Blood Pressure Measurement Techniques

Blood Pressure Measurement Guidelines

• In obese patients, a standard cuff may not provide accurate blood pressure readings; use a large adult or thigh cuff instead.
• Auscultatory gap can occur in 20% of elderly hypertensive patients, leading to inaccurately low systolic pressure readings if missed. Palpate the systolic pressure prior to auscultation.
• Ensure patient’s arm is level with the heart during measurements.
• Postural hypotension is indicated by a drop of more than 20 mmHg when checking blood pressure after 2 minutes of standing.
• In atrial fibrillation, reduce cuff pressure slowly and repeat measurements for accuracy.

Korotkoff Sounds and Respiratory Effects

• Korotkoff sounds signify transition of flow as cuff pressure decreases and are critical in determining blood pressure levels.
• Hemodynamic effects of respiration:
  • Inspiration accelerates heart rate, reduces systolic blood pressure, lowers jugular venous pressure, and splits the second heart sound.
  • Expiration slows heart rate, increases systolic blood pressure, and raises jugular venous pressure, causing second heart sound fusion.

Causes of Increased Pulse Volume

• Physiological causes include exercise, pregnancy, advanced age, and heightened environmental stimuli.
• Pathological causes encompass conditions like hypertension, fever, thyrotoxicosis, anemia, Paget’s disease, and aortic regurgitation.

Heart Sounds

• S1 (first heart sound) originates from closure of mitral and tricuspid valves, best heard at the apex.
• S2 (second heart sound) arises from closure of pulmonic and aortic valves, heard best at the left sternal edge; physiological splitting increases during inspiration.
• S3 is a low-pitched early diastolic sound, normal in children and young adults but indicative of potential pathology in individuals over 40.
• S4 denotes a stiff ventricle, leads to resistance during atrial contraction, often seen with left ventricular hypertrophy.

Common Heart Sound Abnormalities

• Wide splitting of S2 suggests delayed ventricular emptying, such as in right bundle branch block or pulmonary hypertension.
• Fixed wide splitting indicates atrial septal defect, while reversed splitting suggests left ventricular emptying delay.
• Causes for S3 include left ventricular failure, mitral regurgitation, and heart failure associated with tachycardia.
• S4 is noted notably with non-compliant ventricles, often accompanying left ventricular hypertrophy.

Murmur Characteristics

• Radiation of murmurs:
  • Mitral regurgitation radiates to the left axilla.
  • Ventricular septal defect murmurs radiate to the right sternal edge.
  • Aortic stenosis murmurs radiate to the suprasternal notch and carotid arteries.
• Types of murmurs include:
  • Ejection systolic murmurs due to increased flow through normal valves (e.g., severe anemia, pregnancy).
  • Pansystolic murmurs from mitral and tricuspid regurgitation.
  • Diastolic murmurs associated with aortic or pulmonary regurgitation.
  • Continuous murmurs, such as those from patent ductus arteriosus.

Peripheral Arterial Disease (PAD) Symptoms

• Common symptoms in legs include intermittent claudication, rest pain, tissue loss, and acute limb ischemia.
• Abdominal symptoms may manifest as mesenteric ischemia or abdominal aortic aneurysm pain.
• Digital ischemia can present as blue toes or vasospastic symptoms.

Intermittent Claudication in PAD

• Described as cramp-like pain that develops after a constant distance of walking, resolving within a few minutes of rest.

Leriche’s Syndrome

• Presenting symptoms include buttock claudication and erectile dysfunction, indicating occlusion in pelvic arteries.

Claudication Types

• Arterial Claudication: Pain in muscles after walking, unilateral or bilateral, relieved by rest.
• Neurogenic Claudication: Pain over the whole leg often accompanied by tingling, usually immediate relief when bending forward.
• Venous Claudication: Characterized by a bursting sensation in the leg with gradual onset, relieved by leg elevation.

Signs of Acute Limb Ischemia

• Pallor, pulselessness, coldness, paresthesias, pain, and paralysis indicate severe ischemia.

Distinction in Claudication Characteristics

• Claudication distance is the distance a patient can walk before pain onset; total walking distance refers to the maximum distance achievable regardless of pain.

Blood Pressure Measurement Guidelines

• In obese patients, a standard cuff may not provide accurate blood pressure readings; use a large adult or thigh cuff instead.
• Auscultatory gap can occur in 20% of elderly hypertensive patients, leading to inaccurately low systolic pressure readings if missed. Palpate the systolic pressure prior to auscultation.
• Ensure patient’s arm is level with the heart during measurements.
• Postural hypotension is indicated by a drop of more than 20 mmHg when checking blood pressure after 2 minutes of standing.
• In atrial fibrillation, reduce cuff pressure slowly and repeat measurements for accuracy.

Korotkoff Sounds and Respiratory Effects

• Korotkoff sounds signify transition of flow as cuff pressure decreases and are critical in determining blood pressure levels.
• Hemodynamic effects of respiration:
  • Inspiration accelerates heart rate, reduces systolic blood pressure, lowers jugular venous pressure, and splits the second heart sound.
  • Expiration slows heart rate, increases systolic blood pressure, and raises jugular venous pressure, causing second heart sound fusion.

Causes of Increased Pulse Volume

• Physiological causes include exercise, pregnancy, advanced age, and heightened environmental stimuli.
• Pathological causes encompass conditions like hypertension, fever, thyrotoxicosis, anemia, Paget’s disease, and aortic regurgitation.

Heart Sounds

• S1 (first heart sound) originates from closure of mitral and tricuspid valves, best heard at the apex.
• S2 (second heart sound) arises from closure of pulmonic and aortic valves, heard best at the left sternal edge; physiological splitting increases during inspiration.
• S3 is a low-pitched early diastolic sound, normal in children and young adults but indicative of potential pathology in individuals over 40.
• S4 denotes a stiff ventricle, leads to resistance during atrial contraction, often seen with left ventricular hypertrophy.

Common Heart Sound Abnormalities

• Wide splitting of S2 suggests delayed ventricular emptying, such as in right bundle branch block or pulmonary hypertension.
• Fixed wide splitting indicates atrial septal defect, while reversed splitting suggests left ventricular emptying delay.
• Causes for S3 include left ventricular failure, mitral regurgitation, and heart failure associated with tachycardia.
• S4 is noted notably with non-compliant ventricles, often accompanying left ventricular hypertrophy.

Murmur Characteristics

• Radiation of murmurs:
  • Mitral regurgitation radiates to the left axilla.
  • Ventricular septal defect murmurs radiate to the right sternal edge.
  • Aortic stenosis murmurs radiate to the suprasternal notch and carotid arteries.
• Types of murmurs include:
  • Ejection systolic murmurs due to increased flow through normal valves (e.g., severe anemia, pregnancy).
  • Pansystolic murmurs from mitral and tricuspid regurgitation.
  • Diastolic murmurs associated with aortic or pulmonary regurgitation.
  • Continuous murmurs, such as those from patent ductus arteriosus.

Peripheral Arterial Disease (PAD) Symptoms

• Common symptoms in legs include intermittent claudication, rest pain, tissue loss, and acute limb ischemia.
• Abdominal symptoms may manifest as mesenteric ischemia or abdominal aortic aneurysm pain.
• Digital ischemia can present as blue toes or vasospastic symptoms.

Intermittent Claudication in PAD

• Described as cramp-like pain that develops after a constant distance of walking, resolving within a few minutes of rest.

Leriche’s Syndrome

• Presenting symptoms include buttock claudication and erectile dysfunction, indicating occlusion in pelvic arteries.

Claudication Types

• Arterial Claudication: Pain in muscles after walking, unilateral or bilateral, relieved by rest.
• Neurogenic Claudication: Pain over the whole leg often accompanied by tingling, usually immediate relief when bending forward.
• Venous Claudication: Characterized by a bursting sensation in the leg with gradual onset, relieved by leg elevation.

Signs of Acute Limb Ischemia

• Pallor, pulselessness, coldness, paresthesias, pain, and paralysis indicate severe ischemia.

Distinction in Claudication Characteristics

• Claudication distance is the distance a patient can walk before pain onset; total walking distance refers to the maximum distance achievable regardless of pain.