Quickly palpable DP pulse in Geriatrics/Sherman sign predicts aortic regurgitation?

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I am a Podiatrist in Atlanta, GA, USA. Has anyone had any experience or thoughts on this below:

"I have noticed that pedal pulses, particularly the dorsalis pedis pulse, are often weak or absent in older adults, often because of peripheral arterial disease. Searching for a barely palpable dorsalis pedis pulse may take 10 to 20 seconds. I have even confused my own finger pulsations with a barely palpable dorsalis pedis pulse. On the other hand, sometimes the dorsalis pedis pulse is easily and quickly located, literally within 1 to 2 seconds of touching the dorsum of the foot, because it is so prominent, so pulsatile. I was curious about these older adults in whom I easily felt their dorsalis pedis pulse and began to correlate it with isolated systolic hypertension. Soon, however, I realized that I was noticing this quickly palpable dorsalis pedis pulse in some patients with a widened pulse pressure. As I auscultated their precordium, I often heard the early diastolic murmur of aortic regurgitation. And then it dawned on me: The easily or quickly palpable dorsalis pedis pulse occurs in older adults who have chronic aortic regurgitation.

Based on these observations, I would like to propose a new geriatric physical sign, discovered like many of Osler's, by observing and recording something unusual at the bedside. Any adult age > 75, whose dorsalis pedis pulse is quickly located and is unexpectedly prominent, has chronic aortic regurgitation or insufficiency until proven otherwise. The key descriptors are: 1) "quickly" located, ie, appreciated within 1 to 2 seconds of palpating the dorsum of the foot; and 2) "unexpectedly" prominent with a rapid arterial upstroke.

Always respectful of longevity, I have named this new physical finding the Sherman sign, adding it to the long list of eponymous signs of chronic aortic regurgitation, including the Duroziez sign (an intermittent to-and-fro femoral artery murmur generated by femoral artery compression), the Hill sign (a higher systolic blood pressure in the legs compared to the arms), the Quincke sign (exaggerated capillary pulsations in the nail beds), and the Corrigan pulse (a rapidly swelling and falling radial arterial pulse accentuated by wrist elevation). (2) If you find the Sherman sign, which can be positive either unilaterally or bilaterally, but cannot hear an aortic regurgitant murmur with your patient leaning forward and exhaling, consider getting an echocardiogram to confirm mild aortic regurgitation.

Whether this new sign for an old disease proves to be a valid, easily performed, clinical predictor of the presence and/or severity of aortic regurgitation in various populations of older adults remains to be proven. Although Osler said: "The whole art of medicine is in observation," the Sherman sign needs to be studied to determine its sensitivity, specificity, predictive values, and future utility at the bedside."

 

This is a really interesting clinical observation, and one that I would love to see investigated in full. You are certainly right about the variability of pulses in the older population. I often find students quick to announce "Pulses are good, no vascular problems..." regardless of other observations (ie colour, temp, tissue status). As clinicians I find we are also too willing to say "no PVD therefore no IHD". But your anecdotal evidence would clearly indicate that further investigation is warranted.

In Australia we are less likely to go on to auscultate the chest (patients just don't expect us to head north of the foot that far or that enthusiastically). But a gentle referral can always be made to those whose interests lie therein.

cheers,

Felicity

 

Very interesting and follows an excellent scientific aproach. I will use it from now on on general examination and report later the results.

 

This is very interesting.I too will use this test and if + I will bring it up to the PCP.Thank you for the info!

 

if IHD then PVD

As my physician told me "if you've got coronary blockages, it's guarenteed you've got (significant peripheral) blockages". i immediately categorise IHD hX pts "high risk foot" pts, No?

 

What is the cut off point for "older adults"when deciding if a DP pulse is bounding or just healthy ? Chronologically, I have colleagues in their early fifties lining up for their stents in otherwise fit and apparently healthy bodies, and some oldies patients of 80+ participating in the Masters Games.