Central venous pressure: jugular venous pressure is somewhat helpful.

Clinical bottom line (level 1a)

  1. A low jugular venous pressure makes a low central venous pressure more likely (LR+3.4) and a high central venous pressure much less likely (LR-0.2) .
  2. A normal jugular venous pressure is unhelpful in interpreting central venous pressure.
  3. A high jugular venous pressure makes a high central venous pressure more likely, bu does not significantly help with a low central venous pressure.
  4. Agreement between doctors about jugular venous pressure can be poor.
  5. A positive abdominojugular reflux makes congestive cardiac failure likely, but no reflux can safely exclude it.
Cook and Simel: Journal of the American Medical Association 1996; 275 (8): 630-634
Expires July 2003

The study

Systematic review of all studies of
  • Patients: patients who had venous pressure assessed using jugular veins
  • Outcome: central venous pressure


    • Articles found in ? using MEDLINE, ? (search terms: not detailed; available on request ) and bibliographic searches and contacting relevant authors

    Selection criteria: as above
    Appraisal criteria: not detailed
    Articles excluded if:

    unclear how many studies were included
    • target disorder: high or low central venous pressure
    • reference standard: indwelling central venous catheter
    • diagnostic tests:
      • 1. Jugular venous pressure (JVP): use well-lit room; lay patient at 30 ° -45 ° to horizontal; turn head and look for right internal jugular. Raise or lower patient as required (normal patients may need to be laid almost flat). JVP is the vertical height from the highest point of the pulsation to the angle of Louis.
      • 2. Abdominojugular reflux: patients relaxes and breathes through open mouth. Place palm of hand on midabdomen and push at pressure 20-35 mmHg for 15-30 secs- positive if sustained increase in JVP 4 cm or more; negative if sustained increase 3 cm or less, or transient increase 4 cm or more. Repeat if pain, patient holds breath or bears down.

    The evidence


    diagnostic test central venous pressure <5 cm central venous pressure >5 cm LR+
    (95% CI)    		 post-test probability LR-
    (95% CI)    		 post-test probability
    jugular venous pressure low 3.4
    (1.0 to 11)     		-% 0.2
    (0.02 to 1.3)     		-%
    jugular venous pressure normal 1.0
    (0.5 to 2.1)     		-% 0.8
    (0.5 to 1.3)     		-%
    jugular venous pressure high 0.0
    (0.0 to 1.5)     		-% 4.1
    (1.3 to 13)     		-%
    abdominojugular reflux- physicians 6.4
    (0.8 to 51)     		83% 0.8
    (0.6 to 1.0)     		38%
    abdominojugular reflux- ER doctors 6.0
    (1.3 to 29)     		67% 0.7
    (0.5 to 1.1)     		19%
    total

    • K interobserver (students and residents)= 0.65
    • K interobserver (residents and attending physicians)= 0.30
    • abdominojugular reflux:
      • pre-test probability of congestive heart failure in hospitalised patients- 44% (95% CI: 30% to 58%)
      • pre-test probability of congestive heart failure in the emergency department- 25% (95% CI: 13% to 37%)

    Comments

    1. Using the left internal jugular vein to measure the JVP is fine, though the result will be marginally higher than right.
    2. Difficult to see JVP if:
      • very low JVP
      • mechanical ventilation
      • short/fat necks
      • wide central venous pressure swings with respiration, eg. acute asthma
    3. JVP is less accurate if patient is on mechanical ventilation or in a coma.
    4. Kussmaul's sign: paradoxical increase in JVP during inspiration- commonest cause severe right heart failure.
    5. Events are traditionally understood as: A-wave: right atrial contraction (followed by descent when atrium release):
      • absent- atrial fibrillation, sinus tachycardia
      • flutter waves- atrial flutter
      • large- tricuspid stenosis, atrial myxoma, reduced right ventricular compliance (as in hypertrophy, pulmonary hypertension or stenosis) or heart failure
      • gigantic ('Cannon')- A-V dissociation (atrium contracting against a closed tricuspid valve)
      C-wave: closure of the tricuspid valve (appearance often augmented in the neck by the carotid pulse)
      • increased- tricuspid regurgitation, ASD
      X-descent: atrial floor pulled down by contracting ventricle
      • decreased- tricuspid regurgitation
      • increased- atrial fibrillation
      V-wave: right atrium overflows because tricuspid valve is still closed
      • increased- tricuspid regurgitation, ASD, constrictive pericarditis
      Y-descent: tricuspid valve opens and uploads right atrium
      • rapid and deep- constrictive pericarditis
      • gradual-tricuspid stenosis
      • step- tricuspid regurgitation
    6. JVP up in:
      • heart failure
      • reduced right ventricular compliance (eg. RVH)
      • pericardial effusion, tamponade, constriction (Kussmaul's sign- JVP rises paradoxically in constrictive pericarditis (or sometimes in failure or tricuspid stenosis))

    Citation

    1. Cook DJ, and Simel DL: Does this patient have an abnormal jugular venous pressure. Journal of the American Medical Association 1996; 275 (8): 630-634
    Search Terms: handsearch
    Contributor: Chris Ball and Clare Wotton, July 2000
    Reviewer: Clare Liddy

    Clinical Question.
    Patient patients
    Intervention or Exposure jugular venous pressure
    Outcome central venous pressure