Arterial pulse

Definition

Arterial pulse is defined as the rhythmic

expansion of the arterial wall due to
transmission of pressure waves along th
walls of the arteries, which are produced
during each systole of the heart.
Importance
Examination of the arterial pulse provides
physiological information regarding:
1. The working of the heart
2. The circulatory state and hemodynamics (blood
volume, blood pressure and so on)
3. The condition of the blood vessels
4. The state of autonomic activity in the body at
that moment
5. The mental state of the subject
6. The state of body metabolism and temperature
The Radial Pulse

The pulse recorded from the radial artery shows

the following waves.
The pulse wave has an upstroke and a
downstroke. The 'p' wave (percussion wave or
tidal wave) occurs due to ejection of blood from
the ventricle during systole.
The 'd' wave (dicrotic wave) occurs due to
rebound of blood against the closed aortic valve
during diastole.
'n' (dicrotic notch) represents the closure
of the aortic valve.

Sometimes, in the upstroke of the pulse

wave, a small 'a' or anacrotic wave is
seen, which occurs due to change in the
velocity of ejection of blood from the
ventricle towards late systole.
Method of
Examination of
Radial Pulse
Principle

With each ventricular contraction, not

only is the blood pumped into the aorta
but also pressure waves that are
transmitted along the walls of the
vessels are generated. These pressure
waves expand the arterial wall, and the
expansion is palpated as a pulse.
Blood flow speed varies
throughout the circulatory
system; it's fastest in the aorta
(around 30 cm/sec)and slowest
in the capillaries
(around1mm/sec),allowing for
efficient gas and nutrient
Procedure
The arterial pulses are detected by
gently compressing the vessel against
the bone. The radial pulse is examined
by compressing the radial artery against
the head of the radius. For better
elicitation of the pulse, the forearm of the
subject should be semipronated and the
wrist slightly flexed.
The following aspects (parameters) of the pulse
are studied.

1. Rate 2. Rhythm 3. Volume (amplitude)

4. Character
5. Condition of the arterial wall
6. Radiofemoral delay (presence or absence of
delay of the femoral pulses compared with the
radials)
7. Other peripheral pulses
Rate

Count the rate of the pulse, not

immediately after placing

the finger on the artery, but when the

nervousness of the patient subsides.
Count the pulse completely for one
minute.
Pulse rate should be counted only when the
pulse resumes its normal rate. Therefore, it is
advised to feel the radial pulse gently while
eliciting the history of the patient. The pulse
should be counted for a minimum of one
minute. The counting of pulse for 5 or 10
seconds and multiplying it by 12 or 6 to get the
rate per minute is not correct, at least for
beginners. The ideal time is 3 minutes and the
average of the three may be taken.
In conditions of irregularities of the heart,
the counting of radial pulse may not
reflect the true ventricular contractions.In
these conditions, the heart beat should
be counted by auscultating the apex. The
difference between the pulse rate and the
heart rate is called pulse deficit. It should
also be noted that the pulse rate can
never be more than the heart rate.
Rhythm

Rhythm is the spacing order at which

successive pulse waves are felt. When spacing
between all the waves is constant, the pulse is
said to be regular. When spacing is not
constant, the pulse is said to be irregular. The
irregular pulse may have a fixed pattern of
irregularity (irregular at regular intervals) or the
irregularity may not have any pattern
(irregularly irregular).
Volume

It is the degree of expansion of the arterial walls

during each pulse wave. Usually in physiological
conditions, the volume is normal and equal on
both the sides. Normal volume cannot be
described but only be appreciated by palpating
the artery of a normal individual. The pulse
volume gives an indication of the stroke volume
of the left ventricle.
Character

Study the character of the arterial pulse waves.

The character of a normal pulse is described as
'normal when no abnormalities are detected. The
abnormalities may be seen in rate, rhythm or
amplitude of the pulse. Depending on these
changes, various types of abnormal pulses are
described. It should be noted that the character
of the pulse is best appreciated by palpating the
carotid artery in the neck.
Condition of the Arterial Wall
Place three middle fingers on the artery to assess
the condition of the arterial wall. Obliterate the
flow of blood into the artery by pressing the index
finger(Proximal finger), and empty the vessel by
the ring finger(Distal finger). Then palpate the
artery with the middle finger. Roll the artery
against the bone to assess the thickness of the
arterial wall. Normally, the arterial wall is not
palpable or is just palpable. But, in old age, it is
well palpable (thickened) and may be tortuous.
Delay

Compare the appearance of the femoral

pulse with the appearance of the radial
pulse and mark if any delay is present
between them. Normally there is no
radio-femoral delay. Also compare with
the radial pulse of the opposite side.
Other Peripheral Pulses

Palpate the femoral, popliteal,

posterior tibial and dorsalis pedis
artery of both the sides and see if the
pulses are well felt and appear
simultaneously on both sides.
Pulse Rate
The normal pulse rate is 60-100 per minute. The heart
rate is primarily under the control of the autonomic
nervous system. The heart rate increases with
increased sympathetic activity and decreases with
increased parasympathetic activity. A heart rate of
more than 100 is called tachycardia, and less than 60
is called bradycardia. Normally, the heart rate is higher
in children and low in elderly persons. The heart rate
is higher in inspiration and lower in expiration.
Conditions that Alter Heart Rate

Tachycardia

A. Physiological

1.Exercise, 2.After eating, 3.Anger, 4.Emotion

and excitement,
5.Infants and children,
6.Pregnancy
7.High environmental temperature
In exercise, the heart rate increases due to sympathetic
stimulation and due to increased body temperature.
Increased sympathetic discharge to the SA node causes
tachycardia. Tachycardia occurs following eating due to
increased body metabolism that increases body
temperature. The heart rate increases in anger, emotion
and excitement due to increased sympathetic activity. The
exact cause of tachycardia in pregnancy is not known, but
it may be due to the direct action of progesterone on the
SA node.
II. Pathological
Fever Increased body temperature
causes tachycardia by directly
stimulating the SA node.

Anemia—-Tachycardia occurs in anemia

as a compensatory mechanism to
improve blood (oxygen) supply to the
tissues.
Thyrotoxicosis—Thyroxine increases the number of beta
receptors in the heart and also increases the sensitivity of the
beta receptors to catecholamines.

Beriberi

Paget's disease

Arteriovenous fistula

Heart failure
Paroxysmal atrial tachycardia

Ventricular or supraventricular
tachycardia

Other tachyarrhythmias

Shock as seen in hemorrhage

Bradycardia

I. Physiological

Athletes Heart rate is lower in athletes because

of their increased vagal tone
Fear
Grief
Very old age
Meditation and pranayama
II. Pathological

Myxedema In hypothyroidism, the number and

sensitivity of beta receptors to catecholamines
decreases.

Increased intracranial pressure, as in brain

tumours Increased intracranial pressure
decreases heart rate by activating Cushing's
reflex.
Obstructive jaundice—-»In obstructive
jaundice, the concentration of bile salt
increases in the blood. The toxic effect
of bile salt inhibits the SA node, and
therefore produces bradycardia.

Different types of heart block.

Drugs like propranolol and digitalis

Propranolol is a non-specific B-receptor

blocker. Therefore, it produces
bradycardia by inhibiting B-receptors of
the SA node. Digitalis produces
bradycardia by stimülating vagal nuclei
(increases vagal activity) in the medulla.
Rhythm

The normal rhythm is regular. Irregular rhythms may be

regularly irregular or irregularly irregular. Irregular rhythm
may be due to sinus irregularity or premature contraction.

Sinus Irregularity

This is called sinus arrhythmia. In this type of irregularity, the

pulse rate constantly changes with respiration. Normally, the
pulse rate is greater in inspiration than in expiration. In sinus
arrhythmia the variation of heart rate in expiration and
inspiration is more marked.
Premature Contraction
This is called extrasystole. It occurs due to
generation of impulse from an ectopic focus
present in the ventricle. Therefore, this is also
called ectopic beat.

Irregularly Irregular Pulse

This is commonly seen in atrial fibrillation. In this
condition, irregularity occurs not only in the
interval between the beats, but also in the
volume of the beats.
Irregularity Associated with Heart Blocks

1. Partial heart block with dropped beat

2. Atrial flutter with irregular block

In these conditions, irregularity occurs due to

block in conduction, which occurs irregularly.
Pulse Deficit

This is the difference between the pulse rate and the heart
rate. Normally, there is no pulse deficit. However, in
conditions of irregular rhythm some of the heart beats may
be weak. The heart may beat but the contraction may not be
sufficient enough to generate pressure waves in the walls of
the arteries. Therefore, the pulse rate may be less than that of
the rate of heart contraction. Pulse deficit is usually seen in
atrial fibrillation in which the deficit is more than ten. Pulse
deficit seen in other types of heart blocks is usually less than
ten.
Volume

The volume of the pulse is a rough guide to the pulse

pressure. Pulse pressure is the difference between the
systolic and diastolic pressure. The systolic pressure
mainly depends on the stroke volume and the diastolic
pressure on the compliance of the arteries. Therefore, the
volume of the pulse gives an indication of the stroke
volume and the compliance of the vessels. In normal
conditions, where the compliance of the vessels is
normal, the volume of the pulse mainly reflects the stroke
volume.
When the volume of the pulse decreases, the pulse is called
low volume pulse and when the volume increases, the pulse
is called high volume pulse.

Conditions that Alter the Volume of the Pulse

Low Volume Pulse

The low volume pulse is also known as pulsus parvus. It

occurs when the stroke volume of the heart decreases or
when the pulse pressure decreases.
Pulsus
parvus
Pulsus parvus is seen in:

1.Aortic stenosis
2.Obstructive cardiomyopathy
3.Pericardial effusion
4.Constrictive pericarditis
5.Pulmonary stenosis
6.Tight mitral stenosis
7.Shock due to any cause
High Volume Pulse

The high volume pulse is called pulsus magnus. It is seen in

conditions in which the stroke volume is greater and there is
widening of the pulse pressure. Pulsus magnus is seen in:

1.Aortic incompetence
2.Thyrotoxicosis
3.Patent ductus arteriosus
4.Beriberi
5.Anemia
6. Fever
7.Old age (due to increased pulse pressure)
8.Exercise
Pulsus
Magnus
Character

The character of a pulse is described as normal

when no abnormalities are detected. Different
types of abnormal pulses are described in
clinical medicine. Common among these are
anacrotic pulse, dicrotic pulse, water hammer
pulse, pulsus bisferiens, pulsus paradoxus and
pulsus alternans.
Anacrotic Pulse

This is also called anadicrotic pulse, which

means two upbeats. A secondary wave occurs in
the upstroke of the pulse. It is commonly found
in aortic stenosis. The upstroke is slow and
sloping. The anacrotic wave is exaggerated and
has 2 upbeats. Therefore, this pulse is called
anacrotic pulse.
Anacrotic
Pulse
Dicrotic Pulse

A better name for this

is 'twice-beating pulse.
The dicrotic wave is
prominent in this pulse
and gives the
impression of two
beats. Therefore, this
is called dicrotic pulse.
It is commonly seen in
febrile states,
especially in typhoid
fever.
Water Hammer Pulse

This is also called collapsing pulse or

Corrigan's pulse. This is typically seen
in aortic regurgitation. The collapsing
pulse is characterised by a rapid
upstroke and a rapid downstroke
(descent) of the pulse wave. A dicrotic
notch is usually absent. The rapid
upstroke is due to greatly increased
stroke volume and the rapid descent is
due to the collapse of the pulse. The
pulse pressure is therefore very high,
sometimes as high as 100 mm Hg
Causes
1. Common causes—Aortic
incompetence, Patent ductus arteriosus
2. Less common
causes—--Arteriovenous
fistula,Ventricular septal defect (VSD)
Hyperkinetic circulatory states, for
example, thyrotoxicosis, severe anemia
and beriberi
The collapsing pulse is better appreciated when
the patient's arm is elevated and the wrist is
grasped with the palm (of the examiner's hand)
against the palmar surface of the wrist.

The steep rise of the ascending limb of the pulse

wave is due to increased end diastolic volume
(EDV) of the left ventricle, which causes forceful
ejection of blood during systole.
This is because during diastole. in addition to the
ventricular filling from the left atrium, the filling
also occurs from the aorta through the
incompetent aortic valve. The aortic valve does
not close completely, so blood from the aorta
enters into the left ventricle during diastole. This
increases the total EDV of the left ventricle. So,
during systole, the force of contraction of the left
ventricle increases due to the Frank-Starting
mechanism. Therefore, there is a steep rise in the
percussion wave during systole.
The steep fall of the descending limb of the
pulse wave is due to the collapse (sudden
disappearance) of the pulse wave from the
palpating hand. This occurs due to two factors

1. the diastolic run-off of blood into the left

ventricle and

2. rapid run-off of blood into the periphery

because of decreased systemic vascular
resistance.
Pulsus Bisferiens

Pulsus bisferiens is a
combination of the low-rising
pulse (anacrotic pulse) and
the collapsing pulse This is
typically seen in aortic
stenosis associated with
aortic incompetence.
Pulsus Paradoxus

This is a misnomer since there is nothing

paradoxical in this type of pulse. Actually this is
an accentuation of the normal phenomenon
where the volume of the pulse decreases during
inspiration and increases during expiration. In
pulsus paradoxus, during inspiration. the volume
of the pulse is grossly decreased, or may be
absent in severe cases.
Pulsus
Paradoxus
Causes

1. Common causes

Constrictive pericarditis

Pericardial effusion
2. Less common causes

• Emphysema

Asthma (in the acute phase of severe asthma)

Massive pleural effusion

A mass in the thorax

Advanced right ventricular failure

Mechanisms (physiological basis)

1. During inspiration, the intrathoracic pressure

becomes more negative. Blood pools in the
pulmonary vascular bed. This decreases venous
return to the left atrium. So, left atrial filling
decreases, which results in decreased left
ventricular stroke volume. Therefore, the volume
of the pulse decreases in inspiration. This is
more accentuated in the above conditions.
2. During inspiration, the
intra-pericardial pressure increases due
to the traction from the attachments
referred to the pericardium. This
decreases venous return to the heart
and results in low stroke volume. This
is accentuated in pericardial effusion
and constrictive pericarditis.
3. In constrictive pericarditis and
pericardial effusion, the filling of the atria
and ventricles decreases due to
restriction to the expansion of the heart
chambers.The limitation in the diastolic
filling of the atria and the ventricles
during inspiration results in lowering of
left ventricular stroke volume.
4. In advanced stages of right ventricular
failure, increase in lung volume in
inspiration accommodates more blood
than normal due to much decreased
pulmonary vascular resistance. There is a
such decreased right ventricular output.
These two factors result in decreased left
ventricular stroke volume (Decreased
venous return to left atrium).
5. In acute and severe bronchial
asthma, the increased respiratory effort
makes intrathoracic pressure more
negative during inspiration. So, there is
more pooling of blood in the pulmonary
veins, which results in decreased left
ventricular stroke volume.
Pulsus Alternans

The pulse is regular, but alternate beats are strong and

weak. It is difficult to appreciate pulsus alternans by
palpating the artery. Diagnosis is confirmed while
measuring blood pressure. There will be a difference of
5-20 mm Hg in the systolic pressure between two
alternate beats. When the mercury is being lowered, the
stronger beats are heard first, and on further lowering,
the weaker beats also become audible, thus suddenly
doubling the number of audible beats.
Causes

1. Left ventricular failure This

is the commonest cause of
pulsus alternans.
2. Toxic carditis
Physiological basis.
In left ventricular failure, because of the decreased
myocardial contractility, the left
ventricular stroke volume decreases. This results in low
pulse volume. So, the amount of blood left in the ventricle at
the end of systole (end systolic volume of the left ventricle)
increases. Therefore, prior to the next ventricular
contraction, the ventricular volume (EDV) is also increased.
This increases the force of contraction of the left ventricle
in the next beat due to the Frank-Starling mechanism.
Hence, the second beat becomes stronger. Likewise, the
strong beats alternate with the weak beats.
Condition of the Arterial Wall

Normally, in young individuals, the arterial wall is

soft and elastic or may not be palpable. In the
elderly, it is palpable, hard and may be tortuous.
This is due to thickening of the arterial wall by
atherosclerosis. In such a condition, the brachial
and temporal arteries may be quite prominent
and tortuous. The brachial artery may exhibit a
typical dancing movement with each beat, called
locomotor brachii.
Radio-femoral Delay

Normally, there is no delay between the appearance of pulse

in the radial and femoral artery. Radio-femoral delay is
typically seen in coarctation of the aorta (especially when the
constriction is present distal to the origin of the left
subclavian artery).

Other Peripheral Pulses

In the absence of any pathology, all the peripheral pulses are

well felt and appear simultaneously on both sides. Peripheral
pulses may not be felt properly in peripheral vascular
diseases.
Why is the HR reduces during sleep?

Ans. Sympathetic activity decreases and

parasympathetic activity increases in
sleep than in the awake state .
Therefore HR is lower in sleep than in
awake state.
What is the cause of bradycardia in increased intracranial
pressure?

Ans. When intracranial pressure increases as seen in a brain

tumour, the blood flow to the vasomotor centre (VMC) in the
medulla decreases because of the compression of
intracranial blood vessels. This causes local hypoxia and
hypercapnia, and stimulates VMC, which results in intense
vasoconstriction. This is called Cushing's reflex.
Vasoconstriction increases blood pressure, which stimulates
baroreceptors, and the activation of baroreceptor reflex
results in bradycardia. Therefore, bradycardia rather than
tachycardia is one of the important clinical features of raised
intracranial pressure.
18. What is the relationship between pulse rate and blood
pressure?

Ans. Pulse rate is inversely proportional to the blood

pressure but not vice versa. This is called Mary's law. When
blood pressure increases, the baroreceptors present in the
arterial side of the circulation are stimulated. This activates
the baroreceptor reflex, which results in bradycardia and
hypotension. Conversely, when blood pressure decreases,
there is tachycardia. Therefore, heart rate is inversely
proportional to the blood pressure. But, blood pressure
may not change with change in heart rate.