Pulse deficit

With the introduction of auscultation in 1819 by Laennec, it soon became clear that in heart failure patients with irregular heartbeat not all heartbeats lead to a palpable peripheral pulse. This phenomenon was initially referred to as "pulsus deficiens", thus extending the 26 different types of pulse that Galen had characterized to date. However, this definition was not used uniformly.

It was not until 1912 that Robinson and Draper were the first to call the phenomenon of a missing peripheral pulse a "pulse deficit".

A pulse deficit is the difference between the auscultated heartbeat or the heartbeat verified by an ECG and the pulsation measured simultaneously in the periphery.

In their book " Rhythmusstörungen des Herzens", Dr. Dietrich Steinkopff Verlag, Tauer and Albers differentiate the pulse deficit into a complete and an incomplete one.

A complete deficit occurs when the ventricular contraction does not promote stroke volume, whereas in the case of an incomplete deficit the ventricular contraction promotes a stroke volume, but this is haemodynamically ineffective.

The pulse deficit is dependent on position and blood pressure. When the head is lowered, the pulse deficit measured at rest is reduced to a minimum and then returns to the previous values when the head is held upright.

Physical activity also influences the pulse deficit. Even with little physical activity, the pulse deficit already decreases. The cause lies in the increase in arterial pressure. With greater exertion (such as climbing stairs) the deficit can drop to zero. However, as soon as the arterial blood pressure is reduced, the previous pulse deficit reappears.

Implementation

2 examiners are required to measure a pulse deficit. One of them auscultates the heart and counts the auscultated heartbeats within a defined time.

The other examiner measures the radial pulse during this time and counts these beats as well.

Example: With 140 auscultated heartbeats and 80 radial pulse beats, the pulse deficit is 60 beats.

When there is a pulse deficit, the heart's contractions result in so-called frustrated contractions. The ventricles contract, but the stroke volume is not sufficient to trigger a pulse wave in the periphery.

A pulse deficit can be caused by

• absolute arrhythmia in atrial fibrillation (most common cause)
• extrasystoles
• severe hypotension (e.g. in shock)
• arterial circulatory disturbance in the measured extremity (in case of doubt, measure both extremities), etc.

The cardiac output decreases more and more as the pulse deficit increases, as does the cardiac output per minute.

Nevertheless, about 50 % of patients remain without any symptoms. In these cases the pulse deficit is diagnosed as a random finding during the examination. The other 50 % complain mainly about palpitations, reduced performance and occasionally also about presyncope.

The therapy is carried out depending on the underlying disease.

1. Dahmer J et al (2006) Anamnesis and findings. Thieme Publishing House 306
2. Füeßl H S (2001) Internal medicine in question and answer. Thieme Publishing House 123
3. Herold G et al (2018) Internal Medicine Herold Verlag 289
4. Lang E et al (1968) Experimental and clinical studies on the significance of the pulse deficit Basic Research in Cardiology. 55th Thieme Publishing House 104-123
5. Thauer R, Albers C (1969) Rhythm disorders of the heart. Conference of the German Society for Cardiovascular Research. Bad Nauheim from 11-13. 04.04.1969. Dr. Dietrich Steinkopff Verlag 191-192, 194-195, 197