The document discusses jugular venous pressure (JVP) and precordial impulse, providing insights into their physiological significance, measurement techniques, and associated clinical implications. Key concepts include the anatomy of the jugular veins, variations in JVP, signs such as Kussmaul's sign, and methods for assessing the apical impulse as part of a cardiac examination. It emphasizes the importance of proper positioning and techniques for evaluating cardiovascular function and identifying abnormalities.

1. JVP & PRECORDIAL IMPULSE
STUDENT- Dr VINAL J SHAH
CHAIRPERSON- Dr PRAVEEN KUSUBI

2. INTRODUCTION
JVP- reflects Right side of heart.
Right atrial pressure during systole.
Right ventricular filling pressure during
diastole.

3. • JUGULAR VENOUS PULSE:
• Defined as the oscillating top of vertical
column of blood in right IJV that reflects
pressure changes in right atrium in cardiac
cycle.
• JUGULAR VENOUS PRESSURE:
• Vertical height of oscillating column of
blood.

4. Why IJV over EJV?
 IJV are close to RA, direct course from
innominate vein to SVC & RA.
 Valves at proximal part of EJV are more than IJV.
 EJV passes through more fascial plane,
hence, affected by extrinsic compression.
 EJV become small and pulsation barely visible
during venoconstriction due to increased
sympathetic activity.

6. Right IJV preferred than Left IJV?
• Right IJV – in straight line from SVC & RA
• Left IJV– not in straight line.
• Left IJV may get compressed by variety
of normal structures, dilated aorta or
aneurysm.

7. • JVP PULSATION
• CAROTID PULSATION
• Superficial & Lateral in neck
• Deeper & Medial in neck
• Better seen > felt
• Better felt > seen
• Has 2 peaks & 2 troughs/ cardiac cycle
• Has single upstroke
• Descents > crests
• Upstroke brisker & visible than descent.
• X & Y > prominent in inspiration
• No effect
• a decreses, v increase in expiration
• No effect
• JVP falls during inspiration
• No effect
• Digital compression at root of neck
• abolishes JVP
• No effect.

8. “JVP measurement”
Sternal angle/ angle of Louis- approx 5 cm
from centre of RA, constant regardless of
position. Hence reference point.
 30-90 recline, relaxed neck muscles, beam of
light tangentially across skin over IJV exposes
top of oscillating venous column.

11. Normally JVP does not exceed 2-3cm
above the sternal angle.
When JVP is 4cm and more is
considered elevated.

12. Elevated JVP

13. • AJR/HJR? When JVP isborderline elevated/ when
latent RVF or silent TRissuspected
 Method : firm pressure to right hypochondrium or
periumbilical area(10- 30 sec),with quite breath , avoid
valsalva.
 Normally- JVP rises transiently (<15 sec)to <1cm when
abdomen is compressed.
 In positive AJR, JVP remains elevated -----why--- as failing
RV may not be able to receive augmented venous return
to Right heart without a rise in mean venous pressure.

14. • POSITIVE AJR
• FALSE POSITIVE AJR
• 1. Incipient RVF
• 1.COPD
• 2. Compensated RVF
• 2.incresed sympathetic tone
• 3.LVF with volume overload
• 3.systematic constriction
• 4. TR

15. “KUSSMAUL’S SIGN”
• Normally, JVP decreases with inspiration.
• Kussmaul’s sign –Increase in venous
pressure during inspiration.
• MECHANISM- when myo/pericardium is stiff
negative intrathoracic pressure is not transmit
to heart. Heart cannot accommodate inspiratory
raised blood flow. Hence, Raised JVP.

17. KUSSMAUL’S SIGN SEEN IN

18. “GAERTNER’S METHOD”
METHOD: Patient sitting/lying at >30^ elevation,
arm is slowly, passively raised from dependent
position until vein collapses.
Height of the limb above the level of sternal angle at
which vein collapses represents venous pressure.
When venous pressure is normal, veins of hand
collapse at level of sternal angle.

19. “MAY’S SIGN”
• In sitting posture, visible engorged veins on
undersurface of tongue also indicates elevated
venous pressure.

20. Analysis of JV pulsations

21. “a”wave
First positive presystolic wave.
Due to RA contraction which results in retrograde
blood flow into SVC & IJV during RAsystole.
Normally, it is dominant during inspiration, larger
than v wave.
Synchronous with S1 , follows P wave of ECG

22. “x” descent (systolic collapse)
Due to RA relaxation during atrial diastole
often, it is the most prominent motion of
normal JVP which begins during systole, ends
just before S2.
larger than y descent.

23. c wave
• Most often not visible.
• In neck veins - Due to impact of carotid
artery which is adjacent to the IJV.
• In RA recording – due to upward bulging of
the closed TV into RA during RV
Isovolumetric contraction.

24. x’ descent
It is x descent below the c wave .
it is d/t-fall in right atrial pressure during early
RVsystole
- descent of the floor of RA
- downward pulling of TV by
contracting RV.

25. v wave
3rd positive wave , begins in late systole and ends in
early diastole.
d/t RAP d/t continued RA filling during
ventricular systole when TV is closed.
 synchronous with carotid upstroke.
 peaks after S2.

26. “y descent (diastolic collapse)”
its downslope of v wave.
Due to decline in Right atrial pressure because
of RA emptying andRV filling when TV
opens in early diastole.

28. Prominent/ large ‘a’ wave

29. Giant a waves/ Cannon
waves/venous corrigan.
• occur when RA contracts against the
closed TV during RV systole

30. absent a wave
AF- a wave absent as there is no effective
atrial contraction
Sinus Tachycardia- when a wave may fuse
with preceding v wave.

31. Abnormal x descent

32. Abnormalities of v wave

33. Abnormalities of y descent
Rapid y descent- occurs in conditions
with elevated venous pressure,
myocardial dysfunction or severe vent.
dilatation.
Slow y descent-when RA emptying & RV
filling impeded.

34. PRECORDIAL IMPULSE

35. DEFINITION
• Precordium is the anterior aspect of
chest overlying the heart.

36. INSPECTION
Position of patient:
• Supine position with thorax elevated to ≤30
degree
• Chest to be examined tangentially
a)Foot end of bed
b)Patients right side directing a beam of light
across precordium

38. SHAPE OF CHEST
• Muscular Thorax
• Broad Chest
• Pectus Carinatum
• Pectus Excavatum
• Harrison’s Sulci
• Straight Back Syndrome

39. PECTUS CARINATUMNormal chest

40. Harrison sulci

42. BREAST ABNORMALITIES
• Male gynacomastia-Digitalis,Klienfelter
syndrome
• Female hypomastia-MVP
• Widely spaced nipples-Turners
Distended vessels:
• Veins

43. Examination of the precordium
• Precordial prominence with bulging of the
intercostal spaces
• Precordial prominence involving both
intercostal spaces and ribs.
• Precordial bulging of non cardiovascular origin

44. APICAL IMPULSE
• Location.
• Duration.
• Size.
• Force or amplitude.
• Contour.

45. Apical impulse(AI)
• Normal AI defined as lowermost,outermost
point of maximum impulse in early systole
which imparts a perpendicular gentle thurst to
palpating finger followed by medial retraction
in late systole
• 5th left ICS at medial to MCL and <10cm from
midsternal line
• 2-2.5cm in diameter,confined to one ICS
• Lasts for <50% of systole.

46. NORMAL APICAL IMPULSE
• Produced by LV during early systole
• When LVP rises,LV rotates in counterclockwise
direction on its long axis
• Cardiac apex lifts and makes contact with left
anterior chest wall
• Following aortic valve opening,LV chamber
moves away after first half of ejection.
• Thus recorded as early outward thurst
followed by retraction in last part of systole.

47. RV APICAL IMPULSE
• Palpable RV activity reflects level of pul. Artery
pressure,RV size and severity of the TR.
• When RV is large ,precordial activity may
produce a rocking or see-saw motion.
• Greatly enlarged RV may occupy the usual
apex area,literally pushing the LV
posterolaterally

48. • ABSENT APICAL IMPULSE:
CVS Causes
Non-CVS causes
• DOUBLE APICAL IMPULSE:
HOCM
LV ANEURYSM

49. • Lateral displacement-
Skeletal deformity
Intrathoracic patology
Eccentric LVH due to MR or AR
RVH

50. • DOWNWARD DISPLACEMENT:
Aortic aneursysm
Mediastinal new growth
• UPWARD DISPLACEMENT:
Normal Children
Pregnancy
Ascitis
Abdominal Tumour

51. • RIGHT SIDED APICAL IMPULSE:
Dextrocardia
Left massive pleural effusion or pneumothorax
and right sided collapse
Skeletal abnormality

52. Extent of apical impulse:
• Diffuse apical impulse >3cm in diameter or AI
present in more than one ICS due to
CVS:
Eccentric LVH as in AR.
LV aneurysm.
NON CVS:
Thin individuals
Hyperdynamic circulation
Retraction of lung due to fibrosis or collapse

53. Suprasternal pulsations:
Aneurysm of arch of aorta
Thyroidea ima artery
Sternoclavicular pulsations:
 Aortic dissection
 Aneurysm of aorta
 Aortic regurgitation
 Right aortic arch

54. Presence of right 2nd ICS pulsations:
• Aneurysm of ascending aorta or
• Chronic AR

55. Pulsations in left 2nd and 3rd ICS:
• Pulmonary Hypertension
• Increased pulmonary blood flow as in
PDA,ASD
• Idiopathic pulmonary artery dilatation
• Hyperdynamic circulation as in
fever,pregnancy

56. Left parasternal pulsations
• Children and thin adults
• RVH with Pressure overload-
PH,PPH,PS,Pulmonary embolism,cor
pulmonale
• Volume overload-TR,ASD,VSD

57. Left parasternal pulsations
In Moderate To Severe MR due to apparent
anterior systolic movements of normal RV
a)Jet or Squid effect
b)Subsequent systolic expansion of enlarged LA
RWMA

58. EPIGASTRIC PULSATIONS
• Cardiac
• Aortic
• Hepatic

59. ECTOPIC PULSATIONS
• Ectopic LV impulse
• Ectopic LA impulse
• RA impulse
• Ectopic impulse beneath left clavicle-PDA

60. PALPATION
• Examination of the chest for shape and
distended vessels.
• Palpation of precordium for tenderness.
• Palpation of the cardiovascular pulsations
,palpaple sounds,thrills and rubs.

61. TENDERNESS
• Tietze syndrome
• Acute pericarditis
• Acute myocarditis

63. Application of hand in cardiac
palpation

64. Palpation of cardiac apex
Size and extent of the cardiac apex
Normal cardiac apex
Displaced cardiac apex
Double or triple cardiac apex

65. Character of the apex beat

67. Types:
Absent or feeble
Tapping
Hyperdynamic
Heaving

69. Tapping apex beat
• Characteristic of MS
• Palpable equivalent of S1
• Short,sharp and tapping nature

70. Hyperdynamic,hyperkinetic
• Increase in amplitute and duration of
excursion of the apical impulse
• Ill sustained i.e <50%of systole with partial
lifting of examining fingers.
• CVS Causes
• Non CVS Causes

71. Heaving
• Sustained Increase In duration and amplitude
of excursion of apical impulse
• Duration of excursion is >50% of systole with
sustained lift of the examining fingers
• Causes

72. Method of palpation for parasternal heave

74. Palpable low frequency sounds at
apex
• Palpable S3
• Palpable S4
• Palpable pericardial knock

75. Palpable high frequency sounds at
apex
• Palpable loud S1
• Palpable opening snap
• Palpable ejection sounds-Ejection sound of
congenital AS

76. Palpable murmurs-thrills
• Diastolic thrill-MS
• Systolic thrill-severe MR,AS,VSD
• Palpable pericardial rub-Acute pericarditis

77. PALPATION OF LEFT PARASTERNAL
AREA
• Left parasternal lift
• Methods of left parasternal lift:
Heel of the hand
Tips of three fingers(index,middle,ring)
ulnar border of the hand
With simultaneous palpation of apex.
Grade 1-3.

78. Palpation of tricuspid area:
• Palpable low frequency sounds-RV S3,RV S4
• Palpable high frequency sounds-OS of
Tricuspid Stenosis
Palpation of Aortic and pulmonary areas:
• Palpable high frequency sounds-Sys.
HTN,Moderate AS,Dilated aortic
root,PS,Pulmonary HTN
• Palpable murmurs-THRILLS

79. • Palpation of epigastrium
• Palpation of ectopic areas

80. REFERENCES
• Evaluation of patient with heart disease,Carlos
and Jonathan Abrams
• Clinical examination in
cardiology,Vijayaraghava rao
• Manual of practical medicine, R.Alagappan