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Author Aarti Narayan (Edited by Ayokunle Olubaniyi and Alison Leibowitz)
Exam Type USMLE Step 2 CK
Main Category Internal medicine
Sub Category Cardiovascular
Prompt A 35-year-old woman presents to the outpatient department with gradually worsening symptoms of fatigue, dyspnea, and pedal edema over the past 6 months. There is a past medical history of rheumatic fever. The physical examination is positive for hepatomegaly and mild ascites. Echocardiographic studies show thickening and stenosis of tricuspid valve leaflets.

Which of the following findings on the jugular venous pressure (JVP) tracing is most likely to be observed in this patient?

Answer A [[AnswerA::Absent ‘a’ waves]]
Answer A Explanation [[AnswerAExp::Absent ‘a’ waves are seen in patients with atrial fibrillation.]]
Answer B Deep ‘y’ descent
Answer B Explanation [[AnswerBExp::Deep ‘y’ descent is seen in early diastole with severe tricuspid regurgitation. It is also seen with constrictive pericarditis and severe right ventricular failure.]]
Answer C [[AnswerC::Giant ‘a’ waves]]
Answer C Explanation This is the correct answer.
Answer D Prominent ‘v’ wave
Answer D Explanation Prominent ‘v’ wave results from increased volume of blood in right atrium during ventricular systole and is seen in tricuspid regurgitation. It is also seen with constrictive pericarditis and severe right ventricular failure.
Answer E Prominent ‘x’ descent
Answer E Explanation [[AnswerEExp::Prominent ‘x’ descent is seen in constrictive pericarditis.]]
Right Answer C
Explanation [[Explanation::
Jugular venous pressure waveform.png

The image above shows a normal jugular venous pressure tracing.

The patient in this vignette has developed right-sided heart failure secondary to tricuspid stenosis, a condition which is usually a late complication of acute rheumatic fever. Giant or prominent ‘a’ waves are the hallmark of tricuspid stenosis in patients who are in sinus rhythm, and it indicates that the right atrium is contracting against increased resistance. Other examples where giant ‘a’ waves can be seen include: pulmonary hypertension, pulmonic stenosis and right atrial myxoma.
Educational Objective: Fatigue, dyspnea and pedal edema are symptoms of right heart failure. These symptoms, coupled with a history of acute rheumatic fever and echocardiographic evidence of thickened and stenotic tricuspid valve leaflets, make the diagnosis of tricuspid stenosis very likely. Prominent ‘a’ waves are usually found on the jugular venous presure wave form due to the enlargement of the right atrium caused by the stenotic tricuspid valve. Definitive treatment is surgical valve repair or replacement.
References: Roguin A, Rinkevich D, Milo S, et al. Long-term follow-up of patients with severe rheumatic tricuspid stenosis. Am Heart J. 1998;136:103-108.]]

Approved No
Keyword Rheumatic fever, tricuspid stenosis, a wave, prominent a wave, giant a wave
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