Pulsus Paradoxus

Pulsus paradoxus is a decrease of more than 10 millimeters of mercury (mmHg) in the top number of your blood pressure when you breathe in. It’s a sign of a condition that affects your heart or lungs. But only your healthcare provider will notice it.

Pulsus paradoxus (pull-sus-pair-uh-dock-sus) happens because of pressure changes in and around your heart. These changes affect the filling of your heart chambers.

Blood in your heart chambers goes to your lungs to pick up oxygen. Then the blood goes to your body. A disease can limit the amount of blood your heart can handle. This limits how much blood your body’s cells can receive.

How to measure pulsus paradoxus

Using a manual blood pressure cuff, your healthcare provider will follow these steps:

• Inflate the cuff until they don’t hear pulse sounds with a stethoscope or ultrasound wand. They can also use a pulse oximetry monitor to find pulse sounds.
• Deflate the cuff slowly (2 mmHg per second) and listen for a pulse.
• Check the pressure while you’re breathing out.
• Deflate the cuff a little more.
• Check the pressure again while you’re breathing in and out and your provider can hear your pulse.
• Figure out the difference between the two top numbers from when you breathe in and breathe out.

You could have pulsus paradoxus if the difference between the numbers is higher than 10 mmHg.

Note: Providers can use a catheter in your artery (arterial line) to check for this symptom. They may use this method if you’re in intensive care.

If you have pulsus paradoxus, you may also have other symptoms from the condition that’s causing it. These may include:

• Chest pain or pressure
• Shortness of breath
• Dizziness
• Heart palpitations

What are the most common causes of pulsus paradoxus?

A large pericardial effusion is the most common cause. This is a buildup of too much fluid in the sac around your heart. This fluid presses on your heart because the sac can only stretch so much. When the fluid buildup squeezes your heart so much that blood can’t enter, it becomes cardiac tamponade.

Other pulsus paradoxus causes include:

• Heart problems: These include heart attack, poor heart function, stiffening of the sac around your heart (constrictive pericarditis) or stiffening of the muscles in the lower two heart chambers (restrictive cardiomyopathy).
• Lung issues: This includes asthma, excess fluid around your lungs (pleural effusion), collapsed lung, pulmonary embolism or chronic obstructive pulmonary disease (COPD).
• Problems you’re born with: This includes being born without a tricuspid valve in your heart (tricuspid atresia), having a sunken chest wall (pectus excavatum) or having compressed blood vessels in your upper chest (thoracic outlet syndrome, which you can also acquire).
• Other things that compress your heart: These include surgery or having a body mass index (BMI) greater than 30 (having obesity).

In causes of pulsus paradoxus that don’t involve the sac around your heart, both blood pressure numbers (top and bottom) usually fall.

What are the treatments for a condition with pulsus paradoxus?

Pulsus paradoxus isn’t an illness. You don’t need treatment for it. It can tell your provider if the lung or heart disease you have affects how well your heart chambers work. It can help your provider decide when to treat lung or heart disease.

Conditions that cause pulsus paradoxus make it hard for your heart or lungs to function. Some of these problems put pressure on those vital organs. Others involve narrow or blocked parts in your lungs or heart.

Treatment involves managing the underlying cause of this sign. This could mean relieving pressure on your organs. For others, treatment means opening narrow airways or heart valves. Treatments to resolve these issues in your heart or lungs may include:

• Medicines: Diuretics, steroids, blood thinners and NSAIDs can treat multiple conditions.
• Fluid drainage: This treats pleural effusion or cardiac tamponade.
• Air drainage: This treats a collapsed lung.
• Surgery: This treats pectus excavatum, cardiac tamponade, pulmonary embolism, collapsed lung, heart attack, pleural effusion and more.
• Physical therapy: This can help with thoracic outlet syndrome.
• Extra oxygen: This helps with COPD.
• Minimally invasive procedure: This can treat a heart attack or pleural effusion.

What are the possible complications or risks of not treating it?

Some conditions with a link to pulsus paradoxus need prompt treatment. These include cardiac tamponade and a collapsed lung. Delaying care could allow these issues to get worse.

Can this sign be prevented?

Staying current with treatment for lung and heart conditions can keep them in check. It may keep you from getting to a point where you could get pulsus paradoxus.

When should this be treated by a doctor or healthcare provider?

If you have pulsus paradoxus, your provider should treat what’s causing it right away. Prompt treatment typically gives you better results and may prevent other problems.

What is the difference between pulsus paradoxus and alternans?

Pulsus paradoxus is an abnormal drop in systolic blood pressure when you breathe in. With pulsus alternans, your systolic blood pressure changes from heartbeat to heartbeat.