Pulse Character

Mnemonic

Each character names its lesion:

• Slow rising (pulsus tardus et parvus) - aortic stenosis
• Collapsing (water hammer) - aortic regurgitation, best felt with the arm raised
• Bisferiens, two peaks - mixed aortic valve disease
• Jerky - hypertrophic cardiomyopathy
• Pulsus alternans, alternating strong and weak - severe left ventricular failure
• Pulsus paradoxus, a fall of over 10 mmHg on inspiration - cardiac tamponade, severe asthma, constrictive pericarditis
• Bounding - carbon dioxide retention, sepsis, thyrotoxicosis, anaemia, pregnancy

“Slow rising is stenosis, collapsing is regurgitation” covers the two most often tested, and both are aortic.

Pulsus paradoxus is misnamed: it is an exaggeration of the normal inspiratory fall, not a reversal of it.

Radiofemoral delay points to coarctation, and a radioradial delay or unequal pressures to subclavian stenosis or aortic dissection.

Expansion

• Slow rising (pulsus parvus et tardus) - aortic stenosis; small volume with a delayed peak
• Collapsing (water hammer) - aortic regurgitation; rapid rise and fall from a wide pulse pressure. Also seen in patent ductus arteriosus and high output states
• Bisferiens - two systolic peaks; mixed aortic stenosis and regurgitation, or hypertrophic obstructive cardiomyopathy
• Pulsus alternans - alternating strong and weak beats; severe left ventricular failure
• Pulsus paradoxus - inspiratory fall of more than 10 mmHg; tamponade, severe asthma, constrictive pericarditis
• Jerky - hypertrophic obstructive cardiomyopathy

Radiofemoral delay points to coarctation of the aorta, and radioradial delay to subclavian stenosis or aortic dissection.

Note that pulsus paradoxus is not truly paradoxical; it is an exaggeration of the normal small inspiratory fall in systolic pressure.