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A small weak pulse, pulsus parvus, is common in

conditions with a diminished left ventricular stroke
volume, a narrow pulse pressure, and increased
peripheral vascular resistance.
A hypokinetic pulse may be due to hypovolemia, to left
ventricular failure, to restrictive pericardial disease, or to
mitral valve stenosis.
pulsus tardus, In aortic valve stenosis, the delayed
systolic peak results from obstruction to left ventricular
Large, bounding (hyperkinetic) pulse is usually associated
with an increased left ventricular stroke volume, a wide
pulse pressure, and a decrease in peripheral vascular
resistance. This pattern occurs characteristically in
patients with an elevated stroke volume, as in complete
heart block; with hyperkinetic circulation due to anxiety,
anemia, exercise, or fever; or with a rapid runoff of blood
from the arterial system (as caused by a patent ductus
arteriosus or peripheral arteriovenous fistula). Patients
with mitral regurgitation or a ventricular septal defect
may also have a bounding pulse, since vigorous left
ventricular ejection produces a rapid upstroke in the
arterial pulse, even though the duration of systole and the
forward stroke volume may be reduced. In aortic
regurgitation, the rapidly rising, bounding arterial pulse
results from an increased left ventricular stroke volume
and an increased rate of ventricular ejection.
The bisferiens pulse, which has two systolic peaks, is
characteristic of aortic regurgitation (with or without
accompanying stenosis) and of hypertrophic
The dicrotic pulse has two palpable waves, one in systole
and one in diastole. It usually denotes a very low stroke
volume, particularly in patients with dilated
Pulsus alternans is a pattern in which there is regular
alteration of the pressure pulse amplitude, despite a
regular rhythm (Fig. 225-2). It is due to alternating left
ventricular contractile force, usually indicates severe
impairment of left ventricular function, and commonly
occurs in patients who also have a loud third heart sound.
Pulsus alternans may also occur during or following
paroxysmal tachycardia or for several beats following a
premature beat in patients without heart disease