Cardiology

Question 1

What does JVP reflect

Answer 1

• Filling status / right atrial pressure
• Essential to detect for correct fluid management

Question 2

Effect of inspiration on JVP

Answer 2

Inspirations generates negative intrathoracic pressure, causing suction of venous blood towards the heart, causing JVP to fall

Question 3

Normal waves in the JVP

Answer 3

• a wave
• c wave
• x descent
• v wave
• y descent

Question 4

a wave in JVP

Answer 4

• Due to** atrial contraction** - actively push up SVC and into the RV (may cause audible S4)

Question 5

c wave in JVP

Answer 5

An invisible flicker in the x descent to closure of the tricuspid valve, before starting ventricular systole

Question 6

x descent in JVP

Answer 6

1. Downward displacement of the tricuspid valve (as the RV contracts, stretching the RA) - reduces pressure
2. Atrial relaxation (simultaneous)

Question 7

v wave in JVP

Answer 7

Passive filling of blood into the atrium against a closed tricuspid valve

Question 8

y descent

Answer 8

Opening of the tricuspid valve with passive movement of blood from the RA to the RV (causing an S3 when audible)

Question 9

Causes of raised JVP with normal waveform

Answer 9

1. Heart failure (biventricular or isolated RHF)
2. Fluid overload (any cause)
3. Severe bradycardia

Question 10

Raised JVP upon inspiration and drops with expiration

Answer 10

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

Question 11

Kussmaul’s sign

Answer 11

Raised JVP upon inspiration and drops with expiration

Question 12

Causes of Kussmaul’s sign

Answer 12

• Constrictive pericarditis
• Right heart failure

Question 13

Raised JVP with loss of normal pulsations

Answer 13

SVC syndrome - obstruction caused by mediastinal maglignancy

Question 14

JVP: Absent a wave

Answer 14

Atrial fibrillation - no coordinated contraction

Question 15

JVP: Large a wave

Answer 15

• Tricuspid stenosis
• Right heart failure
• Pulmonary hypertension

Question 16

JVP: Cannon wave

Answer 16

• 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

Question 17

JVP: giant v wave

Answer 17

Tricuspid regurgitation

Question 18

JVP: Steep x descent

Answer 18

Tamponade
Cardiac constriction

Question 19

JVP: Steep y descent

Answer 19

Cardiac constriction

Question 20

JVP: Slow y descent

Answer 20

Tricuspid stenosis

Question 21

Causes of absent radial pulse

Answer 21

• 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

Question 22

Collapsing pulse

Answer 22

• Aortic regurgitation
• Patent ductus arteriosus
• Other large extracardiac shunt

Question 23

Slow rising pulse

Answer 23

• Aortic stenosis (delayed percussion wave)

Question 24

Bisferiens

Answer 24

A double shudder due to mixed aortic valve disease with significant regurgitation

Question 25

Jerky pulse

Answer 25

* HOCM

Question 26

Alternans

Answer 26

* 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

Question 27

Paradoxical (pulsus paradoxus)

Answer 27

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)

Question 28

What does cardiac apex pulsation reflects

Answer 28

* 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**

Question 29

Absent apical impulse

Answer 29

* Obesity / emphysema * Right pneumonectomy with displacement * Pericardial effusion or constriction * Dextrocardia

Question 30

Heaving cardiac apex

Answer 30

* **LVH**, sometimes ass. w/ palpable **fourth heart sound**

Question 31

Thrusting/hyperdynamic cardiac apex

Answer 31

**High left ventricular volume** * In MR, AR, PDA, ventricular septal defect

Question 32

Tapping cardiac apex

Answer 32

Palpable first S1 in mitral stenosis

Question 33

Displaced and diffuse/dyskinetic cardiac apex

Answer 33

LV impairment and dilatation * DCM, MI

Question 34

Double impulse cardiac apex

Answer 34

* With dyskinesia is due to LV aneurysm * Without dyskinesia in HCM