Page 31 - Medicine and Surgery

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Chapter 2: Clinical 27

Normal The normal pulsation has a rapid rise in pressure
followed by a slower phase or reduction in pressure.
Slow rising The slow rising pulse is seen in aortic stenosis due
to obstruction of outflow. The pressure in the pulse
rises slowly.
Collapsing The collapsing pulse of aortic regurgitation is
characterised by a large upstroke followed by a
rapid fall in pressure. This is best appreciated with
the arm held up above the head and the pulse felt
with the flat of the fingers.
Alternans Pulsus alternans describes a pulse with alternating
strong and weak beats. It is a sign of severe left
ventricular failure indicating a poor prognosis.
Bisferiens This is the waveform that reults from mixed aortic
stenosis and regurgitation. The percussive wave P T
(P) is due to ventricular systole, the tidal wave (T)
is due to vascular recoil causing a palpable double
pulse i.e. an exaggerated dicrotic notch.
Paradoxus This is an accentuation of the normal situation with
an excessive and palpable fall of the pulse
Inspiration
pressure during inspiration. When severe the pulse
disappears briefly with early inspiration. Occurs in
cardiac tamponade, pericardial constriction and
severe acute asthma.
Figure 2.2 Arterial pulse waveforms.

Once the atrium is filled with blood it contracts to give the ‘a’ wave a
The ‘a’ wave is lost in atrial fibrillation.
The ‘a’ wave is increased in pulmonary stenosis, pulmonary
hypertension and tricuspid stenosis (as a consequence of right
atrial or right ventricular hypertrophy).
a
The atrium relaxes to give the ‘x’ descent; however, the start of
ventricular contraction causes ballooning of the tricuspid valve as c
it closes, resulting in the ‘c’ wave. The further ‘x’ descent is due to
descent of the closed valve towards the cardiac apex. x
a cv wave
With the tricuspid valve closed the return of venous blood fills the v
c
atrium giving the ‘v’ wave.
Tricuspid regurgitation gives a ‘cv’ wave.
x
a
c v
The tricuspid valve opens at the end of ventricular systole giving
the ‘y’ descent.
x y
Figure 2.3 The jugular venous pressure Diastole Systole Diastole
waveform.