Pulsus alternans

Not to be confused with pulsus paradoxus.

Pulsus alternans
File:Pulsus alternans trace.jpg Pulse pressure waveform displaying the variation in pressure between beats in pulsus alternans.
Classification and external resources
Specialty
DiseasesDB	11040
Patient UK	Pulsus alternans

Pulsus alternans is a physical finding with arterial pulse waveform showing alternating strong and weak beats. It is almost always indicative of left ventricular systolic impairment, and carries a poor prognosis.

Pathophysiology

In left ventricular dysfunction, the ejection fraction will decrease significantly, causing reduction in stroke volume, hence causing an increase in end-diastolic volume. There may initially be a tachycardia as a compensatory mechanism to try to keep the cardiac output constant. As a result, during the next cycle of systolic phase, the myocardial muscle will be stretched more than usual and as a result there will be an increase in myocardial contraction, related to the Frank–Starling physiology of the heart. This results, in turn, in a stronger systolic pulse .

Physical examination

File:Arterial Waveform.png

Arterial waveform.

Palpate radial or femoral arteries, feel for regular rhythm but alternating strong and weak pulses Use blood pressure cuff to confirm: Raise blood pressure cuff to over systolic level then, lower slowly towards the systolic level, if hearing alternating loud & soft korotkoff sounds, pulses alternans is indicated.

Clinical significance

Indicative of severe Left-sided heart failure

In literature

D.H. Lawrence, in his famous novel, "Sons and Lovers" elegantly describes pulsus alternans:

"Then he felt her pulse. There was a strong stroke and a weak one, like a sound and its echo. That was supposed to betoken the end."