JUGULAR VENOUS

PULSE (JVP)
 JUGULAR VENOUS PULSE
Pressure change in atrium is directly reflected
in internal jugular veins.
Waves of JVP
Jugular venous pulse (JVP) has five
waves: three positive waves and two
negative waves (descents). The positive
waves are a, c, and v waves, and two
descents are x and y descents.
• a wave: due to atrial contraction.
• c wave: onset of ventricular systole which results bulging of
tricuspid valve ring into the right atrium as the right
ventricular pressure rises.
• v wave: indicates the passive rise in pressure in the right
atrium as venous return continues while the tricuspid valve
remains closed.
• x descent: caused by a fall of right atrial pressure due to
relaxation of the right atrium.
• y descent: due to fall in right atrial pressure when blood
enters into the right ventricle as tricuspid valve opens.
 ABNORMAL JVP WAVES
Conditions of raised JVP
1. Right-side heart failure
2. Obstruction of superior vena cava
3. Increase in circulating blood volume
– Pregnancy
– Acute nephritis
– Over-enthusiastic treatment with IV fluids
4. Congestive heart failure
5. Constrictive pericarditis
6. Tricuspid incompetence
 HEART SOUNDS
• There are first heart sound (S1), second heart
sound (S2), third heart sound (S3) and fourth heart
sound (S4). S1and S2 are heard normally.
First Heart Sound: Represents the beginning of
systole.
Causes: S1 occurs due to vibration set up by:
1. Sudden closure of the AV valves.
2. Rapid increase in tension in the ventricular
muscles during isometric contraction acting on
filled ventricles.
3. Turbulence created in the blood due to
ventricular contraction.
a) Accentuation of first heart sound occurs in:

• Exercise
• Hyperkinetic circulatory states like anemia, beriberi
• Hypertension

b) Diminution of first heart sound occurs in:

• Shock
• Acute myocardial infarction
• Pericardial effusion
• Obesity
• Emphysema
Splitting of S1
• First heart sound has two components: the mitral
and the tricuspid components.
• The mitral valve closes slightly before the
tricuspid valve. This gives rise to splitting of the
first heart sound.
Second Heart Sound
Causes
1. This occurs primarily due to closure of
semilunar valves.
2. Rush of blood into the ventricles due to
opening of the AV valves contributes.
Significance: Signifies the end of clinical systole and
closure of semilunar valves.
a) Loud A2 (aortic component) occurs in:
• Systemic hypertension
• Aortic dilatation
b) Diminished A2 occurs in:
• Aortic stenosis
• Aortic incompetence
c) Loud P2 (pulmonary component) occurs in:
• Pulmonary hypertension
• Pulmonary artery dilation
d) Diminished P2 occurs in:
• Pulmonary stenosis
Splitting of S2
• Splitting of the second sound is due to the gap
between the aortic and pulmonary
components.
• It is easy to detect because sounds of aortic and
pulmonary valve closure are high pitched and can
be separated.
Third Heart Sound
• It is usually heard in conditions in which the
circulation becomes hyperkinetic.
Causes
1. It is caused by the vibration setup in the
ventricle during the early period of rapid ventricular
filling.
2. Rebound fencing of the cusp of the valve and
chordae of the respective valve due to vigorous
elongation of the ventricle caused by rapid inflow of
blood.
Fourth Heart Sound
• Called as atrial sound as it is produced during atrial contraction.
• Presence of the fourth heart sound is always considered as
abnormal.
Causes
1. It is caused by atrial contraction.
2. It is produced by the vibration set up within the ventricle due to inflow
of blood produced by atrial systole.
Occurs just before the first sound, i.e. late in the diastole.
Significance
1. It always indicates an increased stiffness or non-compliance of the
ventricles.
2. It is heard in left ventricular hypertrophy due to hypertension,
myocardial infarction, pulmonary embolism, and pulmonary
hypertension.
 MURMURS
Abnormal heart sound
Murmurs are due to turbulence in the blood flow.
SITE OF ORIGIN: The point of maximal intensity usually
indicates its site of origin.
TIMING & DURATION: Depending on the timing of murmur,
murmurs are classified into systolic, diastolic, or
continuous.
• Depending on the duration, it may be early diastolic, mid-
diastolic, early systolic, pan-systolic, etc.
CHARACTER: The murmur may be soft blowing to harsh,
rough, and rumbling.
 DEFINITIONS & NORMAL VALUES
Cardiac output: Cardiac output is defined as the
amount of blood ejected by each ventricle per
minute.
Cardiac output = stroke volume × heart rate.
• Normal cardiac output in adults is 5–6 lit/min
(approximately 8 % of the body weight)
Stroke Volume: Volume of blood ejected by each
ventricle with each beat.
• NORMAL VALUE: Normal stroke volume is about
70 ml.
End-diastolic Volume: The volume of blood remaining in each ventricle
at the end of diastole is end-diastolic volume (EDV).
Normal value: 130 ml
Ejection Fraction: The percentage of end-diastolic volume ejected
with each beat is the ejection fraction (EF).
EF = SV/EDV × 100.
Normal value: 65%. EF is a good index of myocardial performance.
End-systolic Volume: The volume of blood remaining in each ventricle
at the end of systole is end-systolic volume (ESV).
Normal value: It is about 50 ml.
Cardiac Reserve: Amount of blood that can be pumped by each
ventricle in excess of normal cardiac output.
Normal value: 15–25 lit/min in non-athletes and 20 to 40 lit/min in trained.
 PHYSIOLOGICAL CONDITIONS AFFECTING
CARDIAC OUTPUT
A. Conditions that increase cardiac output
1. Exercise
2. Anxiety
3. Emotion and excitement
4. Increased environmental temperature
5. After eating
6. Pregnancy
B. Conditions that decrease cardiac output
1. Standing from lying posture
2. Excessive sweating
C. Conditions that do not change cardiac output
1. Sleep
2. Mild to moderate change in environmental temperature
Age
• CO is less in elderly which is due to decreased heart rate and stroke
volume
• In children, though the heart rate is more, cardiac output is less due to
less stroke volume.
Gender: Cardiac output is about 10% less in females.
Exercise
• Cardiac output increases in exercise, due to sympathetic
stimulation.
• Cardiac output increases due to increased heart rate and stroke
volume.
• Tachycardia and increased stroke volume occur due to increased
discharge of noradrenergic sympathetic nerves to the heart.
• Sympathetic activity increases by psychic stimuli and stimulation of
receptors in the muscles, joints and tendons. Inhibition of vagal tone
also contributes to tachycardia.
• Stroke volume increases due to increased myocardial contractility by
sympathetic stimulation and also due to increased venous return.
• Venous return increases due to sympathetic venoconstriction and
increased skeletal muscle pump activity. Increased thoracic pump
and mobilisation of blood from the splanchnic and cutaneous beds also
contribute to increased venous return.
Excitement:
• Cardiac output increases in emotional excitements due to sympathetic
stimulation.
After Eating
• Cardiac output increases after eating due to increased metabolism.
 MEASUREMENT OF CARDIAC OUTPUT
Direct Methods
• Cardiac output can be measured directly by placing an
electromagnetic flow meter in the ascending aorta or by
using a cardiometer. These are accurate methods of
measuring cardiac output.
• However, these direct methods are applicable only in
experimental animals or in humans (in patients)
undergoing open thoracic surgery.
• In humans, cardiac output is usually determined by using
Doppler combined with echocardiography.
Indirect Methods
1. Fick method
2. Indicator dilution method
3. Thermo-dilution method
4. Ballistocardiography
5. Echocardiography
6. X-ray method
7. Pulse-pressure method
 FICK METHOD
Definition: Fick principle is defined as the amount of a
substance taken up by an organ or by the whole body per unit
of time is equal to the arteriovenous difference of the
substance times blood flow.
Procedure:
• Cardiac output can be measured by measuring the amount
of oxygen consumed by the body in a given period and
dividing this value by the arteriovenous difference of
oxygen across the lungs.
• The oxygen consumption of the body is measured by
spirometry.
The cardiac output is calculated as:
O2 consumption (mL/min)
Output of left ventricle = ——————————————
(AO2 ) − (VO2)
Advantages
1. Result is accurate
2. No chemical is injected
Disadvantages
1. Catheterization should be done by expert hand
2. Hospitalization is required for catheterization
3. Patient may be apprehensive of catheterization that increases cardiac
output
4. Simultaneous measurement of oxygen consumption makes the process
difficult.
5. It is difficult to measure cardiac output by this method in ambulatory
patients and during exercise.
 INDICATOR DILUTION METHOD
Principle: A known amount of an indicator is injected into circulation
usually through an arm vein and the concentration of the indicator is
measured in serial samples of the arterial blood. The output of the heart is
equal to the amount of indicator injected divided by its average
concentration in arterial blood after a single circulation through the
heart.
Procedure
• This method is popularly known as Hamilton’s dye dilution method.
• The dye injected is usually the Evans’ blue or indocyanine green.
 THERMODILUTION METHOD
Principle
• Same as indicator dilution technique. In this
method, the cold saline is used as the indicator.
Advantages
1. Saline is harmless
2. Cold is dissipated, so recirculation is not a
problem
3. Can be repeated many times, if needed
4. Usually preferred for children as saline is
nontoxic
5. Useful in severely sick patients
(serious patients in intensive care units)
Disadvantages
1. Cardiac catheterization is required.
 OTHER METHODS
1) Echocardiography:This is a noninvasive
technique in which ultrasonic waves emitted
from a transducer detects waves reflected
from various parts of the heart. When it is
combined with Doppler technique it determines the
velocity and volume of flow of blood through
various cardiac valves.
Parameters Seen
1. Size and shape of the heart
2. Pumping efficiency of the heart:
3. Valve abnormalities
Advantages
• It is a non-invasive test.
• Accurate diagnosis and develop a treatment plan that is best.
• It is a safe and painless way
• Transthoracic echocardiography is used in critically ill patients
Limitations
• The major limitation is that it is often difficult to obtain good quality
images from persons who have broad chests, are obese, or are
suffering from chronic lung disease.
2) Ballistocardiography
• In this method, the vibrations generated by each heart-beat are
received and converted into waveforms by a transducer that
records the cardiac activities on an ink recorder.
• However, cardiac output measured by this method is not an accurate
one.
3) X-ray Method
• In this method, a radio-opaque dye is injected intravenously and
then the size of the heart is detected by serial x-rays in systole and
diastole from which cardiac output is measured using computer
programme.
4) Pulse-Pressure Method
• Pulse pressure (difference between systolic and diastolic pressures)
provides a rough idea of cardiac output.