What is pulsus alternans ?

Pulsus alternans is characterised by high and low volume of pulse which is due to alternate high and low stroke

In pulses alternans the alternate pulse waves are weak that is of low volume. In contrast to the ectopics, the rhythm remains regular. In a patient with severe left ventricular failure, pulsus alternans is said to be present.This is better demonstrated in radial arteries in LVF. This is seen due to the some ventricular muscle fibres are healthy and others are degenerated and so, produces normal and weak beat respectively. 

You should always search for gallop rhythm and basal crepitations when pulsus alternans is felt.

What is the mechanism of pulses alternanas ?

This is a reflex mediated process, initiated by an extra systole in LVF, that is sensed by the sensitive baroreceptors of the Carotid sinus. Left ventricular contraction following an extrasystole is strong as there is more diastolic filling during compensatory pause,  which increase the stroke volume hence the pulse volume is increased. This is sensed by the baroreceptors of the Carotid sinus and in turn send inhibitory impulse to atria via Carotid vagoatrial reflex resulting in weak contraction of atria, ventricular filling is reduced and stroke volume and pulse volume is reduced , which is again sensed by the baroreceptor which send the facilitator impulses via Carotid sympathetic atrial reflex resulting in increased atrial contraction and ventricular filling is increased  and also stroke volume is increased hence pulse volume is increased. This reflex activity occuring alternatively producing high and low pulse volume.

How will you demonstrate the Pulses alternans ?

It can be can be felt by palpating fingers but definite demonstration is by sphygmomanometer. Occlude the pulse by raising the pressure, then you should slowly reduce the pressure. Initially the Korotkoff sounds due to the passage of the high volume pulse is heard, further reduction will allow the passage of the weak beat also.

This will produce sudden doubling of the Korotkoff sounds called  as  Gallavardin sign.

Role of diuretics in heart failure

Diuretics are used in heart failure because of 

• Rapid relief of symptoms
• Controls fluid retention
• Appropriate use of diuretics is the key element in the success of other drugs

Diuretics used are

Thiazide diuretics

Loop diuretics

Metalazone 

Potassium sparing diuretics

Thiazide diuretics 

Useful alone or in combination with other diuretics in chronic mild HF

K+ depletion and metabolic alkalosis can occur

Suited only if GFR >50%of normal

Metalazone

Site of action and potency similar to the thiazides 

Effective in the presence of moderate renal failure

Both metolazone and thiazides potentiate intravenousloop diuretics 

Furosemide, Bumetanide, and torsemide

Useful in all forms of HF, particularly in refractory HF and pulmonary edema.

Effective in patients with hypoalbuminemia, hyponatremia, hypochloremia, and with reductions in glomerular filtration rate

The action may be potentiated by I.V.administration and by the addition of other diuretics

Potassium sparing diuretics

Spironolactone acts by competitive inhibition of aldosterone

Amiloride and triamterene act directly on the distal tubule/collecting duct. 

Most effective with loop and/or thiazide diuretics.

Lower dose of spironolactone (25 mg/d), prolong life in patients with advanced HF.

Framingham criteria for diagnosis of congestive cardiac failure

Major criteria 

Paroxysmal nocturnal dyspnea 

Neck vein distention 

Rales 

Cardiomegaly 

Acute pulmonary edema 

S3 gallop 

Increased venous pressure

Positive hepatojugular reflux 

Minor criteria 

Extremity edema 

Night cough 

Dyspnea on exertion 

Hepatomegaly 

Pleural effusion 

Vital capacity reduced by one-third from normal 

Tachycardia (120 beats/min)