Advanced Physical Diagnosis
  • Techniques
• Jugular Venous Pressure
• Jugular Waveforms
  • Demonstrations
Associated Evaluations
  • Patient HX
  • Physical Exam
  • Laboratory & Imaging
Differential Dx
Evidence Base
• Measurement of Jugular Venous Pressure
• Hepatojugular Reflux (HJR)
• Cardiac Hemodynamics
Teaching Tips
[Skill Modules >> Neck & Veins Examination >> Differential Dx ]

Differential Diagnosis: Neck Veins

Abnormal Pulsations

Abnormalities of the Venous Waveforms
Waveform Cardiac Condition
Absent a wave Atrial fibrillation, sinus tachycardia
Flutter waves Atrial flutter
Prominent a waves First-degree atrioventricular block
Large a waves Tricuspid stenosis, right atrial myxoma, pulmonary hypertension, pulmonic stenosis
Cannon a waves Atrioventricular dissociation, ventricular tachycardia
Absent x descent Tricuspid regurgitation
Prominent x descent Conditions causing enlarged a waves
Large cv waves Tricuspid regurgitation, constrictive percarditis
Slow y descent Tricuspid stenosis, right atrial myxoma
Rapid y descent Constrictive pericarditis, severe right heart failure, tricuspid regurgitation, atrial septal defect
Absent y descent Cardiac tamponade


Abnormal A Wave
Abnormally Prominent A Wave
This is usually due to decreased compliance of the right ventricle due to right ventricular hypertrophy. Thus it may indicate right ventricular outflow obstruction, pulmonary vascular obstruction, chronic pulmonary disease, elevated pulmonary wedge pressure form any cause or congestive, hypertrophic or restrictive cardiomyopathy.

Cannon a waves occur during systole.

Giant a waves occur on every beat while cannon a waves result from arrhythmias; and, therefore, are intermittent and on a minority of beat. Causes of cannon a wave are av dissociation from heart block or pacers and premature ventricular contraction.

Absent a wave: In atrial fibrillation, the a wave is absent.

Abnormal V Wave
The v wave is increased when there is increased atrial filling during systole. The most common cause is tricuspid regurgitation. (often called a cv wave or s wave as it begins during the c wave) It is specific but not sensitive for tricuspid regurgitation as a large and compliant atrium can mitigate the effect of the regurgitation on the jugular vein wave forms.

Atrial septal defect also can result in a larger v wave that equals the a wave in its size.

Abnormal X and Y Descents
An absent x descent can result from tricuspid regurgitation.

In constrictive pericarditis and restrictive cardiomyopathy x and y descents can be extremely prominent and rapid and the corresponding a and v wave ascents are notably abrupt. A prominent y descent has been found to occur in about one-third of the patients with constrictive pericarditis, and two thirds of patients with right ventricular infarction. The presence of a rapid y descent excludes the diagnosis of pericardial tamponade.

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