The report of collapsing pulses in both lower limbs but not in the upper limbs [1] reminded me of a reversed phenomenon in a patient I encountered as a medical resident.

A 25-year-old woman was hospitalized for evaluation of severe hypertension and fever 3 weeks after dental extraction. Physical examination at the time of hospitalization showed the blood pressures in both arms to be 190/60 mm Hg, collapsing pulses in both arms, and an early diastolic blowing murmur at the Erb point. The patient reported a history of hypertension and a heart murmur since early childhood. Further examination showed barely palpable noncollapsing pulses in both lower limbs. The patient was found to have coarctation of the descending thoracic aorta and a bicuspid aortic valve complicated by infective endocarditis. An uneventful recovery followed antibiotic therapy for infective endocarditis and surgical correction of her aortic coarctation 6 months later. Her longstanding hypertension, considered to be essential hypertension because nobody felt her pulses in the lower limbs, receded in 1 year without pharmacotherapy.

The patient described by O'Sullivan and Bain [1] had complex congenital heart disease with interruption of the aortic arch and pulmonic valve endocarditis. My patient had a simple form of congenital heart disease complicated by infective endocarditis on a bicuspid aortic valve. Because of the commonly associated aortic coarctation, no collapsing pulse could be found in her lower limbs. In both cases, a careful physical examination avoided the unnecessary cardiologic invasive and noninvasive studies that are currently so common. I agree completely with O'Sullivan and Bain that "in congenital heart disease, detailed clinical examination can be informative and can have a major effect on clinical decision making" [1].