You notice a patient has a strong pulse and then a weak pulse. This pattern continues. Which of the following is likely?
A) Emphysema
B) Asthma exacerbation
C) Severe left heart failure
D) Cardiac tamponade
C) Severe left heart failure
This finding is consistent with pulsus alternans, which is associated with severe left heart failure. Occasionally, a monitor will read only half of the beats because half are too weak to detect. There may also be electrical alternans on EKG. This can be detected by using a blood pressure cuff and lowering the pressure slowly. At one point the rate of Korotkoff sounds will double, because the weaker beats can then “make it through.” The other findings are associated with paradoxical pulse.
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