Most frequently caused by hemodynamically significant aortic regurgitation, pulsus bisferiens is detected by examining the carotid upstroke. Two pulsations are detected in systole. The first is from the pressure increase related to left ventricular ejection. The second systolic pulsation is reflected from the periphery and only palpable in high left ventricular out states such as severe aortic regurgitation. The Valsalva maneuver or inhalation of amyl nitrate can precipitate pulsus bisferiens in some cases.

Pulsus bisferiens can also be seen in hypertrophic obstructive cardiomyopathy (HOCM), patent ductus arteriosus, arteriovenous fistulas and normal hearts in a hyperdynamic state.