Character of Pulse

by | 27 Mar, 2021

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The character of a pulse refers to its strength and volume, and can suggest various pathologies. The carotid pulse should be used when assessing the character of the pulse; palpation should show a smooth rapid upstroke and a more gradual downstroke with each pulse.

Pathological pulse characters

Waterhammer/Large volume pulse

A waterhammer pulse has a sharper upstroke and increased amplitude. It is typically caused by aortic regurgitation.

Slow-rising/Anacrotic pulse

A slow-rising pulse has, as the name suggests, a slower upstroke and reduce amplitude. It is typically caused by aortic stenosis

Pulsus bisfiriens

Pulsus bisfiriens has a character of two narrowly separated peaks during systole. It is caused by mixed aortic stenosis with aortic regurgitation valve disease.

Pulsus alternans

Pulsus alternans develops 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 a stronger contraction in the subsequent pulse due to Startling’s law.

A visual representation of normal and pathological pulses

Pulsus paradoxus

Pulses paradoxus refers to a large drop in pulse volume (corresponding to >10mmHg blood pressure) upon inspiration.


Double impulse apex beat

When palpating the apex beat, a feeling of 2 beats within a single systole is suggestive of 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


  1. Morris DC. The Carotid Pulse. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 20. Available from:


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