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Background: Increased jugular venous pressure, reflecting the increased right atrial pressure, is a classical sign of heart failure (HF) but clinical assessment may be difficult., Methods: In ambulatory patients with HF and control subjects, jugular vein diameter (JVD) was measured using a linear high-frequency ultrasound probe (10 MHz) at rest, during a Valsalva manoeuvre and during deep inspiration. JVD ratio was calculated as diameter during Valsalva to that at rest., Results: 211 patients (mean age 70 years; mean left ventricular ejection fraction 43%) and 20 controls were included. JVD (median and inter-quartile [IQR] range) at rest was 0.17 (0.15-0.20) cm in controls and 0.23 (0.17-0.33) cm in patients with HF (p=0.012), JVD ratio was 6.3 (4.3-6.8) in controls and 4.4 (2.7-5.8) in patients with HF (p=0.001).With increasing quartiles of plasma NT-proBNP, JVD at rest rose (0.20 (0.15-0.23) cm, 0.21 (0.16-0.29) cm, 0.25 (0.18-0.35) cm and 0.34 (0.20-0.53) cm (P=<0.001), whilst JVD ratio decreased (5.4 (4.2-6.4), 4.4 (3.5-6.3), 3.9 (2.4-5.4) and 2.8 (1.7-4.7); p=<0.001). JVD ratio correlated with log (NT-proBNP) (r=-0.39, p=<0.001), LV filling pressures (E/E', r=-0.33, p=<0.001) and left atrial volume (r=-0.21, p=0.002). In a multivariable regression model, only trans-tricuspid gradient and TAPSE were independently associated with JVD ratio (R(2)=0.27)., Conclusions: Distension of the JV at rest relative to the maximum diameter during a Valsalva manoeuvre (JVD ratio) identifies patients with heart failure who have higher plasma NT-proBNP levels, right ventricular dysfunction and raised pulmonary artery pressure., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)