A Quick revision on Pulse & JVP for Undergraduate Medical Students & Postgraduate

1. PULSE & JVP : A QUICK REVISION
DR SUBHANKAR PAUL

2. Definitions
• Pulse : it is the expansion & elongation of the
arterial wall due to pressure imparted by the
column of blood during cardiac cycle
• JVP oscillating top of vertical column of blood
in right IJV that reflects the phasic pressure
changes in Right Atrium in cardiac cycle

3. EXAMINATION OF PULSE
• RATE
• RHYTHM
• VOLUME
• CHARACTER
• CONDITION OF ARTERIAL WALL
• RADIO-RADIAL / RADIO –FEMORAL DELAY
• PERIPHERAL PULSES

4. RATE

5. RELATIVE TACHYCARDIA & RELATIVE
BRADYCARDIA : Related to TEMPARATURE
RELATIVE TACHYCARDIA
• Acute Rheumatic Carditis
• Diphtheric myocarditis
• Tuberculosis
RELATIVE BRADYCARDIA
• Any Viral fever ( Dengue,
Yellow fever : Faget’s sign)
• Enteric fever 1st week
• Pyogenic Meningitis/ Intra
cerebral Abscess
• Brucellosis
1DEGREE F temp rise = increase in Pulse rate by 10/min

6. RHYTHM
Regularly Irregular Rhythm
• Sinus Arrhythmia
• 2ND DEGREE av BLOCK
• Atrial tachyarrhythmias
(MAT and atrial flutter)
with fixed AV block
• Ventricular bigemini,
trigemini.
IRegularly Irregular Rhythm
• Atrial fibrillation
• Atrial or ventricular ectopics
• Atrial tachyarrhythmias
(MAT and atrial flutter) with
varying AV blocks

7. Pulse Deficit (Apex-Pulse Deficit)
It is the difference between the heart rate and
the pulse rate, when counted simultaneously
for one full minute.
Method : single examiner / Double Examiner
Interpretation :
• More than 10per min : atrial Fibrillation
• Pulse deficit Less than 10: MAT / VPC

8. Pulse Volume
• Volume is the movement imparted to your fingers and
reflects the pulse pressure - the difference between
systolic and diastolic blood pressure
• best assessed by palpating the carotid artery
• When pulse pressure is between 30 and 60 mm Hg,
pulse volume is normal.
• When pulse pressure is less than 30 mm Hg, it is a
small volume pulse.
• When pulse pressure is greater than 60 mm Hg, it is a
large volume pulse
• Pulse volume depends on stroke volume and arterial
compliance

9. Character
• Character is the impression of the pulse
waveform obtained
• best assessed in the carotid arteries except.
bisferiens pulse , pulsus alternans, are more
evident in peripheral arteries

10. CATACROTIC PULSE : NORMAL PULSE

11. Hypokinetic Pulse
Small weak pulse
(small volume and
narrow pulse
pressure).

12. Anacrotic Pulse (Parvus et Tardus)
A low amplitude pulse (parvus) with a
slow rising and late peak (tardus).

13. Hyperkinetic Pulse
A high
amplitude
pulse with a
rapid rise
(large
volume
and wide
pulse
pressure).

14. Collapsing Pulse (Water-Hammer
Pulse, Corrigans Pulse)
It is a large volume pulse with a rapid upstroke
(systolic pressure is high) and a rapid
downstroke (diastolic pressure is low).
The rapid upstroke is because of an increased
stroke volume.
The rapid downstroke is because of diastolic
run-off into the left ventricle, and decreased
peripheral resistance and rapid run-off to the
periphery.
Decreased peripheral resistance is due to large
stroke volume stretching carotid and aortic
sinus leading to reflex decrease in peripheral
resistance

15. METHOD OF EXAMINATION

16. Causes
Patent ductus arteriosus
Aortic regurgitation
Arteriovenous fistula
Rupture of sinus of Valsalva.
Thready pulse is seen in shock.
Jerky pulse is seen in HOCM.

17. DOUBLE-BEATING PULSE
PULSUS BISFERIENCE
PULSUS DICROTICUS

18. Pulsus Bisferiens
best felt in brachial and femoral artery
due to ejection of rapid jet of
blood through the aortic
valve. During the peak of
flow, Bernouli’ s effect on the
walls of ascending aorta
causes a sudden decrease in
lateral pressure on the inner
aspect of the wall.
Dissection of aorta (unilateral bisferiens).
Pulsus bisferiens is a single pulse wave with two peaks in systole

19. Pulsus Dicroticus
Mechanism :
due to a very low stroke
volume with decreased
peripheral resistance
It is a single pulse wave with one peak in systole and one peak in diastole

20. Pulsus Alternans
Causes
Left ventricular failure
Typhoid fever
Dehydration
Dilated cardiomyopathy
Cardiac tamponade

21. Pulsus Bigemini
• A pulse wave with a normal beat followed by a
premature beat and a compensatory pause,
occurring in rapid succession, resulting in
alternation of the strength of the pulse
• In pulsus alternans, compensatory pause is
absent, whereas in pulsus bigeminus,
compensatory pause is present.
• Pulsus bigeminus is a sign of digitalis toxicity.

22. Pulsus paradoxus
It is an exaggerated reduction in the strength
of arterial pulse during normal inspiration or
an exaggerated inspiratory fall in systolic
pressure of more than 10 mm Hg during quiet
breathing.
Pulsus paradoxus is best assessed by
measuring the difference in systolic blood
pressure during inspiration and expiration
During deep inspiration Pulse may be absent

23. Reverse pulsus paradoxus
• is an inspiratory rise in arterial pressure.
• Causes
• Hypertrophic obstructive cardiomyopathy
• Intermittent positive pressure ventilation
• Atrioventricular dissociation

24. Condition of Arterial Wall
• Young adult : Not Palpable
• Old Individuals , Hypertensive patients :
Palpable

25. PERIPHERAL PULSES

26. Carotid pulse

29. SYMMETRY of the PERIPHERAL PULSES

30. RADIO-RADIAL & RADIO-FEMORAL
DELAY
• Particularly important for pediatric age group
• Delay of the femoral compared with the right
radial pulse is found in coarctation of the
aorta
Artery Time at which pulse wave arrives
after cardiac systole
Carotid 30 milliseconds
Brachial 60 milliseconds
Radial 80 milliseconds
Femoral 75 milliseconds

31. Radio-femoral Delay

32. CAUSES
RADIO-RADIAL delay
• PRE-SUBCLAVIAN COA
• THORACIC INLET
SYNDROME : CERVICAL RIB
• TAKAYASU’S DISEASE
• AORTIC ARCH ANEURYSM
RADIO-FEMORAL DELAY
• COA
• AORTOARTERITIS
• ATHEROSCLEROSIS OF
AORTA

33. Jugular Venous Pressure & Waveform

34. Definition
• Jugular Venous Pulse:
defined as the oscillating top of vertical
column of blood in right IJV that reflects the
phasic pressure changes in Right Atrium in
cardiac cycle.
• Jugular Venous Pressure:
Vertical height of oscillating column of
blood .

35. Why Internal Jugular Vein?
• IJV has a direct course to RA.
• IJV is anatomically closer to RA.
• IJV has no valves( Valves in EJV prevent
transmission of RA pressure)
• external jugular vein is more superficial & prone
to kinking and partial obstruction as it traverses
the deep fascia of the neck.
• Vasoconstriction Secondary to hypotension ( in
CCF) can make EJV small and barely visible.

37. Why Right Internal Jugular Vein?
• Right jugular veins extend in an almost straight
line to superior vena cava, thus favouring
transmission of the haemodynamic changes
from the right atrium.
• The left innominate vein is not in a straight line
and may be kinked or compressed between
Aortic Arch and sternum, by a dilated aorta, or
by an aneurysm.

39. Method Of Examination
• The patient should be comfortable during the examination.
• Clothing should be removed from the neck and upper thorax.
There should not be any tight bands around abdomen
• Patient reclining with head elevated 45 ° (When the patient
reclines at 45° the upper limit of the JVP is at the level of the
clavicle) Ensure that the neck muscles are relaxed by resting
the back of the head on a pillow. Neck should not be sharply
flexed & slightly rotated towards the opposite side
• Examined effectively by shining a light tangentially across the
neck from the right side of the patient
• → Identify the internal jugular pulsation in between two
heads of SCM , (DIFFERENTIATE it from CAROTID PULSATION)

40. • Identify the timing and waveform of the
pulsation and note any abnormality
• Estimate the vertical height in centimetres
between the top of the venous pulsation and the
sternal angle to give the venous pressure
• If necessary, readjust the position of the patient
until the waveform is clearly visible & if necessary
use the abdominojugular reflux
.

41. Observation

42. • (A) Supine: jugular vein distended, pulsation not
visible. (B) Reclining at 45°: point of transition between
distended and collapsed vein can usually be seen to
pulsate just above the clavicle. (C) Upright: upper part
of vein collapsed and transition point obscured
WHY 45° ?? FOR BETTER VISUALISATION
the pulsation of the internal jugular vein is greatest when the trunk is inclined by less than 30° :
HARRISON’S 17TH

43. Difference from Carotid Pulse
JVP CAROTID PULSE
Better Visible Better Palpable
INSPECTION Oscillatory wavefom with Inward movement
more prominent
Rapid outward jerky movement
Two peaks per heartbeat (in sinus rhythm) One peak per heartbeat
Seen in the triangle formed by the two heads
of the sternomastoid and the clavicle
Seen internal to sternomastoid
Independent of respiration Height of pulsation varies with
respiration (DECREASES in
INSPIRATION)
Independent of position Varies with position of patient
PALPATION Pulsation unaffected by pressure at the root of
the neck
Pulsation diminished by pressure
at the root of the neck
Independent of abdominal pressure Rises with abdominal pressure

44. Observations Made
• the level of venous pressure.
• the type of venous wave pattern.

45. The level of venous pressure

48. The level of venous pressure
• Using a centimeter ruler, measure the vertical
distance between the angle of Louis (manubrio
sternal joint) and the highest level of jugular vein
pulsation.
• Add 5 cm to measure central venous pressure since
right atrium is 5 cm below the sternal angle. Normal
CVP is < 7mm of Hg or 9 cm H2O (1.36 cmH2O = 1.0
mmHg)
• The upper limit of normal is 4 cm above the sternal
angle
• A distance >4.5 cm at 30° elevation is considered
abnormal

50. WHY The sternal angle is used as the
reference point ??
Upto Harrison's 17th edition
• “The sternal angle is used
as the reference point
because the center of the
right atrium lies
approximately 5 cm below
the sternal angle in the
average patient, regardless
of body position”
Harrison's 18th edition onwards
• “the actual distance between the
mid-right atrium and the angle of
Louis varies considerably as a
function of both body size and
the patient angle at which the
assessment is made (30°, 45°, or
60°). The use of the sternal angle
as a reference point leads to
systematic underestimation of
CVP, and this method should be
used less for semiquantification
than to distinguish a normal from
an abnormally elevated CVP”

51. SO , WHAT THEY SUGGEST ????
• “The use of the clavicle may provide an easier
reference for standardization. Venous
pulsations above this level in the sitting
position are clearly abnormal, as the distance
between the clavicle and the right atrium is at
least 10 cm. The patient should always be
placed in the sitting position, with the legs
dangling below the bedside, when an elevated
pressure is suspected in the semisupine
position”

52. Abdomino-jugular reflux
Upto Harrison's 17th edition
• “A positive
abdominojugular test is
best defined as an
increase in JVP during
10 s of firm
midabdominal
compression followed
by a rapid drop in
pressure of 4 cm blood
on release of the
compression”
Harrison's 18th edition onwards
• “The abdominojugular
reflex is elicited with firm
and consistent pressure
over the upper portion of
the abdomen, preferably
over the right upper
quadrant, for at least 10 s. A
positive response is defined
by a sustained rise of more
than 3 cm in JVP for at least
15 s after release of the
hand”

53. Abdomino-jugular reflux

54. • Most common cause of a positive test is RHF/
(incipient Heart Failure )
• Positive test in: Borderline elevation of JVP
Silent TR
Latent RHF
• False Negative: SVC/IVC obstruction
Budd Chiari syndrome
• Positive Test imply SVC and IVC are patent

55. the type of venous wave pattern.

58. • Venous distension due to RA contraction
Retrograde blood flow into SVC and IJV
• Synchronous with S1, Follow P of ECG
• Precede Carotid pulse
a WAVE

59. • The x descent: is due to
X Atrial relaxation
X` Descent of the floor of the right atrium
during right ventricular systole.
Begins during systole and ends before S2
• The c wave:
Occurs simultaneously with the carotid pulse
Artifact by Carotid pulsation
Bulging of TV into RA during ICP

60. v WAVE
• Rising right atrial pressure when blood flows into the
right atrium during ventricular systole when the
tricuspid valve is shut.
• Synchronous with Carotid pulse
• Peaks after S2

61. y DESCENT
• The decline in right atrial pressure when the tricuspid valve
reopens
• Following the bottom of the y descent and before beginning of
the a wave is a period of relatively slow filling of the ventricle,
the diastases period, a wave termed the h wave.

62. Normal pattern of the jugular venous pulse
• The normal JVP reflects phasic pressure changes in
the right atrium and consists of three positive waves
and two negative troughs
• Simultaneous palpation of the left carotid artery &
auscultation of heart soounds at apex aids the
examiner in relating the venous pulsations to the
timing of the cardiac cycle.

63. • Descents are better seen than positive waves.
Normally X descent is more prominent than Y descent.
• The a wave occurs just before the first sound or carotid
pulse.
‘c’ wave succeeds S1 or simultaneous with carotid pulse
( in fact
• The c wave is never seen normally )
• The x descent occurs just prior to the second heart
sound while the y descent occurs after the second
heart sound
• The v wave occurs just after the arterial pulse
Identifying Wave Forms

64. jugular venous pulse
• clinical corelates:
• Abnormalities in Pressure
• Abnormalities in Waveform

65. Abnormalities in jugular venous
Pressure

66. Causes of Elevated JVP
1. Unilateral non-pulsatile
 Innominate vein thrombosis
2. Bilateral non-pulsatile
 SVC obstruction
 Massive right sided pleural effusion
3. Bilateral pulsatile
a. Cardiac
 Cardiac failure
 Tricuspid stenosis
 Tricuspid regurgitation
 Constrictive pericarditis
 Cardiac tamponade
b. Pulmonary : COPD/cor pulmonale
c. Abdominal :
 Ascites
 Pregnancy
d. Iatrogenic Excess IV fluids
Low jugular venous pressure
Hypovolaemia.

67. Abnormalities in jugular venous
Waveform

68. Abnormalities in a wave
• Elevated “a” wave
• Cannon “a” wave
• Absent “a” wave
an increased delay between the a wave and the carotid
arterial pulse in patients with first-degree
atrioventricular block.

69. Elevated “a” wave
• Tricuspid stenosis
• Increased
Resistance to RV
Filling.
 PS
 PAH
Large a waves indicate that the right atrium is contracting against an increased
resistance

70. Cannon “a” wave
IRREGULAR REGULAR
Junctional rhythm
Junctional tachycardia.Atrial-ventricular
Dissociation
(atria contract against
a closed tricuspid
valve)
•Complete heart
block
•VPC
•Ventricular
tachycardia

71. Absent “a” wave
• 1. Atrial fibrillation

72. Elevated “v” wave
1. Tricuspid regurgitation.
2. Right ventricular failure.
3. Restrictive cardiomyopathy.
4. Cor Pulmonale

73. “a” wave equal to “v” wave
ASD
Prominent X descent
followed by a large
V wave
M Configuration
Indicates a large L-R
shunt
With PAH A wave
becomes more
prominent

74. 1. Cardiac tamponade.
2. Constrictive Pericarditis
3. RVMI
4. Restrictive Cardiomyopathy
Prominent “x” descent
Obliteration of “x” descent
1. Tricuspid regurgitation.

75. Prominent “y” descent
1. Constrictive pericarditis.
2. Tricuspid regurgitation.
1. Cardiac tamponade.
2. Right ventricular infarction
Absent “y” descent
Slow “y” descent
1. Tricuspid stenosis.
2. Right atrial myxoma.

76. Tricuspid regurgitation
• Absent X Descent
• CV/ Regurgitant Wave
• Followed by a rapid deep
Y descent
• May cause subtle motion
of ear lobe with each
heart beat

77. Constrictive pericarditis.
• M shaped contour
• Prominent X and Y descent (FRIEDREICH`SIGN)
• Y descent is prominent as ventricular filling is unimpeded
during early diastole.
• This is interrupted by a rapid raise in pressure as the filling is
impeded by constricting Pericardium
• The Ventricular pressure curve exhibit Square Root sign.

78. Kussmaul sign ( Venous Pulsus Paradoxus)
• Normally, the venous pressure should fall by at least
3 mmHg with inspiration
• Kussmaul’s sign is defined by either a rise or a lack of
fallof the JVP with inspiration
CAUSE
 Constrictive Pericarditis
 Severe RHF and advanced left ventricular failure
 Restrictive Cardiomyopathy
 massive pulmonary embolism,
 right ventricular infarction,

79. Raised jugular venous pressure with shock
• Congestive Heart failure
• Cardiac tamponade
• Rt ventricular infarction
• Tension pneumothorax
• Massive pulmonary embolism

80. Recent Studies
• Although the JVP estimates right ventricular filling pressure, it
has a predictable relationship with the pulmonary artery
wedge pressure.
• In a large study of patients with advanced heart failure, the
presence of a right atrial pressure >10 mmHg (as predicted on
bedside examination) had a positive value of 88% for the
prediction of a pulmonary artery wedge pressure of >22
mmHg.
• In addition, an elevated JVP has prognostic significance in
patients with both symptomatic heart failure and
asymptomatic left ventricular systolic dysfunction.
• The presence of an elevated JVP is associated with a higher
risk of subsequent hospitalization for heart failure, death from
heart failure, or both.