The Physical Examination in Cardiovascular Disease: The Pulse
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The pulse can be characterized by
- The rate
- The rhythm or regularity
- The strength
- The symmetry
Rate
Rate, expressed in beats per minute (bpm), is measured by counting over a timed period of 60 seconds. In patients with atrial fibrillation the rate should be measured by auscultation at the cardiac apex, because beats that follow very short diastolic intervals may create a 'pulse deficit' by not generating sufficient pressure to be palpable at the radial artery.
Tachycardia
This is generally defined as a pulse rate > 100 beats per minute.
Bradycardia
This is generally defined as a pulse rate < 60 beats per minute.
Rhythm
Normal sinus rhythm is regular, but in youngs may show phasic variation in rate during respiration (sinus arrhythmia). An irregular rhythm usually indicates atrial fibrillation, but may also be caused by frequent ectopic beats or self-limiting paroxysmal arrhythmias.
Irregulary Irregular
An irregularly irrgular pulse suggests atrial fibrillation or premature atrial contractions PAC.
Strength
Collapsing Pulse
A collapsing pulse is a pulse with a fast upstroke and fast downstroke.
Alternating pulse
An alternating pulse (pulsus alternans) is a pulse with alternating high and low systolic peaks, that occurs in severe left ventricular failure but the mechanism of this clinical situation is unknown.
Paradoxical pulse
A paradoxical pulse is a pulse with an inspiratory decline in systolic pressure >10 mmHg and occurs in cardiac tamponade, less frequently in constrictive pericarditis and obstructive pulmonary disease. It represents an exaggeration of the normal inspiratory decline in systolic pressure and therefore is not a truly paradoxical pulse.
Symmetry
Symmetry of the palpable arteries (radial, brachial, carotid, femoral, popliteal and pedal) should be confirmed. A reduced or absent pulse indicates an obstruction more proximally in the arterial tree. Coarctation of the aorta causes symmetrical reduction and delay of the femoral artery pulses compared with the radial artery pulses.
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