Pulsus alternans

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

Pulsus alternans is a physical finding with arterial pulse waveform showing alternating strong and weak beats.[1] It is almost always indicative of left ventricular systolic impairment, and carries a poor prognosis.


In left ventricular dysfunction, the ejection fraction will decrease significantly, causing reduction in stroke volume, hence causing an increase in end-diastolic volume. 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. There may initially be a tachycardia as a compensatory mechanism to try to keep the cardiac output constant.

Physical examination[edit]

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.[2]

Clinical significance[edit]

Indicative of severe Left-sided heart failure [3]

In literature[edit]

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

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....


  1. ^ Euler, DE (June 1999). "Cardiac alternans: mechanisms and pathophysiological significance.". Cardiovascular research. 42 (3): 583–90. PMID 10533597. doi:10.1016/s0008-6363(99)00011-5. 
  2. ^ Bates
  3. ^ (Bates)