12.11.29 Pulses

Unequal or Delayed

    • Obstructive arterial diseases

      • Most commonly atherosclerosis

    • Aortic dissection

    • Aortic aneurysm

    • Takayasu's disease

    • Supravalvular aortic stenosis

      • Right carotid, brachial, and radial pulses are larger in amplitude and volume than those on the left side

      • Due to preferential streaming of the jet toward the innominate artery

    • Coarctation of the aorta

      • Delay in onset of femoral pulse

Pulsus alternans

    • Definition

      • Variation in pulse amplitude occurring with alternate beats due to changing systolic pressure

    • Aetiology

      • Left ventricular failure

    • Other rare causes

      • Hypertrophic cardiomyopathy and a significant rest or provocable outflow gradient

      • Cardiac tamponade

      • Severe aortic regurgitation

    • Apparent pulsus alternans

      • Due to bigeminal rhythm

    • Mechanism unclear

      • Alternating preload (Frank-Starling mechanism) and incomplete relaxation have been proposed

      • Changes in afterload, which is lower after preceding the strong beat, may also contribute

Pulsus paradoxus

    • Definition

      • Inspiratory decrease in arterial pressure exceeding 20 mmHg

    • Aetiology

      • Cardiac tamponade

      • COPD

      • Hypovolemic shock

      • Constrictive pericarditis

      • Restrictive cardiomyopathy

    • Mechanism

      • Inspiratory decline of left ventricular stroke volume due to an increase in right ventricular end-diastolic volume and decreased left ventricular end-diastolic volume

Pulsus bisferiens

    • Definition

      • Two systolic peaks of the aortic pulse during left ventricular ejection separated by a midsystolic dip

    • Aetiology

      • Aortic regurgitation

      • Common in patients with combined aortic stenosis and aortic regurgitation

      • PDA or arteriovenous fistula

    • Mechanism

      • Unclear

      • Appears to be related to a large, rapidly ejected left ventricular stroke volume associated with increased left ventricular and aortic dp/dt

    • Pitfalls

      • Difficult to establish with certainty that the two peaks are occurring in systole

      • (One peak in systole and the other in diastole = Dicrotic pulse)

Dicrotic pulse

    • Definition

      • Accentuated diastolic dicrotic wave that follows the dicrotic notch

    • Aetiology

      • Severe heart failure

      • Hypovolemic shock

      • Cardiac tamponade

      • Conditions associated with a decreased stroke volume and elevated systemic vascular resistance

    • Mechanism

      • Tends to occur when the dicrotic notch is low (decreased systemic arterial pressure and vascular resistance)

    • Pitfall

      • Frequently confused with pulsus bisferiens at the bedside

      • It is almost impossible to distinguish between these two types of pulse configurations without a pulse recording

Corrigan pulse

    • Definition

      • Abrupt, very rapid upstroke of the peripheral pulse (percussion wave), followed by rapid collapse

    • Aetiology

      • Chronic, hemodynamically significant aortic regurgitation

    • Mechanism

      • Rapid ejection of a large left ventricular stroke volume into a low resistance arterial system

Anacrotic pulse

    • Definition

      • Interruption of the upstroke of the carotid pulse

    • Aetiology

      • Aortic stenosis

Pulsus tardus

    • Definition

      • Delayed upstroke of the ascending limb

    • Aetiology

      • Aortic stenosis

    • Mechanism

      • Prolonged left ventricular ejection time


  • Dicrotic notch

    • Coresponds to aortic valve closure

    • Just as the ventricles enter into diastole, the brief reversal of flow from the aorta back into the left ventricle causes the aortic valves to shut

    • This results in the slight increase in aortic pressure caused by the elastic recoil of the semilunar valves and aorta