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Seminar on Pulse Examination

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1. Introduction

"In the clinical evaluation of cardiovascular disorders, the physical examination is a reflection of underlying hemodynamics. A well-performed physical examination is necessary to provide an initial clinical impression of the type and severity of cardiac disease."

• Fuster and Hurst's The Heart, 15th Edition

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2. Sites of Pulse Examination

• Harrison's Principles of Internal Medicine, 22nd Edition (2025)

• Never examine both carotids simultaneously (risk of syncope/cerebral ischaemia)
• Never press hard - can precipitate carotid sinus hypersensitivity and syncope, especially in the elderly
• Always auscultate for a bruit before palpating

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3. Technique of Palpation

Radial Pulse

Brachial Pulse

Carotid Pulse

• Fuster and Hurst's The Heart, 15th Edition

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4. Characteristics of the Normal Pulse

• S Das, A Manual on Clinical Surgery, 13th Edition

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5. Rate

• Normal: 60-100 beats/minute
• Tachycardia: >100 bpm - seen in fever, shock, thyrotoxicosis, anaemia, anxiety, heart failure
• Bradycardia: <60 bpm - seen in heart block, hypothyroidism, athletic training, vasovagal

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6. Rhythm

• Regular: Normal sinus rhythm
• Regularly irregular: e.g., Wenckebach (Mobitz Type I), coupled extrasystoles (bigeminy)
• Irregularly irregular: Atrial fibrillation (the single most common cause), multiple ectopics

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7. Normal Arterial Pulse Waveform

• Anacrotic limb (upstroke): Rapid rise in pressure during ventricular ejection
• Systolic peak
• Dicrotic notch: Caused by closure of the aortic valve; separates systole from diastole
• Dicrotic limb (downstroke): Passive fall during diastole

1. Stroke volume
2. Ejection velocity
3. Vascular compliance
4. Systemic vascular resistance

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8. Abnormal Pulse Characters

8.1 Pulsus Parvus et Tardus ("Slow-rising, Low Amplitude")

• Small (parvus) and late-peaking (tardus) pulse
• Slurred upstroke, delayed peak, reduced amplitude
• Classic lesion: Severe Aortic Stenosis
• Also seen in: subvalvular/supravalvular aortic stenosis, fixed LV outflow obstruction
• On Doppler: mirrors the delayed contour as prolonged systolic ejection time

8.2 Water Hammer Pulse (Corrigan's Pulse / Collapsing Pulse)

• Bounding pulse with sharp rise and rapid collapse
• Due to: increased stroke volume + wide pulse pressure (high systolic, low diastolic)
• Classic lesion: Severe Aortic Regurgitation
• Also seen in: thyrotoxicosis, patent ductus arteriosus, AV fistulae, severe anaemia
• Clinical test: Raise the arm above the head while palpating the radial pulse - the collapsing quality becomes more apparent

8.3 Bisferiens Pulse ("Two Peaks in Systole")

• Two systolic peaks palpable in a single cardiac cycle
• Seen in:
  • Severe aortic regurgitation (often with mixed aortic valve disease)
  • Hypertrophic obstructive cardiomyopathy (HOCM) - spike-and-dome pattern: rapid first peak (percussion wave from initial unobstructed ejection), then a second tidal wave after mid-systolic obstruction sets in
  • Patients on intra-aortic balloon counterpulsation (IABP) - second pulse is diastolic

8.4 Anacrotic Pulse

• Notch or shoulder felt on the ascending limb of the pulse (anacrotic notch)
• Seen in severe aortic stenosis
• The upstroke is slow and interrupted

8.5 Dicrotic Pulse

• Exaggeration of the dicrotic notch, palpable as a second wave on the descending limb
• Seen in: septic shock, severe peripheral vasoconstriction, hypovolemic shock, cardiac tamponade
• Usually associated with hypotension and narrow pulse pressure

8.6 Pulsus Alternans

• Beat-to-beat alternation in pulse amplitude (one strong, one weak) in a regular rhythm, independent of respiration
• Mechanism: cyclic changes in intracellular calcium and action potential duration
• Classic lesion: Severe LV systolic dysfunction (also aortic stenosis)
• An ominous sign - suggests very profound ventricular systolic dysfunction
• May be associated with T-wave alternans on ECG, which increases arrhythmic risk
• Different from pulsus paradoxus - variations are NOT respirophasic

8.7 Pulsus Paradoxus

• Fall in systolic BP >10 mmHg during inspiration
• A misnomer - a small drop (<10 mmHg) with inspiration is actually normal
• Mechanism: Exaggerated interventricular dependence during inspiration
• Classic lesion: Cardiac tamponade
• Also seen in: Constrictive pericarditis, massive pulmonary embolism, severe obstructive lung disease (asthma/COPD), tension pneumothorax, hemorrhagic shock
• Measurement: Inflate BP cuff above systolic pressure. Deflate slowly. Note the pressure at which Korotkoff sounds first appear (expiration only) and the pressure at which they are heard with every beat. Difference >10 mmHg = paradoxus. Deflation must be slow.
• Pulsus paradoxus may be palpable at the brachial or femoral artery when >15 mmHg

• Harrison's Principles of Internal Medicine, 22nd Ed. (2025); Fuster and Hurst's The Heart, 15th Ed.

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9. Pulse Waveform Diagrams (Carotid)

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10. Pulse Volume and Amplitude

• Fuster and Hurst's The Heart, 15th Ed.

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11. Jugular Venous Pulse (JVP)

Differentiating JVP from Carotid Pulse

Normal JVP Waveform: a, c, v Waves; x, y Descents

JVP Abnormalities

• Tricuspid stenosis, pulmonary hypertension, pulmonary stenosis, right ventricular hypertrophy

• Complete heart block (irregular cannon waves), nodal/ventricular tachycardia, ventricular ectopics

• Atrial fibrillation

• Regurgitant flow back into RA during systole; in severe TR, merges with a wave

• Also: severe TR (rapid ventricular filling after large v wave)

• Normal: JVP falls on inspiration (increased venous return is accommodated)
• Kussmaul's sign: JVP rises on inspiration - seen in constrictive pericarditis, restrictive cardiomyopathy (and can be seen in RV infarction)

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12. Estimation of JVP / CVP

CVP (cm H₂O) = Vertical height of JVP pulsation above the angle of Louis + 5 cm

• No visible pulsation = CVP < 8 cm H₂O (normal)
• Pulsation at clavicle = ~10 cm H₂O
• Mid-neck = ~15 cm H₂O
• Angle of jaw = ~20 cm H₂O

• In very high CVP (constrictive pericarditis), the pulsation may not be visible until patient is standing
• In very low CVP, patient may need to be almost supine before pulsations appear
• Hepatojugular reflux: Sustained pressure on the liver for 10-15 seconds causes a transient rise in JVP >4 cm - suggests elevated central venous pressure or right heart failure

• Fuster and Hurst's The Heart, 15th Ed.

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13. Special Pulse Patterns - Summary Table

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14. Clinical Correlations

• Both: elevated JVP, pulsus paradoxus (tamponade > constrictive)
• Constrictive: prominent y descent + Kussmaul's sign; Tamponade: absent y descent, preserved x descent

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15. Key Points for Examinations

1. The pulse rate, rhythm, volume, character, and condition of the vessel wall must all be systematically assessed
2. Carotid pulse gives the best information about contour (character)
3. Pulsus paradoxus is measured with a BP cuff - a difference >10 mmHg between expiratory and all-cycle systolic is pathological
4. Pulsus alternans = regular rhythm + alternating amplitude = severe LV dysfunction
5. JVP is measured from the angle of Louis + 5 cm (total CVP)
6. Kussmaul's sign (JVP rises on inspiration) = constrictive pericarditis / restrictive cardiomyopathy
7. A prominent y descent favours constriction; absent y descent with prominent x favours tamponade
8. Bisferiens pulse - two systolic peaks - seen in HOCM (spike and dome) and severe AR

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• Fuster and Hurst's The Heart, 15th Edition - Physical Examination: Arterial and Venous Pulse
• Harrison's Principles of Internal Medicine, 22nd Edition (2025) - Cardiovascular Examination
• S Das, A Manual on Clinical Surgery, 13th Edition - Physical Examination
• Goldman-Cecil Medicine, International Edition - Auscultation and Jugular Veins
• Miller's Anesthesia, 10th Edition - Arterial Pulse Waveform Analysis