What are the abnormal types of pulse?

From the Guidelines

Abnormal types of pulse include tachycardia, bradycardia, irregular pulse, bounding pulse, weak pulse, pulsus paradoxus, pulsus alternans, pulsus bisferiens, water-hammer pulse, and pulsus bigeminus, which can be associated with various cardiovascular conditions such as atrial fibrillation, cardiac tamponade, heart failure, and aortic regurgitation. These abnormal pulse characteristics can provide valuable information about heart rhythm, strength of cardiac contraction, and vascular resistance, and often warrant further cardiac evaluation including ECG, echocardiography, or other diagnostic tests depending on the suspected underlying condition 1.

Key Abnormal Pulse Types

• Tachycardia (rapid pulse >100 beats per minute)
• Bradycardia (slow pulse <60 beats per minute)
• Irregular pulse (arrhythmias like atrial fibrillation)
• Bounding pulse (strong and forceful as in high cardiac output states)
• Weak pulse (diminished amplitude as in shock or heart failure)
• Pulsus paradoxus (abnormal decrease in pulse strength during inspiration, seen in cardiac tamponade)
• Pulsus alternans (alternating strong and weak beats, indicating severe heart failure)
• Pulsus bisferiens (double-peaked pulse in aortic regurgitation)
• Water-hammer pulse (rapid upstroke and collapse in aortic regurgitation)
• Pulsus bigeminus (paired beats due to premature contractions)

Diagnostic Evaluation

Assessment of abnormal pulses should include rate, rhythm, amplitude, and special characteristics, with findings correlated with other clinical signs and symptoms. Further cardiac evaluation may be necessary, including ECG, echocardiography, or other diagnostic tests, depending on the suspected underlying condition 1.

Clinical Significance

Abnormal pulse types can be indicative of underlying cardiovascular conditions, and prompt recognition and evaluation are crucial to guide management and improve patient outcomes. The most recent and highest quality study, such as the 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay, provides valuable guidance on the diagnosis and management of abnormal pulse types 1.

From the Research

Abnormal Types of Pulse

The following are abnormal types of pulse:

• Pulsus paradoxus: an exaggeration of the normal inspiratory decrease in systolic blood pressure, defined as an inspiratory drop in systolic blood pressure >10 mm Hg 2, 3
• Pulsus alternans: an arterial pulse waveform that shows alternating strong and weak beats despite a regular rhythm, indicating severe left ventricular dysfunction and poor prognosis 4, 5
• Biventricular pulsus alternans: a rare condition characterized by regular rhythm with beat-to-beat alternation of systolic pressures in both ventricles, associated with severe left ventricular dysfunction and left anterior descending coronary artery disease 5

Clinical Conditions Associated with Abnormal Pulse Types

These abnormal pulse types can occur in various clinical conditions, including:

• Cardiac tamponade 2, 6
• Constrictive pericarditis 3, 6
• Asthma 2, 3
• Pulmonary embolism 5
• Left ventricular dysfunction 4, 5
• Coronary artery disease 5
• Systemic hypertension 5
• Aortic stenosis 5