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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3230_Библиотеки_им_академика_М_И_Перельмана
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CHAPTER 7 Cardiovascular signs
152
Pulse amplitude high (bounding pulse)
This is an indication of the width of the pulse pressure. It can be con-
firmed by a large difference between the systolic (SBP) and diastolic
(DBP) blood pressure.
Main differential diagnoses and typical outline evidence
Aortic
insufficiency
Suggested by: striking “water hammer” quality. Systolic
BP
high (e.g., >160 mmHg) and diastolic BP very low
(e.g., <50 mmHg) early diastolic murmur, forceful,
displaced apex impulse
Confirmed by: echocardiogram and cardiac
catheterization showing diastolic leaking of the
aortic valve
Atherosclerosis Suggested by: older age. Systolic BP high (e.g., >160
mmHg) and diastolic
BP not low (e.g., >80 mmHg)
Confirmed by: echocardiogram to exclude aortic
incompetence
Severe anemia Suggested by: pallor. Systolic BP high (e.g., >160
mmHg) and diastolic BP normal (e.g., <85 mmHg)
Confirmed by: Hbd (e.g., <10 grm/dL)
Bradycardia of
any cause with
normal
myocardium
Suggested by: slow heart rate (e.g., <50 bpm)
Confirmed by: ECG
showing slow rate and type of
rhythm
Hyperkinetic
circulation
e.g., due to
hypercapnia,
thyrotoxicosis,
fever, Paget’s
disease, AV
fistula
Suggested by: warm peripheries and features of cause,
e.g., cyanosis, tremor, lid lag, fever, skull deformity, etc.
Confirmed by: high pCO
2
(if hypercapnia)
or
iFT4,
± iFT3
and dTSH (if thyrotoxic) or fever or
i hydroxyproline (if Paget’s disease)
PULSE AMPLITUDE LOW (THREADY PULSE)1
153
Pulse amplitude low (thready pulse)
This is an indication of the width of the pulse pressure. It can be
confirmed by a small difference between the systolic and diastolic blood
pressure.
Main differential diagnoses and typical outline evidence
Poor cardiac
contractility
due to ischemic
heart disease,
cardiomyopathy,
cardiac tampo-
nade, constrictive
pericarditis
Suggested by: quiet heart sounds, iJVP, peripheral
edema, basal lung crackles
Confirmed by: poor LV function on echocardiogram
Hypovolemia
due to blood
loss, dehydration
Suggested by: cold peripheries, thirst, dry skin and
mucous membranes, low urine output
Confirmed by: blood urea nitrogen (BUN)i, Hbd
(in blood loss) or i (if hemo-concentrated)
Poor vascular
tone,
hypotension
e.g., due to
septic shock
Suggested by: warm peripheries, thirst, dry skin, durine
output
Confirmed by: hypotension, other evidence of sepsis
(positive blood cultures, azotemia)
Aortic stenosis Suggested by: slowly rising carotid pulse, characteristic
systolic murmur
Confirmed by: echocardiogram and cardiac
catheterization
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CHAPTER 7 Cardiovascular signs
154
Blood pressure high (hypertension)
High blood pressure is defined as systolic BP >140 mmHg and diastolic
BP >90 mmHg. The level treated depends on presence of risk factors.
Generally, any sustained systolic BP
over 140 is treated, but in diabetics,
>130 systolic or >85 diastolic is treated.
Main differential diagnoses and typical outline evidence
Temporary
hypertension
with no risk
factors
Suggested by: normal blood pressure <140 mmHg
systolic and <90 mmHg diastolic when repeated
Confirmed boy: 24-hour ambulatory blood pressure
monitoring
Essential
hypertension
95% of cases
Suggested by: sustained hypertension
Confirmed by: 24-hour ambulatory blood pressure moni-
toring. No symptoms or signs of specific cause, normal
BUN and electrolytes, and prompt control on
treatment
Hypertension
of pregnancy
(pre-eclampsia
sometimes
progressing to
eclampsia)
Suggested by: only occurring during pregnancy. Very
high BP
and seizures in eclampsia
Confirmed by: resolution or improvement when
pregnancy over or terminated
Renovascular
hypertension
due to renal
artery stenosis or
primary renal
disease
Suggested by: established renal impairment too soon to
be caused by hypertension
Confirmed by: BUN and creatinine raised, Hbd
(in established renal failure), hyper-reninemia.
Ultrasound or isotope scan of kidneys and ureters.
Arteriogram or MR angiogram of the renal arteries
Endocrine
hypertension
due to primary
hyperaldostero-
nism (Conn’s
syndrome if
tumor too),
Cushing’s
syndrome, pheo-
chromocytoma
Suggested by: proximal muscle weakness in Cushing’s
syndrome or severe aldosteronism. Paroxysms of
vascular symptoms in pheochromocytoma
Confirmed by: i aldosterone and d renin, i
24-hour urinary free cortisol, etc., in Cushing’s
syndrome. iVMA
and metanephrines i in
pheochromocytoma
BLOOD PRESSURE HIGH (HYPERTENSION)1
155
Vascular
hypertension
due to coarctation
of the aorta,
subclavian artery
stenosis
Suggested by: upper extremity hypertension (right
arm), normal in legs (and left arm in subclavian artery
stenosis). Delayed arterial pulse between upper and
lower extremities suggests coarctation of the aorta.
Confirmed by: MRA/angiography
Drug induced
due to NSAIDs,
estrogen,
steroids,
erythropoietin
Suggested by: drug history
Confirmed by: resolution or improvement when drug
stopped
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CHAPTER 7 Cardiovascular signs
156
Blood pressure very low (hypotension)
Main differential diagnoses and typical outline evidence
Cardiogenic—
low output
due to poor
myocardial
contraction,
valvular stenosis
or regurgitation,
etc.
Suggested by: very low BP, fast or slow heart rate,
peripheral and central cyanosis, quiet heart sound
± abnormal murmur, cool extremities. High or normal
JVP, abnormal heart rhythms, enlarged heart, echocar-
diogram findings of systolic or diastolic dysfunction,
valve stenosis, or regurgitation
Confirmed by: echocardiogram with findings indicating
low cardiac output, right heart catheterization
showing low cardiac output
Low circulating
blood volume
due to
hemorrhage (GI
etc.) dehydration,
etc.
Suggested by: very low BP, fast heart rate, peripheral
cyanosis, JVP low, cool extremities. Background
evidence of cause
Confirmed by: low CVP, ECG, normal heart on CXR.
Improvement with blood, plasma expander, intrave-
nous (IV) fluids with CVP monitoring
Loss of
vascular tone
(“distributive”
shock)
due to septicemia,
adrenal failure,
etc.
Suggested by: very low BP, fast heart rate, peripheral
cyanosis, JVP
low or normal, warm extremities.
Background evidence of cause
Confirmed by: low CVP, normal heart on CXR.
Improvement in BP and CVP with blood transfusion,
volume expansion (IV
fluids), glucocorticoids, and
antibiotics
POSTURAL FALL IN BLOOD PRESSURE1
157
Postural fall in blood pressure
Postural fall in blood pressure
(orthostatic hypotension)
To be significant, the blood pressure must fall >30 mmHg, remain low for
at least 1 minute, and be accompanied by dizziness.
Main differential diagnoses and typical outline evidence
Drug induced
due to excessive
dose of hypoten-
sive agent
(opiates, benzo-
diazepines, other
sedatives,
antidepressants)
Suggested by: drug history
Confirmed by: by resolution or improvement after
stopping or reducing drug
Autonomic
neuropathy
due to diabetes
mellitus or tabes
dorsalis (rarely)
Suggested by: history of long-standing diabetes
(common) or tabes dorsalis (rare). Also, diarrhea,
abdominal distension, and vomiting (gastroparesis),
impotence, urine frequency
Confirmed by: ECG
monitor of beat-to-beat
variation: <10 beats per minute (bpm) change in heart
rate on deep breathing at 6 breaths/minute or getting
up from lying
Idiopathic
orthostatic
hypotension
Suggested by: no other features except elderly
Confirmed by: isolated phenomenon
Volume
depletion
due to mild
or early
dehydration or
hemorrhage
Suggested by: history of vomiting or diarrhea or poor
po intake or melena or hematochezia; poor skin tur-
gor, dry axillae; labs showing azotemia with BUN rise
disproportionate to creatinine rise
Confirmed by: low urine Na or FENa; anemia; evidence
of hemorrhage; response to fluids or blood
transfusion
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CHAPTER 7 Cardiovascular signs
158
BP/pulse difference between arms
This refers to asymmetric pulses or BP differential >15 mmHg.
Main differential diagnoses and typical outline evidence
Old or acute
thrombosis in
atheromatous
artery or
aneurysm or
dissection of
ascending aorta
Suggested by: associated peripheral vascular disease
Confirmed by: MRA/angiography
Supravalvular
aortic stenosis
(congenital)
Suggested by: “elfin-like” facies, ejection systolic
murmur, angina, and syncope
Confirmed by: angiography
Subclavian steal
syndrome
Suggested by: associated neurological symptoms.
Exercising right arm induces cerebral ischemia.
Confirmed by: angiography showing abnormal
subclavian artery
Thoracic inlet
syndrome
Suggested by: bracing shoulder aggravating BP
difference
Confirmed by: MRA/angiography showing abnormal
subclavian artery
Aortic arch
syndrome,
Takayasu’s
syndrome
Suggested by: in young Asian female with cerebral and
peripheral ischemic symptoms
Confirmed by: angiography showing abnormal
subclavian artery
BP/PULSE DIFFERENCE BETWEEN ARMS AND LEGS1
159
BP/pulse difference between arms
and legs
A BP difference >15 mmHg. Awide cuff must be used for the thigh. The
patient’s arms and leg must be level when measuring BP.
Main differential diagnoses and typical outline evidence
Old or acute
thrombosis in
atheromatous
artery or
aneurysm or
dissection of
descending
thoracic or
abdominal aorta
or iliac arteries,
especially in
diabetics
Suggested by: associated peripheral vascular disease.
Atrophic skin and hair loss on lower legs
Confirmed by: Doppler ultrasound of legs to try to
find remediable flow reduction. Angiography to try to
identify surgically remediable arterial stenosis
Coarctation of
aorta
Suggested by: ejection systolic murmur presenting in
childhood or early adult life, rib notching on CXR
Confirmed by: stenosis on angiography
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CHAPTER 7 Cardiovascular signs
160
Prominent leg veins ± unilateral leg
swelling
Main differential diagnoses and typical outline evidence
Varicose veins ±
incompetent
communicating
valves
Suggested by: veins distended and tortuous made
worse when standing. Cough impulse felt and
Trendelenberg test shows filling down along extent
of communicating valve leaks
Confirmed by: clinical findings usually, but if doubt,
use Doppler ultrasound probe to confirm whether or
not incompetence is present in the saphenofemoral
junction or short saphenous vein behind the knee
Thrombophlebitis Suggested by: tender, hot veins with redness of
surrounding skin
Confirmed by: resolution on antibiotics
Deep vein
thrombosis
(DVT)
Suggested by: immobility, prominent dilated veins;
warm, tender, swollen calf; other risk factors for DVT
Confirmed by: reduced flow on compression Doppler
ultrasound, blockage seen on venography
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