Pulsus bisferiens

A bisferiens 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, such as aortic insufficiency, in which a large volume of blood is rapidly ejected from the left ventricle. The pulse can be palpated in peripheral arteries or observed on an arterial pressure wave recording. (See Detecting pulsus bisferiens and Comparing arterial pressure waves, page 548.)

History

After you detect a bisferiens pulse, review the patient’s history for cardiac disorders. Next, find out what medication he’s taking, if any, and ask if he has any other illnesses. Also ask about the development of any 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.

Physical assessment

Take the patient’s vital signs, and auscultate for abnormal heart or breath sounds. Then complete the cardiopulmonary assessment.

Medical causes

Aortic insufficiency

Aortic insufficiency is the most common organic cause of bisferiens 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, 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).

Aortic stenosis with aortic insufficiency

A bisferiens pulse is commonly seen in aortic stenosis that’s accompanied by moderately severe aortic insufficiency. In aortic stenosis, the pulse rises slowly and the second wave of the double beat is the more forceful one. This disorder is commonly accompanied by dyspnea and fatigue. Chest pain and syncope aren’t specific in the combined lesion, but they do suggest predominant aortic stenosis.

High cardiac output states

Pulsus bisferiens commonly occurs with high cardiac output states, such as anemia, thyrotoxicosis, 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.

Patient counseling

Teach the patient about the treatment of the underlying disorder. If the patient complains of fatigue, encourage him to take frequent rest periods throughout the day. Tell the patient to weigh himself daily and to report an increase of more than 3 lb (1.4 kg). Discuss signs and symptoms of heart failure to report to the health care provider.

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Book Source Details

• Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
• Author(s): Springhouse
• Year of Publication: 2007
• Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.

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More About This Book: Title: Signs & Symptoms: A 2-in-1 Reference for Nurses Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-58255-318-1

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