PULSE

The arterial pulse reflects left ventricular performance and the vascular system's response to ejection. It consists of an
ascending limb, peak, and descending limb, with the pulse wave traveling along the aorta at about 5 m/sec. Key factors
affecting the pulse's shape include stroke volume, left ventricular contractility, and the condition of the aortic valve. A higher
stroke volume or ejection velocity leads to a sharper upstroke and higher peak, while reduced stroke volume or contractility
results in a less sharp upstroke. Arterial system compliance, peripheral vascular resistance, and aortic runoff also influence
the pulse morphology.

Table 1: Determinats of Pulse

Determinant Factors
- Stroke volume
Left Ventricle - Left ventricular contractility
- Velocity of left ventricular ejection
- Normal
- Stenotic
Aortic Valve
- Regurgitation
- Combined stenosis and regurgitation
- Compliance or distensibility
Arterial
- Peripheral vascular resistance
System
- Aortic runoff

ARTERIAL PULSE WAVEFORM

1. Percussion Wave: This is the initial upstroke of the arterial pulse waveform, representing the rapid ejection of
blood from the left ventricle into the aorta during systole.
2. Tidal Wave: This is the peak of the pulse wave, which occurs after the percussion wave and represents the
maximum pressure achieved during systole as the aorta and other large arteries distend.
3. Dicrotic Notch: This small dip in the pulse waveform occurs after the tidal wave and is associated with the closure
of the aortic valve at the end of systole. It marks the transition between systole and diastole.
4. Dicrotic Wave: Following the dicrotic notch, this wave represents a brief increase in pressure due to the recoil of
the aorta after the aortic valve closure.
5. Anacrotic Notch: This notch is seen in abnormal pulse waveforms, particularly in conditions like aortic stenosis.
It appears during the ascending limb of the waveform before reaching the tidal wave.
Technique of Palpating the Pulse: Various Sites

Carotid Artery:
§ Location: Located on the side of the neck, adjacent to the trachea.
§ Usage: Most suitable for evaluating the character of the arterial pulse because it is close to the aortic valve.
§ Technique: The patient lies supine with the neck slightly turned to relax the sternomastoid muscle. The pulse is
palpated using the middle three fingers along the lateral border of the trachea. This pulse is often used in
emergencies and is synchronized with the first heart sound (S1).

Brachial Artery:
§ Location: Found in the upper arm, near the elbow’s inner aspect.
§ Usage: This is the next best site if the carotid artery is not accessible. It’s commonly used in infants and during
blood pressure measurement.
§ Technique: The arm should be slightly bent at the elbow. The pulse is palpated with two or three fingers in the
antecubital fossa, medial to the biceps tendon.

Radial Artery:
§ Location: On the wrist, just below the thumb.
§ Usage: The most common site for pulse measurement in routine examinations. It's particularly useful for detecting
peripheral pulse characteristics such as a collapsing or dicrotic pulse.
§ Technique: The pulse is felt with the tips of the index and middle fingers placed over the radial artery.

Femoral Artery:
§ Location: Located in the groin, where the leg meets the pelvis.
§ Usage: Best for detecting a paradoxic pulse, particularly in conditions like cardiac tamponade, where the pulse
volume may be low and difficult to detect at more distal sites.
§ Technique: The patient lies supine, and the pulse is palpated just below the inguinal ligament, halfway between
the pubic symphysis and the anterior superior iliac spine.

Popliteal Artery:
§ Location: Behind the knee in the popliteal fossa.
§ Usage: Used when evaluating circulation to the lower leg and foot, often in cases of suspected peripheral artery
disease.
§ Technique: The patient bends their knee slightly, and the examiner palpates deeply in the midline of the popliteal
fossa with both hands encircling the knee.

Posterior Tibial Artery:

§ Location: Just behind the medial malleolus of the ankle.
§ Usage: Commonly used to assess the circulation to the foot, especially in patients with diabetes or peripheral
vascular disease.
§ Technique: The pulse is palpated with the fingers placed just behind the ankle bone, with the foot slightly
extended.

Dorsalis Pedis Artery:

§ Location: On the dorsum of the foot, between the first and second metatarsal bones.
§ Usage: Used to assess peripheral circulation to the lower extremities.
§ Technique: The pulse is palpated lightly, as it is often weak or difficult to find, particularly in older adults or
those with arterial disease.
EVALUATION COMPONENTS OF THE PULSE

Rate
o The number of beats per minute (normal range is 60-90/min). Tachycardia is over 100/min, and
bradycardia is below 60/min

CAUSES OF SINUS TACHYCARDIA (MORE THAN 100 BEATS/MINUTE)

- Exercise, stress, anxiety, emotional excitement
- Excess of caffeine (tea and coffee), alcohol, smoking
- Pyrexia (fever)
- Pain
- Hyperthyroidism
- Heart failure, Acute Myocardial Infarction (AMI), acute pulmonary embolism
- Medications – sympathomimetics, vasodilators
- Pheochromocytoma

Rhythm:
Refers to the regularity of the pulse. A regular rhythm has equal intervals between beats, while an irregular
rhythm may indicate arrhythmias.
§ Regular Rhythm: If the intervals between heartbeats are consistent, the rhythm is regular. A regular
rhythm suggests normal sinus rhythm.
§ Irregular Rhythm: If the intervals between beats are inconsistent, the rhythm is irregular. Irregular
rhythms can be further classified:

o Regularly Irregular: The irregularity follows a pattern (e.g., bigeminy, where every other beat
is premature).

o Irregularly Irregular: There is no discernible pattern to the irregularity, which is often seen in
atrial fibrillation.

Rhythm Type Associated Conditions

- Sinus Arrhythmia
- 2nd Degree AV Block
Regularly Irregular Rhythm
- Atrial Tachyarrhythmias (MAT and Atrial Flutter) with Fixed AV Block
- Ventricular Bigeminy, Trigeminy
- Atrial Fibrillation
Irregularly Irregular Rhythm - Atrial or Ventricular Ectopics
- Atrial Tachyarrhythmias (MAT and Atrial Flutter) with Varying AV Blocks

Volume and Tension:

o Volume: The force or amplitude of the pulse, which reflects the stroke volume of the heart. A strong
pulse suggests good cardiac output, while a weak pulse may indicate low output or shock.

Low Volume Pulse

• Definition: A low volume pulse, also referred to as a weak or thready pulse, is associated with a narrow pulse
pressure. Pulse pressure is the difference between systolic and diastolic blood pressure.
High Volume Pulse

• Definition: A high volume pulse, also known as a bounding pulse, is associated with a wide pulse pressure.

Pulse Pressure Pulse Pressure

Description
Type Range (mmHg)

Narrow Pulse Less than 30 Indicates reduced stroke volume or increased peripheral resistance; seen in conditions
Pressure mmHg like severe aortic stenosis, cardiogenic shock, and heart failure.

Normal Pulse Reflects a balanced cardiac output and vascular resistance, typical in healthy
30 to 40 mmHg
Pressure individuals.

Indicates increased stroke volume or decreased arterial compliance; seen in

Wide Pulse Greater than 60
conditions like aortic regurgitation, hyperthyroidism, anemia, and in elderly patients
Pressure mmHg
with stiff arteries.

CHARACTER
The character of the pulse refers to the quality and waveform of the pulse as it is felt upon palpation. It provides important
information about the condition of the cardiovascular system, particularly the heart and arteries. The character of the pulse
is influenced by factors such as stroke volume, arterial compliance, and the presence of any valve abnormalities.

Pulse Character Associated Causes

Pulsus Parvus et
Aortic Stenosis
Tardus
Pulsus Bisferiens Hypertrophic Obstructive Cardiomyopathy (HOCM), Aortic Regurgitation with Stenosis
Pulsus Bigeminus Premature Ventricular Contractions (PVCs)
Pulsus Alternans Severe Left Ventricular Dysfunction
Pulsus Paradoxus Cardiac Tamponade, Severe Asthma, Constrictive Pericarditis
Collapsing Pulse Aortic Regurgitation, Patent Ductus Arteriosus (PDA)
Low Cardiac Output States: Cardiomyopathy, Myocarditis, Cardiac
Dicrotic Pulse
Tamponade, Typhoid Fever

Vessel Wall:
Assessment of the arterial wall's texture. Normal vessels are smooth and elastic, while atherosclerosis may cause hardening
and irregularities, indicating advanced cardiovascular disease.

Peripheral Pulses:
Pulses in areas such as the radial, femoral, popliteal, and dorsalis pedis arteries are evaluated. The absence or weakness of
peripheral pulses may suggest peripheral artery disease (PAD).

RADIO-RADIAL DELAY
Definition:
 • Radioradial delay refers to a difference in timing between the pulses in the radial arteries of both arms. Normally,
the pulse in both radial arteries should be synchronous.

Assessment:

1. Palpation: Place the index and middle fingers of each hand over the radial arteries of both wrists simultaneously.

2. Comparison: Compare the timing of the pulse waves in each artery. If there is a noticeable delay or difference in
the pulse between the two arms, this is termed radioradial delay.

Causes:

• Subclavian Artery Stenosis: Atherosclerosis or other causes of narrowing in one of the subclavian arteries can
cause a delayed pulse on the affected side.

• Aortic Dissection: A tear in the aortic wall can cause differential flow in the subclavian arteries, leading to
radioradial delay.

Artery Time at which pulse wave arrives after cardiac systole

Carotid 30 milliseconds
Brachial 60 milliseconds
Radial 80 milliseconds
Femoral 75 milliseconds

RADIOFEMORAL DELAY
Definition:

• Radiofemoral delay refers to a difference in timing between the radial pulse (at the wrist) and the femoral pulse (in
the groin). Normally, the pulse wave should arrive at the femoral artery slightly before or at the same time as it
does at the radial artery, given the proximity of the femoral artery to the heart.

Assessment:

1. Palpation: Palpate the radial pulse with one hand and the femoral pulse with the other hand simultaneously.

2. Comparison: Compare the timing of the pulse waves. If the femoral pulse is delayed relative to the radial pulse,
this is termed radiofemoral delay.

Causes:

• Coarctation of the Aorta: The most common cause of radiofemoral delay is coarctation of the aorta. The
narrowing typically occurs distal to the origin of the left subclavian artery, which affects blood flow to the lower
body, causing a delay in the femoral pulse.

• Atherosclerosis of the Aorta: Severe atherosclerotic disease involving the aorta or iliac arteries can also cause
radiofemoral delay.

• Aortic Dissection: A dissection that involves the descending aorta can lead to impaired blood flow to the lower
extremities, resulting in a delayed femoral pulse.

APEX-PULSE DEFICIT
Apex-pulse deficit (often referred to as simply "pulse deficit") is a clinical finding where there is a difference between the
heartbeats heard at the apex of the heart (using a stethoscope) and the palpable pulses at a peripheral site, such as the
radial artery. This phenomenon typically indicates that not all heartbeats are resulting in an effective pulse that can be felt
in the periphery.

Assessment of Apex-Pulse Deficit:

1. 2 examiner technique:
One examiner will use a stethoscope and calculate number of heart beats in one minute. The other
examiner will simultaneously palpate pulse and count it in one minute. The difference in both examiner
will be the apex pulse deficit.
2. Single examiner technique:
Same examiner will simultaneously auscultate the heart as well as palpate the pulse for one minute. The
number of times when the heart beat is heard but the pulse is missed is calculated as apex pulse deficit.
Or
Same examiner in the 1st minute will auscultate the heart beat for one minute and count it. In the next
minute, the same person will palpate the pulse and count it in one minute. The difference will be the apex
pulse deficit.

Causes of Apex-Pulse Deficit:

• Atrial Fibrillation: This is the most common condition associated with a pulse deficit. In atrial fibrillation, the
heart beats irregularly and often ineffectively, leading to some heartbeats that do not generate enough force to
produce a palpable pulse. Apex Pulse deficit is >10/min.

• Premature Ventricular Contractions (PVCs): During a PVC, the ventricles contract prematurely, often without
sufficient time to fill properly, resulting in a weaker contraction that may not generate a detectable peripheral
pulse. Apex Pulse deficit is <10/min.

• Heart Failure: In severe heart failure, the weakened heart may not generate sufficient force with each beat to
produce a palpable pulse.

COLLAPSING PULSE
A collapsing pulse, also known as a water hammer pulse, is characterized by a rapid downstroke in the arterial pulse
following a sharp and high-volume upstroke. This phenomenon occurs in conditions where there is significant regurgitation
or backflow of blood from the aorta or the arterial system. Aortic regurgitation is the primary cause, where the arterial
system behaves as if it is open at both ends during diastole, leading to a rapid decrease in pulse pressure after systolic
ejection.
The collapse in the pulse is attributed to the backward flow of blood into the left ventricle and the reflex vasodilation
mediated by the carotid baroreceptors, secondary to the large stroke volume. Clinically, the collapsing pulse is best detected
at the radial artery, with the patient’s arm elevated above the shoulder to align the artery with the central aorta,
facilitating the detection of the direct systolic ejection and diastolic backflow.

Causes of Collapsing Pulse

Hyperkinetic Circulatory
Conditions with Aortic Run-off
States
Pregnancy Aortic regurgitation
Fever Patent ductus arteriosus
Anemia Aortopulmonary window
Thyrotoxicosis Rupture of sinuses of Valsalva into right heart chambers
Beriberi Arteriovenous fistula
Systemic to pulmonary artery shunt in cyanotic heart disease with reduced pulmonary
Paget’s disease of bone
flow
Hyperkinetic Circulatory
Conditions with Aortic Run-off
States
Hyperkinetic heart syndrome
Cirrhosis of liver
Drug-induced vasodilatation

Examination Technique for Collapsing Pulse

§ Position the Patient: Have the patient sit or lie down comfortably with the arm fully extended.
§ Elevate the Arm: Raise the patient’s arm above the level of the heart to align the radial artery with the
aorta.
§ Palpate the Radial Pulse: Use the pads of your fingers to palpate the radial pulse, feeling for a rapid
upstroke followed by a sudden collapse.
§ Confirm Findings: A collapsing pulse is characterized by a strong initial beat that quickly diminishes.
This finding is often associated with conditions like aortic regurgitation.

Pulsus Paradoxus

Mechanism:

• Pulsus paradoxus is an exaggerated decrease in systolic blood pressure (>10 mmHg) during inspiration.
Normally, there is a slight decrease in blood pressure during inspiration due to increased venous return to the
right side of the heart, which shifts the interventricular septum slightly and reduces left ventricular filling.
However, in pulsus paradoxus, this effect is amplified due to underlying pathology, leading to a significant
reduction in stroke volume and, consequently, systolic blood pressure.

Causes:

• Cardiac Tamponade: The most common cause of pulsus paradoxus. During normal inspiration, the negative
intrathoracic pressure increases venous return to the right side of the heart. In cardiac tamponade, the heart is
compressed by the fluid in the pericardium, so the right ventricle cannot expand into the pericardial space.
Instead, it bulges into the left ventricle, reducing left ventricular filling and consequently lowering stroke volume
and systolic blood pressure during inspiration. This results in pulsus paradoxus.

• Constrictive Pericarditis: The thickened, fibrotic pericardium restricts the heart's ability to expand, similarly
leading to an exaggerated ventricular interdependence leading to exaggerated decrease in stroke volume during
inspiration.

• Severe Asthma or COPD: Hyperinflation of the lungs during inspiration increases intrathoracic pressure,
reducing venous return to the left side of the heart and thereby decreasing left ventricular stroke volume.

• Massive Pulmonary Embolism: Can cause right ventricular strain, which may lead to a similar mechanism as in
cardiac tamponade.

Clinical Detection:

• Measured using a blood pressure cuff. The pressure at which the Korotkoff sounds are first heard only during
expiration (but not during inspiration) is noted. The pressure difference between the onset of these sounds and
when they are heard throughout the respiratory cycle (in both inspiration and expiration) indicates the degree of
pulsus paradoxus.

REVERSED PULSUS PARADOXUS

Reversed pulsus paradoxus is defined as an increase in pulse amplitude during inspiration and a decrease during expiration,
which contrasts with the typical decrease in pulse amplitude during inspiration seen in standard pulsus paradoxus. This
phenomenon is typically observed in specific clinical settings, such as during positive pressure ventilation or in certain
cardiac conditions like iso-rhythmic AV dissociation and hypertrophic obstructive cardiomyopathy.

Causes of Reversed Pulsus Paradoxus:

1. Positive Pressure Breathing with Artificial Ventilators:

o Mechanism: Positive pressure ventilation causes an increase in intrathoracic pressure during
inspiration, leading to an increase in stroke volume and pulse amplitude, and a decrease during
expiration as intrathoracic pressure drops.
2. Iso-rhythmic AV Dissociation:
o Mechanism: In this condition, the atrial activity precedes ventricular activity during inspiration and
follows it during expiration. The increased atrial contribution during inspiration enhances stroke
volume, resulting in an increase in pulse amplitude, while the lack of atrial contribution during
expiration reduces stroke volume, leading to a decrease in pulse amplitude.
3. Hypertrophic Obstructive Cardiomyopathy (HOCM):
o Mechanism: The precise mechanism for reversed pulsus paradoxus in HOCM is not well understood. It
may relate to dynamic changes in left ventricular outflow obstruction during the respiratory cycle.

Cause Description
Positive Pressure Breathing with During positive pressure ventilation, intrathoracic pressure is higher during
Artificial Ventilators inspiration, leading to an increase in stroke volume and pulse amplitude.
Atrial activity precedes ventricular activity during inspiration, enhancing stroke
Iso-rhythmic AV Dissociation
volume and increasing pulse amplitude during inspiration.
Hypertrophic Obstructive The exact mechanism is unclear, but it may involve dynamic changes in left
Cardiomyopathy (HOCM) ventricular outflow tract obstruction during the respiratory cycle.

Pulsus Alternans
Pulsus Alternans is a phenomenon characterized by the regular alternation of strong and weak pulse beats without changes
in respiratory or heart cycle length.

Mechanism:

• Pulsus alternans is characterized by alternating strong and weak pulse beats while the rhythm remains regular. It
is due to an alternating stroke volume with each heartbeat, often linked to varying contractile force of the left
ventricle.

Types:

• Total Alternans: Occurs when weak contraction fails to open the aortic valve, resulting in complete absence of
alternate pulse

• Independent Alternans: Alternation involving only one ventricle, either right or left.

• Concordant Alternans: Simultaneous alternation of both ventricles.

• Discordant Alternans: Alternating alternation between the ventricles.

• Compound Alternans: Additional weaker beats superimposed on routine alternans.

Detection:
Pulsus alternans can be detected by sphygmomanometer, especially when aortic pressure alternates by more than 20 mmHg,
and is also palpable at the peripheral pulse. It often accompanies variation in the intensity of Korotkoff sounds.
 Causes:
A. Severe aortic stenosis
B. Severe pulmonic stenosis
C. Dilated cardiomyopathy
D. Myocarditis

Electrical alternans, an independent phenomenon, has no connection to pulsus alternans.

PULSUS PARVUS

Pulsus Parvus et Tardus is a specific type of pulse that is characterized by two key features:

1. Parvus (Small): The pulse is weak or low in amplitude. This means that the upstroke of the pulse wave is reduced,
resulting in a small or faint pulse that is difficult to palpate.
2. Tardus (Delayed): The pulse has a slow, delayed upstroke. This indicates that the pulse wave takes longer than normal
to reach its peak after the heart contracts, leading to a prolonged rise time of the pulse wave.

Clinical Significance

Aortic Stenosis: Pulsus parvus et tardus is most commonly associated with severe aortic stenosis. In this condition, the
aortic valve is narrowed, which restricts blood flow from the left ventricle into the aorta. As a result, less blood is ejected
with each heartbeat (parvus), and the time it takes for the blood to be ejected is prolonged (tardus).

Peripheral Arterial Disease:: Severe narrowing or blockage in major peripheral arteries can cause a delayed and weakened
pulse in the affected extremities, although this is more often localized rather than generalized as seen in aortic stenosis.

Causes of Pulsus Parvus et tardus

Aortic Stenosis
Subaortic Stenosis
Coarctation of the Aorta
Hypertrophic Obstructive Cardiomyopathy (HOCM)
Severe Peripheral Arterial Disease (PAD)
Severe Heart Failure

PULSUS BIGEMINUS

Characteristics:
Rhythm: Irregular, with alternating normal and premature beats (often premature ventricular contractions, PVCs).

Pulse Strength: The premature beat is typically weaker due to less ventricular filling time.

Clinical Assessment:
§ Palpation: When palpating the pulse, you will feel a strong beat followed closely by a weaker beat, followed by a
longer pause. This creates a pattern of "paired" beats.
§ Auscultation: On auscultation, the heart sounds may reveal an extra beat (corresponding to the premature beat)
that is often followed by a compensatory pause.
 § ECG Correlation: An electrocardiogram (ECG) will typically show a normal QRS complex followed by a
premature QRS complex, often with a compensatory pause after the PVC.

DICROTIC PULSE
A dicrotic pulse is a unique type of arterial pulse that is characterized by a double beat during the cardiac cycle, with the
second beat (known as the dicrotic wave) occurring after the closure of the aortic valve during diastole.

Mechanism
1. Normal Pulse Wave Dynamics:

o In a healthy cardiovascular system, after the heart contracts and ejects blood into the aorta (systole), the
aortic valve closes to prevent backflow of blood into the left ventricle.

o A pulse wave generated by the ejection of blood travels through the arteries. Part of this wave reflects
back from peripheral arterial sites, creating a secondary wave that typically coincides with the dicrotic
notch on the arterial pressure waveform.

2. The Dicrotic Notch:

o The dicrotic notch represents the brief increase in aortic pressure following the closure of the aortic valve
and is normally seen on the downstroke of the arterial waveform. This notch is typically small and not
palpable in healthy individuals.

3. Dicrotic Wave:

o The dicrotic wave is a small secondary pulse that follows the primary systolic peak. In normal
conditions, this wave is not usually palpable. However, under certain pathological conditions, the
dicrotic wave becomes exaggerated and can be felt as a separate, distinct pulse during diastole.

Mechanisms Leading to a Dicrotic Pulse

1. Low Cardiac Output States:

o Conditions such as cardiomyopathy, myocarditis, cardiac tamponade, or severe heart failure result in
reduced stroke volume — the amount of blood ejected by the left ventricle with each contraction.

o In these states, the arterial system is underfilled because less blood is being pumped into it. This
underfilling leads to a less distended arterial tree, making it more compliant.

2. Reflection of the Pulse Wave:

o In an underfilled arterial system, the reflected pulse wave from the periphery returns more slowly. Because
the system is less distended, the reflected wave doesn’t lose as much energy and can merge with the
original wave during diastole, creating a distinct, palpable dicrotic wave.

o This wave is amplified due to the combination of a slow-moving primary pulse wave and the enhanced
reflection from the periphery.

3. Rigid Arterial System:

o In contrast, when the arterial system is rigid and non-distensible, such as in systemic hypertension, the
reflection wave travels rapidly and meets the original pulse wave early, losing its distinctiveness.
Therefore, a dicrotic pulse is not present in such conditions.

Causes
o Cardiomyopathy and Myocarditis: The heart’s weakened pumping ability leads to a low stroke volume,
and the slow return of the reflected wave becomes more prominent.
 o Cardiac Tamponade: The accumulation of fluid in the pericardium compresses the heart, leading to a
low cardiac output and similar effects on the pulse.

o Aortic Valve Replacement: After surgery for aortic regurgitation, the hemodynamic changes can
sometimes lead to a dicrotic pulse as the heart adjusts to the new valve dynamics.

BISFERIENS PULSE:
Bisferiens pulse is a type of arterial pulse characterized by a double systolic peak, meaning two distinct beats can be felt
during the systolic phase of the cardiac cycle. This pulse is typically best palpated in the carotid artery and is indicative of
specific cardiovascular conditions that alter the normal pattern of blood ejection from the heart.

Double Systolic Peak:

o The hallmark of bisferiens pulse is the presence of two distinct systolic peaks during one cardiac cycle.
The first peak is due to the initial ejection of blood from the left ventricle, while the second peak is often
related to a reflected wave or a delayed ejection due to specific hemodynamic conditions.

Mechanism of Bisferiens Pulse:

1. Aortic Regurgitation with Aortic Stenosis:

o Dual Mechanism: The first systolic peak occurs due to the rapid ejection of blood into the aorta, while the
second peak is caused by a reflected wave due to the partially filled aorta after regurgitation, which then
gets pumped again during the remaining systole.

o Combined Lesions: Patients with both aortic stenosis (which causes an obstruction to blood flow) and
aortic regurgitation (which allows blood to flow back into the ventricle) can develop this double-peaked
pulse.

2. Hypertrophic Obstructive Cardiomyopathy (HOCM):

o Dynamic Outflow Obstruction: In HOCM, the thickened septum can cause an obstruction in the left
ventricular outflow tract, leading to a brief obstruction after the initial ejection. The second systolic peak
occurs after this obstruction is temporarily relieved.

o Character of Pulse: The first peak corresponds to early systole, and the second, typically lower peak,
occurs as the left ventricle overcomes the obstruction.

3. Hyperdynamic Circulation:

o In hyperdynamic states, such as with severe aortic regurgitation or high-output cardiac states (like
thyrotoxicosis), the forceful ejection of blood can cause a prominent initial peak followed by a secondary
peak due to the rapid refilling and ejection from the ventricle.

PULSE CHARACTERISTICS IN VALVULAR HEART DISEASES

Valvular Heart Disease Pulse Type Pulse Description Mechanism

Weak and slow-rising pulse Obstruction of blood flow through the
Pulsus Parvus et
Aortic Stenosis (small volume and delayed stenotic aortic valve leads to reduced stroke
Tardus
upstroke). volume and delayed ejection.
The left ventricle ejects a large volume
Collapsing Pulse Rapid, forceful upstroke
quickly due to the regurgitant flow,
Aortic Regurgitation (Waterhammer followed by a sudden
followed by a rapid fall as blood
Pulse) collapse.
regurgitates back into the left ventricle.
Valvular Heart Disease Pulse Type Pulse Description Mechanism
Pulse may be normal or have Reduced stroke volume due to limited left
Normal or Reduced
Mitral Stenosis reduced volume depending on ventricular filling secondary to the stenotic
Volume Pulse
the severity. mitral valve.
Pulse may be normal or Regurgitation into the left atrium reduces
Normal or Brisk slightly brisk, depending on effective forward stroke volume, but the
Mitral Regurgitation
Pulse the severity and chronicity of peripheral pulse is usually not as affected
the condition. as in aortic valve diseases.
Hypertrophic The first peak is due to the initial left
Obstructive Double-peaked pulse with two ventricular ejection, and the second peak is
Bisferiens Pulse
Cardiomyopathy systolic peaks. due to the reflected wave caused by
(HOCM) obstruction in the outflow tract.
Double-peaked pulse with two Combination of increased stroke volume
Aortic Stenosis with
Bisferiens Pulse systolic peaks, similar to (due to regurgitation) and delayed ejection
Aortic Regurgitation
HOCM. (due to stenosis).
The regurgitation of blood into the right
A strong and forceful jugular
Severe Tricuspid Bounding Jugular atrium during systole leads to increased
venous pulse, often visible in
Regurgitation Pulse venous pressure and a prominent jugular
the neck.
pulse.

Pulse charcteristics in Congenital Heart Diseases

Congenital Heart Disease Pulse Characteristic

Normal, but may be diminished during cyanotic episodes
Tetralogy of Fallot (TOF)
("tet spells").
Patent Ductus Arteriosus (PDA) Bounding pulse with wide pulse pressure.
- Upper Extremities: Normal or bounding.
Coarctation of the Aorta - Lower Extremities: Weak or absent, with radiofemoral
delay.
Atrial Septal Defect (ASD) Generally normal, may have slightly increased amplitude.
- Small VSD: Generally normal.
Ventricular Septal Defect (VSD)
- Large VSD: May have a bounding pulse.
Transposition of the Great Arteries (TGA) Typically normal, but cyanosis is prominent.
Ebstein’s Anomaly Often normal; may be weak or irregular in severe cases.
Hypoplastic Left Heart Syndrome (HLHS) Weak and thready pulse.
Truncus Arteriosus Bounding pulse due to high stroke volume.
Total Anomalous Pulmonary Venous Return
Generally normal.
(TAPVR)

Pulse Characteristics in Cardiomyopathies and Pericardial Diseases

Condition Pulse Characteristic

Dilated Cardiomyopathy (DCM) Weak and thready pulse due to reduced cardiac output.
Condition Pulse Characteristic
Hypertrophic Obstructive Bisferiens pulse (double systolic peak) due to dynamic outflow
Cardiomyopathy (HOCM) obstruction.
Weak pulse, often with a rapid, low-volume character due to poor
Restrictive Cardiomyopathy
ventricular filling.
Pulsus paradoxus (exaggerated decrease in pulse amplitude
Cardiac Tamponade
during inspiration).
Pulsus paradoxus, though often less pronounced than in cardiac
Constrictive Pericarditis
tamponade.
Typically normal pulse, but may become weak as effusion
Pericardial Effusion without Tamponade
progresses.

MCQs

1. Which of the following arteries is most commonly used to measure the pulse in an adult?

• A) Carotid artery

• B) Radial artery

• C) Femoral artery

• D) Brachial artery

• Answer: B) Radial artery

• Explanation: The radial artery is most commonly used due to its accessibility and ease of palpation.

2. A dicrotic pulse is most likely to be seen in which of the following conditions?

• A) Hypertension

• B) Cardiomyopathy

• C) Aortic stenosis

• D) Mitral valve prolapse

• Answer: B) Cardiomyopathy

• Explanation: Dicrotic pulse is typically seen in low cardiac output states like cardiomyopathy.

3. Pulsus paradoxus is best described as:

• A) A decrease in systolic blood pressure during inspiration greater than 10 mmHg.

• B) An increase in pulse amplitude during inspiration.

• C) A pulse that alternates between strong and weak beats.

 • D) A bounding pulse with wide pulse pressure.

• Answer: A) A decrease in systolic blood pressure during inspiration greater than 10 mmHg.

• Explanation: Pulsus paradoxus is an exaggerated decrease in systolic BP during inspiration, often seen
in cardiac tamponade.

4. Which pulse characteristic is associated with aortic stenosis?

• A) Collapsing pulse

• B) Pulsus bisferiens

• C) Pulsus parvus et tardus

• D) Pulsus alternans

• Answer: C) Pulsus parvus et tardus

• Explanation: Aortic stenosis causes a weak and delayed pulse due to the obstruction of blood flow.

5. In which condition would you expect to find a bisferiens pulse?

• A) Mitral stenosis

• B) Aortic regurgitation

• C) Atrial fibrillation

• D) Tricuspid regurgitation

• Answer: B) Aortic regurgitation

• Explanation: Bisferiens pulse is often seen in aortic regurgitation, especially when associated with
aortic stenosis.

6. Which of the following conditions is least likely to present with a bounding pulse?

• A) Aortic regurgitation

• B) Hyperthyroidism

• C) Aortic stenosis

• D) Patent ductus arteriosus

• Answer: C) Aortic stenosis

• Explanation: Aortic stenosis typically presents with a weak pulse, not a bounding one.

7. Pulsus alternans is indicative of:

• A) Cardiac tamponade

• B) Severe left ventricular failure

 • C) Pulmonary embolism

• D) Mitral stenosis

• Answer: B) Severe left ventricular failure

• Explanation: Pulsus alternans, where the pulse alternates between strong and weak beats, is a sign of
severe left ventricular dysfunction.

8. Which artery is most commonly used for pulse measurement in infants?

• A) Radial artery

• B) Carotid artery

• C) Brachial artery

• D) Femoral artery

• Answer: C) Brachial artery

• Explanation: The brachial artery is preferred in infants because it is easier to palpate than the radial
artery.

9. Which of the following describes a regular irregular pulse?

• A) Atrial fibrillation

• B) Ventricular bigeminy

• C) Sinus arrhythmia

• D) Atrial flutter

• Answer: B) Ventricular bigeminy

• Explanation: Ventricular bigeminy is a regularly irregular pulse due to the repeating pattern of normal
and premature beats.

10. A collapsing pulse is most likely to be associated with:

• A) Aortic regurgitation

• B) Mitral stenosis

• C) Pulmonary hypertension

• D) Atrial septal defect

• Answer: A) Aortic regurgitation

• Explanation: A collapsing or "water hammer" pulse is characteristic of aortic regurgitation due to the
rapid backflow of blood into the left ventricle.
11. In which condition is radiofemoral delay commonly observed?

• A) Aortic regurgitation

• B) Coarctation of the aorta

• C) Mitral valve prolapse

• D) Hypertrophic cardiomyopathy

• Answer: B) Coarctation of the aorta

• Explanation: Coarctation of the aorta causes delayed femoral pulse relative to the radial pulse.

12. Which of the following best describes the pulse in hypertrophic obstructive cardiomyopathy (HOCM)?

• A) Pulsus parvus et tardus

• B) Pulsus bisferiens

• C) Dicrotic pulse

• D) Pulsus alternans

• Answer: B) Pulsus bisferiens

• Explanation: HOCM often presents with a bisferiens pulse due to the dynamic obstruction of blood
flow.

13. A weak and thready pulse is most indicative of:

• A) Hypertension

• B) Shock

• C) Aortic stenosis

• D) Mitral regurgitation

• Answer: B) Shock

• Explanation: A weak and thready pulse is commonly seen in shock due to poor cardiac output and
reduced peripheral perfusion.

14. Which of the following conditions is associated with a bounding pulse and wide pulse pressure?

• A) Cardiac tamponade

• B) Aortic stenosis

• C) Aortic regurgitation

• D) Pulmonary hypertension

• Answer: C) Aortic regurgitation

 • Explanation: Aortic regurgitation leads to a bounding pulse and wide pulse pressure due to increased
stroke volume and regurgitation of blood into the left ventricle.

15. Pulsus paradoxus is most commonly associated with which of the following conditions?

• A) Aortic stenosis

• B) Constrictive pericarditis

• C) Mitral stenosis

• D) Hyperthyroidism

• Answer: B) Constrictive pericarditis

• Explanation: Constrictive pericarditis and cardiac tamponade are commonly associated with pulsus
paradoxus.

16. Which pulse characteristic is associated with severe heart failure?

• A) Pulsus paradoxus

• B) Pulsus alternans

• C) Dicrotic pulse

• D) Collapsing pulse

• Answer: B) Pulsus alternans

• Explanation: Pulsus alternans is a sign of severe left ventricular failure and is indicative of poor cardiac
function.

17. A patient with atrial fibrillation is most likely to have which type of pulse?

• A) Regularly irregular

• B) Irregularly irregular

• C) Pulsus bisferiens

• D) Pulsus alternans

• Answer: B) Irregularly irregular

• Explanation: Atrial fibrillation is characterized by an irregularly irregular pulse due to the chaotic atrial
electrical activity.

18. Which of the following is not a cause of a dicrotic pulse?

• A) Typhoid fever

• B) Cardiomyopathy
 • C) Aortic stenosis

• D) Cardiac tamponade

• Answer: C) Aortic stenosis

• Explanation: Aortic stenosis typically causes a pulsus parvus et tardus, not a dicrotic pulse.

19. Which pulse is described as having a rapid upstroke followed by a sudden collapse?

• A) Pulsus bisferiens

• B) Pulsus alternans

• C) Collapsing pulse

• D) Pulsus paradoxus

• Answer: C) Collapsing pulse

• Explanation: A collapsing pulse, also known as a "water hammer" pulse, is characteristic of aortic
regurgitation.