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Normal

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Small, Weak Pulses

Large, Bounding Pulses

Bisferiens Pulse

Pulsus Alternans

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Paradoxical Pulse

Bigeminal Pulses

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The pulse pressure is about 30-40 mm Hg. The pulse contour is smooth and rounded. (The notch on the descending slope of the pulse wave is not palpable.)

The pulse pressure is diminished, and the pulse feels weak and small. The upstroke may feel slowed, the peak prolonged. Causes include (1) decreased stroke volume, as in heart failure, hypovolemia, and severe aortic stenosis, and (2) increased peripheral resistance, as in exposure to cold and severe congestive heart failure.

The pulse pressure is increased and the pulse feels strong and bounding. The rise and fall may feel rapid, the peak brief. Causes include (1) an increased stroke volume, a decreased peripheral resistance, or both, as in fever, anemia, hyperthyroidism, aortic regurgitation, arteriovenous fistulas, and patent ductus arteriosus, (2) an increased stroke volume due to slow heart rates, as in bradycardia and complete heart block, and (3) decreased compliance (increased stiffness) of the aortic walls, as in aging or atherosclerosis.

A bisferiens pulse is an increased arterial pulse with a double systolic peak. Causes include pure aortic regurgitation, combined aortic stenosis and regurgitation, and, though less commonly palpable, hypertrophic cardiomyopathy.

The pulse alternates in amplitude from beat to beat even though the rhythm is basically regular (and must be for you to make this judgment). When the difference between stronger and weaker beats is slight, it can be detected only by sphygmomanometry. Pulsus alternans indicates left ventricular failure and is usually accompanied by a left-sided S3.

This is a disorder of rhythm that may masquerade as pulsus alternans. A bigeminal pulse is caused by a normal beat alternating with a premature contraction. The stroke volume of the premature beat is diminished in relation to that of the normal beats, and the pulse varies in amplitude accordingly.

A paradoxical pulse may be detected by a palpable decrease in the pulse's amplitude on quiet inspiration. If the sign is less pronounced, a blood-pressure cuff is needed. Systolic pressure decreases by more than 10 mm Hg during inspiration. A paradoxical pulse is found in pericardial tamponade, constrictive pericarditis (though less commonly), and obstructive lung disease.

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