Pulmonary hypertension is known for being difficult to diagnose, but there are some physical signs that may offer a clue:
- Giant A waves in the jugular venous pulse.
- Loud P2
- a parasternal heave at the left lower sternal border
1) Giant A waves in the jugular venous pulse can be a sign of pulmonary hypertension. The A stands for atrial systole, and is present just before the carotid impulse. Paul Wood, a famous cardiologist and teacher from the 20th century, recorded in 1957 a 20 minute video introducing this topic. http://catalogue.wellcome.ac.uk/record=b1666332~S3 (accessed July 26, 2011). Jugular waveform analysis is somewhat of a lost art, being ignored in most modern studies, despite the fact that in Dr. Wood’s cases the sign is easily discerned. To my knowledge the sensitivity is not known.
2) A loud P2 in some cases can be discerned at the bedside in the emergency department. Physiologic splitting happens on inspiration, and A2 (aortic sound) comes first, followed by P2 (pulmonic sound). A loud P2 is thought to be 38%-57% sensitive for pulmonary hypertension(Pilatis 2000, Sompradeekul 2010). Audio samples are encouraged, and an example is found at http://www.easyauscultation.com/cases.aspx?CourseCaseOrder=5&CourseID=24 (accessed July 26, 2011). This is best heard with the diaphragm in the pulmonic area with the patient leaning forward.
3) A parasternal heave is recognized by placing the palm on the patient’s parasternal area, with the elbow locked. An impulse upward is considered a heave. It was estimated as having 38% sensitivity for pulmonary hypertension (Pilatis 2000).
Historical signs of physical diagnosis sometimes are sometimes ignored for low sensitivity. However, these signs present with varying degrees of intensity, and certainly it behooves us to be prepared so that we can recognize those presentations that are discernible.
Take home points:
Physical signs of pulmonary hypertension include giant A waves, a loud P2, and a parasternal heave.