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From the Heart
December 26, 2019

The David Sign

Author Affiliations
  • 1Division of Clinical Affairs, Marian University College of Osteopathic Medicine, Indianapolis, Indiana
JAMA Cardiol. Published online December 26, 2019. doi:10.1001/jamacardio.2019.4874

On a recent trip to Florence, Italy, I observed Michelangelo’s David in the Accademia Galleria and was struck by an interesting observation: the external jugular vein on the right side of David’s neck is distended well above his clavicle. Classic physical diagnosis teaching tells clinicians to observe the height of the jugular veins to estimate central venous pressure (unless there is jugular venous outflow obstruction). Preferably, the internal jugular vein is used for observation, but often the internal jugular vein is difficult to visualize, and thus the smaller, less reliable, external jugular vein can be used, because it is more superficial and easier to see. Importantly, neither jugular vein is normally persistently visible above the clavicle at rest in the upright position, as it clearly is in the David (Figure). This finding on the David is a sign of elevated intracardiac pressures and possible cardiac dysfunction.

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