What is the management approach for a patient with a collapsing or bounding pulse?

Management of Collapsing or Bounding Pulse

A collapsing or bounding pulse indicates significant aortic regurgitation or a high-output cardiac state requiring immediate echocardiographic evaluation to determine the underlying cause and guide definitive management. 1, 2

Immediate Clinical Assessment

• Recognize the characteristic pulse features: The collapsing pulse has two components—a forceful, slapping upstroke (water-hammer pulse) followed by a rapid collapse, which can be appreciated on routine radial pulse examination without necessarily elevating the arm 2

• Assess hemodynamic stability immediately: Check for signs of heart failure including respiratory distress, hypotension, altered mental status, or shock 1

• Examine for associated physical findings: Look for a widened pulse pressure, bruit over major vessels (particularly periumbilical in neonates), and signs of volume overload 1

Diagnostic Evaluation

• Obtain urgent transthoracic echocardiography to identify the underlying cause, which most commonly includes:

  • Severe aortic regurgitation 2, 3
  • Arteriovenous malformations or fistulas 1
  • High-output cardiac failure states 1

• Perform CT angiography if arteriovenous malformation is suspected, particularly when a bruit is present or in cases of unexplained high-output failure 1

Management Based on Underlying Cause

For Aortic Regurgitation with Heart Failure

• Stabilize with medical management: Administer supplemental oxygen, diuretics (furosemide 20-40 mg IV, repeated at 1-4 hourly intervals), and vasodilators if blood pressure permits 4

• Provide ventilatory support if oxygen tension cannot be maintained above 60 mmHg despite high-flow oxygen (8-10 L/min by mask) 4

• Consider urgent surgical consultation for valve replacement in acute severe aortic regurgitation with hemodynamic compromise 4

For Arteriovenous Malformations

• Stabilize with medications and mechanical ventilation as needed for respiratory distress and heart failure 1

• Arrange transcatheter closure using coils, vascular plugs, or other closure devices for accessible arteriovenous communications 1

• Monitor for resolution of pulmonary hypertension following successful closure of the shunt 1

Critical Pitfalls to Avoid

• Do not rely solely on arm elevation to detect the collapsing pulse—the slapping upstroke character is more diagnostically important and can be appreciated during routine pulse examination 2

• Do not assume the pulse becoming stronger with arm elevation is pathological—this is a normal physiological phenomenon that can create diagnostic confusion 2

• Do not delay echocardiography in patients with a bounding pulse and signs of heart failure, as the underlying cause requires urgent identification 1

• Do not overlook neonatal presentations—in newborns with respiratory distress and bounding pulses, consider congenital arteriovenous malformations, particularly umbilical arteriovenous communications 1

Hemodynamic Monitoring

• Assess for associated conditions that may complicate the clinical picture, such as cardiac tamponade (which typically presents with pulsus paradoxus rather than bounding pulse) or right ventricular dysfunction 5, 6

• Monitor for development of pulmonary hypertension in high-output states, which may require specific management 1