Loud presystolic sounds over the jugular veins associated with high venous pressure

Abstract

W E recently stumbled onto the fact that loud sounds could be recorded during atria1 systole over the jugular veins of patients with large P waves and elevated pressure in the right atrium. This led us to review the previous reports on auscultation over the jugular veins and finally to the conclusion that this phenomenon had escaped the notice even of those who had an intense interest in venous pulses and sounds. The published jugular phonograms do not show any presystolic sounds similar to those we have obtained, although faint sounds due to atria1 systole have been recorded repeatedly in the last four decades. Our first observation was the result of noting huge presystolic ballistocardiographic waves, headward and rightward, in a man with mitral stenosis, mild failure of the right side of the heart and a P-R interval of 0.26 seconds. (Fig. 1.) Routine precordial phonocardiograms showed a faint apical first sound, ascribable to the long A-V interval, together with classical presystolic murmurs and loud pulmonic second sounds. (Fig. 2.) No gallop could be detected over the precordium but as there were large spiked P waves, giant jugular a waves and minimal venous collapse in either systole or early diastole, the possibility of a tight tricuspid stenosis was considered. Phonograms taken from the right jugular bulb exhibited a loud, split presystolic sound. (Fig. 2.) The first and second sounds, faint in this area, were quite loud just below the clavicle where no presystolic sound was recorded. (Fig. 2.) Later, catheterization established the presence of tricuspid stenosis with normal pulmonary arterial pressure, and angiocardiograms showed a large right auricle which failed to empty in twenty seconds. In brief, seeing huge presystolic gallop waves in the ballistocardiograms with no gallop in routine precordial sound traces, led to recording a jugular gallop sound and establishing the diagnosis of tricuspid disease in a patient long considered to have pure mitral stenosis. The next day the same sound was recorded in a young woman returning for study after a mitral valvulotomy. Here, too, the gallop was not apparent just caudal to the right clavicle but the first and second sounds, together with a loud systolic murmur, also could be heard over the jugular vein, so that there was a local gallop rhythm not audible over the precordium. (Fig. 3.) In this patient there was no functional stenosis or insufficiency of the tricuspid valve since the jugular pressure falls sharply after the c and u waves. (Fig. 3.) Thus we learned that the presystolic gallop over the jugular bulb was not pathognomonic of tricuspid stenosis. Within a few days opportunity arose to seek this sound in two patients with congenital heart disease who had previously been catheterized and known to have high right auricular pressure without mitral or tricuspid disease. Both had a presystolic gallop of great intensity, recorded only over the jugular bulb. (Fig. 4.) Failure to record anything but faint sounds or inaudible vibrations from the jugular bulb of normal subjects or from patients with left ventricular failure and normal venous pressures, forced us to conclude that a loud presystolic sound limited to the veins was pathognomonic of right atria1 hypertension. The main facts concerning the first twelve subjects with loud presystolic jugular sounds are