Friedreich’s Sign

The normal jugular venous waveform contains two descents, x and y. The x descent, which corresponds to the combination of right atrial relaxation and depression of the atrial floor during ventricular contraction, is normally dominant. The y descent occurs as a result of passive ventricular filling during early diastole. A sharp and deep y descent that becomes more dominant than the x descent is known as Friedreich’s sign. It is associated with constrictive pericarditis and restrictive cardiomyopathy.

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Patient 3

This is a middle-aged man with recent orthotropic heart transplant complicated by hemorrhagic pericardial effusion who was admitted with dyspnea and elevated filling pressures along with Friedreich’s sign, concerning for constrictive physiology, perhaps subacute constrictive pericarditis.