Jugular Venous Pressure (JVP)

Raised JVP

•    Right heart failure (commonly due to LV failure, pulmonary HTN)

•    Fluid overload

•    Constrictive pericarditis

•    Cardiac tamponade

•    Tricuspid regurgitation

Waveforms

•    Prominent ‘a’ wave

o    Increased right atrial contraction against stiff RV

o    Seen in pulmonary hypertension, pulmonary stenosis

•    Cannon ‘a’ waves

o    Atrial contraction against closed tricuspid valve

o    Seen in complete heart block (CHB), ventricular tachycardia

•    ‘v’ wave prominence

o    Severe tricuspid regurgitation

Absent ‘a’ wave

•    Atrial fibrillation

Arterial Pulse

Character

•    Collapsing (water hammer) pulse

o    Aortic regurgitation

o    PDA, high output states (anaemia, thyrotoxicosis)

•    Slow-rising (anacrotic) pulse

o    Severe aortic stenosis

•    Bisferiens pulse (double systolic peak)

o    Hypertrophic obstructive cardiomyopathy (HOCM)

o    Mixed aortic regurgitation + stenosis

•    Pulsus alternans

o    Severe LV dysfunction

•    Pulsus paradoxus (>10 mmHg drop in SBP on inspiration)

o    Tamponade

o    Severe asthma/COPD exacerbations

Heart Sounds

S1

•    Loud: mitral stenosis (due to stiff valve closure)

•    Soft: mitral regurgitation (incomplete closure), severe mitral stenosis (calcified valve)

S2

•    Widely split: right bundle branch block, pulmonary stenosis

•    Fixed split: atrial septal defect (ASD)

•    Single S2: severe aortic or pulmonary stenosis

Additional sounds

•    S3 (ventricular gallop)

o    Volume overload states: MR, HF

o    Normal in young adults/athletes

•    S4 (atrial gallop)

o    Stiff ventricle: LVH, hypertrophic cardiomyopathy, aortic stenosis

•    Ejection click

o    Bicuspid aortic valve

o    Pulmonary stenosis

•    Opening snap

o    Mitral stenosis

Apex Beat

•    Displaced laterally and/or inferiorly

o    LV dilatation (DCM, MR, AR)

•    Heaving apex (sustained)

o    LV pressure overload (aortic stenosis, hypertension)

•    Thrusting apex (hyperdynamic)

o    Volume overload (MR, AR)

Other Bedside Signs

•    Corrigan’s sign: visible carotid pulsation (AR)

•    Quincke’s sign: capillary pulsation in nail bed (AR)

•    De Musset’s sign: head nodding with pulse (AR)

•    Malar flush: mitral stenosis (pulmonary hypertension)

•    Xanthelasma, tendon xanthomas: hyperlipidaemia (familial hypercholesterolaemia)

Extra Revision Pearls

•    Cannon ‘a’ waves → classic clue for complete heart block (atria contracting against closed tricuspid)

•    Bisferiens pulse mnemonic: "bi" = "two" = HOCM or mixed aortic valve disease

•    Pulsus paradoxus clue → tamponade, severe asthma/COPD

•    Fixed split S2 almost always = ASD

•    Opening snap timing after S2 inversely related to severity of mitral stenosis (shorter interval = more severe)

•    Corrigan’s and Quincke’s signs → high-volume pulse clues for AR