• Right heart failure (commonly due to LV failure, pulmonary HTN)
• Fluid overload
• Constrictive pericarditis
• Cardiac tamponade
• Tricuspid regurgitation
• 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
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
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
• 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)
• 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
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Author & Educational Disclaimer
Author:
Dr Phillip Cockrell BM FRCP DipClinEd
Dr Phillip Cockrell is a UK Consultant Physician in Internal Medicine, currently working at Queen Alexandra Hospital, Portsmouth University Hospitals NHS Trust. He has previously worked as a registrar across Intensive Care Medicine, Gastroenterology, Cardiology, Stroke Medicine, Acute Medicine, and Respiratory Medicine.
He has held senior leadership roles including Associate Clinical Director of the Acute Medical Unit, Clinical Director of Internal Medicine, and Chief of Medicine. Dr Cockrell has over 15 years’ experience in postgraduate medical education, having lectured extensively across the MRCP syllabus and contributed to MRCP revision teaching and course development.
Dr Cockrell holds a Bachelor of Medicine (BM), Fellowship of the Royal College of Physicians (FRCP), and a Diploma in Clinical Education (DipClinEd). His teaching approach is based on structured consolidation of complex medical topics to support efficient and effective revision for postgraduate examinations.
Purpose of this content:
The material on this page is intended solely for educational purposes to support revision for the MRCP (UK) Part 1 examination. It reflects examination-relevant principles of internal medicine and is designed to aid learning and pattern recognition.
Medical disclaimer:
This content is designed for postgraduate medical examination revision and does not constitute medical advice, diagnosis, or treatment guidance and must not be used as a substitute for professional clinical judgement, local guidelines, or specialist consultation. Clinical decisions should always be made in the context of individual patient circumstances and current national guidance.
