Pulse parvus et tardus

Specialty: Cardiovascular.

• slow and late pulse
• carotid pulse of low amplitude and slow rise

Why it occurs

• Severe degenerative or rheumatic aortic valve stenosis
• Severe aortic coarctation (typically palpated in lower extremity pulses)
• Fixed obstruction of the left ventricular outflow tract
• Membranous aortic subvalvular stenosis
• Extreme systolic heart failure with critically low stroke volume

Initial workup

Two-dimensional transthoracic echocardiogram and continuous Doppler to quantify the aortic valve area by continuity equation (area <1.0 cm2 or <0.6 cm2/m2 of body surface indicates severity), evaluate the mean transvalvular gradient (>40 mmHg indicates severity) and the maximum gradient, as well as evaluate the LVEF; Low-dose dobutamine echocardiography in cases of suspected low-flow, low-gradient aortic stenosis with reduced ejection fraction; Coronary angiography prior to surgical or endovascular valve intervention (TAVI).

Standard management

• Nitroglycerin — use with extreme caution and under strict monitoring if there is concurrent chest pain, as patients with severe aortic stenosis and pulse parvus et tardus are critically dependent on preload; very low doses by infusion or sublingual spray, avoiding profound hypotension
• Furosemide — used with great care and in minimal doses in case of concomitant pulmonary congestion to avoid hemodynamic collapse; 10 to 20 mg orally or intravenously
• Atorvastatin — statin indicated to reduce global cardiovascular risk in patients with associated coronary atherosclerosis; 40 mg once daily orally
• Metoprolol (beta-blocker at very low doses only if strictly necessary to control associated rapid atrial fibrillation, ensuring that cardiac output is not critically decreased).