Pulse

1
Pulse
2
The pulse has been studied for centuries.

• Information gained
• Frequency, regularity
• Patency of peripheral arteries
• Characteristics of the arterial pressure pulse
  wave
• The arterial pulse contour changes to the
  periphery
• Resistance viscosity, vessel geometry opposes
  flow HR independent
• Inertia mass opposes rate of change of flow, HR
  dependent
• Compliance distensibility opposes changes of
  blood volume, HR-dependent

3
Location of Pulses

• Carotid similar to central aortic pulse (delay
  of 20msec)
• Radial used to assess the volume and
  consistency of the peripheral vessels.
• Brachial
• Femoral
• Posterior tibial
• Dorsalis pedis
• Look for any differences in the pulse amplitude,
  contour, or upstroke.

4
Factors Influencing the Pulse

• Stroke volume
• Rate of ejection
• Distensibility of peripheral arteries
• Peripheral resistance
• Pulse rate
• Pulse pressure
• Size of the vessel
• Distance from the heart

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Normal Pulse (1/2)

• The normal central aortic pulse wave is
  characterized by a fairly rapid rise to a
  somewhat rounded peak.
• The anacrotic shoulder, present on the ascending
  limb, occurs at the time of peak rate of aortic
  flow just before maximum pressure is reached.
• The less steep descending limb is interrupted by
  a sharp downward deflection, coincident with AV
  closure, called incisura.
• The pulse pressure is about 30-40 mmHg.

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Normal Pulse (2/2)

• As the pulse wave is transmitted peripherally,
  the initial upstrokes becomes steeper, the
  anacrotic shoulder becomes less apparent, and the
  incisura is replaced by the smoother dicrotic
  notch.

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Abnormal Pulses

• Inequality in the amplitude of the peripheral
  pulses
• Obstructive arterial diseases , most commonly
  artherosclerosis
• Aortic dissection
• Aortic aneurysm
• Takayasu arteritis (pulseless disease)
• Supravalvular aortic stenosis (fixed form of LVOT
  caused by narrowing of ascending aorta)

8
Pulsus Parvus

• The pressure is diminished, and the pulse feels
  weak and small, reflecting decreased stroke
  volume (e.g. heart failure), restrictive
  pericardial disease, hypovolemia, mitral
  stenosis, and increased peripheral resistance
  (e.g. exposure to cold, severe CHF).
• Pulsus Parvus et Tardus (weak and delayed)
  ?Aortic Stenosis

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Aortic Stenosis (1/2)

• LVOT obstruction
• Reduces SV, prolongs LV total ejection time, and
  retards the rate of initial stroke output into
  the aorta and distal arterial system.
• Anacrotic character (anacrotic pulse)
• Interruption of the upstroke of the carotid
  pulse. AS is likely to be hemodynamically
  significant when the anacrotic notch is felt
  immediately after the onset of the upstroke.

10
Aortic Stenosis (2/2)

• Delayed upstroke of the ascending limb (pulsus
  tardus)
• Prolonged LV ejection time.
• Appreciated by simultaneous palpation of carotid
  pulse and auscultation fo the interval between S1
  and S2.
• Normally the carotid pulse occurs closer to S1
  in severe AS closer to S2.
• Thrill (carotid shudder)

11
Bisferiens Pulse

• Increased arterial pulse with a double systolic
  peak.
• Second peak, the tidal wave, presumed to
  represent a reflected wave from the periphery.
• Causes hemodynamically significant AR
• HCM rarely palpable rapid LV ejection during
  early systole, rapid decline due to LVOT
  obstruction, and tidal wave from periphery.

12
Bigeminal Pulse

• Normal beat alternating with a premature
  contraction.
• SV of the premature beat diminished, and pulse
  varies in amplitude accordingly.
• May masquerade as pulsus alternans
• Causes decreased BP (e.g. severe HF, hypovolemic
  shock, cardiac tamponade) and peripheral
  resistance (e.g. fever), s/p aortic valve
  replacement.
• Present in normal individuals after exercise.

13
Pulsus Alternans (1/2)

• Variation in pulse amplitude occurring with
  alternate beats due to changing systolic
  pressure.
• When the cuff pressure is slowly released while
  taking BP, phase I Korotkoff sounds are initially
  heard only during the alternate strong beats
  with further release of cuff pressure, the softer
  sounds of the weak beat also appear.
• Degree of pulsus alternans can be quantitated by
  measuring the pressure difference between the
  strong and the weak beat.

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Pulsus Alternans (2/2)

• Causes
• Left ventricular failure usually accompanied by
  a left-sided S3.
• May be seen in patients with severe AR
• Frequently precipitated by ectopic beats
  (bigeminal pulse)
• Mechanisms
• Alternating preload and afterload, incomplete
  relaxation,
• Change in ventricular contractility, causing
  changes in end-diastolic volume and pressure.

15
Pulsus Paradoxus (1/2)

• Pressure drop gt 20 mmHg during inspiration.
• Normally, systolic arterial pressure falls 8-12
  mmHg during inspiration.
• Evaluated with sphygmomanometer
• when the cuff is slowly released the systolic
  pressure at expiration is first noted. With
  further slow deflation of the cuff, the systolic
  pressure during inspiration can also be detected.
  

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Pulsus Paradoxus (2/2)

• Causes
• Cardiac Tamponade
• COPD, hypervolemic shock
• infrequently in constrictive pericarditis and
  rescrictive cardiomyopathy.
• Mechanism
• Decreased LV-SV due to an increased RV-EDV and
  decreased LV-EDV during inspiration.
• In cardiac tamponade, the interventricular septum
  shifts toward the LV cavity during inspiration
  (reverse Bernheims effect) b/c of increased
  venous return to RV, decreasing the LV preload.
• Decrease in pulmonary venous return to the LV
  during inspiration also contributes to decreased
  LV preload.

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Bounding Pulses (1/2)

• A.K.A. water-hammer pulse or the Corrigan pulse.
• Most commonly in chronic, hemodynamically
  significant AR.
• Seen in many conditions associated with increased
  stroke volume PDA, large arteriovenous fistula,
  hyperkinetic states, thyrotoxicosis anemia, and
  extreme bradycardia.
• Not seen in acute AR, since SV may not have
  increased appreciably.

18
Bounding Pulses (2/2)

• Physical signs of aortic insufficiency are
  related to the high pulse pressure and the rapid
  decrease in blood pressure during diastole due to
  the AI
• Lighthouse sign (blanching flushing of
  forehead)
• de Musset's sign (head nodding in time with the
  heart beat)
• Ladolfi's sign (alternating constriction
  dilatation of pupil)
• Becker's sign (pulsations of retinal vessels)
• Müller's sign (pulsations of uvula)
• Corrigan's pulse (rapid upstroke and collapse of
  the carotid artery pulse)
• (Watson's) Water-hammer pulse
• Quincke's sign (pulsation of the capillary bed in
  the nail)
• Mayen's sign (diastolic drop of BPgt15 mm Hg with
  arm raised)
• Rosenbach's sign (pulsatile liver)
• Gerhardt's sign (enlarged spleen)
• Duroziez's sign (systolic and diastolic murmurs
  heard over the femoral artery when it is
  gradually compressed)
• Hill's sign (A 20 mmHg difference in popliteal
  and brachial systolic cuff pressures, seen in
  chronic severe AI)
• Traube's sign (a double sound heard over the
  femoral artery when it is compressed distally)
• Lincoln sign (pulsatile popliteal)
• Sherman sign (dorsalis pedis pulse is quickly
  located unexpectedly prominent in agegt75 yr)