An Unusual Cause of a “Double Pulse”

Article Outline

• Abstract
• Introduction
• Report
• Discussion
• References
• Copyright

We report an unusual cause of a dicrotic pulse that was detected in a patient with no underlying cardiac disease. We postulate that this was the result of elastic recoil from a huge abdominal aortic aneurysm. The palpable double pulsation of either a dicrotic pulse or pulsus bisferiens is evidence of significant cardiac disease but may be associated with other cardiovascular pathology.

Keywords: Double pulse, Dicrotic pulse, Pulsus bisferiens

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Introduction 

The “double pulse” sign is the identification of two palpable arterial pulsations per cardiac cycle. It usually suggests significant cardiac disease but here we report an unusual cause of this interesting clinical sign.

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Report 

A 71-year-old gentleman was referred urgently with a three month history of constipation and a large abdominal mass. Clinical examination revealed a pulsatile mass lying principally within the left iliac fossa. An ultrasound scan revealed a large tubular structure containing swirling internal echoes consistent with an abdominal aortic aneurysm. This prompted an immediate CT scan which revealed the full extent of the problem (Fig. 1). At the level of the coeliac axis the aorta measured 3cm in diameter and expanded into a huge aneurysm measuring 26cm in maximum transverse diameter but did not involve the iliac arteries. The aneurysm extended up to the left subphrenic space, compressing the left psoas and kidney and down into the pelvis and into the femoral canal. It also eroded the anterior cortex of the third lumbar vertebra and the blade of the ilium (Fig. 2, Fig. 3).

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• Fig. 1 

  CT image of huge abdominal aortic aneurysm with extensive left sided component extending deep to inguinal ligament.

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• Fig. 2 

  CT image revealing erosion of L3 vertebra.

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• Fig. 3 

  CT image revealing erosion of wing of ilium.

The patient was promptly admitted to the vascular ward where cardiovascular examination demonstrated a “double pulse” (Fig. 4). Cardiac auscultation confirmed that the first impulse occurred during systole and the second during diastole and therefore should be described as a dicrotic pulse. The first and second heart sounds were normal and no added sounds or murmurs were detected. His jugular venous pressure was not raised and there were no signs of pulmonary oedema. A transthoracic echocardiogram was attempted but no diagnostic views were obtainable.

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• Fig. 4 

  Dicrotic pulse represented on pulse oximeter.

Treatment options were discussed but the patient did not want to expose himself to the risks of either endovascular, open surgery or a hybrid approach. His constipation was ameliorated with aperients and he was discharged to a nursing home.

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Discussion 

A normal (carotid) pulse is felt as a single wave but pulse tracings may record two peaks during systole. The former, known as the “percussion wave”, occurs early in systole and is the rapidly transmitted impact of left ventricular ejection. The second or “tidal wave” represents the reflected wave from the periphery of the upper body.¹ Following left ventricular ejection the closure of the aortic valve results in an incisura in the pressure trace called the dicrotic notch which is then followed by the dicrotic wave (usually impalpable) which is the combination of the elastic recoil of the aorta and aortic valve plus the reflected wave from the periphery of the lower body.²

In a dicrotic (Greek: di=twice & krotos=beat) pulse, the first impulse, as in health, represents ejection of blood from the left ventricle. The second palpable peak occurs after the second heart sound in diastole and is the exaggerated dicrotic wave that follows the dicrotic notch.³, ⁴ It is recognised to occur in severe heart failure, hypovolaemic shock, tamponade and in young patients with septicaemia.¹, ², ³ In the absence of these usual causes, we postulate that the elastic recoil from this huge aneurysm to be the source of the second, diastolic pressure wave. Indeed, it's predilection in young patients with the causes listed above suggests that an element of elasticity in the peripheral vasculature is required.⁵

The second type of “double pulse” is pulsus bisferiens (Latin: bis=twice & ferio=strike). Here the palpable double impulse occurs during systole as a result of the percussion and tidal waves becoming separated by a mid-systolic dip. It is a feature of aortic regurgitation or combined aortic stenosis with predominant regurgitation when a high stroke volume is ejected rapidly from the ventricle. It is also seen in patients with hypertrophic cardiomyopathy when the mid-systolic dip is the result of outflow obstruction.

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References 

1. Perlof JK, Braunwald E. Physical examination of the heart and circulation. In:  Braunwald E,  Zipes DP,  Libby P editor. Heart disease: a textbook of cardiovascular medicine. Philadelphia: WB Saunders; 2001;pp. 15–52
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2. O'Rouke RA, Silverman ME, Shaver JA. The history, physical examination and cardiac auscultation. In:  Fuster V,  Alexander RA,  O'Rouke RA editor. The heart. New York: McGraw-Hill; 2004;pp. 217–294
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3. Ewy GA, Rios JC, Marcus FI. The dicrotic arterial pulse. Circulation. 1969;39:655–661
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4. Orchard RC, Craige E. Dicrotic pulse after open heart surgery. Circulation. 1980;62:1107–1114
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5. Talley JD. Dicrotism: examples and review of the dicrotic pulse. J Ark Med Soc. 1996;92:507–508
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