Pulsus bisferiens is a hyperdynamic, double-peaking systolic pulse, characterized by two distinct systolic peaks separated by a midsystolic dip. The first peak (percussion wave) reflects the initial ejection of blood from the left ventricle, and the second peak (tidal wave) represents a peripheral reflection or reverberation. Typically, the first peak is taller or more forceful than the second.

This pulse pattern occurs in conditions where a large stroke volume is rapidly ejected, such as aortic insufficiency, high-output states, or hypertrophic obstructive cardiomyopathy. The pulse can be palpated in peripheral arteries or recorded on an arterial pressure waveform.

Pathophysiology

• Rapid left ventricular ejection: Produces two systolic peaks, often associated with wide pulse pressure.

• Peripheral wave reflection: The second peak arises from reflected waves in the arterial tree.

• Associated cardiac conditions: Increased stroke volume, hyperdynamic circulation, or obstruction of left ventricular outflow contribute to the characteristic waveform.

Detection

• Palpation: Lightly palpate carotid, brachial, radial, or femoral arteries. The carotid artery is often the easiest site.

• Auscultation: Listen to heart sounds; the two palpable peaks should occur between S1 and S2.

• Waveform analysis: Arterial pressure tracings can clearly differentiate pulsus bisferiens from normal, pulsus alternans, or pulsus paradoxus.

History and Physical Examination

• Review cardiac history and current medications.

• Ask about associated symptoms: dyspnea, chest pain, fatigue, palpitations.

• Determine the duration, triggers, and variability of symptoms with activity or rest.

• Record vital signs and auscultate for abnormal heart or lung sounds.

Medical Causes

Special considerations

• Prepare for diagnostic tests: ECG, chest X-ray, echocardiography, cardiac catheterization, or angiography to determine the underlying cause.

• Monitor for heart failure signs, hypotension, or arrhythmias.

Patient counseling

• Educate about recognizing heart failure symptoms and when to seek care.

• Advise planning rest periods to reduce cardiac workload.

• Emphasize adherence to medical therapy and follow-up appointments.

Pediatric pointers

• Pulsus bisferiens may be observed in children with large patent ductus arteriosus, congenital aortic stenosis, or aortic insufficiency.

• Assessment may require calm and cooperative positioning to accurately palpate the double systolic peak.

References

1. Buttaro TM, Tybulski J, Bailey PP, Sandberg-Cook J. Primary care: A collaborative practice. St. Louis (MO): Mosby Elsevier; 2008. p.444–447.

2. Sommers MS, Brunner LS. Pocket diseases. Philadelphia (PA): F.A. Davis; 2012.

3. Colyar MR. Well-child assessment for primary care providers. Philadelphia (PA): F.A. Davis; 2003.

4. McCance KL, Huether SE, Brashers VL, Rote NS. Pathophysiology: The biologic basis for disease in adults and children. 7th ed. Maryland Heights (MO): Mosby Elsevier; 2014.

5. Goldberger ZD, Bonow RO, Mann DL, Zipes DP. Braunwald’s heart disease: A textbook of cardiovascular medicine. 12th ed. Philadelphia (PA): Elsevier; 2021.