Arterial Pulse Variants

Differential Overview

Phenomena

❑ Irregularly irregular pulse

❑ Asymmetric pulses

❑ Bounding pulse

❑ Bisferiens pulse

❑ Bigeminal pulse

❑ Pulsus alternans

❑ Pulsus paradoxus

❑ Thready pulse

❑ Pulsus parvus et tardus

❑ Narrow pulse pressure

Diagnostic Approach

Examine the pulse using the method of trisection: apply pressure until the pulse is maximal, and then vary pressure while concentrating on phases of the pulse.

Early Chinese medicine based diagnosis primarily on careful examination of the pulse. There were six sets of pulses, each connected with a specific part of the body and each believed to register even the subtlest physiological changes within it. The principal pulses were Fu, a light-flowing pulse like a piece of wood floating on water; Ch’en, a deeply impressed pulse like a stone thrown into water; Ch’ih, a pulse with three beats to one cycle of respiration; and Shu, a pulse with six beats to one cycle of respiration.

Clinical Findings

Irregularly irregular pulse  A hallmark of atrial fibrillation, the amplitude of each beat varies with the filling interval. It can also be found with PVCs, PACs, and multifocal atrial tachycardia. PVCs are recognized by a regular rhythm with a dropped beat followed by a compensatory pause, then a beat of increased amplitude. PACs throw the rhythm out of synchrony.

Asymmetric pulses  Consider subclavian artery atherosclerosis, arterial thrombosis (especially with atrial fibrillation), thoracic outlet compression, or aortic dissection.

Bounding pulse  A hyperkinetic pulse with a rapid large-amplitude upstroke and rapid collapse is associated with increased stroke volume or decreased arterial compliance. The classic “collapsing pulse” is found in aortic regurgitation, along with the manifestations of diastolic murmur, pulsating retinal arteries, and nailbed pulsations (Quincke pulses). It also occurs in thyrotoxicosis (a rapid and snapping pulse), pregnancy, fever, anemia, patent ductus arteriosus, and arteriovenous fistula. A slow, bounding pulse, which is caused by a prolonged ventricular filling time, may be found in complete heart block.

Bisferiens pulse  The pattern is a tapping percussion wave with a rapid early rise, a decline, then a second tidal wave. This pulse is classically found
in hypertrophic cardiomyopathy and in combined aortic stenosis and regurgitation.

Bigeminal pulse  This is palpable as a strong pulse alternating with a weak one, the second beat caused by decreased ventricular filling with an early contraction. Occasionally, the alternate beat is so weak as to be nonpalpable, in which case the auscultated heart rate is twice the palpated pulse. It is found in ventricular bigeminy and digoxin overdose.

Pulsus alternans  The amplitude varies with each pulse and is accentuated after a premature contraction. A loud S₃ gallop is usually present. Although usually due to severe left ventricular dysfunction, a decreased pulse after a premature contraction suggests hypertrophic obstructive cardiomyopathy.

Pulsus paradoxus  The easiest way to obtain this measurement is to start above systole, deflating the cuff until the first sounds are heard, with the pulse disappearing during inspiration. Continue to deflate the cuff until the heart sounds are rapid and regular. A difference between these measures of more than 10 mm Hg is abnormal. Increased pulsus paradoxus may be observed in severe asthma, pericardial tamponade, pulmonary embolism, and hypovolemic shock. It does not occur with constrictive pericarditis, severe CHF, or right ventricular failure.

Thready pulse  A low-volume thready pulse is found in hypovolemic or septic shock, severe aortic stenosis, and severe left ventricular dysfunction. Intense vasoconstriction may produce a diminished pulse with normal stroke volume.

Pulsus parvus et tardus  The classic finding in hemodynamically significant aortic stenosis, the carotid pulse is low in volume and has a slowly rising upstroke with a prolonged plateau. A “shudder” may also be felt.

Narrow pulse pressure  Defined as (systolic–diastolic)/systolic ,0.25, it may be found with pericardial tamponade, constrictive pericarditis, or aortic stenosis.

Pictures

Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5

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