CVS according to Harrison
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Cardiovascular Examination — Harrison's Principles of Internal Medicine, 22E (2025)
1. Jugular Venous Pressure (JVP) and Waveform
The JVP is the single most important bedside measurement for estimating volume status.
- Preferred vein: Internal jugular (IJV) — external jugular is valved and not directly in line with the SVC/RA
- Measurement: Vertical distance from the top of the jugular venous pulsation to the sternal angle (angle of Louis)
-
4.5 cm at 30° elevation = abnormal
- The sternal angle tends to underestimate CVP; use it to distinguish normal from elevated, not for precise quantification
- Venous pulsations above the clavicle in the sitting position are clearly abnormal (clavicle to RA ≥ 10 cm)
- Units: bedside = cmH₂O; convert to mmHg: 1.36 cmH₂O = 1.0 mmHg
-
Distinguishing JVP from Carotid Pulse
| Feature | JVP | Carotid |
|---|---|---|
| Waveform | Biphasic (in sinus rhythm) | Monophasic |
| Compressible | Yes (easily obliterated) | No |
| Changes with posture/inspiration | Yes | No |
JVP Waveform Components
| Wave/Descent | Mechanism | Clinical significance |
|---|---|---|
| a wave | Right atrial presystolic contraction; after P wave, before S1 | Prominent → ↓ RV compliance; Absent → AF |
| Cannon a wave | RA contracts against closed tricuspid (AV dissociation) | Identifies wide complex tachycardia as ventricular in origin |
| x descent | Fall in RA pressure after tricuspid valve opening | Obliterated in TR, cardiac tamponade |
| c wave | Closed tricuspid pushed into RA in early systole | Interrupts x descent |
| v wave | Atrial filling during ventricular systole | Accentuated in TR; merges with c wave in severe TR |
| y descent | Tricuspid valve opens → RA empties | Rapid in TR; slow/absent in tamponade; exaggerated in constrictive pericarditis |
Kussmaul's sign: Paradoxical rise in JVP with inspiration → seen in constrictive pericarditis, RV infarction, severe RV failure, and sometimes restrictive cardiomyopathy.
2. The Arterial Pulse
- Assessed at the carotid for character/contour; radial/femoral for rate and rhythm
- Compare brachial and femoral pulses simultaneously to exclude aortic coarctation
Pulse Abnormalities
| Pulse | Description | Condition |
|---|---|---|
| Pulsus bisferiens | Two systolic peaks | Severe AR, HOCM |
| Pulsus alternans | Alternating strong/weak beats, regular rhythm | Severe LV dysfunction |
| Pulsus paradoxus | SBP drop >10 mmHg with inspiration | Cardiac tamponade, severe asthma/COPD |
| Pulsus parvus et tardus | Small volume, delayed peak | Severe AS |
3. Precordial Inspection & Palpation
- Apex beat (PMI): Normally at the 5th ICS, mid-clavicular line — sustained, non-displaced
- Laterally displaced → LV enlargement
- Sustained/heaving impulse → LV hypertrophy or pressure overload
- Hyperdynamic → volume overload (MR, AR)
- Right ventricular lift/heave: Palpable at the left sternal border → RV pressure/volume overload (pulmonary HTN, ASD)
- Thrills: Palpable murmurs (grade ≥4); location corresponds to the origin of the murmur
4. Auscultation
First Heart Sound (S1)
- Caused by mitral and tricuspid valve closure
- Loud S1: Hyperkinetic states, tachycardia, MS (stiff but mobile leaflets)
- Soft S1: Prolonged PR interval, severe MR, calcified/immobile mitral leaflets
- Variable S1: AF, complete heart block
Second Heart Sound (S2)
- A2 (aortic closure) + P2 (pulmonic closure)
- Normal: Splits with inspiration (A2 before P2)
| S2 Pattern | Mechanism | Condition |
|---|---|---|
| Wide physiologic splitting | Delayed P2 (prolonged RV ejection) | RBBB, PS |
| Fixed splitting | A2-P2 interval wide and unchanging with respiration | Secundum ASD |
| Paradoxical/reversed splitting | Delayed A2 — components split at expiration, close at inspiration | LBBB, RV pacing, severe AS, HOCM, acute ischemia |
| Narrow/single S2 | ↑ P2 approaches A2 | Pulmonary arterial hypertension |
| Loud P2 | Pulmonary hypertension | Audible at apex; palpable at 2nd LICS |
Third Heart Sound (S3)
- Low-pitched, occurs in early diastole (after S2), best heard at apex with bell
- Mechanism: Abrupt tensing of mitral apparatus as rapid ventricular filling decelerates
- Pathologic S3 (in adults >40 yrs): Dilated LV with ↓ EF, severe MR or AR
- Physiologic S3: Normal in children, young adults, athletes, pregnancy
Fourth Heart Sound (S4)
- Low-pitched, occurs in late diastole (presystolic), requires atrial contraction
- Never normal; indicates stiff/non-compliant ventricle
- Conditions: LVH, severe AS, HCM, HTN, acute MI
- Absent in AF (no atrial contraction)
- Summation gallop: S3 + S4 merge in tachycardia
Systolic Sounds
- Ejection sound (high-pitched, early systolic): Bicuspid aortic or pulmonic valve; aortic/pulmonary root dilation
- Pulmonic ejection sound = only right-sided event that decreases with inspiration
- Softens/disappears as bicuspid aortic valve calcifies
- Non-ejection click (mid-late systolic): MVP — single or multiple; click-murmur moves away from S1 with squatting and toward S1 with standing
Diastolic Sounds
- Opening snap (OS) of MS: High-pitched, shortly after S2; A2-OS interval inversely proportional to LA-LV pressure gradient (shorter = more severe MS); absent with heavy calcification
- Pericardial knock (PK): High-pitched; slightly later than OS; corresponds to abrupt cessation of ventricular expansion; seen in constrictive pericarditis; associated with exaggerated y descent in JVP
- Tumor plop: Low-pitched; atrial myxoma; position-dependent
5. Cardiac Murmurs
Grading (Levine Scale)
| Grade | Features |
|---|---|
| 1 | Very faint, requires concentration |
| 2 | Faint but heard immediately |
| 3 | Moderately loud, no thrill |
| 4 | Loud with thrill |
| 5 | Very loud, heard with stethoscope barely on chest |
| 6 | Audible without stethoscope |
Dynamic Auscultation — Key Maneuvers
| Maneuver | Effect on Preload | Effect on AS/MR/TR | Effect on HOCM | Effect on MVP click |
|---|---|---|---|---|
| Valsalva (strain) | ↓ | ↓ | ↑ | Click moves toward S1 |
| Standing | ↓ | ↓ | ↑ | Click moves toward S1 |
| Squatting | ↑ | ↑ | ↓ | Click moves away from S1 |
| Passive leg raise | ↑ | ↑ | ↓ | — |
| Handgrip (isometric) | ↑ afterload | ↑ (MR, AR) | ↓ | — |
| Amyl nitrite | ↓ afterload | ↓ MR/AR, ↑ AS | ↑ | — |
HOCM murmur: Harsh systolic at LLSB; increases with anything that decreases preload or afterload (standing, Valsalva); decreases with squatting/handgrip.
Summary Mnemonics
- S3: "Ken-tuc-KY" — ventricular filling sound, failure/volume overload
- S4: "Ten-nes-SEE" — atrial kick against stiff ventricle, pressure overload
- Fixed S2 split → ASD
- Reversed S2 split → LBBB
- OS → MS (closer to S2 = more severe)
- PK → Constrictive pericarditis
Source: Harrison's Principles of Internal Medicine, 22nd Edition (2025, McGraw Hill Medical), Chapter 246 — Cardiovascular Examination
Test for CVS
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Here is a 20-question MCQ test based on the CVS Examination content from Harrison's 22E. Answer all questions, then scroll down for the answer key.
CVS Examination — Harrison's 22E
Self-Assessment Test (20 MCQs)
1. The single most important bedside measurement to estimate volume status is:
- A) Blood pressure
- B) Jugular venous pressure
- C) Capillary refill time
- D) Peripheral pulse volume
2. JVP >4.5 cm above the sternal angle is measured at which patient position?
- A) 45° elevation
- B) 60° elevation
- C) 30° elevation
- D) Supine (0°)
3. A patient in sinus rhythm has a prominent a wave in the JVP. The most likely cause is:
- A) Tricuspid regurgitation
- B) Atrial fibrillation
- C) Reduced right ventricular compliance
- D) Constrictive pericarditis
4. Cannon a waves in the jugular venous waveform during a wide complex tachycardia indicate:
- A) SVT with aberrant conduction
- B) Ventricular tachycardia (AV dissociation)
- C) Atrial flutter with 2:1 block
- D) Wolff-Parkinson-White syndrome
5. Which of the following conditions causes fixed splitting of S2?
- A) Pulmonary arterial hypertension
- B) Left bundle branch block
- C) Secundum atrial septal defect
- D) Severe aortic stenosis
6. Paradoxical (reversed) splitting of S2 is characterised by:
- A) Components audible at inspiration, narrow at expiration
- B) Components audible at expiration, narrowing with inspiration
- C) Fixed wide split unaffected by respiration
- D) Single S2 with loud P2
7. A 35-year-old woman has a mid-systolic click that moves closer to S1 on standing. The diagnosis is:
- A) Aortic stenosis
- B) Hypertrophic obstructive cardiomyopathy
- C) Mitral valve prolapse
- D) Pulmonary stenosis
8. The A2–OS interval in mitral stenosis is inversely proportional to:
- A) Mitral valve area
- B) Right atrial pressure
- C) The LA–LV diastolic pressure gradient
- D) Pulmonary capillary wedge pressure
9. A pericardial knock is best associated with:
- A) Cardiac tamponade
- B) Constrictive pericarditis
- C) Atrial myxoma
- D) Restrictive cardiomyopathy
10. Kussmaul's sign (paradoxical rise of JVP with inspiration) is seen in all of the following EXCEPT:
- A) Constrictive pericarditis
- B) Right ventricular infarction
- C) Cardiac tamponade
- D) Severe right ventricular failure
11. An S4 gallop is absent in which rhythm?
- A) Sinus tachycardia
- B) Atrial fibrillation
- C) First-degree AV block
- D) Right bundle branch block
12. Which maneuver increases the murmur of hypertrophic obstructive cardiomyopathy (HOCM)?
- A) Squatting
- B) Passive leg raise
- C) Valsalva (strain phase)
- D) Isometric handgrip
13. A pathologic S3 in an adult >40 years is most consistent with:
- A) Athlete's heart
- B) Pregnancy
- C) Dilated cardiomyopathy with reduced EF
- D) Left ventricular hypertrophy
14. The pulmonic ejection sound is unique among right-sided events in that it:
- A) Increases in intensity with inspiration
- B) Decreases in intensity with inspiration
- C) Is unaffected by the respiratory cycle
- D) Disappears with squatting
15. In tricuspid regurgitation, which JVP waveform change is most characteristic?
- A) Prominent a wave and slow y descent
- B) Absent a wave and rapid y descent
- C) Prominent v wave and rapid y descent
- D) Cannon a wave with fixed JVP
16. A loud P2 that can be palpated at the second left intercostal space indicates:
- A) Aortic stenosis
- B) Pulmonary arterial hypertension
- C) Pulmonary stenosis
- D) Atrial septal defect
17. A systolic murmur that decreases with squatting is most likely due to:
- A) Mitral regurgitation
- B) Tricuspid regurgitation
- C) Aortic stenosis
- D) Hypertrophic obstructive cardiomyopathy
18. Which pulse abnormality is classically associated with cardiac tamponade?
- A) Pulsus bisferiens
- B) Pulsus alternans
- C) Pulsus paradoxus
- D) Pulsus parvus et tardus
19. A grade 4/6 murmur differs from a grade 3/6 murmur by the presence of:
- A) Radiation to the neck
- B) A palpable thrill
- C) Audibility without a stethoscope
- D) A diastolic component
20. The opening snap of mitral stenosis becomes absent when:
- A) The LA-LV gradient increases
- B) The anterior mitral leaflet becomes heavily calcified and immobile
- C) The heart rate increases
- D) Pulmonary hypertension develops
✅ Answer Key
| Q | Answer | Key Teaching Point |
|---|---|---|
| 1 | B | JVP = single most important bedside volume status marker |
| 2 | C | >4.5 cm above sternal angle at 30° elevation = abnormal |
| 3 | C | Prominent a wave → ↓ RV compliance (e.g., PS, pulmonary HTN) |
| 4 | B | Cannon a waves = AV dissociation → VT |
| 5 | C | Fixed S2 split = secundum ASD (hallmark) |
| 6 | B | Reversed split: audible at expiration, narrows with inspiration |
| 7 | C | MVP click moves toward S1 on standing (↓ preload) |
| 8 | C | Shorter A2-OS = higher LA-LV gradient = more severe MS |
| 9 | B | Pericardial knock = constrictive pericarditis |
| 10 | C | Tamponade causes Kussmaul's sign rarely; classic for constriction/RV infarct |
| 11 | B | S4 requires atrial contraction — absent in AF |
| 12 | C | Valsalva ↓ preload → ↑ HOCM obstruction → louder murmur |
| 13 | C | Pathologic S3 in adults = dilated LV, ↓ EF, severe MR/AR |
| 14 | B | Pulmonic ejection sound = only right-sided event that ↓ with inspiration |
| 15 | C | TR → prominent v wave + rapid y descent |
| 16 | B | Palpable P2 at 2nd LICS = pulmonary arterial hypertension |
| 17 | D | HOCM ↓ with squatting (↑ preload → ↓ obstruction) |
| 18 | C | Pulsus paradoxus (>10 mmHg SBP drop with inspiration) = tamponade |
| 19 | B | Grade 4 = thrill present; Grade 6 = audible without stethoscope |
| 20 | B | Calcified, immobile leaflets → OS (and loud S1) disappear |
Scoring:
- 18–20 correct → Excellent
- 14–17 → Good, review missed topics
- <14 → Revisit the CVS examination notes before proceeding
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