EpistemisBisferiens pulse
Specialty: Cardiovascular.
Why it occurs
- Severe aortic valve regurgitation isolated or associated with moderate aortic stenosis
- Hypertrophic obstructive cardiomyopathy (with dynamic left ventricular outflow tract obstruction)
- Severe hyperdynamic states with increased arterial stiffness
- Persistence of the ductus arteriosus with large volume flow
Initial workup
Complete transthoracic echocardiogram with tissue Doppler to rigorously quantify ventricular function, differentiate between fixed and dynamic obstruction of the left ventricular outflow tract, evaluate the dynamic and static transvalvular aortic gradient, estimate the thickness of the interventricular septum and the posterior wall, and quantify the regurgitation volume of the aortic valve; Holter electrocardiographic monitoring to rule out non-sustained ventricular tachycardia.
red flags
Detection of an arterial pulse with two distinguishable systolic peaks during gentle palpation of the carotid, radial or femoral artery, associated with repetitive stress syncope, oppressive anginal chest pain, dyspnea at rest or acute respiratory failure, a harsh ejective systolic murmur that increases in intensity with the Valsalva maneuver or a high-frequency aspiration diastolic murmur. Indicates advanced structural heart disease with critical hemodynamic overload and risk of lethal ventricular arrhythmias or sudden death.
Standard management
- Propranolol — non-selective beta blocker indicated of choice in obstructive hypertrophic cardiomyopathy to reduce the gradient of the ventricular outflow tract through a negative inotropic effect, and prolong diastole; 20 to 80 mg three or four times a day orally, adjusting according to clinical response and heart rate
- Verapamil — non-dihydropyridine calcium antagonist indicated as an alternative if beta-blockers are contraindicated; 120 to 360 mg daily in divided doses, monitoring blood pressure and monitoring for the development of conduction blocks
- Ramipril — ACEI indicated only if the bisferiens pulse is due to pure aortic insufficiency without a dynamic obstructive component to reduce afterload; 2.5 to 5 mg per day orally
- Furosemide (indicated with caution if there are symptoms of pulmonary congestion; 20 mg per day orally).
Educational guidance for study. It is NOT a prescription recommendation. The actual choice depends on the cause, the patient, and current guidelines.
- Area
- Cardiovascular
- Listed causes
- 4
- Treatment options
- 4