JVP
In the JAMA rational clinical exam series, elevated JVP (or JVD) has a reported pooled +LR of 5.1 and -LR of 0.66 for discriminating CHF from other causes of dyspnea in the ED [1].
In Stephen McGee’s Evidenced Based Physical Diagnosis, JVD has a reported +LR 3.9 but a non-significant -LR for suggesting elevated left heart filling pressure [2].
The κ for JVD inter-rater agreement has been reported anywhere from 0.08 (poor agreement) to 0.7 (substantial) [2].
Given the lower performance and potentially low agreement, why learn how to measure the JVP? Because you need it to identify Abdominojugular Test (AJT), a better exam finding suggesting CHF.
Jugular Veins
The EJ traverses over the SCM.
The IJ is mostly covered by the SCM except near the angle of the mandible.
We recommend finding the EJ for JVP.
- When looking for JVD classical teaching advocated using the IJ, but by Bernoulli’s equation the EJ should be equivalent (though there may be other minor forces contributing).
- Both the EJ and IJ have valves. Really!
Visit the Stanford 25 for more on JV pulsation or watch their video:
What patient angle?
I remember being taught to put the angle of the bed at 30º. But the angle needed to see the JV meniscus above the sternal angle and not be lost above the angle of the mandible depends on the patient’s CVP.
The goal is get the JV meniscus between the sternal angle and angle of the mandible.
- Low CVP may require bed <30º
- High CVP may require >60º
How to find the EJ
Try tangential lighting, a vein finder (image), or an ultrasound (US-JVD).
Ultrasound (US-JVD)
You can use ultrasound to estimate the JVP. The operating characteristics are similar as to estimating JVD visually, can be used when finding the JV is difficult (i.e. habitus) and may especially helpful in exlcuding CHF as a cause of dyspnea. In one study of 119 ED patients it had a +LR 2.4 and -LR 0.01 [3].
More about measuring the JVP and the venous waveforms is at the Stanford 25 including an alternative assessment for CVP (shown in the video below).
Jump to discussion of discriminating CHF from other causes of dyspnea in the ED.
- CS Wang, et al. Does this dyspneic patient in the emergency department have congestive heart failure?
JAMA. 2005 Oct 19;294(15):1944-56. - Stephen McGee’s Evidenced Based Physical Diagnosis, 4th ed, Elsevier, Philadelphia, PA, 2018.
- T Jang et al. Jugular venous distension on ultrasound: sensitivity and specificity for heart failure in patients with dyspnea. Am J Emerg Med. 2011 Nov;29(9):1198-202.
