What is Water Hammer Pulse?
A water hammer pulse refers to a strong, bouncing pulse that quickly rises and falls. This is often observed during a standard physical examination. It occurs in various normal and abnormal body conditions but is primarily associated with aortic regurgitation, a condition where the heart’s aortic valve doesn’t close tightly, causing some of the blood to flow backward into the heart.
In 1833, Dr. Dominic John Corrigan first noticed the water hammer pulse. He observed a sudden swelling and deflation of the carotid arteries – major blood vessels in the neck that supply blood to the brain, neck, and face – in patients suffering from aortic regurgitation. This distinct pulse was further studied by Dr. Thomas Watson in 1844.
Dr. Watson likened this pulse to the feeling produced by a Victorian-era toy called a water hammer. This toy was a tube filled halfway with fluid and the remaining part was a vacuum. When the tube was flipped, the impact created a sound similar to that of a hammer hitting something. This is why this type of pulse is called ‘water hammer’ pulse.
What Causes Water Hammer Pulse?
There can be different reasons behind some health conditions. These reasons may be linked to normal bodily functions, an overly active bloodstream, or heart problems.
Here are some examples for each group:
Normal bodily functions:
* Physical activities, like exercise
* A high body temperature, or fever
* Being pregnant
Overly active bloodstream:
* Thyrotoxicosis, a condition caused by an excess of thyroid hormone in the body
* Anemia, a condition where your blood has fewer red blood cells than normal
* Paget’s disease, a condition that disrupts the replacement of old bone tissue with new bone tissue
* Liver cirrhosis, a late stage of scarring (fibrosis) of the liver caused by long-term liver diseases
* Thiamine deficiency, or beriberi, a condition that happens when your body is lacking in vitamin B1
* High blood pressure in the arteries, also known as systolic hypertension
* Arteriovenous fistula, an abnormal connection between an artery and a vein
* Cor pulmonale, a condition that causes the right side of the heart to fail
Heart problems:
* Aortic regurgitation, a condition where the heart’s aortic valve doesn’t close tightly, allowing some of the blood that was pumped out of your heart’s main pumping chamber to leak back into it
* Patent ductus arteriosus, a persistent opening between two major blood vessels leading from the heart
* Aortopulmonary window, a rare heart defect where there is a hole connecting the major artery taking blood from the heart to the lungs (the pulmonary artery) with the one taking blood from the heart to the body (the aorta)
* Sinus of Valsalva rupture, a rare condition where the walls of the aorta fall apart near the heart
* Leaking aortic valve prosthesis, a problem with an artificial heart valve replacement
* A ventricular septal defect with aortic regurgitation, a combination of a hole in the wall separating the two lower chambers of the heart and a problem with the aortic valve
* Truncus arteriosus, a rare type of heart disease present at birth (congenital), in which a single blood vessel (truncus arteriosus) comes out of the right and left ventricles, instead of the normal 2 vessels (pulmonary artery and aorta)
* Mitral regurgitation, a disorder in which the heart’s mitral valve doesn’t close properly, allowing blood to flow backward in your heart
* Complete heart block, a condition where the electrical signals from the upper chambers of the heart don’t reach the lower chambers, causing the heart to beat too slowly.
Risk Factors and Frequency for Water Hammer Pulse
Aortic regurgitation, a condition often noticed with a symptom called a water hammer pulse, is quite common. The Framingham study discovered that about 4.9% of people have aortic regurgitation, and 0.5% experience it in a moderate or severe form. This condition tends to occur more in men than in women. The symptoms typically become most noticeable when people are in their 40s to 60s.
Signs and Symptoms of Water Hammer Pulse
The medical history of a patient is crucial in identifying the cause of symptoms like the water hammer pulse. Factors like alcohol abuse could point towards conditions like cirrhosis. By getting a thorough non-heart related history, physicians can also diagnose conditions such as anemia, hyperthyroidism, fever, pregnancy, cirrhosis, Marfan syndrome, immune system disorders, and syphilis. Also, a detailed heart history can help in identifying potential long-term issues with heart valves or septum, particularly in the context of congenital heart diseases.
The universal method to detect a water hammer pulse involves comparing the patient’s heartbeat when their arm is elevated above their heart level. Firstly, the patient needs to lay flat on their back with a slight tilt upwards. The doctor finds the patient’s radial pulse on the wrist and lifts the patient’s arm above their head. The water hammer pulse would feel like a quick, tapping sensation flowing through the patient’s forearm, a phenomenon caused by the quick release of blood from the arm when the heart relaxes, augmented by gravity.
Testing for Water Hammer Pulse
The process of diagnosing the cause of a water hammer pulse, which is an unusually strong pulse that can signal heart conditions, often starts with a physical examination and a medical history check. Based on these initial investigations, your doctor will decide which laboratory tests and scans are necessary.
For example, if your doctor suspects you have thyrotoxicosis, a condition where your thyroid is overactive, they may measure your thyroid-stimulating hormone or T4 levels. If you’re a woman who could possibly be pregnant, a urine pregnancy test might be needed. If you need to be checked for Marfan, a genetic disorder affecting the body’s connective tissue, a genetic test might be ordered. If your doctor suspects you have a collagen vascular disease, which affects the connective tissue in your body, they might order rheumatological blood work. If anemia, a condition where you lack enough healthy red blood cells, is suspected, a complete blood count test might be ordered. Finally, an abdominal ultrasound may be done if there’s a suspicion of cirrhosis, which is severe scarring of the liver.
Chronic aortic regurgitation, a condition where the aortic valve in your heart doesn’t close properly, often results in a water hammer pulse. In this case, a special ultrasound of your heart, known as a transesophageal echocardiogram, may be needed. This can help the doctor examine the structure of your valve, quantify the amount of aortic regurgitation, understand the shape and size of your aorta, and identify the type of regurgitation you have.
All this information is crucial for your doctor to decide whether you need surgery or valve repair.
Treatment Options for Water Hammer Pulse
The treatment for a medical condition known as a water hammer pulse varies, depending on the root cause of the issue.
One common cause of water hammer pulse is chronic aortic regurgitation. This is a condition where the aortic valve in the heart doesn’t close tightly, causing some blood to leak back into the heart. When this happens, the heart and aorta (the main blood vessel supplying the body) have to work harder to pump blood, which can lead to a water hammer pulse – a pulse that is quick and strong, then suddenly collapses.
According to the 2017 guidelines set out by the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery for managing heart valve diseases like aortic regurgitation, deciding whether an aortic valve repair or replacement is needed depends on various factors. These factors include the size of the aorta, how bad the leaking is, how the patient is feeling, and how well the left side of the heart is working.
Doctors may advise surgery for patients with severe aortic regurgitation, in certain circumstances. This is more common in patients who are already showing clear symptoms and those whose heart’s left side is already pumping less than half of the blood it receives. This is also advised for patients who are already undergoing other heart surgeries, such as bypass graft surgery, which diverts blood around blocked arteries in the heart, or surgeries on the aorta or other heart valves.
For patients who don’t have symptoms and, whose heart’s left side is functioning normally, regular check-ups are very essential. This is to keep tabs on the heart’s function through tests like an echocardiogram, a type of ultrasound scan that shows the heart in action. Changes in how well the patient can perform physical activity should also be noted, as these can indicate whether surgery is becoming necessary.
What else can Water Hammer Pulse be?
Here are some health conditions that might have similar symptoms or could be confused with each other:
- Acute Coronary Syndrome
- Aortic regurgitation (leakage of the aortic valve)
- Aortic stenosis (narrowing of the aortic valve)
- Arteriovenous fistula (abnormal connection between an artery and a vein)
- Blunt Abdominal Trauma
- Heart Failure
- Infective Endocarditis (infection of the inner lining of the heart)
- Mitral Regurgitation (leakage of the mitral valve)
- Mitral Stenosis (narrowing of the mitral valve)
- Myocardial Infarction (heart attack)
- Pregnancy
- Severe anemia (low iron in the blood)
- Thyrotoxicosis (high levels of thyroid hormone)
- Tricuspid Stenosis (narrowing of the tricuspid valve)
- Volume depletion (significant loss of body water)
