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What is the mechanism of the x descent in the cardiac cycle?
The v wave occurs primarily during diastole.
False
What condition might lead to a prominent v wave?
Tricuspid regurgitation (TR)
A reduced or absent x descent can be seen in conditions such as _______.
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Match the following conditions with their associated features:
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What causes a large 'a' wave in the jugular venous pulse?
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A giant 'a' wave is associated with atrial contraction against a closed tricuspid valve.
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What does the 'c' wave in the jugular venous pulse represent?
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An _____ 'a' wave indicates that there is atrial fibrillation present.
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Match the following conditions with their associated jugular venous pulse findings:
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Which condition is associated with a pulseless rise in JVP?
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Kussmaul's sign indicates a decrease in JVP during inspiration.
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What does an RA pressure greater than 8 cm H₂O indicate?
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Elevated JVP can be a result of __________ pressure and __________ compliance of the right ventricle.
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Match the following causes of elevated JVP with their related conditions:
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What is the primary cause of a rapid Y descent in JVP?
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A prominent a wave in JVP is associated with pulmonary hypertension.
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During which phase of the cardiac cycle does the Y descent occur?
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The H wave occurs _____ to an A wave during long diastole due to decreased heart rate.
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Match the following cardiac conditions with their effects on JVP:
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Which of the following characteristics is true for the jugular venous pulse (JVP)?
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Abdominal compression has no effect on JVP.
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What does an increase in JVP after 10 seconds of periumbilical compression indicate?
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To measure JVP, the patient should be positioned at a _____ degree angle.
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Match the characteristics to the respective types of pulses:
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Study Notes
x Descent
- Occurs during atrial relaxation in diastole
- A prominent x descent is seen in constrictive pericarditis (CCP) and cardiac tamponade (CT)
- A reduced or absent x descent is seen in right ventricular failure (RVF), tricuspid regurgitation (TR), and atrial fibrillation (AF)
V Wave
- Occurs during atrial filling, primarily in systole, just before the peak of the v wave
- A prominent v wave is often caused by increased right atrial volume during ventricular systole
- Common causes include:
- Tricuspid regurgitation (TR)
- Cor pulmonale
- High superior vena cava pressure due to RVF
- Right ventricular hypertrophy
- Atrial septal defect (ASD) with mitral regurgitation (MR)
- Common causes include:
- A reduced v wave is seen in states of hypovolemia and hypotension
a Wave
- Represents atrial contraction in diastole, just before systole
- Precedes the upstroke of the carotid pulse and follows the P wave of the ECG
- A large a wave is indicative of the atria contracting against resistance
- Common causes include:
- Right ventricular hypertrophy
- Right ventricular hypertrophy
- Tricuspid stenosis (TS)
- Right atrial myxoma
- Pulmonary hypertension
- Common causes include:
- A giant a wave (Cannon a wave) is caused by the atria contracting against a closed tricuspid valve
- In regular rhythms, this is seen in:
- Atrioventricular nodal reentrant tachycardia (AVNRT)
- Atrioventricular reentrant tachycardia (AVRT)
- In irregular rhythms, this is seen in:
- Ventricular tachycardia with atrioventricular dissociation
- Complete heart block (CHB)
- In regular rhythms, this is seen in:
- An absent a wave is seen in:
- Atrial fibrillation (AF)
- Hyperkalemia (increased serum potassium)
c Wave
- Represents the upward bulge of the tricuspid valve during isovolumetric contraction and coincides with the first heart sound (S₁)
Y Descent
- Represents right atrial emptying, leading to a decrease in right atrial pressure
- Occurs in diastole, following the opening of the atrioventricular valve
- A rapid y descent is seen in constrictive pericarditis, also known as Friedreich’s sign
- It is seen in conditions causing prominent V wave.
- A slow y descent is seen in:
- Tricuspid stenosis (TS)
- Right atrial myxoma
- Impaired right atrial emptying and right ventricular filling
h Wave
- A small wave that appears just prior to the a wave in long diastole due to a decreased heart rate
Other Important Information
- Aortic stenosis (AS), aortic regurgitation (AR), and mitral regurgitation (MR) usually do not cause changes in JVP
- Mitral stenosis (MS) causes a prominent a wave due to pulmonary hypertension
- A Jugular Venous Pressure (JVP) greater than 3 cm above the sternal angle is considered elevated
- Right atrial pressure is calculated by adding 5 to the JVP height in centimeters (cm H₂O)
- A right atrial pressure greater than 8 cm H₂O is considered elevated
- Right ventricular end-diastolic pressure is equal to right atrial pressure
Causes of Elevated JVP
- A pulseless rise in JVP is indicative of superior vena cava obstruction. All other causes lead to a pulsatile rise.
- Circulatory overload can cause an elevated JVP and is seen in:
- Renal failure
- Liver cirrhosis
- Excessive fluid administration
- Increased right ventricular pressure and decreased compliance can lead to an elevated JVP and is seen in:
- Pulmonary stenosis
- Pulmonary hypertension
- Right ventricular failure/right ventricular hypertrophy
- Right ventricular infarction
- Right ventricular inflow impedance can cause elevated JVP and is seen in:
- Tricuspid stenosis (TS)/atresia
- Right atrial myxoma
- Chronic constrictive pericarditis
Kussmaul's Sign
- An increase in JVP with inspiration
- Indicative of:
- Constrictive pericarditis (CCP)
- Tricuspid stenosis (TS)
- Restrictive cardiomyopathy (RCM)
Abdominojugular Reflex (AJR)
- Previously known as the Hepatojugular reflex
- Performed by compressing the periumbilical region for 10 seconds
- A rise in JVP during the procedure suggests impending right heart failure
- The principle is that abdominal compression increases venous return, which a faulty or dilated right ventricle cannot accommodate without a rise in pressure.
Measurement of JVP
- The patient should be positioned at a 45° angle
- Use a ruler to measure the highest point of JVP
- Measure perpendicular to the ruler at the sternal angle
- The sternal angle is 5 cm above the center of the right atrium
Difference between IJV and Carotid Pulses
- The Internal Jugular Vein (IJV) pulse is superficial and lateral in the neck, while the carotid pulse is deeper and medial
- The IJV pulse is better seen than felt, while the carotid pulse is better felt than seen
- The IJV pulse has 2 peaks and 2 troughs, while the carotid pulse has a single upstroke
- Descents are more obvious in the IJV pulse, while the carotid pulse has a brisker and visible upstroke
- Digital compression abolishes the IJV pulse, while it has no effect on the carotid pulse
- The IJV pulse falls during inspiration, while the carotid pulse does not change with respiration
- Abdominal compression elevates the IJV pulse, but has no effect on the carotid pulse
Waveform Components
- The waveform has 3 positive waves: "a," "c," and "v"
- It also has 3 descents: "x descent," "y descent"
Inference
- A JVP greater than 3 cm above the sternal angle is elevated
- Right atrial pressure is estimated using the formula: (5 + JVP height in cm) cm H₂O
- A right atrial pressure greater than 8 cm H₂O is considered elevated
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Description
This quiz explores the characteristics and clinical implications of cardiac waveforms, including the x descent, v wave, and a wave. Understand how these waves relate to conditions such as constrictive pericarditis, tricuspid regurgitation, and right ventricular failure. Test your knowledge on the physiological and pathological relevance of these waveform patterns.
