Inter-observer variation in reading JVPs.
A frequently quoted study1 found a kappa statistic (a measure of the agreement beyond chance) of 0.42 when comparing the ability of interns and registrars to read JVPs when assessed against a gold standard of the CVP. A number of this size is conventionally taken to indicate only moderate agreement.
Using the external JVP
This is conventionally taught to be inappropriate unless the patient has tricuspid regurgitation, where the internal JVP simply reflects right ventricular systolic pressure. However a small study (35 patients) in an ICU setting showed that clinical evaluation of the external JVP correlated very well with CVP Vinayak AG, Levitt J, Gehlbach B, et al. Usefulness of the external jugular venous examination in detecting abnormal central venous pressure in critically ill patients. Arch Intern Med. 2006;166:2132.. This meshes nicely with an earlier study which showed good agreement between measurements from cannulated external jugulars and CVP in mechanically ventilated patients Parker JL, Flucker C, Maguire A, et al. Comparison of external jugular and central venous pressures in mechanically ventilated patients. Br J Anaesthesia. 2000;85:165P..
Peripheral venous collapse
In situations where the JVP is difficult to identify, it may be worth looking for evidence of peripheral venous collapse by inspecting the veins on the back of the hand while positioned next to the patient’s side. If they are distended in this position, and collapse when the arm is elevated, the point of elevation above the sternal angle may be of some value in identifying and elevated venous pressure; the ‘anthem sign” (placing the hand over the sternal angle) allows easier identification of elevation but has a the disadvantage of potential venous compression by a flexed elbow.2
Abdomino-jugular reflux as a prognostic sign
The sign is not very well studied. One retrospective study looked at its prognostic value in a heart failure trial and found it had some ability to predict 6 month mortality.3
Cook DJ. Clinical assessment of central venous pressure in the critically ill. Am J Med Sci. 1990;299:175. ↩
Rizkallah J, Jack M, Saeed M, Shafer LA, Vo M, et al. (2014) Non-Invasive Bedside Assessment of Central Venous Pressure: Scanning into the Future. PLoS ONE 9(10): e109215. doi:10.1371/journal.pone.0109215 ↩
Uemura K,Omar H, Guglin M.Clinical and Prognostic Significance of Positive Hepatojugular Reflux on Discharge in Acute Heart Failure: Insights from the ESCAPE Trial. BioMed Research International. 2017;https://doi.org/10.1155/2017/5734749 ↩