A Wave (Cannon A Wave)


Article Author:
Benjamin Senst
Hajira Basit


Article Editor:
Sandeep Sharma


Editors In Chief:
Linda Lindsay


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
4/29/2019 10:21:10 PM

Introduction

Cannon A waves are a physical exam finding and formed by an exaggerated right atrial pressure wave indicating cardiac dysrhythmia. Patients may complain of a feeling of neck pulsation. Cannon A waves are one of many pathologies of the jugular venous pressure curve.[1][2][3][2]

Etiology

Cannon A waves are related to rhythm disturbances causing changes in the cardiac blood flow. Different dysrhythmias may cause cannon A waves. Heart block may lead to cannon a waves, in particular, third-degree (complete) heart block. It may be seen with ventricular tachycardia as a result of the inherent AV dissociation of the arrhythmia. Another cause is Pacemaker syndrome without proper synchronization of atria and ventricles. [4]

Cannon A waves need to be distinguished from giant A waves that occur in right heart structural changes such as tricuspid valvulopathies, right ventricular hypertrophy, and pulmonary hypertension. To the observer of the jugular, venous-pressure giant A waves and Cannon A waves may appear similar. From physical exam alone it might be difficult to differentiate between the 2.

Epidemiology

Recent literature does not describe the frequency of cannon A waves in rhythm disturbances.

Pathophysiology

The normal function of the heart is to create forward blood flow. During each cardiac cycle, blood is pushed from the atria to the ventricles passing through the atrioventricular valves. Central venous pressure is measured in the right atrium. The bedside clinician can directly assess the jugular venous pulse by observing the patients neck. When obtaining a central or jugular venous pressure curve, its course can be described as 3 positive and 2 negative deflections. [5][6]The 3 positive deflections are:

  • Atrial contraction (A wave)
  • Ventricular contraction (C wave)
  • Venous passive filling of the right atrium (V wave)

The negative deflections are:

  • Atrial relaxation (X wave)
  • Emptying of the right atrium (Y wave)

A proper heart function requires a synchronized action of the myocardium. When the cardiac rhythm is disturbed, the heart cannot provide proper blood flow. Cannon A waves are an example of this. Rhythm disturbances cause mechanical problems since atrial contraction can occur when the tricuspid valve is closed. The tricuspid valve is closed because the pressure in the ventricle is greater than in the atrium. The reflection of the pressure wave travels up the venous system and can be examined in the jugular vein as exaggerated a wave pulsation.

A waves are the expression of proper atrial contraction. In opposition to exaggerated A waves, missing A waves might indicate atrial standstill.

History and Physical

Patients may complain of pulsations in the neck and abdomen as the pulse wave travels back the venous system. Other symptoms such as a headache, cough, and jaw pain can occur. Ask the patient for polyuria since increased atrial stress leads to higher BNP levels which in return will cause polyuria. Cannon A waves are associated with higher right atrial pressures. Erlebacher et al. describe that this may result in baroreceptor mediated systemic hypotension.

Inspection of venous jugular pulsation should be done parallel to auscultation of the heart. Remember the relation of the venous pressure curve to the heart sounds. This is important to differentiate the different pulsation phenomena. The A wave is followed closely by the S1 heart sound as the closure of the atrioventricular valves causes it.

The characteristic appearance of the neck vein pulsation is called frog sign according to Contreras-Valdes et al.

According to Ranjith et al. it is helpful to differentiate between regular and irregular Cannon waves since regular Cannon A waves might be caused by junctional or ventricular rhythm. Whereas, atrioventricular dissociation, ectopic atrial beats can result in irregular A waves.

Evaluation

Patients complaining of symptoms that can be related to cannon A waves or direct physical exam positive for cannon A waves should undergo further testing. To identify the cause of Cannon A waves and to distinguish from giant A waves an ECG and echocardiography should be performed. The ECG is helpful to look for rhythm disturbances. For visualization of structural changes, an ultrasound examination of the heart can be performed with attention to the right heart looking for hypertrophy, tricuspid pathology, and pulmonary hypertension.[7][1][8] 

Treatment / Management

Treatment of Cannon A waves depends on the underlying pathology.

Differential Diagnosis

When inspecting the patient's neck, a variety of pulsation phenomena might be seen. One should first divide between arterial and venous pulsations by location and strength on palpation. There are higher pressures existent in the arterial than in the venous circulation. The venous pressure curve can be altered in different ways and cannon A waves may be mistaken. For example, giant C and V wave can occur in tricuspid regurgitation. This is called Lancisi sign. Jugular vein distension can result from a pulmonary embolism as part of Becks Triad. A number of changes to the jugular venous pressure curve need to be distinguished. This illustrates the importance of venous pressure as a window to the right heart.

Consultations

Cannon A waves relate to cardiologic pathology. Since then the patient may be referred to cardiologic consultation.

Pearls and Other Issues

  • The physical exam is key as it allows for fast and direct detection of cardiac pathologies.
  • The central venous pressure curve is important for the identification of right heart abnormalities.
  • Be confident with the normal jugular venous pressure curve and pathologic changes it may show.
  • When observing pulsations of the neck, remember Cannon A waves as a possible cause and perform an ECG and echo as additional tests.

Enhancing Healthcare Team Outcomes

Clinicians (nurse practitioners, physicians, physician assistants) may notice a pulsating sensation in the neck. One cause for this might be a phenomenon called Cannon A wave. It is an exaggerated pulse wave of atrial contraction, usually when the atria contract blood is pushed into the ventricles. When the cardiac action is not well synchronized as might be the case in cardiac rhythm abnormalities, blood pushes against the closed tricuspid valve and create a reverse pulsation into the venous system. The pressure wave might be felt in the neck, jaw, and abdomen. A feeling of pulsation should prompt further investigation. When Cannon A waves are found, further investigations may be needed to identify the reason why the heart rhythm is not well synchronized. A cardiology consultation may be necessary.


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A Wave (Cannon A Wave) - Questions

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What condition is associated with cannon A waves?



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Atrial contractions are responsible for which jugular venous pulses?

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What does the A wave indicate on a pulmonary artery catheter tracing?



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An "a" wave of the jugular venous pulse is produced by which of the following?



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When cannon a waves are seen what primary investigation should be done?



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A Wave (Cannon A Wave) - References

References

Ranjith MP,Shajudeen K,Prasanth S, Regular cannon wave. Indian heart journal. 2016 Sep     [PubMed]
Zamboni P, Why Current Doppler Ultrasound Methodology Is Inaccurate in Assessing Cerebral Venous Return: The Alternative of the Ultrasonic Jugular Venous Pulse. Behavioural neurology. 2016     [PubMed]
Chua Chiaco JM,Parikh NI,Fergusson DJ, The jugular venous pressure revisited. Cleveland Clinic journal of medicine. 2013 Oct     [PubMed]
Tenczer J,Littmann L, More on jugular venous pulse (JVP) tracings and cannon waves. American heart journal. 1978 Jul     [PubMed]
Senthelal S,Maingi M, Physiology, Jugular Venous Pulsation null. 2018 Jan     [PubMed]
Wexler RK,Pleister A,Raman SV, Palpitations: Evaluation in the Primary Care Setting. American family physician. 2017 Dec 15     [PubMed]
Braga A,Oliveira A,Domingues K,Andrade MJ,Abecacis M,Neves JP, Diagnostic Challenges in Chronic Constrictive Pericarditis. Revista portuguesa de cirurgia cardio-toracica e vascular : orgao oficial da Sociedade Portuguesa de Cirurgia Cardio-Toracica e Vascular. 2017 Jul-Dec     [PubMed]
Applefeld MM, The Jugular Venous Pressure and Pulse Contour null. 1990     [PubMed]

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