Clinical Skills

Cardiovascular System
Continue to lesson 1.1
 Introduction

• WASH HANDS
• Introduce
• Consent
• Expose
• Offer them a blanket
• 45 degrees
• Are you in any pain?
 Focused History Taking
symptoms
• 1.Chest pain
• •SOCRATES 5.Ankle swelling
•Does it get worse as the day
• 2.SOB goes on
• •PND 6.Any claudication?
• •Orthopnoea 7.Risk factors
1.Smoke
• 3.Syncope / dizziness 2.DM
• •What happened before, 3.High BP
during, after 4.Cholesterol
• 4.Palpitation 5.Diet / exercise
6.FH
• •Tap it out, how often
and how long? Any
triggers
 SIGNS OF HEART DISEASE
Appearance
Although cardiac patients may appear healthy and comfortable at rest, many with
acute myocardial infarction appear anxious and restless
Diaphoresis may result from hypotension due to pericardial tamponade,
tachyarrhythmias, myocardial infarction, or the presence of a high vagal state
Cold and clammy skin or pallor suggests low cardiac output
Patients with severe chronic heart failure or other long-standing low cardiac output
states may appear cachectic.
Cyanosis
may be central, due to arterial desaturation, or peripheral. Central cyanosis may be
caused by pulmonary disease, left heart failure, or right-to-left intracardiac or
intrapulmonary shunting;
Clubbing
may be present in chronic cyanotic states
Edema
may be present. Severe right heart failure may also present with ascites and scrotal
edema
Vital Signs
 Risk factors for Ischaemic Heart
Disease
1. Hyperlipidaemia
2. Diabetes mellitus
3. Smoking
4. Hypertension
5. Obesity
6. Family history
Physical Examination
 Vital signs and general data
four standard primary vital signs indicate the status of
the body’s vital functions

Heart rate (pulse)

Respiratory rate
Blood pressure
Body temperature

General
state of nutrition
JVP
 Normal values

Heart rate

Newborn 100-160
0-5 months 90-150
6-12 months 80-140
1-3 years 80-130
3-5 years 80-120
6-10 years 70-110
11-14 years 60-105
15-20 years 60-100 ?
Adults 50-80 ?
Cardiac output is the volume of blood pumped into the arteries by the heart
And equals the result of the stroke volume per minute (HR). In healthy person
The pulse reflects the heart beat

The apical pulse is a central pulse located at the apex of the heart-point of
maximal impulse (PMI)

The peripheral pulse is pulse located away from the heart

Rate of the pulse is expressed in beats per minute

Factors affecting the pulse are:

Age, gender, exercise, fever, BP changes, medications, hypovolemia, stress,
position changes, pathology
 Pulse

The arterial pulse is produced by the

ejection of blood into the aorta, the pulse
consists of a smooth and rapid upstroke
a gradual descent to the dicrotic notch,
which represents the closure
of the aortic valve
The tidal wave is the second
wave, it is related to pressure in the
vessel, and occurs during peak systolic
pressure. The tidal wave is usually smaller
than the percussion wave, but it may be
increased in hypertensive or elderly
patients.
USMLE Step 2 - Question 7
A 42 year old male with a history of hypertension has been
experiencing dyspnea on exertion. He denies any chest pain. His
blood pressure is 140/40, heart rate 90, and  respirations 18.
Physical examination reveals elevated jugular venous pressure
and an early systolic ejection sound is heard. A III/IV early
diastolic decrescendo murmur heard best at the right upper
sternal border is present along with a I/IV diastolic rumble at the
apex. Also noted is a II/VI systolic ejection murmur at the right
upper sternal border. What other physical exam finding might you
expect?
A. Pulses bispheres
B. Pulsus alternans
C. Pulsus paradoxus
D. Pulses parvus et tardus
pulses characteristics  
Aortic valve double pulse felt due to
pulses
regurgitation. the backflow of blood in
bispherens early diastole
severe left ventricular showing alternating
Pulsus alternant
failure strong and weak beats
in cardiac tamponed or Abnormally large
Pulsus
severe asthma decrease in systolic blood
paradoxus exacerbations pressure and pulse wave
amplitude during
inspiration. The normal
fall in pressure is less
than 10 mm Hg.

aortic valve stenosis. pulse is weak/small

Pulsus parvus et
(parvus), and late
tardus (tardus) relative to its
usually expected
character
 pulsus paradoxus (PP) decrease in systolic blood pressure and pulse wave
amplitude during inspiration. The normal fall in pressure is less than 10 mmHg ,
The paradox in pulsus paradoxus is that, on clinical examination, one can detect
beats on cardiac auscultation during inspiration that cannot be palpated at the radial
pulse. It results from an accentuated decrease of the blood pressure, which leads to
the (radial) pulse not being palpable and may be accompanied by an increase in the
jugular venous pressure height (Kussmaul's sign). As is usual with inspiration, the
heart rate is slightly increased, due to decreased left ventricular output.
Measurement PP is quantified using a blood pressure cuff and stethoscope
(Korotkoff sounds), by measuring the variation of the systolic pressure during
expiration and inspiration. Inflate cuff until no sounds (as is normally done when
taking a BP) slowly decrease cuff pressure until systolic sounds are first heard during
expiration but not during inspiration, (note this reading), slowly continue decreasing
the cuff pressure until sounds are heard throughout the respiratory cycle, (inspiration
and expiration)(note this second reading). If the pressure difference between the two
readings is >10mmHg, it can be classified as pulsus paradoxus.
cause
cardiac tamponade
constrictive pericarditis. One study found that pulsus paradoxus occurs in less than
20% of patients with constrictive pericarditis.
pericardial effusion
cardiogenic shock
VIDEO
Pulsus Bisferens

A Findings

Pulsus bisferiens has two beats per cardiac cycle, both of which occur in systole

Pulsus bisferens is detected by palpating the brachial or carotid pulse with moderate
compression of the vessel, or by using the blood pressure cuff. When using the
blood pressure cuff, the clinician hears a quick double tapping sound instead of the
typical single sound. (The clinician can mimic the double sound by saying “pa-da…
pa-da” as fast as possible

Clinical Significance
Pulsus bisferens is a finding in patients with moderate-to-severe aortic regurgitation
Pulsus bisferens also occurs in patients with combined aortic stenosis and
regurgitation, though the principal lesion is usually the regurgitation and the stenosis
…
I Pulsus Alternans

A Findings
Pulsus alternans describes a regular pulse that has alternating strong and weak
beats The pulse must be absolutely regular to diagnose pulsus alternans and
distinguish it from the bigeminal pulse, which also has beats of alternating strength
although the rhythm is irregular. Rarely, in patients with pulsus alternans, the weak
pulse is so faint that it is imperceptible, with only half of the beats reaching the radial
artery (total alternans). Pulsus alternans is often accompanied by alternation of the
intensity of heart sounds and murmurs (auscultator alternans).

Palpating the radial pulse or using the blood pressure cuff is the best way to detect
pulsus alternans. When using the blood pressure cuff, the clinician should stop
deflating the cuff at the first appearance of Korotkoff sounds and hold the cuff
pressure just below systolic …
Pulsus Parvus Et Tardus
A Findings and Technique
Pulsus parvus et tardus describes a carotid pulse with a small volume (pulsus
parvus) that rises slowly and has a delayed systolic peak . It is routinely detected by
palpation.
 Clinical Significance
Pulsus parvus et tardus is a finding of aortic stenosis. Of its two components, pulsus
tardus is the better discriminator, detecting severe aortic stenosis with a sensitivity of
31% to 90%, specificity of 68% to 93%, positive LR of 3.3, and negative LR of 0.4

 Pathogenesis
Pulsus tardus depends on both obstruction to flow and the compliance of the vessel
distal to the obstruction. The pulse waveform rises rapidly in stiff vessels but slowly in
more compliant vessels, which act like low-pass filters and remove the high-frequency
components of the waveform.]That the delay in the pulse reflects the severity of
obstruction is a principle also used by Doppler sonography to gauge the severity of
renal …
Dicrotic Pulse

The dicrotic pulse has two beats per cardiac cycle, but, unlike pulsus bisferiens, one
peak is systolic and the other is diastolic It is usually detected by palpation of the
carotid artery.
The second wave of the dicrotic pulse is identical in timing to the small dicrotic wave of
normal persons, obvious on arterial pressure tracings but never palpable. The dicrotic
wave is felt to represent rebound of blood against the closed aortic valve.
 Clinical Significance
The dicrotic pulse occurs in younger patients with severe myocardial dysfunction, low
stroke volumes, and high systemic resistance. In patients who have had valvular
replacement surgery, the finding of a persistent dicrotic pulse is associated with a poor
prognosis.
Pathogenesis
A dicrotic pulse relies on the simultaneous presence of two conditions: low stroke
volume, which significantly lowers the height of the pulse’s initial systolic wave, thus
increasing the …high systemic resistance
Hyperkinetic Pulse
A Findings
The hyperkinetic pulse strikes the examiner’s fingers with unusually abrupt and
strong force
Hyperkinetic pulses may have either a normal pulse pressure (e.g., severe
mitral regurgitation, hypertrophic obstructive cardiomyopathy) or increased
pulse pressure (e.g., aortic insufficiency and other disorders with abnormal
aortic runoff). In both severe mitral regurgitation and hypertrophic obstructive
cardiomyopathy, the blood is ejected rapidly from the left ventricle but the
integrity of the aortic valve preserves a normal arterial diastolic and pulse
pressure In aortic regurgitation, the rapid ejection of blood is accompanied by
an incompetent aortic valve, which causes a very low diastolic pressure in the
aortic root, thus increasing the pulse pressure and causing the Corrigan pulse
or water-hammer pulse characteristic of this disorder (strong and then
colaps)
 
Pulses and Hypovolemic Shock
In patients with hypovolemic shock, the peripheral pulses
provide a rough guide to the patient’s systolic blood pressure.
As blood pressure progressively diminishes, the radial pulse
generally disappears first, then the femoral pulse, and finally
the carotid pulse.
Abnormalities:
1- Rate:
Normal: 60-100 bpm
Abnormal: either <60= bradycardiaor OR >100= tachycardia

2- Rhythm:
Normal: regular rhythm
Abnormal: Irregular which is either regularly irregular (ectopic beats) or irregularly
irregular (AF).

3- Volume:
Normal volume
Small volume: HF or peripheral vascular dis.
Large volume: either physiological or pathological anaemia ,fever, thyrotoxicosis
 Examination - Pulse
• Radial artery • Character and volume
• Rate (normal = 60-100) assessed from carotid artery
• Volume –strength-amplitude (force of blood
– Bradycardia (<60) with each beat)
– Tachycardia (>100) • Collapsing pulse (aortic
• Rhythm regurgitation or pulsus
– Regular bisferens)
– Irregular • Pulsus alternans (left
• Radiofemoral delay ventricular failure)
(coarctation of the aorta) • Pulse deficit (atrial fibrillation)
• Optionally raise arm to see if
less circulation.
The radial pulse
is used commonly to assess
heart rate.

Pulse

Pulse and respirations are

related because the heart
and lungs work together.
Normally, an increase or
decrease in one causes the
same effect on the other

Ratio of pulse to respirations

 is 4:1
Pulse site Reason for use
radial accessible
carotid Cardiac arrest/shock in adults
To assess circulation of the brain
apical To determine discrepancies with radial
pulse
-when peripheral pulse is irregular
-in known heart, lung and kidney
disease
-in infants
Discrepancy means that heart is weak
or there is vascular disease
In conjunction with some medications
(routinely in children)
 
brachial To measure BP
femoral To determine circulation in leg
In cardiac arest
popliteal To determine circulation in the lower
part of the leg
 HEART RATE AND RHYTHM

If the rhythm is regular

and the rate seems normal, count the
rate for 15 seconds and multiply by
4. If the rate is unusually fast or slow,
however, count it for 60 seconds.

When the rhythm is irregular, the

rate should be evaluated by cardiac
auscultation,
 Blood Pressure
Normal Blood Pressure by Age

Approximate Age Range Systolic Range Diastolic

Range
1-12 months 75-100 50-70
1-4 years 80-110 50-80
3-5 years 80-110 50-80
6-13 years 85-120 55-80
Adults 95-140 60-90
Arterial blood pressure measure of the pressure caused by the blood as it flows
through the arteries
Systolic pressure result of contraction of the ventricles-highest pressure
Pulse pressure The difference between diastolic and systolic pressure
(normally 40 mmHg, in exercises up to 100mmHg)
BP is measured in mm of mercury and recorded as a fraction: systolic over diastolic
Affects by:
1. Pumping action of the heart (weak-less blood pumped out, low cardiac output,
decreased BP)
(strong:pumped blood volume higher-higher cardiac
output-
increased BP)
2. Peripheral vascular Resistance (increase BP especially diastolic)
Resistance is created by capacity, elasticity and viscosity)
3. Blood volume decreased in haemorrhage and dehydration
Increased in rapide IV infusion
4. Blood viscosity: BP higher in higher viscosity (proportion RBC to plasma-hematocrit)
 blood pressure

BP is result of cardiac output and peripheral vascular resistance

Systolic blood pressure is the peak pressure in the arteries

Diastolic blood pressure is the lowest pressure

in the arteries and depends on peripheral resistance

The difference in the systolic and diastolic pressures is the

pulse pressure

Systolic blood pressure in the legs is 15 to 20 mm Hg greater than

in the arms, even while the individual is lying flat.
 Physical *Ideally, ask the patient to avoid
smoking or drinking caffeinated
Examination beverages for 30 minutes before the
vital signs blood pressure is taken and to rest
BLOOD PRESSURE for at least 5 minutes.
Choice of Blood Pressure Cuff
* Check to make sure the
examining room is quiet and
Cuff
Bladder comfortably warm. Make sure the
arm selected is free of clothing.
There should be no arteriovenous
fistulas for dialysis, scarring from
prior brachial artery cutdowns, or
Width of the inflatable bladder of the cuff
should be about 40% of upper arm signs of lymphedema (seen after
circumference (about 12–14 cm in the axillary node dissection or
average adult) radiation therapy).
Length of inflatable bladder should be
*Palpate the brachial artery to confirm
about 80% of upper arm circumference
(almost long enough to encircle the arm) that it has a viable pulse.
If anaeroid, recalibrate periodically before * Position the arm so that the brachial
use artery, is at heart level—roughly level
 BLOOD PRESSURE

*The lower border of the cuff should be about 2.5 cm above the antecubital crease.
Secure the cuff snugly. Position the patient’s arm so that it is slightly flexed at the
elbow.
*estimate the systolic pressure by palpation the radial artery, rapidly inflate the cuff
until the radial pulse disappears
*Read this pressure on the manometer and add 30 mm Hg to it.
*Deflate the cuff promptly and completely and wait 15 to 30 seconds.
*inflate the cuff rapidly again to the level just determined, and then deflate it
slowly at a rate of about 2 to 3 mm Hg per second.
*Note the level at which you hear the sounds (Korotkoff sounds)
This is the systolic pressure
*Continue to lower the pressure slowly until the sounds become muffled and
then disappear. To confirm the disappearance of sounds, listen as the pressure
falls another 10 to 20 mm Hg. Then deflate the cuff rapidly to zero.
This is diastolic pressure
*Blood pressure should be taken in both arms at least once. Normally, there
may be a difference in pressure of 5 mm Hg and sometimes up to 10 mm Hg.
Subsequent readings should be made on the arm with the higher pressure
 BLOOD PRESSURE
Hypertension
Stage 3 >180. >110
Stage 2 160-179 100-109
Stage 1 140-159 90-99
Prehyp. 130-139 85-99
Normal 120-129 80-85

In patients taking antihypertensive medications or patients with

a history of fainting, postural dizziness, or possible depletion of
blood volume, take the blood pressure in three positions—
supine, sitting, and standing (unless contraindicated).
Hypotension
Systolic BP between 85 and 100mmHg
Causes: analgesics, bleeding, severe burns, dehydration
Orthostatic hypotension falls of BP when patient change
position to sits or to stand
It is mostly result of peripheral vasodilatation when blood leave
Central body organs
Monitoring to avoid falls:
Place a patient in supine position for 10 min.
Record the pulse and BP
Assist the patient to sit or stand and immediately recheck BP and
PR
A rise in PR 15-30/min and drop in BP 20mmHg systolic and
10mmHg diastolic
Indicates orthostatic hypotension
Respiratory Rate
Normal Respiratory Rate by Age

Approximate Age Range Respiratory

Rate
Newborn 30-50
0-5 months 25-40
6-12 months 20-30
1-3 years 20-30
3-5 years 20-30
6-10 years 15-30
11-14 years 12-20
15-20 years 12-30
Adults 16-20
 RESPIRATORY RATE AND RHYTHM

Count the number of respirations in 1 minute either by visual inspection or palpation

or by subtly listening over the patient’s trachea with your stethoscope during your
examination of the head and neck or chest.

Normally adults take 14 to 20 breaths a minute

See if expiration is prolonged- suggests narrowing in the bronchioles

 respiration

Rapid Shallow Breathing (Tachypnea)

restrictive lung disease,
pleural chest pain,
elevated diaphragm
Rapid Deep Breathing Hyperpnoea, Hyperventilation
exercise, anxiety, metabolic acidosis, brainstem injury.
Slow Breathing
May be secondary to diabetic coma, drug-induced respiratory
depression, increased intracranial pressure
Cheyne-Stokes respirations
Periods of increasing and decreasing depth of respiration between
periods of apnea Strokes, head injuries, brain tumors, congestive
heart failure

COUNT AFTER TAKING THE PULSE – KEEP YOUR FINGERS ON THE PULSE SITE
NORMAL RESPIRATORY RATE FOR ADULT IS 14 – 20 BREATHS PER MIN.
 temperature
The average normal core temperature is
generally considered to be between 98.0°F
(36.6°C) and 98.6°F (37°C) when
measured orally and about 1°F higher
when measured rectally.

Liebermeister's rule
Faget's sign
Sustained fevers
A persistent low-grade fever with 2 peaks each week
Relapsing fevers
Extreme fever higher than 41°C (106° F)
 TEMPERATURE

oral temperatures, glass or electronic thermometer

glass thermometer, shake the thermometer down to
35°C (96°F) or below, insert it under the tongue, instruct the patient to
close both lips, and wait 3 to 5 minutes
hot or cold liquids, and even smoking, can alter the temperature reading.
In these situations it is best to delay measuring the temperature for 10 to
15 minutes.
electronic thermometer takes about 10 seconds

rectal temperature ask the patient to lie on one side with the hip flexed.
Select a rectal thermometer with a stubby tip, lubricate it, and insert it
about 3 cm to 4 cm (11⁄2 inches) into the anal canal
Remove it after 3 minutes, electronic in 3 sec

tympanic membrane temperature

external auditory canal has to be free of cerumen, Position the probe in
the canal so that the infrared beam is aimed at the tympanic membrane
(otherwise the measurement will be invalid). Wait 2 to 3 seconds until the
digital temperature reading appears.
 state of nutrition
The nutritional status of the patient based on height and weight is interpreted by
the body mass index

BMI= weight (kg)/high (meters)2

BMI= weight (pounds)/hight (inches)2 x 703

Advantage: easy to calculate

Disadvantage: patient with malnutrition and excess fluid retention will have
normal BMI or muscular body builder shall be consider as obese

BMI 18,5 to 25 kg/m2 is considered

to have a healthy waight
Below 18,5 is malnutrition
BMI 25-29,9 is overweigh
BMI over 30 is obese
 Jugular venous pressure
• Which vein is it
• Internal jugular vein
• Why are we examining it
• Gives us an indication of RA pressure
• Normal
• <4cm from angle of louis
• What happens in inspiration to the JVP?
• Waveform
 Jugular venous pressure

Kussmaul's sign
Place Pt. sitting up at 90°.
JVP becomes more distended during inspiration (classically constrictive
pericarditis, currently severe RHF). This is opposite of what happens in normal
pt.
Usually negative in cardiac tamponade.

“a” wave is produced by right atrial contraction

‘‘x’’ descent is caused by atrial relaxation (just before
ventricular contraction)
drop in right atrial pressure is terminated by the
‘‘c’’ wave (tricuspid valve closer)
ascending limb of the ‘‘v’’: During ventricular
systole, the right atrium begins to fill with blood
returning through the venae cavae. At the end of
ventricular systole, tricuspid valve opens, causing
descending part of “V” wave
This drop in right atrial pressure produces the
S1 occurs with 'a' and ‘‘y’’ descent
'c' wave, S2 occur with Normally, only the ‘‘a’’ and ‘‘v’’ waves are visible on
'v' wave examination.
Pt. must be at 45°. Pt's head tilted
upwards and facing slightly away
from Dr.
Use the internal jugular, not external
jugular.
External jugular is lateral to SCM and
easier to see. Internal jugular is
medial/behind the clavicular head
of SCM

In normal person, usually. can't see the

JVP when pt is at 45°,
but can be seen when pt is in
Supine position
•hepatojugular reflux
•Exert pressure on liver for 15 sec. Venous return to right atrium increases.
•JVP will rise transiently in normal person.
•Check if remains elevated (RVF).

•Causes of elevated JVP

•too much fluid:
• Fluid overload [esp. IV infusion]
•It's clogging up before gets to heart:
• SVC obstruction

• RVF
• Bradycardia
• Constrictive pericarditis
• Pericardial effusion
• Tricuspid stenosis or regurgitation

•Other:
• Hyperdynamic circulation
 Abnormal waveform causes

Dominant a wave •Tricuspid regurgitation

• Pulmonary stenosis Absent x descent
• Pulmonary • Atrial fibrillation
hypertension Exaggerated x descent
• Tricuspid stenosis • Cardiac tamponade
Cannon a wave • Constrictive pericarditis
• Complete heart block Sharp y descent
• Paroxysmal nodal • Constrictive pericarditis
tachycardia • Tricuspid regurgitation
• Ventricular tachycardia Slow y descent
Dominant v wave [easily • Right atrial myxoma
heard].
Y descent is lost because the right atrium
is compressed by external fluid.
You are called to evaluate a 57-year-old man with pressure-like chest pain that
occurred while he was shovelling the snow. The pain radiates to the jaw and medial
aspect of the left arm. The patient denies dizziness, nausea, vomiting, or
palpitations. He has a past medical history of hypertension and he smokes 2 packs
of cigarettes per day. He has a brother who had a myocardial infarction that required
balloon angioplasty when he was in his forties. The patient has recently been told to
modify his diet because of a recently discovered high glucose and cholesterol level.
On physical examination the patient appears pale and diaphoretic. Blood pressure is
160/100 mm Hg and pulse is 108/min. His extremities are cool. Heart examination
reveals an S4 gallop. Lungs are normal. Peripheral pulses are palpable and
bilaterally equal. He has no peripheral edema. Which of the following is the most
likely diagnosis?

a. Right ventricular infarction

b. Cardiogenic shock
c. Acute myocardial infarction
d.Congestive heart failure (CHF)
e. Prinzmetal’s angina
Myocardial infarction occurs when an atherosclerotic plaque
ruptures or ulcerates. Patients having a myocardial infarction are
typically anxious, restless, and uncomfortable secondary to the
extreme pain. They may be demonstrating the Levine sign (clenching
of the fist to demonstrate the severity of the pain). Risk factors for this
patient include male gender, positive family history, hypertension,
diabetes mellitus, tobacco use, and hyperlipidemia. ECG will show
ST elevations and cardiac isoenzymes (troponin, CPK-MB fraction,
and LDH) will be elevated. Patients with Prinzmetal’s angina have
recurrent attacks of chest pain at rest or while asleep (unstable
angina) due to a focal spasm of an epicardial coronary artery. The
diagnosis is confirmed by detecting the spasm after provocation
during coronary arteriography. Cardiogenic shock is a form of
severe left ventricular heart failure; patients are typically hypotensive.
Right ventricular infarction is a complication of inferoposterior
myocardial infarction; patients present with JVD, the Kussmaul sign,
and hypotension.
 The Kussmaul sign is seen in which of the
following disorders?

a. Cardiomyopathy
b. Left ventricular infarction
c. Right ventricular infarction
d. Septal wall dysfunction
e. Tricuspid regurgitation
The Kussmaul sign (inspiratory distension of the
neck veins) is seen in right ventricular infarction, right
heart failure, constrictive pericarditis, superior vena
cava syndrome, and tricuspid stenosis. Inspiration
normally generates a negative intrapleural pressure,
which sucks blood into the heart. With certain
diseases, there is impairment of right heart filling and
blood cannot enter the heart, causing venous
pressure to rise. In these patients, inspiration will
cause a paradoxical rise in venous pressure
(Kussmaul sign). The Kussmaul sign is never seen in
uncomplicated cardiac tamponade. Right ventricular
infarction is seen in up to 30% of inferior wall
infarctions; patients usually present with hypotension
and raised venous pressure (Kussmaul sign).
The a wave of the jugular
venous pulse represents which
of the following?

a. Right ventricular contraction

b. Right atrial contraction
c. Passive atrial filling
d. The open tricuspid valve
e. Filling of the right ventricle
The activity of the right side of the heart is transmitted
normally through the jugular veins as a visualized pulse.
The a wave is due to venous distension caused by atrial
contraction. It is the most dominant wave, especially
during inspiration. The a wave is not present during atrial
fibrillation. Exaggerated a waves are called cannon waves
and are due to the right atrium contracting against
increased resistance (i.e., PS, TS, complete heart block).
The c wave of the venous pressure curve occurs as a
result of ventricular contraction, which forces the TV back
toward the atrium. For that reason it is simultaneous with
the carotid pulse. If the TV is incompetent, the c wave will
be increased. The v wave is the result of atrial filling while
the AV valves are closed. The v wave becomes large with
TR. The downward x slope is caused by atrial filling and
the y slope is caused by the open TV and the rapid filling
of the ventricle.