Pulse Character

by | 27 Mar, 2021

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The carotid pulse should be used when assessing the character of the pulse, which refers to the strength or volume of a pulse. The character of a pulse can suggest various pathologies.

Pathological characters

Waterhammer/Large volume pulse

Cause: Aortic regurgitation

Slow-rising/Anacrotic pulse

Cause: Aortic stenosis

Pulsus bisfiriens

Cause: Aortic stenosis with aortic regurgitation

Pulsus alternans

Occurs in left ventricular systolic impairment. The pulse alternates between low and high volume; a low ejection fraction produces the low volume pulse, which leads to ventricular filling and stronger contraction due to Startling’s law in the subsequent pulse.

A visual representation of normal and pathological pulses

Pulsus paradoxus

A large drop in pulse volume (corresponding to >10mmHg blood pressure) upon inspiration.


Double impulse apex beat

Cause: Hypertrophic obstructive cardiomyopathy (HOCM)

Absent radial pulse

Occasionally, a radial pulse may be completely absent and cannot be palpated or found on ultrasound.

Causes include:

  • Iatrogenic e.g. post-catheterisation, radial artery harvest
  • Congenital absence
  • Aortic dissection involving the subclavian artery
  • Peripheral artery embolism
  • Compression by cervical rib
  • Takayasu’s arteritis


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