With the examinerвЂ™s hand wrapped around the patientвЂ™s wrist, the radial pulse is palpated. The fundamental principle of eliciting the water hammer pulse is to elevate the patient's arm above the heart and to palpate the patient's forearm with the examiner's palm.В The first step is to place the patient in a supine position at a slight recline. A detailed cardiac history, especially regarding congenital heart diseases, will be necessary when suspecting long-term valvular or septal defects.

For example, alcohol abuse in a patient with the water hammer pulse sign could lead to the diagnosis of cirrhosis.В Getting a detailed extracardiac history can help diagnose conditions such as anemia, thyrotoxicosis, fever, pregnancy, cirrhosis, Marfan, rheumatological disorders, and syphilis.

The history will be vital in determining the etiology of the water hammer pulse. Systolic heart failure results in stroke volume decrease and forward blood flow. However, as the left ventricle continues to stretch, and with the resultant cardiac remodeling, systolic heart failure eventually develops. Increasing these pressures accentuates the water hammer pulse. As aortic regurgitation continues to progress and worsen, the systolic pressure and pulse pressure continue to rise. These effects increaseВ the stroke volume and therefore the systolic pressure.В Secondly, the sympathetic nervous system releases catecholamines and the renin-angiotensin-aldosterone axisВ works to increase cardiac output to try to maintain a normal mean arterial pressure. First, due to the regurgitant fraction of blood flow, the heart undergoes chamber dilation and eccentric hypertrophy. Compensation for the decrease in diastolic pressure occurs in two ways. Pulse pressure is the difference between the systolic and diastolic pressure. The decrease in diastolic pressure from the regurgitant flow also causes an increase in pulse pressure. The second cause is the rapid emptying of the arterial system. The first cause is the sudden fall in diastolic pressure in the aorta, which is due to regurgitation of blood from the aorta, orВ вЂњaortic run-off,вЂќ into the left ventricle through the leaky valve. The rapid downstroke is partly due to two causes. This increased stroke volume is secondary to an increase in end-diastolic volume from the retrograde blood flow from the aorta into the left ventricle during ventricular diastole, or relaxation. An increased stroke volume filling the relatively empty arterial vessels causes the rapid upstroke when feeling the water hammer pulse. The pathophysiology in patients with aortic regurgitation is different. In physiological and hyperdynamic circulatory states, the fall in systemic vascular resistance and increased cardiac output causesВ the water hammer pulse.

Bounding pulse