Pulsus bisferiens

A biferious pulse is a hyperdynamic, double-beating pulse characterized by two systolic peaks separated by a midsystolic dip. Both peaks may be equal or either may be larger; usually, however, the first peak is taller or more forceful than the second. The first peak (percussion wave) is believed to be the pulse pressure; the second (tidal wave), reverberation from the periphery. Pulsus bisferiens occurs in conditions in which a large blood volume is rapidly ejected from the left ventricle, as in aortic insufficiency. The pulse can be palpated in peripheral arteries or observed on an arterial pressure wave recording.

To detect pulsus bisferiens, lightly palpate the carotid, brachial, radial, or femoral artery. (The pulse is easiest to palpate in the carotid artery.) At the same time, listen to the patient’s heart sounds to determine if the two palpable peaks occur during systole. If they do, you’ll feel the double pulse between S₁ and S₂. (See Comparing arterial pressure waves, page 520.)

History and physical examination

After you detect a biferious pulse, review the patient’s history for cardiac disorders. Next, find out what medication he’s taking, if any, and ask if he has other illnesses. Also, ask about the development of associated signs and symptoms, such as dyspnea, chest pain, or fatigue. Find out how long he has had these symptoms and if they change with activity or rest. Then take his vital signs and auscultate for abnormal heart or breath sounds.

Medical causes

Aortic insufficiency

Aortic insufficiency is a heart defect that’s the most common organic cause of a biferious pulse. Most patients with chronic aortic insufficiency are asymptomatic until ages 40 to 50. However, exertional dyspnea, worsening fatigue, orthopnea and, eventually, paroxysmal nocturnal dyspnea may develop.

Acute aortic insufficiency may produce signs and symptoms of left-sided heart failure and cardiovascular collapse, such as weakness, severe dyspnea, hypotension, a ventricular gallop, and tachycardia. Additional findings include chest pain, palpitations, pallor, and strong, abrupt carotid pulsations. The patient may also exhibit widened pulse pressure and one or more murmurs, especially an apical diastolic rumble (Austin Flint murmur).

High cardiac output states

Pulsus bisferiens commonly occurs with high output states, such as anemia, thyrotoxicosis, a fever, and exercise. Associated findings vary with the underlying cause and may include moderate tachycardia, a cervical venous hum, and widened pulse pressure.

Hypertrophic obstructive cardiomyopathy

About 40% of patients with hypertrophic obstructive cardiomyopathy have pulsus bisferiens because of a pressure gradient in the left ventricular outflow tract. Recorded more often than it’s palpated, the pulse rises rapidly, and the first wave is the more forceful one. Associated findings include a systolic murmur, dyspnea, angina, fatigue, and syncope.

Special considerations

Prepare the patient for diagnostic tests, such as an electrocardiogram, chest X-ray, cardiac catheterization, or angiography, to help determine the underlying cause of the abnormal pulse.

Pediatric pointers

Pulsus bisferiens may be palpated in children with a large patent ductus arteriosus as well as those with congenital aortic stenosis and insufficiency.

Book Source Details

• Book Title: Handbook of Signs & Symptoms (Third Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.

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Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Handbook of Signs & Symptoms (Third Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-402-1

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