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Pulsus paradoxus in pericardial disease

Barry A Borlaug, MD
Section Editor
Martin M LeWinter, MD
Deputy Editor
Brian C Downey, MD, FACC


Systemic blood pressure is not constant but varies slightly from heart beat to heart beat and between inspiration and expiration. Normally, the systolic blood pressure decreases by less than 10 mmHg during inspiration, but a decline of this magnitude is not detectable on examination of the peripheral pulse. Moderate to severe cardiac tamponade, and occasionally constrictive pericarditis, induce hemodynamic changes that enhance the inspiratory fall in systolic blood pressure. This exaggerated drop in systemic blood pressure during inspiration is termed pulsus paradoxus (waveform 1 and waveform 2).

Although Kussmaul named this phenomenon pulsus paradoxus, the paradox to which he referred was not the change in blood pressure but rather that the pulse palpated on examination is of variable strength, while precordial activity is regular [1]. The name is somewhat misleading, since the direction of systolic blood pressure change is the same as in normal subjects (albeit more exaggerated in pathologic instances) and is therefore not paradoxical.

Pulsus paradoxus will be discussed here, including its proper measurement, pathophysiology, and clinical conditions in which it may be present. Specific clinical conditions in which pulsus paradoxus may be present are discussed in greater detail separately. (See "Cardiac tamponade" and "Constrictive pericarditis".)


Pulsus paradoxus can be thought of as a direct result of competition (ie, enhanced chamber interaction) between the right and left sides of the heart for limited space; for the right heart to fill more, the left heart must fill less. The interaction of multiple forces results in the excessive inspiratory fall in systemic blood pressure, but enhanced chamber interaction, especially in cardiac tamponade, is by far the principal mechanism.

Although enhanced chamber interaction is the most important mechanism, several other complex mechanisms contribute [2].

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Literature review current through: Nov 2017. | This topic last updated: Nov 15, 2017.
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