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Home , Aortic pressure, Cannon A waves, Korotkoff sounds, Pulse pressure

CHAPTER Back to Bedside Basics - , Pressure and Jugular Venous Pulse

195 Ruchit A Shah, BR Bansode

INTRODUCTION peak is palpable. Percussion wave is more prominent than In the era of electrocardiogram and , the tidal wave. Anacrotic notch, tidal wave, dicrotic notch clinical bedside examination is a forgotten art. However and dicrotic wave are not palpable. accurate these investigations may be, evaluation of As the pulse wave travels from to the peripheral the patient is incomplete without a detailed physical ; i) the upstroke becomes steeper, ii) systolic peak examination. In this chapter we shall discuss the basic becomes high, iii) systolic upstroke time becomes shorter, bedside art and clinical relevance of examination of the iv) ejection time increases, v) systolic pressure increases, arterial pulse, and jugular venous pulse. vi) increases, vii) diastolic pressure THE ARTERIAL PULSE decreases, viii) mean pressure decreases, ix) anacrotic shoulder disappears, x) sharp incisura is replaced by a Physiology - The arterial pulse begins with aortic valve smoother and latter dicrotic notch, followed by a dicrotic opening and ejection of blood from the left into wave. The carotid is a large artery close to the aortic the . The nature of arterial pulse depends on left valve and its contour resembles that of central aortic pulse. ventricular , ejection velocity, compliance, Hence the carotid pulse and not the peripheral pulse is distensiblity and capacity of arterial system. The pulse used to assess the volume and contour (Table 1). contour is a result of frequency waves produced by antegrade blood flow and reflection of the waves returning With aging, and , there is from the peripheral circulation. decreased compliance, increased and of the arterial tree. The noncompliant The central aortic pulse wave is described as early systolic, arterial tree contributes to increased pulse wave velocity late systolic and diastolic component (Figure 1). The and the tidal wave becomes more sustained. early systolic component (percussion wave) has a rapid upstroke. It is due to early systolic ejection of blood which Examination - Varying degrees of pressure is applied with is stored in central aorta. The normal pulse has a brief the finger pads of the thumb or first two fingers to assess crest which is slightly sustained and somewhat rounded. upstroke, systolic peak and diastolic slope of the pulse The mid and late systolic component (anacrotic notch (trisection method). Attempt should be made to assess the and shoulder) has a rounded summit or peak. It is due to rate, rhythm, volume, amplitude, contour and stiffness of propagation of blood from central aorta to periphery and the arterial wall. Focus on the speed and quality of early reflection of the waves from the upper limbs. is rise, peak and drop off of the arterial pulse. initiated by a negative wave (dicrotic notch). The nadir A. Rate and Rhythm - This information is derived of dicrotic notch coincides with aortic leaflet closure (A2 from the . Count the arterial pulse for component of S2) and the positive wave is due to reflection 15 s and multiply by 4 to get the pulse rate. The of waves from the lower limbs. Normally only the systolic rate should be compared with the pulse rate. A pulse deficit of >6 beats/min is suggestive

Table 1: Comparison of the pulse in central aorta and peripheral artery Central artery (Aorta) Peripheral artery (Brachial) i. Upstroke has a i. Steep upstroke rounded dome ii. Anacrotic notch on ii. Disappearance of ascending limb anacrotic notch on ascending limb iii. Descending limb has iii. Incisura in descending Fig. 1: Normal arterial pulse. Note the rapid upstroke of incisura followed by limb is by dicrotic percussion wave, rounded peak of tidal wave and fall off in late replaced dicrotic wave notch followed . The dicrotic notch coincides with S2 by dicrotic wave CARDIOLOGY 890 apex pulsedeficit of>6beats/min. -Irregularinrateandrhythmwith following twobeats Atrial prematurecomplex-Thereisashortpause following theprematurebeat. Ventricular prematurecomplex-There isalargepause Differentiating between irregular iv. iii. ii. i. Regularly irregular Table 3:Irregular pulses b. iii. ii Pharmacological i. a. per minute) (>100beats Table oftachycardia 2:Causes andbradycardia 1st and2nddegree Pulsus alternans Pulsus bigeminy Sinus tachycardia , supraventricular atrial tachycardia, Atrial fibrillation, Tachyarrhythmia - hypotension, hypoxia , hemorrhage, thyrotoxicosis, Non cardiac-Fever, myocarditis, , myocardial infarction, - Heartfailure,acute Pathological -Cardiac caffeine alcohol, nicotine, ephedrine, atropine, isoproterenol, epinephrine, amiodarone, - Amyl nitrate, anxiety, excitement childhood, exercise, Infancy, Early Physiological - Sinus tachycardia iii. ii. i. Irregularly irregular b. iii. ii. i. a. per minute) (<60beats contractions ventricular Frequent premature tachycardia Multifocal atrial Atrial fibrillation block. second degree AV complete heartblock, Bradyarrhythmia - Chagas disease enteric fever, sepsis, obstructive jaundice, hypothermia, , myxedema, raised Non cardiac- cardiac transplant sinoatrial block,post vasovagal syncope, myocardial infarction, - Inferiorwall Pathological -Cardiac Lithium blockers, propafenone, Pharmacological -Beta Athletes, duringsleep Physiological - Sinus Bradycardia a. B. Severe aortic regurgitationSeveretwo aortic -bifidpulsewith systolic peaks, Fig. 2:Carotid pulsewaveforms sounds. A-Normal, andheart B - Severe stenosis -anacrotic pulsewithslow Aortic upstroke, C- spike anddomepattern, pulse-onepeakinsystole, E-Dicrotic D - Hypertrophic obstructive cardiomyopathy obstructive D -Hypertrophic -bifidpulsewith and severe cirrhosis. patent regurgitation, aortic ductus arteriosus, large A-V fistula, Paget’s disease like runoff arterial distal increased with states output high viii) and intake alcohol vii) environment, humid and hot vi) exercise, v) thyrotoxicosis, iv) anemia, iii) anxiety, with subjects elderly arteriosclerosis and systolichypertension,ii) i) in seen is It compliance. arterial volume, in pressure, sympathetic activity or decreased arterial stroke increase ejection, to ventricular due larger is left has It amplitude. It wave - pulse Pulse (Bounding) Hyperkinetic Character andvolumeofthepulse(Figure2) between 60-100beatsperminute(Tables for 2,3). factor risk a variesrhythm sinus Normal death. cardiac sudden is and dysfunction autonomic with associated is It arrhythmia. sinus called is it lengthens and with expiration by >120 ms during quiet breathing, inspiration with shortens length cycle the When intervals. regular at occurs pulse normal The contraction. ventricular premature of suggestive is beats/min <6 and fibrillation atrial of another indiastole CHAPTER 195 891 two pulse waves. It is better appreciated inspiration. during It is seen in cardiomyopathy young pressure, blood patients low output, with having cardiac low dysfunction, severe left high systemic ventricular vascular post tamponade, in pericardial during inspiration resistance, tachycardia, regurgitation mitral or aortic for replacement valve with left ventricular dysfunction and occasionally in young. with fever rhythm sinus during present is It - alternans Pulsus when patient’s peak systolic arterial pressure and pulse volume are alternately beat to beat alteration in left to due It occurs strong and weak. ventricular ejection pressure and signifies severe left ventricular dysfunction. to in (It electrical seen as complex alternans QRS is of which amplitude the in has not variation a related beat to appreciated best is It beat effusions). pericardial massive be may It arteries. brachial or radial the in clinically gallop. S3 like failure heart of signs with associated It can also be detected by slow decompression of the cuff whilethe alteration listening of . to detected Whenbe can systolic it Hg mm >20 by alternates pressure by palpation of the peripheral pulse with patient’s breath held in deep expiration. It after is accentuated a PVC, Valsalva maneuver, abrupt posture or deep inspiration. upright - Kussmaul. This term There was inspiratory fall is in coined systolic blood pressure in which by marked and audible palpable peripheral arterial pulse and exaggerated Korotkoff sounds disappear blood in inspiration. pressure cuff The is inflatedsystolic beyondpressure and slowly deflated. the peak The degree of paradoxus is the difference between the systolic pressure at which the Korotkoff sounds areheard first during expiration and the point all at beats which are well heard respiration. The during word both paradoxus phases is of during falls normally a pressure systolic because misnomer inspiration by 4-6 mm Hg. In the pulsus difference paradoxus is >10 be breathing quietly and not deep breathing mm Hg. The patient must or performing Valsalva maneuver. It pericardial is tamponade, seen in constrictive emphysema, pericarditis, asthma, severe failure and marked obesity. congestive cardiac Mechanism - is a continuum from effusion to full blown circulatoryThe hemodynamic collapse. effects depend on the amount of effusion and the pericardialrelationship. pressure As volume fluid accumulates in pericardial sac, there is increased left and right sided atrial and ventricular pressures which equalize at a pressure similar to intrapericardial increases the pressure. venous return to the right side of the Inspiration heart at a period when the total heart volume is e. f. Hypokinetic Hypokinetic Pulse - A small or diminished pulse is due to low cardiac ventricular stroke output volume, shorter left with ventricular reduced left ejection time or unsustained intense pulse vasoconstriction. volume suggests An decreased obstruction, without stroke whereas a pulse left of small volume slow suggests . It rising is ventricular seen in i) severe left sustained ventricular dysfunction, ii) congestive outflow cardiac failure, iii) hypotension and iv) outflow tract obstruction. left ventricular Pulsus parvus et tardus - It is a slow rising pulse with delayed systolic peak and upstroke. It is best appreciated with simultaneous and carotid palpation. In aortic stenosis, it is associated (carotid shudder).with a carotid thrill Water Hammer (Collapsing pulse) pulse or or Corrigan Pulsus Celer by - Thomas This Watson after term a comprised of a glass partly vessel water filled with was Victorian coined toy which and vacuum. It produces a being slapping turned impact over. on In aortic is regurgitation, an early, brief peak and there a swift descent without dicrotic notch which gives a collapsing sensation. To elicit this, the patient’s arm is suddenly raised above the head and the anterior the faces palm the that so hand examiner’s wrist grasped with the aspect of wrist. The collapsing nature can be after felt each systole. The brief peak is due to ejection rapid of increased stroke descent is due volume. to diastolic run off The (back flow into swift to to the periphery due run off rapid left ventricle), decreased systemic vascular resistance and reflex vasodilatation mediated by carotid baroreceptors. states circulatory hyperkinetic in seen be also may It like patent ductus window, arteriovenous arteriosus, fistula, rupture aortopulmonary of valsalva into right heart of sinus and tetrology of Fallot with bronchopulmonary collaterals. Double beating pulse - Simultaneous auscultation to delineate the timing and palpation are necessary of the twice beating pulse. Bisferiens pulse - The double peaked pulse occurs in systole and is best detected compression by of light the but brachial firm artery with finger. a single It combined is seen aortic in aortic pure aortic regurgitation stenosis and regurgitation, high output states normal heart. It is with likely to disappear after onset of with predominant cardiac failure. congestive Bifid pulse - A bifid or spike andsignificant dome patternin in palpable rarely but recorded, is systole cardiomyopathy. hypertrophic obstructive Dicrotic pulse - The first wave and the second accentuated component is a occurs in systole diastolic reflection wave On occurring simultaneous auscultation, diastole. in S2 separates the c. d. e. i. ii. iii b. CARDIOLOGY 892 D. C. ih er fiue Te rcil n crtd uss are pulses carotid and brachial infants The or failure. heart hypertension with with patients in suspected be bifurcation, should Coarctation artery. iliac aortic external or iliac common of diseases obstructive and aorta of radials at 80 ms. Radiofemoral delay is seen in coarctation carotids at 40 ms, brachials at 60 ms, femorals at 75 ms and the reaches pulse aortic central The - Delay Radiofemoral vii. vi. v. iv. iii. ii. i. Unequal/ diminished/absentpulse Grade 4-Highvolume/bounding Grade 3-Normal Grade 2-Palpable butdiminished Grade 1-Feeble Grade 0- Absent pulse Grading ofpulses Table 4:Gradingofpulses l ple sol b plae ad compared and palpated be bilaterally (Tables 4and5). should pulses All tortuosity. irregularity of surface seen in arteriosclerosis and the note to try Also cord. mergewith a like feels it to age old in seems it surrounding tissue,inmiddle ageitispalpableand age, young In finger. second and index the between wall vessel the roll must examiner The - wall arterial the of Condition pericardial regurgitation/ adhesions. aortic defect/ ventricular septal defect/ septal atrial with tamponade Pulsus paradoxusmaybeabsentincases of cardiac isorrhythmic AV dissociation. and ventilation pressure positive with tamponade cardiac in seen be may paradoxus pulsus Reverse pressure. a markeddepressionofstrokevolumeandsystolic causes filling ventricle left of reduction inspiratory so curve, Starling of limb ascending steep the on operates The intamponade leftventricle. ventricle and left filled under left the of filling blood intothepulmonarycirculationcausesunder of pooling inspiratory filling. Also and compliance dimensions, ventricular left reduces This left. the dimensions pushing the interventricular septum to diastolic ventricular right the increases This fixed. Dissection ofaorta Coarctation ofaorta Acute microembolism subclavian left artery innominate, of Subclavian stealsyndrome anticus syndrome scalenus rib, cervical - syndrome outlet Thoracic Takayusu arteritis otc eugtto, urvlua ari seoi and stenosis mitral regurgitation. aortic supravalvular regurgitation, aortic stenosis/ aortic + valve aortic bicuspid with associated is coarctation when absent be may delay radiofemoral The both hands. compression pressure till both pulses are felt equally with pulse. femoral the the Vary at fingers the above are pulse radial the at fingers examiner’s the that so artery femoral the over wrist patient’s the placing by demonstrated be can This pressure. pulse low a and peak late rise, of rate slow a have pulses extremity lower whereas bounding, xre b te er drn ssoe I i te mut of amount the is It systole. during heart the by exerted pressure maximum the is pressure blood Systolic wall. potential energy or lateral force per unit area of the vessel Physiology -Theblood pressure isthemeasureof BLOOD PRESSURE x. ix. viii. vii. vi. v. iv. iii. ii. i. Table ofpalpation 5:Sites ofvarious pulses individuals. metatarsal. Itmaybeimpalpablein2%ofnormal (between firstandsecondtoe)againstthe of extensorhallucislongusanddigitorum Dorsalis Pedis -Itisbestfeltbetween thetendons cm behindthemedialmalleolusoftibia. relaxed between plantaranddorsiflexion.Itisfelt1 Posterior Tibial-Thepatient’sfootshouldbe resting onthepatella. are placedinthepoplitealfossawiththumbs flexed at120degrees.Thefingertipsofbothhands Popliteal -Thepatientliessupinewiththeknees against theheadoffemur. and pubicramusbelowtheinguinalligament Femoral -Itisfeltmidway between theiliaccrest wrist slightlyflexed. radius withtheforearmslightlypronatedand ring fingerscompressingagainsttheheadof Radial -Itisfeltwiththetipofindex,middleand the antecubitalfossamedialtobicepstendon. Brachial -Itisfeltagainstthehumerusjustabove Axillary -Itisfeltagainstthemiddleofhumerus clavicle. the anglebetween thesternocleidomastoidand pressure exerteddownbackandmediallyin against thefirstribwithshoulderdepressed Subclavian artery-Itiseffectively compressed vice versa. left thumbisusedtopalpatetherightarteryand the examinerrelaxessternocleidomastoid.The patient’s neck.Rotatingtheneckslightlytowards carotid artery.Itisbestfeltinthelower halfofthe There itbifurcatesintotheexternalandinternal level attheupperborderofthyroidcartilage. Common carotid artery -ItterminatesatC4 zygomatic processanteriortothetragus. Superficial temporalartery-Itispalpableover the CHAPTER 195 893 17 13 22-24 32-33 35-42 Bladder length Represents peak systole Initially low intensity Occurs 10-15 mm Hg below peak systolic pressure gap occurs Auscultatory when phase 2 sounds are soft, absent or missed by examiner 15-20 mm Hg below phase II It occurs 5-8 mm Hg the diastolic above sounds Used as true diastolic pressure 8 11 12-13 15-17 18-20 Bladder width Onset of auscultatory sound Swishing sound or murmur Crisp, easily heard Abrupt damping or muffling of tapping sounds Disappearance of sound Phases of Korotkoff sounds Phases of Korotkoff I II III IV V systolic individual, normal a In - hypotension Orthostatic blood pressure falls by 10-12 mm Hg and diastolic blood pressure remains same or Orthostatic hypotension is fall in systolic blood pressure may increase on standing. by >20 mm Hg and/or diastolic blood mm pressure Hg by >10 on moving from within 3 supine minutes. It to may or may standing not be position associated with compensatory tachycardia. , in seen is It syncope. or It giddiness manifests as dysfunction, autonomic insufficiency, postural diabetics, elderly and with vasodilators (alpha nitrates, diuretics). blockers, beta blockers, Ambulatory BP monitoring - a It record gives of 24 hours of blood pressure. Blood pressure is higher when awake, alert, mentally or physically active and early It morning. is lower during rest and sleep. Patients in blood whom the pressure does not fall by of risk higher a at are Hg mm 135/85 than greater average 10-20% at night or an It is indicated in events. cardiovascular the posterior tibial artery or dorsalis pedis artery with a piece. pediatric bell chest Korotkoff sounds arise asdistension result a of arterial walls of oscillation with every from cardiac of the artery by the blood due to partial occlusion impulse pressure cuff. Shock, low stroke volume and peripheral vasoconstriction cause weak Korotkoff sounds. This can be enhanced by hand elevation or exercises for 5-10 times. isometric handgrip 24-33 33-42 42-50 17-26 13-20 Mid arm circumference Mid arm Standard adult Standard Large adult Thigh Small adult Child Table 6: Sphygmomanometer cuff size 6: Sphygmomanometer Table (cm): size cuff Sphygmomanometer Cuff type work done by the heart. Systolic arterial pressure depends pressure arterial Systolic heart. the by done work on the stroke volume, velocity of left ventricular ejection, distensiblity of pressure minimum the vessels is pressure blood and Diastolic diastole. volume of blood exerted during at diastole. It is end the load against which the depends pressure arterial diastolic The work. to has heart length cycle cardiac arteriolar resistance, peripheral on and compliance of the arterial tree. is the product of and stroke volume Arterial (CO=HRxSV). blood pressure is the product of cardiac output and peripheral pressure is resistance the difference between systolic and diastolic (BP=COxPR). blood pressure (approximately 40 The mm Hg). Mean blood pulse pressure is the sum of diastolic blood pressure and 1/3rd mm Hg). pulse pressure (approximately 95-100 Measurement of blood pressure - The blood pressure is measured with an aneroid or mercury manometer. The bladder length/width should be circumference. 80%/40% The ratio of of cuff the width to length arm should be 1:2 6). (Table The center of the rubber bladder should be on the . wrapped tightly around the The arm. The diaphragm or blood bell pressure cuffof the is is firmly placed at the brachial artery, so that the upper edge of the stethoscope is in contact with the distal edge of the cuff.seated The patient comfortably, should back be supported, bared upper legs arm, uncrossed with the arm at level of is heart. inflated The 20 cuff mm above Hg the pointpulse when is the radial no longer prevents palpable. underestimation This of palpatory auscultatory gap. The systolic and diastolic pressures are blood method pressure due then estimated by auscultatory to method. Cuff should be deflated at <3 mm Hg/sec. The column should be read to is pressure systolic peak of level The Hg. mm 2 nearest the the point at which two consecutive Korotkoff sounds are heard. The disappearance of the Korotkoff sounds is the true diastolic pressure. After every cuff inflation, deflate the cuff completely and allow sufficientand timesubject forthe venous between talking no be should There return. observer. In severe aortic regurgitation and hyperkinetic be pressure should circulatory states, the diastolic recorded in both phase IV and there V. In is beat atrial to fibrillation, beat variation in blood an of average three readings is taken as a blood pressure. pressure; hence For measurement of lower limb pressure, the patient lies prone; the thigh cuff is wrapped around and auscultate the popliteal fossa. If a thigh cuff is not available, an arm cuff can bewrapped around the leg lower and auscultate CARDIOLOGY 894 vi. v. iv. iii. ii. i. oferror inbloodpressureSources measurement resistance anddecreasedintravascular volume(Table 8). pulse pressure arises due to increased peripheral narrow A resistance. peripheral stroke decreased in and increase volume to due arises pressure pulse wide A mm Hg(Table 7). <20 by arms. pressures arm exceed both pressures leg Systolic Hg. in measured mm 10 than less is arms be both in difference the Normally should pressure Blood and criticalischemia. of peripheral , and <0.3 indicates rest pain Values>0.9). (normal pressures systolic suggestiveis <0.9 arm two blood the of systolic higher the of by ratio divided ankle the in pressure is It - index brachial Ankle v. iv. iii. ii. i. vi. v. iv. iii. ii. i. limbs (>10mmHg) Differential BPinupper Table 7:Differential bloodpressure Arm belowheart level venous congestion inarm Excessive Thin arm with large cuff Fat armwithsmallcuff Cuff appliedtooloose systolic pressure peak detect to Failure Physiologic variations Error intechnique, syndrome Subclavian steal syndrome Thoracic outlet stenosis Supravalvular Dissecting aortic catheterization post cardiac Takayusu’s arteritis, atherosclerosis, - embolism, Arterial occlusion Episodic hypertension Autonomic dysfunction White coathypertension Drug inducedhypotension Drug resistanthypertension vrsiain f blood pressure of Overestimation Widened auscultatory gap of Korotkoff sounds intensity Decreased Pseudohypotension recognize Falsely elevated readings to inflation, auscultatory gap initial failure too rapid inflation, Insufficient v. iv. iii. ii. i. and leg(>20 Differential BPinarm sign) regurgitation (Hill’s Severe aortic syndrome Subclavian steal Aortic archsyndrome Coarctation ofaorta Hg) vii. negative intrathoracic pressure causes increased venous increased causes pressure intrathoracic negative inspiration, During descent. Y is individuals, the descent than prominent X more and In normal wave V the than larger is wave diastole. A the during filling right heart passive to due arises wave Hirschfelder) from (H H The descent. Y the called wave negative a causes This to valve tricuspid open and blood flows from right the atrium to right ventricle. causing pressure atrial intra the below falls pressure ventricular the diastole, ventricular S2. after peaks and pulse carotid the Atearly of point this with synchronous is It diastole. early in ends and systole late in begins It wave. V the called wavepositive second This leadstoariseintherightatrialpressurecausing a valve. tricuspid closed a with systole ventricular during ends before S2. The great empty into the right atrium and systole during begins descent X The point. lowest its pulled downwards. The latter part of X descent, X’ reaches also is valvering tricuspid the phase this During ventricularsystole. right early during falls pressure atrial right continues, relaxation atrial right the wave.As separate a as visible not usually is It pulsations. carotid transmitted with confused be can It S1. of component tricuspid the to positive corresponds wave C a of onset The produces wave. C called wave systole isovolumic during tricuspid tricuspid closed valve of the motion of bulging upward closure The to valve. leads This the pressure. above atrial rise to pressure intraventricular the causing descent. X of commences systole portion ventricular right the Simultaneously, early relaxing, the starts causing atrium falls right pressure the As upstroke. the carotid and S1 to prior immediately ECG, of wave P the of peak the at positive begins wave A The a wave. A the produces called wave This veins. jugular and cava vena It superior the diastole. into retrogradely ventricular flow to of blood causes end also at ventricle right the to its pressure rises pushing thebloodfrom right atrium contracts, atrium right the When 3). (Figure physiology cardiac sided right the about information useful provide Physiology - Careful examination of the venous pulse can Jugular venous pulse v. iv. iii. ii. i. Wide pulsepressure Table ofnarrow 8:Causes andwidepulsepressure Arm above heartlevel Complete heartblock Truncus arteriosus arteriosus Patent ductus Aortic regurgitation hot weather , hyperthyroidism, exercise, anemia, , circulation - Hyperkinetic pressure blood of Underestimation iii. ii. i. Narrow pulsepressure Diabetic ketoacidosis Severe aorticstenosis CHAPTER 195 895 Carotid arterial Carotid arterial pulse Deep in neck, Medial than Better felt seen Single brief visible upstroke No change No change Not easily compressible No change Jugular venous Jugular venous pulse Low in neck, lateral than Better seen felt and crests Two two troughs Descent more obvious than crest A and V waves more prominent Decrease in mean pressure Can be obliterated with gentle pressure Transient increase in pressure Table 9: Differences between Jugular venous pulse and pulse and venous Jugular between 9: Differences Table arterialCarotid pulse Location Contour Inspiration Upright position Compressibility Abdominal compression cm is the upper limit of normal pulsations. for By venous pressure. If can obtain the actual venous adding 5 cm, we it is not visible, deep inspiration can bring out the waves. is which Louis of angle the above cm 4 is level normal The or 6 mm Hg. equal to 9 cm of water It is recommended to use the X and Y descent to time the venous pulse. The negative X descent is between S1 and S2 and X’ is simultaneous with radial pulse. The A wave is visible as a flickering pulsation just before the carotid pulse is felt. During auscultation, the A wave coincides with S4 and is almost simultaneous with S1. The V wave after the V wave. peaks just after S2 and Y descent begins Internal jugular pulsations are visible but not palpable. indirect pulsations of the jugular bulb and internal The jugular veins are transmitted to the overlying soft skin and tissue. The internal jugular veins the external are jugular preferred veins - to i) the internal jugular have veins no valves. ii) The 90 nearly external of each bends two with cava vena superior with jugulars communicate degrees whereas internal jugulars communicate directly. iii) External jugular passes planes and is easily affected by extrinsic compression. iv) through many fascial sympathetic stimulation in heart failure causes Increased vasoconstriction of external jugular veins. Right internal jugular vein is preferred because vein jugular it internal Left cava. runs vena superior the a to course straight line runs into the left innominate vein which is not a straight line. Abdominojugular (Hepatojugular) reflux - The patient is positioned such that the upper level of venous column is at mid Gentle neck but level. firm compression is applied with the hand in the right upper quadrant for at least 10 descent occurs in systole and Y descent in diastole and descent occurs in systole coincides with S1 and the V wave coincides with S2. The X The coincides with S2. V wave coincides with S1 and the Fig. 3: Normal jugular venous pulse. The large A wave almost A wave large The pulse. jugular venous 3: Normal Fig. pooling of blood which leads descent. During to expiration, prominent A X wave diminishes and reflection. becomes the dominant positive wave and Y V Examination - The patient should be reclining comfortably without any tension on neck tissues. The chin is elevated and head rotated to the tangential lighting. left. Lean It over is to preferable patient while the to examining the left right have side side of the of neck. sternal The angle of Louis is 5 cm above the mid right atrium the whether supine, 45 degree or 90 degree position is given. Louis. of angle the from measured is pressure venous The The thorax should be positioned venous at the If identified. an well is angle column venous the where of peak the pressure is too low, pressure the If breaths. place deep take to him ask and the elevation patient supine with leg is too high, the pulsations may be behind the angle of the mandible, so keep the patient at 90 degree and examine. The height of the A and V taken as the wave venous pressure. scale Two during method is used. inspiration is A horizontal scale at the peak of the venous column cuts the vertical scale kept at the angle of Louis. For 2 cm supine is the upper limit of normal and for 45 degree 4.5 CARDIOLOGY 896 prominent V wave. Insevere TR, there isventriculization witha rapid Y descent. withaprominent C-Constrictivepericarditis Y B -Compared to thenormalwaveform, inmild TR, there isa wave associated withreduced RVcomplianceandelevated RV enddiastolic pressure. Itcorresponds to rightsided S4. Fig. 4:Abnormaljugularvenous waveforms. A A-Large descent which corresponds to the pericardial knockdescent whichcorresponds to (K) the pericardial iii. ii. i. Increased jugularvenous pressure arterial pulse(Table andCarotid 9) pulse venous Jugular between Differences of tongue(May’ssign) surface under and hand the of dorsum the of veins the at Elevated venous pressure can also be estimated by looking chronic obstructive lungdiseasemayhave with afalsepositive test. Patients Hg. 15mm than greater systemic pressure and wedge PA and failure heart predicts It hypervolemia vasoconstriction. regurgitation, tricuspid silent failure, ventricular right latent in positive be will It response. positive a is seconds 15 least at for cm 3 than more pressure venous the of Elevation pressure. venous person, normal prolonged pressure a will not cause a In sustained elevation of mouth. open an with comfortably seconds. The patient is instructed not to strain and breathe i. Wood Paul valve. atrium described giant A waves asvenous Corrigan. tricuspid right closed the a when against contracts occur waves A cannon called A waves giant Intermittent - waves A Cannon or Giant iii. ii. i. AwavesLarge ii. i. Decreased jugularvenous pressure ABNORMALITIES OF JUGULAR VENOUS PULSE (FIGURE 4) INCREASED A WAVE AMPLITUDE tnss rgt til yoa constrictive myxoma, Fluid overload, renalfailure atrial pericarditis right -Tricuspid stenosis, impedance inflow ventricular Right elevation ofrightventricular fillingpressure to leading stiffen to ventricle right the cause may necrosis myocardial infarction ventricular right In ventricular failure following left ventricular failure. stenosis, pulmonary arteryhypertension,right Reduced right ventricular compliance - pulmonary eua cno wvs Jntoa rhythm, Junctional - waves cannon Regular stenosis, aortic valvular and asymmetric) and (symmetric effect -seeninhypertrophiccardiomyopathy the causing ventricle right of relationship interventricularvolume pressure the alters septum hypertrophied the hypertrophy, ventricular left In acute disease, right ventricular cardiomyopathy vascular infarction, ventricular right embolism, pulmonary pulmonary stenosis, severe - pulmonary arterial hypertension, pulmonic pressure diastolic end ventricular right in increased to leads It ventricularhypertrophy. right seen is compliance ventricular right Reduced stenosis, rightatrialmyxoma,tricuspidatresia atrial contraction-Tricuspid increased right Increased resistance to right atrial emptying causes Hypotension, shock Hypovolemia, dehydration Bernheim CHAPTER 195 897 Severe Severe tricuspid regurgitation has a prominent Y wave large regurgitant the following descent failure right ventricular Severe with mitral regurgitation septal defect Atrial CARDIAC DISORDERS CARDIAC ii. iii. iv. The Y descent is diminutive when right atrial emptying or right ventricular filling myxoma and right atrial tricuspid stenosis tamponade, is hampered - pericardial Kussmaul’s sign - Normally during inspiration, due intrathoracic pressure, there negative is fall in the jugular to venous pressure by at least 3 mm Hg. A rise in pressure venous or failure to decrease with inspiration is called overload volume sided right of states In sign. Kussmaul’s and reduced right ventricle cannot accommodate the increased ventricular volume and compliance, the the pressure right rises. It is seen in constrictive restrictive pericarditis, cardiomyopathy, pulmonary embolism, right failure. heart systolic advanced and infarction, ventricular murmur, continuous a is hum The - hum venous Cervical loudest in diastole produced by turbulence in neck veins when head is turned transverse to the by the veins jugular left. internal the of compression It occurs due to mild process of the atlas. It is right supraclavicular area and detected base of the by neck in sitting auscultating the position. It is common in children, young output adults, states high and patients undergoing hemodialysis. It can be confused with murmurs of aortic patent regurgitation, ductus arteriosus, A-V fistula and carotid arterial . Aortic stenosis - detected best is and ejection ventricular left to Pulse obstruction - In aortic in the carotid stenosis, artery. The there classic pulse is parvus is called et pulsus tardus or anacrotic carotid pulse pulse. in The valvular hallmark aortic stenosis of with is delayed slow upstroke rising (pulsus parvus), which is a delayed smooth prolonged peak peak with a gradual drop off (pulsus tardus or plateau pulse), small to hemodynamic volume due obstruction at the valve, palpable thrill a across of blood by ejection caused to turbulence due narrow orifice and a prominent anacrotic notchjet effectdue to produced by ejection of blood across a narrow valve or decreased velocity of blood flow during ejection early (anacrotic pulse). Palpation cannot anacrotic notch. detect The severity the of valvular obstruction proportional to the degree of abnormality of the carotid is pulse. A lag between onset of apical impulse and carotid impulse predicts area a of valve <1 sq cm (100% specific). The severity of aortic stenosis may be masked with high stiffness vessel increased children, in states output cardiac aortic regurgitation, in elderly, associated hypertension, low stroke volume and severity of aortic stenosis is exaggerated congestive by impaired left heart failure. The ventricular function, hypovolemia and mitral A stenosis. bisferiens pulse may be seen when aortic associated stenosis with is moderate to severe aortic regurgitation and preserved left ventricular function. Bisferiens pulse disappears with onset of congestive heart failure. Pulsus In constrictive pericarditis, a prominent Y descent is descent Y prominent a pericarditis, constrictive In (pericardial sound filling diastolic a with associated knock). This is called Fredrich’s sign. In right ventricular overload states the x descent may be prominent - atrial septal defect. In tricuspid regurgitation, increased or blunting causes systole ventricular during blood right atrial obliteration of x descent with a prominent v wave (Lanci’s sign) called systolic or regurgitant wave In atrial fibrillation, lossof Awaves causes the V to become more prominent waves Other - large septal atrial defect with septal shunt left (Gerbode’s defect, defect), severe ventricle heart failure, cor ventricular to right pulmonale. atrial The x descent becomes deeper when vigorous right vigorous when deeper becomes descent x The tamponade, cardiac - occurs contraction ventricular pericarditis. constrictive As severity of tricuspid large by a replaced is blunt and gets the x descent regurgitation increases, regurgitant wave. size, in reduced is trough X the fibrillation, atrial In but preserved. Irregular Irregular cannon waves - complete A-V heart dissociation, block, ventricular pacing, ventricular tachycardia. and ventricular extrasystoles Ventricular Ventricular tachycardia dissociation AV isorrhythmic conduction, with 1:1 retrograde Y DESCENT Y V WAVE X DESCENT DESCENT X Rapid Y descent (Diastolic pressure. venous trough is exaggerated due to elevated collapse) - The Y descent i. ii. iii. and states hypovolemic in seen is It - waves V Diminished hypotension following use of nitrates atrial restrictive non in seen be may waves V and A Equal septal defect, constrictive rhythm sinus in failure ventricular right pressure, venous pericarditis with increased pressure with increased venous Prominent V wave head bobbing, pulsatile systolic pulsations of earlobe, - In severe exophthalmos cases and pistol it shot sound may over jugular veins the cause internal i. ii. i. ii. X descent Prominent Absent X descent i. Decreased A wave Decreased A amplitude wave - Right atrial injury during can cause heart surgery cannulation in open surgical amplitude. A wave reduction in Absent A waves - In atrial fibrillation, the atriallost. kick is ii. CARDIOLOGY 898 iii. ii. i. diastolic pressure. the decreases and reflux diastolic of duration increases and increases the diastolic pressure, whereas bradycardia reflux of diastolic for time and disappearance the Tachycardiashortens sound. end sounds of Korotkoff ventricular muffling at left maximal measured is pressure is diastolic the Hence pressure. diastolic pressure than diastolic lower true never zero, measured approaches sphygmomanometer pressure the Though pressure. of the severity to assess thantheincrease aortic regurgitation, insystolic blood diastolic indicator of better a decrease is of pressure degree The widens. pressure regurgitation increases, the diastolic pressure decreases and pulse aortic of severity the As - pressure Blood tachycardia incongestive heartfailure. low cardiac output, heart failure, arterial vasoconstriction with and attenuated be may signs These regurgitation. aortic chronic severe or moderate indicates signs these of nonauscultatory signs of aortic regurgitation. The presence the arterial tree have along a bounding quality giving rise to all the pulses Arterial ventricle. left the into blood of low systemic vascular resistance and early diastolic reflux ejection aortic of by caused pulse collapsing or amplitude fall abrupt an by of followed and force pulse the increases The volume stroke large - The quality. collapsing Pulse a has regurgitation - regurgitation Aortic higher Hg than theleftarm. mm 10-20 be may arm blood right the The in pressure obstruction. valve aortic of features pulse having carotid left with arteries brachial carotid, and right subclavian in amplitude vessels pulse innominate greater causes right which the in blood selective of have streaming jet Patients - stenosis aortic Supravalvular hypertension ortricuspidstenosis. artery pulmonary and stenosis mitral with associated is wave stenosis aortic when elevated A be may It prominent effect). (Bernheim to leading left compliance decreased ventricular be would there septum, hypertrophied be will and it hypertrophy ventricular cases left of the presence In of normal. most In - pulse venous Jugular and pressure diastolic lowerwidening pulsepressure. be would there severity depending on If thereisassociated aortic regurgitation, stenosis. aortic with associated pressure blood high have stenosis can aortic hypertension with Patients of narrows. pressure pulse severity the As increases, thesystolicarterialpressuredecreasesand - pressure Blood ventricular dysfunction. left with stenosis aortic severe in seen be may alternans PERIPHERAL SIGNS OF AORTIC REGURGITATION o ses h svrt o ari rgriain 20- - regurgitation aortic of severity the assess to used is arteries popliteal and brachial the between pressure blood systolic in difference - A sign Hill’s Water hammerpulse best appreciatedinbrachial artery Bisferiens pulse - A double peaked systolic impulse, iv. xi. x. ix. viii. vii. Head andNeck vi. v. Eyes Hypertrophic cardiomyopathy - Pulse - The carotid pulse mean maybeelevated. The absent. be may signs Peripheral alternanas. pulsus pressure with a near normal diastolic blood pressure with there will be sinus tachycardia, slightly low systolic blood regurgitation, aortic acute In - regurgitation aortic Acute xix. xviii. xvii. Abdomen xvi. xv. Lower limb xiv. xiii. xii. Upper limb Palmar click - A palpable, abrupt flushing of the palms insystole of flushing abrupt palpable, A - click Palmar AR 4+ angiographic - Hg mm 3+ >60 angiographic AR, - Hg mm 40-60 AR, 2+ angiographic - Hg mm 40 ou’ sg - ustl sencaiua joint dissection sternoclavicular Pulsatile aortic with associated is regurgitation aortic when - sign Logue’s pulsations lingual Strong tongue depressor the of movement down - and up by demonstrated sign Minervi’s Muller’s sign-Visible pulsationsoftheuvula (dancing carotids) Corrigan’s sign - Visible pulsations of carotid artery the headwitheachheartbeat of bobbing or Visibleoscillation - sign Musset’s De Becker’s sign-Prominent retinalarterypulsations in systoleanddiastolerespectively Landolfi’s sign - Contraction and dilatation of pupil Dennison’s sign-Pulsatile cervix Gerhardts’s sign-Pulsatile spleen Rosenbach’s sign-Pulsatile liver the pressing femoral arteryproximaltothestethoscope. by perceived is murmur systolic A reversal offlowindiastole. produces a toandfrobruitcaused by exaggerated stethoscope of the edge distal tothe femoral artery Durozeiz’s sign- the stethoscopelightlyplaced on the femoral artery with sound systolic large A - Traube of shot Pistol artery radial the over sounds shot Pistol - sign Palfrey’s glass slideagainstthelips. sequential similar phenomenon can be observed by pressing a Exaggerated A fingernail. of tip the to applied is when pressure light fingernail - the of blanching and reddening pulse Quincke’s artery brachial the of Pulsations - brachialis Locomotor ih pesr apid o the to applied pressure Light CHAPTER 195 899 Mark E Essentials Silverman. of cardiac physical diagnosis by Jonathan Abrams, 1987:13-54. Philadelphia, Lea and Narasimhan R, Febiger, Vahe S, Franklin S. The art and science of cardiac physical examination with , jugular and precordial pulsations, 2nd ed. 2015:20-140. New Delhi: Jaypee, Jules Constant. Essentials of bedside cardiology, 2nd ed. Humana press inc, 2003:29-88. Mann, Zipes, Libby, Bonow. Braunwald’s heart disease a Philadelphia: ed. 10th medicine, cardiovascular of textbook Elsevier Saunders, 2015:98-102. internal of principles Harrison’s al. et Hauser Fauci, Kasper, medicine, 19th ed. 2015 Michael G, William D. Hutchison’s clinical methods, 23rd ed. Saunders, 2012. Andrew H, David G. Chamberlain’s symptoms and signs in clinical medicine, 13th ed. 2010. REFERENCES 1. 2. 3. 4. 5. 6. 7. associated associated with severe mitral regurgitation, the arterial pulse is coincident brisk with midsystolic click has been and recorded but is not palpable. collapsing. A retraction Tricuspid notch regurgitation - significant Pulse tricuspidregurgitation - amplitude Hemodynamically may result arterial pulse. in low atrial fibrillation. associated Many patients may Jugular have venous pressure importance - than It auscultation. tricuspid Sometimes, regurgitation, has the in more mean elevated. severe venous In diagnostic such pressure a is situation, examine the patient in it a sitting or standing may position. Do be not necessary conclude to that the jugular unless venous the upper pulse level of is the wave form normal is identified in supine, 45 degree or increases, sitting position. X As disappears. severity the descent The V wave is augmented and is Y descent is more prominent. In attenuated severe tricuspid regurgitation, there and C-V wave, regurgitant like severe plateau or rounded a is ultimately V wave or S wave. This V wave is a systolic wave which is followed by a sharp, steep trough called the Y descent. earlobes pulsatile and eyeballs prominent cases, severe In have been observed. With inspiration, due to increase in right ventricular inflow, the wave V hasand a highera prominent peak Y descent. In atrial fibrillation, there is disappearance of A wave with presence of a V dominant wave which may simulate the regurgitation. V wave of tricuspid has a rapid, jerky, sharp upstroke which taps against the fingers, followed bya midsystolic dip or collapse which is followed by a second late diastolic dome or pointed finger pulse). The rapid wave upstroke isdue (spike and to early, exaggerated emptying of the left ventricle and the second peak is probably a reflectedwave or rebound correlates dip midsystolic of magnitude The phenomenon. with the left ventricular - gradient. In normal a individual, the postextrasystolic long pulse pause is larger after than normal. In a obstructive variety after an extrasystolic of hypertrophic cardiomyopathy, pulse, there is contractility Starling effect and which increase stays the causes same obstruction. or reduces. This is increase called Brokenborough So, the phenomenon. pulse Jugular venous pulse - The A appears wave as is a prominent flicking and motion prior It carotid to is due upstroke. to stiffRV myocardium and strong right atrial contraction. A more prominent A wave indicates right obstruction. outflow tract ventricular Mitral stenosis - Pulse - normal The or carotid has arterial pulse contour. decreased is If pulse associated with volume atrial fibrillation,associated If volume. pulse variable with irregular be thewill and pulse normal with mitral or aortic regurgitation, there is an increase in of rise. the carotid pulse amplitude and rate uncomplicated in normal be may It - pulse venous Jugular mitral stenosis. There will be patients a with prominent A pulmonary wave artery in hypertension rhythm as in a result sinus of right ventricular hypertrophy and decreased right ventricular compliance. In presence right ventricular failure, of mean pressure will be elevated. In atrial fibrillation, wave A waves. attenuated with irregular V disappears, X descent is mitral severe or moderate In - Pulse - regurgitation Mitral regurgitation, the carotid pulse is decreased pulse volume or quick rising, poorly sustained brisk or jerky with and low amplitude. It is due to decreased stroke forward volume because of regurgitation. Jugular venous pulse - It cases. is As normal right in heart uncomplicated failure sets hypertension causes in, rise in pulmonary mean venous pressure. artery This causes a prominent A wave suggestive right of an ventricular elevated end diastolic pressure. functional tricuspid Patients regurgitation with have a which increases on inspiration. prominent wave V Mitral valve prolapse - abnormality Majority of of patients the have no arterial or venous pulse. When