Diagnostic Utility of Examination
of the Carotid Pulse Apex Impulse
Jugular Venous Pulse
Mary Beth Fontana M.D.
Cardiovascular Medicine
Block Learning Objectives
 Evaluate carotid pulse and auscultate for bruits
 Localize and characterize the apex impulse
 Identify jugular venous pulse components and assess
jugular venous pressure
 Describe the abnormalities of the carotid pulse, apex
impulse, and jugular venous pulse in cardiac and
pericardial disease
Resources
 Lilly doesn’t have specific sections on carotid pulse or
apex impulse, instead describing them with some
specific diagnoses.
 Jugular venous pulse; Chapter 2, pp.29-30
 This module summarizes the abnormalities of all 3 that
are pertinent to diagnosis
Learning Objectives
 For the carotid pulse, apex impulse, jugular
venous pulse be able to:
Describe the normal characteristics
 Describe the method of examination
 Explain the pathophysiology causing abnormalities of
the components of each
 The abnormalities described are mentioned in the clinical
examination of the individual diagnoses

Carotid Pulse
 Palpate between larynx and sternocleidomastoid muscle
 Marker of ventricular systole
 Rapid upstroke and slower decline
Normal Carotid Pulse
Rapid
upstroke
Dicrotic
notch
Abnormal Carotid Pulse
 Increased volume, rapid upstrokes




Sympathetic stimulation increases stroke volume and upstroke
velocity
Bradycardia-larger stroke volume per beat
Aortic valvular regurgitation
Aging stiffens walls – flow is transmitted more rapidly which
raises systolic blood pressure and maintains the rapid upstroke
Pulsus Parvus
 Reduced stroke volume



Left ventricular failure
Severe fixed LV outflow obstruction
Blood volume depletion
Pulsus Tardus
 Slow upstrokes



Obstruction to flow between heart and carotid
Most common is valvular aortic stenosis
Turbulent flow in carotid is audible—called a BRUIT and can
cause a palpable vibration of the arterial wall – called a THRILL
Pulsus Parvus &Tardus
Valvular Aortic Stenosis
carotid
ECG
Slow
upstroke
Small
volume
Bisferiens or Bifid Carotid
 Two systolic peaks


Rapid ejection of a large stroke volume as in severe aortic
valvular regurgitation. The elastic artery reverberates
Initial rapid ejection followed by slow ejection in the same systole.
Seen in dynamic muscular subvalvular aortic obstruction, called
hypertrophic obstructive cardiomyopathy. Only the initial spike is
palpable
Bisferiens Carotid Pulse
Aortic Regurgitation
2 systolic peaks
Bisferiens Carotid Pulse
Hypertrophic Obstructive Cardiomyopathy
spike
dome
Dicrotic
notch
Pulsus Alternans
Sign of severe left ventricular failure
Aortic
pressure
Strong beat from larger
LV diastolic volume
Weak beat from smaller
LV diastolic volume
Paradoxical Pulse
Sign of fluid under pressure in the pericardial space-- tamponade
expiration
Aortic
pressure
inspiration
15mmHg drop
Greater than 10 mmHg fall in systolic pressure with inspiration
LV Apex Impulse
Recording of the apex impulse- usually
only the E is palpable
A wave may be
palpable at time
of S4
Systolic contraction of LV
contacting the chest wall is
palpable– the E point
Rapid filling wave
may be palpable at
time of an S3
LV Apex Impulse
 Midclavicular line 5th intercostal space in the supine and
upright position
 Palpable in 50%
 Quarter size or smaller
 Marker of ventricular systole
 Size of impulse, duration, and magnitude can be
assessed in left lateral position
Abnormal Apex
 Enlarged LV - displaced toward left axilla
 Prominent heave- ejection of large stroke volume
 Sustained- Poor LV systolic function, prolongation of
ejection time from obstruction to LV outflow
 Double or triple apex impulses - palpable gallop(s)
Normal JVP - RA
a = atrial
contraction
C=upward
thrust of T
valve
v = atrial filling with T valve closed
during ventricular systole
x =atrial
relaxation,
emptying
y descent = atrial
emptying in early
diastole
Carotid artery and internal jugular vein
anatomy
JVP Examination
Elevate head 10-15 degrees to see
waves and estimate pressure. If JVP
visible at 45 degrees, RA pressure is
abnormally high
Measure vertical distance above
manubrial-sternal junction and add 5 to
get RA pressure.
Time events by feeling carotid pulse on
opposite side of neck; a is before
carotid, v peak is after. The c is not
seen
Descents are more rapid than ascents
of waves
JVP normally goes down with
inspiration
Elevated Jugular Venous Pressure
 Increased blood volume- pregnancy, heart failure
 Obstruction to atrial emptying- pericardial disease,
tricuspid valve obstruction, noncompliant RV
 Absent wave forms- SVC obstruction
 Further elevation with inspiration- Kussmaul’s signconstrictive pericarditis
Abnormal A Wave, Attenuated Y Descent
Large a wave due to
stenosis of tricuspid valve
Attenuated y descent
Also seen when the RV muscle has reduced compliance
Large V wave-tricuspid valve regurgitation
No a wave –
loss of atrial
contraction,
atrial fibrillation
V
Y
The RA is filling from the vena cavae and from the RV during ventricular systole when the T valve should
be closed. The Y descent is rapid from emptying a large volume into the RV
AV Dissociation – Cannon A waves
P waves and QRS’s occur independently due to complete block
of conduction at the AV node
A
Atrial contraction when
tricuspid valve is closed
A
P
P
RA – JVP Tamponade
20mm. Hg
Good X
descent
Attenuated Y
descent
Fluid under
pressure in the
pericardial space
prevents passive
ventricular filling
in early diastole
JVP – RA Accentuated Y Descent
Constrictive Pericarditis
y
Constriction raises RA pressure, early diastolic filling is rapid until
constricting pericardium limits filling
Summary & Advice
Thank you for completing this module
•
•
I hope that I was able to teach the subject clearly.
If you have any questions, write to me:
MaryBeth.Fontana@osumc.edu