In a patient with pulsus paradoxus, which triad of diagnoses should you consider?

• A. Pericarditis, pericardial effusion and an obstructive lung issue
• B. Endocarditis, MI and pulmonary embolism
• C. Stroke, TIA and carotid disease
• D. Heart failure, pleural effusion and pulmonary hypertension

Answer: (C)

Pulsus paradoxus is an exaggerated drop in systolic blood pressure with inspiration, reflecting impaired filling of the left ventricle as intrathoracic pressures fluctuate and the ventricles interact. This finding most strongly points to conditions that affect the pericardial space or cause large inspiratory pressure swings, such as pericardial disease (pericarditis or pericardial effusion with possible tamponade) and obstructive lung disease.

So the triad you should consider with pulsus paradoxus includes pericardial disease (pericarditis or pericardial effusion/tamponade) and an obstructive lung process. The other combinations involve cerebrovascular disease or non–pericardial cardiac issues, which don’t fit the typical mechanism behind pulsus paradoxus.