ABNORMAL FINDINGS IN PULSEAbnormality can be in the:

Rate

Rhythm

Volume

Character

Condition of vessel wall

Radiofemoral delay

ABNORMAL FINDINGS IN PULSE RATE

1.Tachycardia(Pulse Rate>100 bpm)

2.Bradycardia(Pulse Rate<60 bpm)

TACHYCARDIASinus rhythm Arrhythmia

Exercise Atrial Fibrillation

Infants Atrial flutter

Excitement/Anxiety Ventricular Tachycardia

Pheochromocytoma

Fever

Hyperthyroidism

MEDICATION:

Ca channel blockers(Nifedipine)

Sympathomimetics(e.g. salbutamol)

Vasodilators

BRADYCARDIA

Sinus rhythm Arrhythmia

Sleep Carotid Sinus hypersensitivity

Athletic training Sick Sinus Syndrome

Hypothyroidism Second-Degree heart block

MEDICATION: Complete heart block

Beta-blockers

Digoxin

Verapamil, Diltiazem

ABNORMAL FINDINGS IN RHYTHM

If Irregular:

Occasionally irregular

Regularly Irregular

Irregularly Irregular

CAUSES OF AN IRREGULAR PULSEOccassionally Irregular Pulse

• Extrasystole

Regularly Irregular Pulse

• Ectopic beat occuring at a regular interval

• Second degree atrioventricular block

• Sinus arrhythmia

Irregularly Irregular Pulse

• Atrial Fibrillation

• Multiple ectopics

PULSE APEX DEFICITDifference in heart rate and

pulse rate

Atrial Fibrillation (>10/min)

Multiple ectopics (<10/min)

ABNORMALITIES IN PULSE VOLUME

High Volume Pulse

Low Volume Pulse

Varying Volume

High Volume PulsePhysiological causes:Exercise

Pregnancy

Advanced Age

Increased Environmental

Temperature

Pathological causes• Arteriosclerosis

• Aortic regurgitation

• PDA

• Arteriovenous fistula

• Fever

• Thyrotoxicosis

• Anaemia

• Beri-Beri

• Complete heart block

• Cirrhosis liver

Low Volume PulseCauses:

Left Ventricular Failure

Hypovolemia

Peripheral arterial disease

Shock

Severe Aortic Stenosis

Pericardial Effusion

Varying Volume Combination of low, normal or high

volume pulse in varying manner

Seen in:

Atrial fibrillation

Ventricular Tachycardia

CONDITION OF VESSEL WALLCan be:

Normal-Soft

Thickened-firm to hard and cord-like

Elderly due to artherosclerosis

CHARACTER OF PULSE Collapsing pulse

Slow rising pulse

Pulsus bisferiens

Pulsus parvus et tardus

Pulsus bigeminus

Pulsus alternans

Pulsus paradoxus

Anacrotic pulse

Dicrotic pulse

Collapsing pulse/Water-hammer pulse/Corrigan’s pulse

Collapsing pulse Sharp rise

Ill-sustained

Sharp fall

Wide pulse pressure(>80mmHg)

High volume collapsing pulse in:

Aortic regurgitation

PDA

Normal volume collapsing pulse in:

Mitral Regurgitation

Mechanism

In aortic regurgitation, during diastole:

Left ventricle receives

normal pulmonary venous return+portion of blood

ejected into the aorta => large stroke volume-

vigorously ejected=> rapidly rising carotid pulse

Collapses in early diastole – backflow through

aortic valve

Exaggerated at the radial artery by liftng the

arm.

Slow Rising Pulse Gradual upstroke with a reduced peak

Occur late in systole

Seen in severe aortic stenosis

Mechanism

Fixed obstruction restricts the rate at which

blood can be ejected from the left ventricle.

Pulsus Bisferiens Increased pulse with double systolic peak

seperated by a distinct mid-systolic dip.

Causes:

Aortic regurgitation

Concomitant aortic stenois and regurgitation

Pulsus Parvus et Tardus Weak and delayed pulse

Seen in conditions with:

diminished left ventricular stroke volume

Narrow pulse pressure

Increased peripheral vascular resistance

Aortic stenosis

Pulsus bigeminus Regular alteration of pulse pressure

amplitude.

Caused by premature ventricular contraction that follows each regular beat

Occurs in:

AV block

Sinoatrial block with Ventricular Escape

Pulsus alternans Beat-to-beat variation in pulse volume with a

normal rhythm.

Rare

Occurs in :

Advanced heart failure

Toxic myocarditis

Paroxysmal Tachycardias

Following Premature beat

Pulsus Paradoxus Exaggeration of the normal variability of

pulse volume with breathing.

Inspiratory decline in systolic pressure greater than 10mm Hg.

Occurs in:Cardiac tamponade

Constrictive pericarditis

Percardial effusion

Anacrotic Pulse Slow rising

Double beating pulse

Both waves felt in systole

Seen in Aortic Stenosis

Dicrotic Pulse Twice beating

First wave in systole, second wave in

diastole

Seen when PR and DP is low

Felt due to hypotonia of vessel wall

Seen in:

Fever (e.g. typhoid fever)

CCF

Cardiac Tamponade

RADIO-FEMORAL DELAY Most common cause: Coarctation of aorta

Children:

Upperlimb pulses are usually normal

Reduced volume lowerlimb pulses

Adults:

Usually presents hypertension and heart failure

Other causes:

• Atherosclerosis of aorta

• Thrombosis or embolism of aorta

OTHER PERIPHERAL PULSATIONS

Normal-All pulsations felt equally

Absence of peripheral pulsations:

Peripheral vascular disease

Coarctation of aorta- decreased and delayed

femoral pulsation

Takayasu’s disease: decreased upper limb

pulsation

CAUSES OF ABSENT RADIAL PULSE

Anatomical abnormality

Severe atherosclerosis

Takayasu arteritis (Pulseless disease)

Embolism in radial artery

Death

ABNORMAL FINDINGS IN JUGULAR VENOUS PULSE

Raised in :

Right sided heart failure caused by chronic

pulmonary hypertension in severe lung

disease(COPD)

Cor pulmonale

Increased intrathoracic pressure-tension

pneumothorax or severe acute asthma.

Massive pulmonary embolism- very high JVP

Giant ‘a’ wave: Tricuspid valve stenosis

Cannon ‘a’ wave: Complete heart block & Ventricular tachycardia

Giant ‘v’ wave: Tricuspid Regurgitation

Prominent ‘x’ and ‘y’ descents: Constrictive pericarditis

THANK YOU