Femoral pulse delayed compared to the radial (Femororadial delay)

Specialty: Cardiovascular.

• radio-femoral pulse delay
• asynchrony of radial and femoral pulses

Why it occurs

• Coarctation of the aorta (infaductal or postductal, typically diagnosed in young people with hypertension)
• Obstructive or complicated thoracic aortic aneurysm
• Severe atherosclerotic stenosis of the distal abdominal aorta
• Leriche syndrome (bilateral aortoiliac occlusion)
• Takayasu arteritis with involvement of the descending aorta

Initial workup

Simultaneous measurement of blood pressure in all four limbs (right arm, left arm, right leg, left leg) to document the systemic tension gradient (gradient >20 mmHg between arm and leg is highly pathognomonic of coarctation or dissection); Transthoracic Doppler echocardiogram to visualize the aortic arch (search for narrowness or turbulence in suprasternal projection); Computed tomography angiography (CT-Angio) of the thoracic and abdominal aorta (definitive study of choice); Chest x-ray to identify the sign of Roesler's costal notches (bone erosion due to dilated collateral intercostal arteries).

Standard management

• Metoprolol — beta blocker indicated if there is severe arterial hypertension in the upper limbs or if aortic dissection is confirmed, to reduce heart rate and blood pressure by reducing ventricular ejection force; 25 to 100 mg per day orally or intravenous infusion according to emergency protocol
• Enalapril — ACEI indicated for the long-term management of arterial hypertension in patients with coarctation of the aorta, strictly monitoring renal function after ruling out stenosis of the associated renal artery; 5 to 20 mg per day orally
• Atorvastatin — statin indicated to reduce the progression of aortic obstructive atherosclerotic disease; 40 mg once daily orally
• Acetylsalicylic acid (antiplatelet for the prevention of thrombotic events in arterial lesions; 100 mg per day orally).