Diagnostic Utility of Examination of the Carotid Pulse Apex Impulse Jugular Venous Pulse Mary Beth Fontana M.D. Cardiovascular Medicine.

Diagnostic Utility of Examination of the Carotid Pulse Apex Impulse Jugular Venous Pulse

Mary Beth Fontana M.D.

Cardiovascular Medicine

Block Learning Objectives

Evaluate carotid pulse and auscultate for bruits  Localize and characterize the apex impulse  Identify jugular venous pulse components and assess

jugular venous pressure Describe the abnormalities of the carotid pulse, apex

impulse, and jugular venous pulse in cardiac and pericardial disease

Resources

Lilly doesn’t have specific sections on carotid pulse or apex impulse, instead describing them with some specific diagnoses.

Jugular venous pulse; Chapter 2, pp.29-30 This module summarizes the abnormalities of all 3 that

are pertinent to diagnosis

Learning Objectives

For the carotid pulse, apex impulse, jugular venous pulse be able to: Describe the normal characteristics Describe the method of examination Explain the pathophysiology causing abnormalities of

the components of each The abnormalities described are mentioned in the clinical

examination of the individual diagnoses

Carotid Pulse

Palpate between larynx and sternocleidomastoid muscle Marker of ventricular systole Rapid upstroke and slower decline

Normal Carotid Pulse

Rapid upstroke

Dicrotic notch

Abnormal Carotid Pulse

Increased volume, rapid upstrokes Sympathetic stimulation increases stroke volume and upstroke

velocity Bradycardia-larger stroke volume per beat Aortic valvular regurgitation Aging stiffens walls – flow is transmitted more rapidly which

raises systolic blood pressure and maintains the rapid upstroke

Pulsus Parvus

Reduced stroke volume Left ventricular failure Severe fixed LV outflow obstruction Blood volume depletion

Pulsus Tardus

Slow upstrokes Obstruction to flow between heart and carotid Most common is valvular aortic stenosis Turbulent flow in carotid is audible—called a BRUIT and can

cause a palpable vibration of the arterial wall – called a THRILL

Pulsus Parvus &Tardus Valvular Aortic Stenosis

Slow upstrokecarotid

ECG

Small volume

Bisferiens or Bifid Carotid

Two systolic peaks Rapid ejection of a large stroke volume as in severe aortic

valvular regurgitation. The elastic artery reverberates Initial rapid ejection followed by slow ejection in the same systole.

Seen in dynamic muscular subvalvular aortic obstruction, called hypertrophic obstructive cardiomyopathy. Only the initial spike is palpable

Bisferiens Carotid PulseAortic Regurgitation

2 systolic peaks

Bisferiens Carotid PulseHypertrophic Obstructive Cardiomyopathy

spike

dome

Dicrotic notch

Pulsus Alternans

Aortic pressure

Strong beat from larger LV diastolic volume

Weak beat from smaller LV diastolic volume

Sign of severe left ventricular failure

Paradoxical PulseSign of fluid under pressure in the pericardial space-- tamponade

inspiration15mmHg drop

Aortic pressure

Greater than 10 mmHg fall in systolic pressure with inspiration

expiration

LV Apex Impulse

Recording of the apex impulse- usually only the E is palpable

Systolic contraction of LV contacting the chest wall is palpable– the E pointA wave may be

palpable at time of S4

Rapid filling wave may be palpable at time of an S3

LV Apex Impulse

Midclavicular line 5th intercostal space in the supine and upright position

Palpable in 50% Quarter size or smaller Marker of ventricular systole Size of impulse, duration, and magnitude can be

assessed in left lateral position

Abnormal Apex

Enlarged LV - displaced toward left axilla Prominent heave- ejection of large stroke volume Sustained- Poor LV systolic function, prolongation of

ejection time from obstruction to LV outflow Double or triple apex impulses - palpable gallop(s)

Normal JVP - RA

a = atrial contraction

C=upward thrust of T valve

x =atrial relaxation, emptying

v = atrial filling with T valve closed during ventricular systole

y descent = atrial emptying in early diastole

Carotid artery and internal jugular vein anatomy

JVP Examination

Elevate head 10-15 degrees to see waves and estimate pressure. If JVP visible at 45 degrees, RA pressure is abnormally high

Measure vertical distance above manubrial-sternal junction and add 5 to get RA pressure.

Time events by feeling carotid pulse on opposite side of neck; a is before carotid, v peak is after. The c is not seen

Descents are more rapid than ascents of waves

JVP normally goes down with inspiration

Elevated Jugular Venous Pressure

Increased blood volume- pregnancy, heart failure Obstruction to atrial emptying- pericardial disease,

tricuspid valve obstruction, noncompliant RV Absent wave forms- SVC obstruction Further elevation with inspiration- Kussmaul’s sign-

constrictive pericarditis

Abnormal A Wave, Attenuated Y Descent

Also seen when the RV muscle has reduced compliance

Large a wave due to stenosis of tricuspid valve

Attenuated y descent

Large V wave-tricuspid valve regurgitation

V

Y

The RA is filling from the vena cavae and from the RV during ventricular systole when the T valve should be closed. The Y descent is rapid from emptying a large volume into the RV

No a wave – loss of atrial contraction, atrial fibrillation

AV Dissociation – Cannon A waves

Atrial contraction when tricuspid valve is closed

P P

P waves and QRS’s occur independently due to complete block of conduction at the AV node

AA

RA – JVP Tamponade

20mm. Hg

Good X descent

Attenuated Y descent

Fluid under pressure in the pericardial space prevents passive ventricular filling in early diastole

JVP – RA Accentuated Y Descent Constrictive Pericarditis

y

Constriction raises RA pressure, early diastolic filling is rapid until constricting pericardium limits filling

Summary & Advice

Carotid Pulse Apex Impulse JVP Quiz

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