What is the management of Pulsus bisferiens?

Management of Pulsus Bisferiens

The management of pulsus bisferiens should be directed at treating the underlying cardiovascular condition causing this distinctive double-peaked pulse pattern, most commonly hypertrophic cardiomyopathy (HCM) or severe aortic regurgitation.

Understanding Pulsus Bisferiens

Pulsus bisferiens is a physical examination finding characterized by a double-peaked pulse during a single cardiac cycle. It is classically associated with:

• Hypertrophic cardiomyopathy (HCM), especially with left ventricular outflow tract obstruction (LVOTO) 1
• Severe aortic regurgitation 2
• Less commonly, thoracoabdominal aortic aneurysms 3

Diagnostic Approach

Physical Examination Findings

• Double-peaked carotid pulse (pulsus bisferiens)
• In HCM: Often accompanied by a harsh systolic murmur at the lower left sternal border
• Associated findings in HCM may include:
  • Prominent apical impulse
  • S4 heart sound
  • Systolic murmur that increases with Valsalva maneuver or standing 1

Diagnostic Testing

1. Echocardiography: First-line diagnostic test for suspected HCM or valvular disease 1

   • Assess degree of myocardial hypertrophy
   • Evaluate for dynamic LVOTO
   • Assess mitral regurgitation
   • Evaluate aortic valve morphology and function

2. Exercise Echocardiography: Recommended for symptomatic patients with HCM who do not have resting or provocable LVOTO ≥50 mmHg on standard echocardiography 1

3. Cardiac Catheterization: May provide characteristic hemodynamic findings 4

   • Significant pressure gradient across LVOT in HCM
   • Brockenbrough-Braunwald-Morrow sign (absence of expected increase in pulse pressure after premature ventricular contraction)

Management Strategies

For Hypertrophic Cardiomyopathy

1. Medical Therapy:

   • Beta-blockers: First-line therapy to reduce heart rate, improve diastolic filling, and decrease LVOTO
   • Non-dihydropyridine calcium channel blockers (verapamil, diltiazem): Alternative if beta-blockers are contraindicated
   • Disopyramide: Can be added for persistent symptoms despite beta-blockers

2. Invasive Management for symptomatic patients with significant LVOTO (≥50 mmHg) despite optimal medical therapy:

   • Surgical septal myectomy: Recommended with intraoperative transesophageal echocardiography to guide the procedure 1
   • Alcohol septal ablation: Alternative for patients at high surgical risk, with TTE or TEE guidance using intracoronary contrast 1
   • Follow-up echocardiography 3-6 months after septal reduction therapy 1

3. ICD Implantation: Consider for patients at high risk for sudden cardiac death

For Aortic Regurgitation

1. Medical Therapy:

   • Vasodilators (ACE inhibitors, ARBs) to reduce afterload
   • Diuretics for symptom management if heart failure develops

2. Surgical Management:

   • Aortic valve repair or replacement for severe symptomatic AR
   • Consider surgery for asymptomatic patients with LV dysfunction or significant LV dilation

Monitoring and Follow-up

• Patients with HCM should undergo repeat echocardiography every 1-2 years to assess disease progression 1
• More frequent monitoring for patients with significant symptoms or disease progression
• Additional imaging after any change in clinical status 1

Special Considerations

• Avoid vasodilators and diuretics in patients with obstructive HCM as they can worsen obstruction
• Avoid strenuous exercise in patients with significant LVOTO
• Family screening is essential in HCM cases, as it is often inherited in an autosomal dominant pattern 1

Remember that pulsus bisferiens is a physical finding that indicates underlying cardiovascular pathology requiring thorough evaluation and targeted treatment of the primary condition.