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The Life-Changing Implications of Evaluation of Jugular Venous Pressure

      To the Editor:
      Correct evaluation of jugular venous pressure (JVP), in all its details,

      Jardine DL, Adamson P, Crozier IG. Measuring jugular venous pressure: do not turn the head! Am J Med. https://doi.org/10.1016/jamjmed.2021.12.024 [Article in press].

      can be a matter of life-changing, if not life-saving, importance. The details that matter most include the precaution to relax the neck muscles, encapsulated in the warning “Do not turn the head”,

      Jardine DL, Adamson P, Crozier IG. Measuring jugular venous pressure: do not turn the head! Am J Med. https://doi.org/10.1016/jamjmed.2021.12.024 [Article in press].

      which I have previously taken the opportunity to champion,
      • Jolobe OMP
      Rapid response: the lives of patients with markedly elevated jugular venous pressure rapid response.
      notwithstanding prevailing received wisdom to the contrary.
      • Bromage D
      • Mayhew J
      • Sado D
      Managing heart failure related peripheral oedema in primary care.
      Also crucial to mitigating the risk of overlooking the presence of raised JVP is the invocation to flex the trunk “to whatever angle makes the wave form most obvious,”

      Jardine DL, Adamson P, Crozier IG. Measuring jugular venous pressure: do not turn the head! Am J Med. https://doi.org/10.1016/jamjmed.2021.12.024 [Article in press].

      because that may be the diagnostic maneuver pivotal to generating the “right angle” for eliciting a raised JVP.
      • Reed MC
      • Dhaliwal G
      • Saint S
      • Nallamothu B
      Clinical problem-solving. The right angle.
      In the latter report, that strategy was crucial to identification of constrictive pericarditis as the underlying (and eminently reversible) cause of ascites.
      • Reed MC
      • Dhaliwal G
      • Saint S
      • Nallamothu B
      Clinical problem-solving. The right angle.
      Sloppy terminology, exemplified by “JVP raised 2 cm,”
      • Jolobe OMP
      Jaundice as a presentation of heart failure.
      has been an occasional unhappy by-product of undisciplined evaluation of JVP. To counteract that tendency, clinicians must adhere to the use of recognizable anatomic landmarks such as the angle of the sternum

      Jardine DL, Adamson P, Crozier IG. Measuring jugular venous pressure: do not turn the head! Am J Med. https://doi.org/10.1016/jamjmed.2021.12.024 [Article in press].

      or, in the case of a markedly elevated JVP, the angle of the jaw; the latter a useful landmark when the height of the venous column is visible only when the patient is sitting bolt upright.
      • Gimlette TMD
      Constrictive pericarditis.
      The final rhetorical exercise is to monitor the response of the JVP to a course of diuretic therapy. A JVP that remains markedly elevated despite a diuresis sufficiently vigorous to generate a significant degree of weight loss
      • Conti CR
      • Friesinger GC
      Chronic constrictive pericarditis clinical and laboratory findings in 11 cases.
      or hypovolemia
      • Nkomo VT
      • Stepanek J
      • Rumberger JA
      71-year-old man with syncope and chronic leg edema.
      is highly suggestive of a diagnosis of constrictive pericarditis,
      • Conti CR
      • Friesinger GC
      Chronic constrictive pericarditis clinical and laboratory findings in 11 cases.
      ,
      • Nkomo VT
      • Stepanek J
      • Rumberger JA
      71-year-old man with syncope and chronic leg edema.
      the latter an eminently reversible underlying cause of the syndrome of congestive heart failure.

      References

      1. Jardine DL, Adamson P, Crozier IG. Measuring jugular venous pressure: do not turn the head! Am J Med. https://doi.org/10.1016/jamjmed.2021.12.024 [Article in press].

        • Jolobe OMP
        Rapid response: the lives of patients with markedly elevated jugular venous pressure rapid response.
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        • Mayhew J
        • Sado D
        Managing heart failure related peripheral oedema in primary care.
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        • Dhaliwal G
        • Saint S
        • Nallamothu B
        Clinical problem-solving. The right angle.
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        Jaundice as a presentation of heart failure.
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        • Friesinger GC
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