Cardiology Flashcards
What does JVP reflect
- Filling status / right atrial pressure
- Essential to detect for correct fluid management
Effect of inspiration on JVP
Inspirations generates negative intrathoracic pressure, causing suction of venous blood towards the heart, causing JVP to fall
Normal waves in the JVP
- a wave
- c wave
- x descent
- v wave
- y descent
a wave in JVP
- Due to** atrial contraction** - actively push up SVC and into the RV (may cause audible S4)
c wave in JVP
An invisible flicker in the x descent to closure of the tricuspid valve, before starting ventricular systole
x descent in JVP
- Downward displacement of the tricuspid valve (as the RV contracts, stretching the RA) - reduces pressure
- Atrial relaxation (simultaneous)
v wave in JVP
Passive filling of blood into the atrium against a closed tricuspid valve
y descent
Opening of the tricuspid valve with passive movement of blood from the RA to the RV (causing an S3 when audible)
Causes of raised JVP with normal waveform
- Heart failure (biventricular or isolated RHF)
- Fluid overload (any cause)
- Severe bradycardia
Raised JVP upon inspiration and drops with expiration
Kussmaul’s sign
* Opposite of what occurs in health
* Implies that the right heart chambers cannot increase in size to accomodate increased venous return
* Due to constriction (constrictive pericarditis
Kussmaul’s sign
Raised JVP upon inspiration and drops with expiration
Causes of Kussmaul’s sign
- Constrictive pericarditis
- Right heart failure
Raised JVP with loss of normal pulsations
SVC syndrome - obstruction caused by mediastinal maglignancy
JVP: Absent a wave
Atrial fibrillation - no coordinated contraction
JVP: Large a wave
- Tricuspid stenosis
- Right heart failure
- Pulmonary hypertension
JVP: Cannon wave
- Caused by atrioventricular dissociation, when atria and ventricles contract at the same time
- Atrial flutter, atrial tachycardias
- Third-degree (‘complete’) heart block
- Ventricular tachycardia & ventricular ectopics
JVP: giant v wave
Tricuspid regurgitation
JVP: Steep x descent
Tamponade
Cardiac constriction
JVP: Steep y descent
Cardiac constriction
JVP: Slow y descent
Tricuspid stenosis
Causes of absent radial pulse
- Iatrogenic (post-cath, arterial line)
- Blalock-Taussing shunt for congenital heart disease (ToF)
- Aortic dissection with subclavian involvement
- Trama
- Takayasu’s arteritis
- Peripheral arterial embolus
Collapsing pulse
- Aortic regurgitation
- Patent ductus arteriosus
- Other large extracardiac shunt
Slow rising pulse
- Aortic stenosis (delayed percussion wave)
Bisferiens
A double shudder due to mixed aortic valve disease with significant regurgitation
Jerky pulse
- HOCM
Alternans
- Severe LV dysfunction
The EF is reduced, meaning the end-diastolic volume is elevated. This may sufficiently stretch the myocytes to improve the EF of the next heart beat
* This leads to pulses that alternate from weak to strong
Paradoxical (pulsus paradoxus)
An excessive reduction in the pulse with inspiration (drop in sBP > 10 mmHg) occurs with
* Left ventricular compression
* Tamponade
* Constrictive pericarditis
* Severe asthma (as venous return is compromised)
What does cardiac apex pulsation reflects
- Ventricle striking the schest wall during isovolumetric contractions
- Gives indication of the position of the LV and size
- Typically palpable in the 5th intercostal space in the midclavicular line
Absent apical impulse
- Obesity / emphysema
- Right pneumonectomy with displacement
- Pericardial effusion or constriction
- Dextrocardia
Heaving cardiac apex
- LVH, sometimes ass. w/ palpable fourth heart sound
Thrusting/hyperdynamic cardiac apex
High left ventricular volume
* In MR, AR, PDA, ventricular septal defect
Tapping cardiac apex
Palpable first S1 in mitral stenosis
Displaced and diffuse/dyskinetic cardiac apex
LV impairment and dilatation
* DCM, MI
Double impulse cardiac apex
- With dyskinesia is due to LV aneurysm
- Without dyskinesia in HCM
