Fatigue, facial flushing, and ankle and abdominal swelling in a 53 year old manBMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a2042 (Published 30 October 2008) Cite this as: BMJ 2008;337:a2042
All rapid responses
What the authors state is undoubtedly true that "it is not until the
jugular venous pressure is carefully examined that the diagnosis is
considered"(1). This is true, not only in the context of constrictive
pericarditis, but also in the context of congestive cardiac failure(2).
However, jugular venous pulsation is not readily amenable to careful
scrutiny, partly because this can best be undertaken only under the
optimum conditions of good ambient light, careful positioning of the
patient, and an unhurried clinical examination. All three stages are prone
to error but the degree of error can be mitigated by simplifying the
procedure for positioning of the patient, which currently consists of
variable inclination of the upper body while utilising the sternal angle
as the reference point.
In a prospective, comparative study comprising 96
patients who subsequently underwent right sided catheterisation(to
evaluate central venous pressure), one group of investigators assessed
whether estimating neck vein distension with the patient only in the
sitting position could be used to detect elevated central venous pressure.
The reference point was the right clavicle, and a deep venous column(ie
internal jugular vein) visibly distended above the right clavicle was
taken to denote abnormal elevation of central venous pressure. What the
investigators discovered was that distension of the internal jugular vein,
visible above the right clavicle when the patient was sitting bolt
upright, had sensitivity of 65% and specificity of 85% to identify truly
elevated central venous pressure(3).
Accordingly, through the use of that
simple manouvre, evaluation of JVP will not be allowed to lapse into
disuse, and, in possibly 65% of heart failure patients, its elevation will
be detected before echocardiographic referral, thereby potentially
avoiding the diagnostic trap of equating intact left ventricular ejection
fraction with absence of heart failure.
(1) Abbott R and Dalton HR
Fatigue, facial flushing, and ankle and abdominal swelling in a 53 year
British Medical Journal 2008:337:a2042
(2) van 't Laar A
Why is the measurement of jugular venous pressure discredited?
The Netherlands Journal of Medicine 2003:61:268-72
(3)Sinisalo J., Rapola J., Rossinen J., Kupari M
Simplifying the estimation of jugular venous pressure
American Journal of Cardiology 2007:100:1779-81
Competing interests: No competing interests