Apex beat

From Wikipedia, the free encyclopedia

The apex beat, also called the point of maximum impulse (PMI), is the furthermost point outwards
(laterally) and downwards (inferiorly) from the sternum at which the cardiac impulse can be felt. The cardiac
impulse is the result of the heart rotating, moving forward and striking against the chest wall during systole.
[edit]Identification
The normal apex beat can be palpated in the precordium left 5th intercostal space, at the point of
intersection with the left midclavicular line. In children the apex beat occurs in the fourth rib interspace
medial to the nipple. The apex beat may also be found at abnormal locations; in many cases
of dextrocardia, the apex beat may be felt on the right side.
[edit]Interpretation

Algorithm for classification of the apex beat characters
Lateral and/or inferior displacement of the apex beat usually indicates enlargement of the heart,
called cardiomegaly. The apex beat may also be displaced by other conditions:
Pleural or pulmonary diseases
Deformities of the chest wall or the thoracic vertebra
Sometimes, the apex beat may not be palpable, either due to a thick chest wall, or conditions where
the stroke volume is reduced; such as during ventricular tachycardiaor shock.
The character of the apex beat may provide vital diagnostic clues:
A forceful impulse indicates pressure overload in the heart (as might occur in hypertension)
An uncoordinated (dyskinetic) apex beat involving a larger area than normal
indicates ventricular dysfunction; such as an aneurysm following myocardial infarction
An algorithm for the classification of some common apex beat characters is shown in the image.

The exam includes several parts:
position/lighting/draping
inspection
palpation
auscultation
Contents
[hide]
1 Position/Lighting/Draping
2 Inspection
3 Palpation
o 3.1 Palpation of the apex beat
4 Auscultation
5 See also
6 References
7 External links
[edit]Position/Lighting/Draping
Position - patient should be supine and the bed or examination table
should be at a 45 degree angle. The patient's hands should remain at
his or her sides with the head resting on a pillow.
Lighting - adjusted so that it is ideal for examinaton and the examiner
does not obstruct the light falling on the patient.
Draping - the chest and neck should be fully exposed.
[edit]Inspection
General Inspection:
- inspect the patient status whether he or she is comfortable at rest or
obviously short of breath.
[1]

- Inspect the neck for increased jugular venous pressure (JVP)or
abnormal waves.
[2]

Then inspect the precordium for:
visible pulsations
apex beat
masses
scars
lesions
signs of trauma and previous surgery (e.g. median sternotomy)
permanent Pace Maker
praecordial bulge
[edit]Palpation
The valve areas are palpated for abnormal pulsations (known
as thrills) and precordial movements (known as heaves). Heaves are
best felt with the heel of the hand at the sternal border.
[edit]Palpation of the apex beat
The apex beat is typically palpable in the left fifth intercostal space
and 1 cm medial to the mid-clavicular line. It is not palpable in some
patients due to obesity or emphysema.
The apex beat should be described by the following characteristics
(which can be remember with the mnemonic SALID:
S - Size - Is it larger than one interspace?
A - Amplitude - Is it weak?
L - Location - Is it in the fifth intercostal space at the mid-clavicular
line?
I - Impulse - Is it monophasic or biphasic?
D - Duration - Is it abnormally sustained?
Causes for absent apex beat:
D - Dextrocardia
R - Apex behind a Rib
P - Pericardial Effusion
O - Obesity
P - Left Pleural Effusion
E - Emphysema
To accurately determine the location of an apex beat which can be felt
across a large area, feel for the most lateral and inferior position of
pulsation. An apex beat in the axilla would indicatedcardiomegaly or
mediastinal shift. Note that the apex beat does not exactly correspond
to the apex of the heart.
[edit]Auscultation
One should comment on
S1 and S2 - if the splitting is abnormal or louder than usual. Should
sound like [lub-dub lub-dub]
and the presence of
S3 - think Kentucky - the emphasis and timing of the syllables in
the word Kentucky is similar to the pattern of sounds in a precordial
S3. Some examiners can hear these sounds better by listening for
a [lub de dub] sound.
S4 - think Tennessee - the emphasis and timing of the syllables in
the word Tennessee is similar to the pattern of sounds in a
precordial S4. Some examiners can hear these sounds better by
listening for a [T lub-dub] sound.
If S4 S1 S2 S3 were all present it would sound like [T-lub-de-dub]
Also known as a quadruple gallop rhythm
diastolic murmurs (e.g. aortic regurgitation, mitral stenosis)
systolic murmurs (e.g. aortic stenosis, mitral regurgitation)
pericardial rub (suggestive of pericarditis)
[edit]
The Apex Beat and palpation of the chest wall
The apex beat is the lateral most point of the cardiac impulse palpable on the chest wall. It is
usually localized with reference to the rib level at which it occurs- representing the x-axis, with the
mid clavicular line, representing the y axis. The mid-clavicular line is drawn from a point midway
along the clavicle and descending vertically downwards, and often does not coincide with the
location of the nipple. The apex is usually located in the fifth intercostal space in the mid-clavicular
line. Laterally displacement may be best described with reference to the anterior axillary line or
even the mid axillary line. (Insert illustration here)
Patient Positioning

The apex beat is usually observed with the patient lying at 45 to the horizontal. If not identified,
it can sometimes be accentuated by sitting the patient forward or rotating the patient to the left
side.
Inspection

The apex beat can often be seen, especially in slim persons. The normal pulse is about 3 cm in
diameter. Examine the left and right sides of the chest in case of dextrocardia.
Palpation
Palpation with the palm of the hand and fingers should start at a lateral position and move more
anteriorly in order to avoid missing a displaced beat. A displaced apex beat usually indicates
dilation of the left ventricle. Hypertrophy generally does not lead to a displaced apex beat.
Apex beat
A normal apex beat is about 3-4cm in diameter, or a little more than 1.5 fingertips. A wider
diameter apex beat suggests dilation of the left ventricle.
(a) The hyperkinetic apex

(also referred to as hyperdynamic or pressure loaded)
This is a forceful and sustained apical impulse, often seen in left ventricular hypertrophy due to
whatever cause.
(b) The sustained apical movement.
A sustained apex beat suggests cardiomyopathy or severe aortic stenosis.
c) The double apical impulse
This is a distinct double movement of the apex with sinus rhythm, that may be found in
hypertrophic cardiomyopathy. , a left ventricular aneurysm involving the anterior wall or apex
The further palpation of the chest wall
The palpation of the chest wall during the cardiac exam should not end with the palpation of the
apex. There is more to be found.
a) Palpating for a left parasternal heave
Normally only a slight inward movement is palpable. A sustained outward movement is referred to
as a heave. The presence of a left parasternal heave suggests dilation of the right ventricle, an
anterior mediastinal structure. It can also be due to marked left atrial dilatation as may be seen in
mitral stenosis.
A systolic downward movement of the right ventricle may also be felt in the epigastrium. This may
be palpated by placing the palmar aspect of your thumb under the left costal margin with the tip of
the thumb towards the xiphoid process. An enlarged right ventricle can be felt tapping downwards
on the surface of the thumb. Sometimes it is necessary to ask the patient to take and hold a deep
breath to palpate the enlarged ventricle.
b) Hyperkinetic movement of the left sternal edge
Unlike a left parasternal heave, this is a non-sustained outward movement of the left sternal edge.
Most commonly this is due to a hyperdynamic circulation for example due to fever, but it may be a
sign of an atrial septal defect- in this circumstance it is caused by increased filling of the right
ventricle. Look for the fixed splitting of the second heart sound, a prominent y decent in the neck
veins, a soft systolic murmur in the 2nd left intercostal space as other signs to support this
diagnosis.
c) Hyperkinetic movement of the right parasternal edge
This is found in severe tricuspid regurgitation, or mitral regurgitation. In the former it is due to
expansion of the right atrium and liver, in the latter dilation of the left atrium.
d) Left parasternal movement in severe mitral regurgitation
In patients with very severe mitral regurgitation the left atrium of the heart can become massively
dilated, and its rapid filling during ventricular contraction can push the heart forward creating a
late systolic left parasternal impulse. This occurs even when the right ventricle, which overlies the
left atrium, is of normal dimensions.
e) Thrills
A thrill is a vibration like movement of the chest wall caused by turbulent blood flow over a heart
valve. It is a palpable murmur . Thrills are usually best palpated using the distal palm. Aortic and
pulmonary stenotic lesions produce murmurs that are best felt with the patient leaning forward
and in full expiration.
f) A palpable P2
A palpable pulmonary component of the second heart sound (P2) is considered a sign of
pulmonary hypertension. It is felt with the fingertips as a tapping movement. Palpate over the
pulmonary area of the chest- the left sternal edge, second intercostal space, again with the patient
sitting forward



Normal landmark
Palpate sternal angle [angle of Louie], which is 2nd rib.
Space below is 2nd intercostal space.
Count down to 5th intercostal.
1cm medial to midclavicular line.
Pediatric heart is different. See Pediatric Heart Reference.
Palpating deviation
Dr makes a claw.
Put middle finger in 5th intercostal space on lateral ribcage.
Place rest of hands fingers in spaces above and below.
Move claw around medially, finding the apex beat.
Absent apex beat causes
DOPES:
Death
Obesity
Pericarditis
Emphysema, other COPD
Sinus inversus
Apex deviation causes
With trachea shift also:
Mediastinal shift
Without trachea shift:
Cardiomegaly
Scoliosis
Pectus excavatum
Sinus inversus
Abnormal apex beat types
Double impulse:
What: systole has 2 impulses.
DDx: hypertrophic cardiomyopathy.
Dyskinetic:
What: uncoordinated, easily palpable.
DDx: MI.
Hyperdynamic:
What: forceful, sustained apex beat.
DDx: AS, HTN.
Hyperkinetic:
What: coordinated, palpated beat is distributed over greater area.
DDx: LV dilation.
Tapping apex:
What: S1 sound is palpable. See Heart Sounds Reference.
DDx: mitral stenosis.


Apex beat is defined as the lowermost and outermost point of definite cardiac impulse.
It means, you have to locate the lowermost part of cardiac impulse on the chest first and then
trace it to the outermost (lateral most) point where you can feel the impulse.
And, it is not the other way around, ie., outermost and lowermost point



Apex beat
The apex beat, also called the point of maximum impulse (PMI), is the
furthermost point outwards (laterally) and downwards (inferiorly) from the
sternum at which the cardiac impulse can be felt. The cardiac impulse is the result
of the heart rotating, moving forward and striking against the chest wall during
systole.
The normal apex beat can be palpated in the precordium left 5th intercostal space,
at the point of intersection with the left midclavicular line. In children the apex
beat occurs in the fourth rib interspace medial to the nipple. The apex beat may
also be found at abnormal locations; in many cases of dextrocardia, the apex beat
may be felt on the right side.
Lateral and/or inferior displacement of the apex beat usually indicates enlargement
of the heart, called cardiomegaly. The apex beat may also be displaced by other
conditions:
Pleural or pulmonary diseases
Deformities of the chest wall or the thoracic vertebra
Sometimes, the apex beat may not be palpable, either due to a thick chest wall, or
conditions where the stroke volume is reduced; such as during ventricular
tachycardia or shock.
The character of the apex beat may provide vital diagnostic clues:
A forceful impulse indicates pressure overload in the heart (as might occur
in hypertension)
An uncoordinated(dyskinetic) apex beat involving a larger area than normal
indicates ventricular dysfunction; such as an aneurysm following
myocardial infarction



Blood pressure: The blood pressure is the pressure of the blood within the arteries. It is produced
primarily by the contraction of the heart muscle. It's measurement is recorded by two numbers. The
first (systolic pressure) is measured after the heart contracts and is highest. The second
(diastolic pressure) is measured before the heart contracts and lowest. A blood pressure cuff is used
to measure the pressure. Elevation of blood pressure is called "hypertension".


blood pressure
1. the pressure of blood against the walls of any blood vessel.
2. the pressure of blood on the walls of the arteries, dependent on the energy of the heart action,
elasticity of the arterial walls, and volume and viscosity of the blood;
the maximum or systolic pressure occurs near the end of the stroke output of the left ventricle, and
the minimum or diastolic late in ventricular diastole.
central venous pressure (CVP) the venous pressure as measured at the right atrium, done by
means of a catheter introduced through the median cubital vein to the superior vena cava.
cerebrospinal pressure the pressure or tension of the cerebrospinal fluid, normally 100150 mm. as
measured by the manometer.
detrusor pressure the pressure exerted inwards by the detrusor urinae muscles of the bladder wall.
diastolic pressure , diastolic blood pressure see blood p.
end-diastolic pressure the pressure in the ventricles at the end of diastole, usually measured in the
left ventricle as an approximation of the end-diastolic volume, or preload.
intracranial pressure (ICP) pressure of the subarachnoidal fluid.
intraocular pressure the pressure exerted against the outer coats by the contents of the eyeball.
intravesical pressure the pressure exerted on the contents of the urinary bladder; the sum of the
intra-abdominal pressure from outside the bladder and the detrusor pressure.
maximum expiratory pressure (MEP) a measure of the strength of respiratory muscles, obtained
by having the patient exhale as strongly as possible against a mouthpiece; the maximum value is
near total lung capacity.
maximum inspiratory pressure (MIP) a measure of the strength of respiratory muscles, obtained by
having the patient inhale as strongly as possible with the mouth against a mouthpiece; the maximum
value is near the residual volume.
mean arterial pressure (MAP) the average pressure within an artery over a complete cycle of one
heartbeat.
mean circulatory filling pressure a measure of the average (arterial and venous) pressure
necessary to cause filling of the circulation with blood; it varies with blood volume and is directly
proportional to the rate of venous return and thus to cardiac output.
negative pressure pressure less than that of the atmosphere.
oncotic pressure the osmotic pressure due to the presence of colloids in solution.
osmotic pressure the pressure required to prevent osmosis through a semipermeable membrane
between a solution and pure solvent; it is proportional to the osmolality of the solution. Symbol .
partial pressure the pressure exerted by each of the constituents of a mixture of gases.
positive pressure pressure greater than that of the atmosphere.
positive end-expiratory pressure (PEEP) a method of mechanical ventilation in which pressure is
maintained to increase the volume of gas left in the lungs at the end of exhalation, reducing shunting
of blood through the lungs and improving gas exchange.
pulmonary artery wedge pressure (PAWP), pulmonary capillary wedge pressure (PCWP)
intravascular pressure as measured by a catheter wedged into the distal pulmonary artery ; used to
measure indirectly the mean left atrial pressure.
pulse pressure the difference between systolic and diastolic pressures.
systolic pressure , systolic blood pressure see blood p.
Valsalva leak point pressure the amount of pressure on the bladder by a Valsalva maneuver at
which leakage of urine occurs; a measure of strength of the urethral sphincters.
venous pressure the pressure of blood in the veins.
wedge pressure blood pressure measured by a small catheter wedged into a vessel, occluding it,
e.g., pulmonary capillary wedge p.
wedged hepatic vein pressure the venous pressure measured with a catheter wedged into the
hepatic vein; used to locate the site of obstruction in portal hypertension.

Dorland's Medical Dictionary for Health Consumers. 2007 by Saunders, an imprint of Elsevier, Inc. All rights reserved.

blood pressure
n.
Abbr. BP The pressure exerted by the blood against the walls of the arteries, maintained by the contraction of
the left ventricle, the resistance of the arterioles and capillaries, the elasticity of the arterial walls, and by the
viscosity and volume of the blood. Also called arteriotony.
The American Heritage Medical Dictionary Copyright 2007, 2004 by Houghton Mifflin Company. Published by Houghton Mifflin
Company. All rights reserved.

blood pressure (BP)
Etymology: AS, blod + L, premere, to press
the pressure exerted by the circulating volume of blood on the walls of the arteries and veins and on
the chambers of the heart. Blood pressure is regulated by the homeostatic mechanisms of the body
by the volume of the blood, the lumen of the arteries and arterioles, and the force of cardiac
contraction. In the aorta and large arteries of a healthy young adult, blood pressure is approximately
120 mm Hg during systole and 70 mm Hg during diastole. See also hypertension, hypotension.
method The indirect blood pressure is most often measured by auscultation, using an aneroid or
mercury sphygmomanometer, a stethoscope, and a blood pressure cuff. With the upper arm at the
level of the heart, the cuff is placed around the upper arm and inflated to a pressure greater than the
systolic pressure, occluding the brachial artery. The diaphragm of the stethoscope is placed over the
artery in the antecubital space, and the pressure in the cuff is slowly released. No sound is heard until
the cuff pressure falls below the systolic pressure in the artery; at that point a pulse is heard. As the
cuff pressure continues to fall slowly, the pulse continues, first becoming louder, then dull and
muffled. These sounds, called sounds of Korotkoff, are produced by turbulence of the blood flowing
through a vessel that is partially occluded as the arterial pressure falls to the low pressure of diastole.
When the cuff pressure is less than the diastolic pressure, no pulse is heard. Thus the cuff pressure
at which the first sound is heard is the systolic blood pressure, indicative of the pressure in the large
arteries during systole; the cuff pressure at which the sounds stop is the diastolic blood pressure,
indicative of the pressure in the arteries during diastole. A variation of this method involves the use of
palpation in place of auscultation in the antecubital space to determine the systolic pressure (the
pressure at which a pulse is first palpated). Another variation uses a transducer in the cuff to translate
changes in ultrasound frequency caused by blood movement within the artery to audible sounds.
Blood pressure may be monitored directly by means of a strain gauge or mercury manometer after a
cannula has been placed in an artery. The flush method is used when blood pressure is difficult to
measure by other methods. The cuff is applied, and complete capillary emptying is performed, usually
with an elastic bandage. The cuff is inflated, the elastic bandage is removed, and the earliest
discernible flush is observed as the cuff is deflated. This method measures mean blood pressure.
interventions The intervals at which the patient's blood pressure is to be taken are specified. The
pressure in both arms is taken the first time the procedure is performed; persistent major differences
between the two readings is indicative of a vascular occlusion. Alternatively, the blood pressure may
be taken using the thigh and the popliteal space when the leg is at the level of the heart. The width of
the cuff should be one third to one half the circumference of the limb used. Thus, a larger cuff is
required for a large patient or for any patient if the pressure is taken at the thigh.
outcome criteria Any factor that increases peripheral resistance or cardiac output increases the
blood pressure. Therefore, it is important to obtain a blood pressure reading when the patient is at
rest. Increased peripheral resistance usually increases the diastolic pressure, and increased cardiac
output tends to increase the systolic pressure. Blood pressure increases with age, primarily as a
result of the decreased distensibility of the veins. As a person grows older, an increase in systolic
pressure precedes an increase in diastolic pressure.


What is Blood Pressure?
Blood is carried from the heart to all parts of your body in vessels called arteries. Blood pressure is the force
of the blood pushing against the walls of the arteries. Each time the heart beats (about 60-70 times a
minute at rest), it pumps out blood into the arteries. Your blood pressure is at its highest when the heart
beats, pumping the blood. This is called systolic pressure. When the heart is at rest, between beats, your
blood pressure falls. This is the diastolic pressure.

Blood pressure is always given as these two numbers, the systolic and diastolic pressures. Both are
important. Usually they are written one above or before the other, such as 120/80 mmHg. The top number
is the systolic and the bottom the diastolic. When the two measurements are written down, the systolic
pressure is the first or top number, and the diastolic pressure is the second or bottom number (for example,
120/80). If your blood pressure is 120/80, you say that it is "120 over 80."

Blood pressure changes during the day. It is lowest as you sleep and rises when you get up. It also can rise
when you are excited, nervous, or active.

Still, for most of your waking hours, your blood pressure stays pretty much the same when you are sitting
or standing still. That level should be lower than 120/80. When the level stays high, 140/90 or higher, you
have high blood pressure. With high blood pressure, the heart works harder, your arteries take a beating,
and your chances of a stroke, heart attack, and kidney problems are greater.
What causes it?
In many people with high blood pressure, a single specific cause is not known. This is called essential or
primary high blood pressure. Research is continuing to find causes.

In some people, high blood pressure is the result of another medical problem or medication. When the cause
is known, this is called secondary high blood pressure.
This section National Heart, Lung, and Blood Institute
What is high blood pressure?
A blood pressure of 140/90 or higher is considered high blood pressure. Both numbers are important. If one
or both numbers are usually high, you have high blood pressure. If you are being treated for high blood
pressure, you still have high blood pressure even if you have repeated readings in the normal range.

There are two levels of high blood pressure: Stage 1 and Stage 2 (see the chart below).

Categories for Blood Pressure Levels in Adults*
(In mmHg, millimeters of mercury)
Category
Systolic
(Top number)
Diastolic
(Bottom number)
Normal Less than 120 Less than 80
Prehypertension 120-139 80-89
High Blood Pressure Systolic Diastolic
Stage 1 140-159 90-99
Stage 2 160 or higher 100 or higher


* For adults 18 and older who:
Are not on medicine for high blood pressure
Are not having a short-term serious illness
Do not have other conditions such as diabetes and kidney disease

Note: When systolic and diastolic blood pressures fall into different categories, the higher category should
be used to classify blood pressure level. For example, 160/80 would be stage 2 high blood pressure.
There is an exception to the above definition of high blood pressure. A blood pressure of 130/80 or higher is
considered high blood pressure in persons with diabetes and chronic kidney disease.


Blood pressure

Blood pressure is a measurement of the force applied to the walls of the arteries as the heart pumps
blood through the body. The pressure is determined by the force and amount of blood pumped, and
the size and flexibility of the arteries.
Blood pressure is continually changing depending on activity, temperature, diet, emotional state,
posture, physical state, and medication use.
How the Test is Performed
Blood pressure is usually measured while you are seated with your arm resting on a table. Your arm
should be slightly bent so that it is at the same level as your heart. Your upper arm should be bare,
with your sleeve comfortably rolled up.
Blood pressure readings are measured in millimeters of mercury (mmHg) and are given as two
numbers. For example, 110 over 70 (written as 110/70).
The top number is the systolic blood pressure reading. It represents the maximum pressure
exerted when the heart contracts.
The bottom number is the diastolic blood pressure reading. It represents the minimum
pressure in the arteries when the heart is at rest.
Watch this video about:Blood pressure
To obtain your blood pressure measurement, your health care provider will wrap the blood pressure
cuff snugly around your upper arm, positioning it so that the lower edge of the cuff is 1 inch above the
bend of the elbow.
The health care provider will locate the large artery on the inside of the elbow by feeling for
the pulse and will place the head of the stethoscope over this artery, below the cuff. It should not rub
the cuff or any clothing because these noises may block out the pulse sounds. Correct positioning of
the stethoscope is important to get an accurate recording.
Your health care provider will close the valve on the rubber inflating bulb and then will squeeze it
rapidly to inflate the cuff until the dial or column of mercury reads 30 mmHg higher than the usual
systolic pressure. If the usual systolic pressure is unknown, the cuff is inflated to about 210 mmHg.
Next, the valve is opened slightly, allowing the pressure to fall gradually (2 to 3 mmHg per second).
As the pressure falls, the level on the dial or mercury tube at which the sound of blood pulsing is first
heard is recorded. This is the systolic pressure.
As the air continues to be let out, the sounds will disappear. The point at which the sound disappears
is recorded. This is the diastolic pressure (the lowest amount of pressure in the arteries as the heart
rests).
The procedure may be performed two or more times.
How to Prepare for the Test
The test may be done at any time with your arm supported and held at the level of your heart. When
your doctor needs to compare the current reading to previous ones, the test is usually done after you
rest for at least 5 minutes.
All you need to perform a blood pressure measurement is a cuff and a device (stethoscope or
microphone) to detect the sound of the pulse in the artery.
How the Test Will Feel
You will feel the pressure of the cuff on your arm. If the test is repeated a few times, you may feel
temporary numbness or tingling in your hand.
Why the Test is Performed
The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood
Pressure recommends screening adults for high blood pressure every 2 years if their blood pressure
is normally less than 120/80 mmHg.
Adults with high blood pressure or prehypertension should have their blood pressure checked every
year or more often.
Most people cannot tell if their blood pressure is high because there are usually no symptoms.
High blood pressure increases the risk of heart failure, heart attack, stroke, and kidney failure.
If you have high blood pressure, blood pressure measurements can help determine if your medicine
and diet changes are working.
Low blood pressure may be a sign of a variety of illnesses, including heart failure, infection, gland
disorders, and dehydration.
Normal Results
In adults, the ideal top number (systolic pressure) should be less than 120 mmHg. The bottom
number (diastolic pressure) should be less than 80 mmHg.
What Abnormal Results Mean
Prehypertension:
Top number is consistently 120 to 139 or the bottom number reads 80 to 89.
Stage 1: Mild high blood pressure:
Top number is consistently 140 to 159 or the bottom number reads 90 to 99.
Stage 2: Moderate to severe high blood pressure:
Top number is consistently 160 or over or the bottom number reads 100 or over.
Low blood pressure (hypotension):
Top number reading lower than 90 or pressure 25 mmHg lower than usual
Blood pressure readings may be affected by many different conditions, including:
Cardiovascular disorders
Neurological conditions
Kidney and urological disorders
Pre-eclampsia in pregnant women
Psychological factors such as stress, anger, or fear
Various medications
"White coat hypertension" may occur if the medical visit itself produces anxiety
Risks
There are no significant risks associated with checking blood pressure.
If you have vascular access (shunt) for kidney dialysis on your arm, you should not have your blood
pressure checked in that arm.
Considerations
Repeated measurements are important. A single high measurement does not necessarily mean you
have high blood pressure. On the other hand, a single normal measurement does not necessarily
mean that you don't have high blood pressure.
Blood pressure readings taken at home can provide important information to your doctor. Such
readings may be a better measure of your current blood pressure than those taken at your doctor's
office, as long as you make sure your machine is accurate. You can ask your health care provider to
compare readings in the office. Many people become nervous at the doctor's office and have higher
readings that they normally would at home. This is called white coat hypertension.
Consult your provider if your blood pressure measurements are consistently high or low or if you have
symptoms at the same time as the high or low reading.
Alternative Names
Diastolic blood pressure; Systolic blood pressure

blood pressure
n. Abbr. BP
The pressure exerted by the blood against the walls of the blood vessels, especially the arteries. It varies with the
strength of the heartbeat, the elasticity of the arterial walls, the volume and viscosity of the blood, and a person's
health, age, and physical condition.
The American Heritage Dictionary of the English Language, Fourth Edition copyright 2000 by Houghton Mifflin Company. Updated in
2009. Published by Houghton Mifflin Company. All rights reserved.

blood pressure
n
(Life Sciences & Allied Applications / Physiology) the pressure exerted by the blood on the inner walls
of the arteries, being relative to the elasticity and diameter of the vessels and the force of the
heartbeat
Collins English Dictionary Complete and Unabridged HarperCollins Publishers 1991, 1994, 1998, 2000, 2003

blood pressure
The pressure of the blood in the vessels, especially the arteries, as it circulates through the body. Blood pressure
varies with the strength of the heartbeat, the volume of blood being pumped, and the elasticity of the blood
vessels. Arterial blood pressure is usually measured by means of a sphygmomanometer and reported in
millimeters of mercury as a fraction, with the numerator equal to the blood pressure during systole and the
denominator equal to the blood pressure during diastole. See more at hypertensionhypotension

In medicine, one's pulse represents the tactile arterial palpation of the
heartbeat by trained fingertips. The pulse may be palpated in any
place that allows an artery to be compressed against a bone, such as
at the neck (carotid artery), at the wrist (radial artery), behind
the knee (popliteal artery), on the inside of the elbow (brachial artery),
and near the ankle joint (posterior tibial artery). The pulse can also be
measured by listening to the heart beat directly (auscultation),
traditionally using a stethoscope.
Contents
[hide]
1 Physiology
2 Normal Pulse Rates
3 Evaluation
4 Common pulse sites
o 4.1 Upper limb
o 4.2 Lower limb
o 4.3 Head/neck
o 4.4 Torso
5 See also
6 References
[edit]Physiology
The pulse is a decidedly low tech/high yield and antiquated term still
useful at the bedside in an age of computational analysis of cardiac
performance. Claudius Galen was perhaps the first physiologistto
describe the pulse.
[1]
The pulse is an expedient tactile method of
determination of systolic blood pressure to a trained
observer. Diastolic blood pressure is non-palpable and unobservable
by tactile methods, occurring between heartbeats.
Practitioners in Chinese Medicine are trained in Pulse Diagnosis and
seek six different pulses in each wrist, each corresponding to specific
organs of the body. The Chinese practitioner is trained to evaluate the
frequency, rhythm and volume of the pulse and may characterize it as
strong, thready, slippery or floating.
[2]

Pressure waves generated by cardiac systole move the artery walls,
which are pliable and compliant. These properties form enough to
create a palpable pressure wave.
The Heart Rate may be greater or lesser than the Pulse
Rate depending upon physiologic demand. In this case, the heart rate
are determined by auscultation or audible sounds at the heart apex, in
which case it is not the pulse. The pulse deficit (difference between
heart beats and pulsations at the periphery) is determined by
simultaneous palpation at the radial artery and auscultation at the
heart apex.
Pulse velocity, pulse deficits and much more physiologic data is
readily and simplistically visualized by the use of one or more arterial
catheters connected to a transducer and oscilloscope. This invasive
technique has been commonly used in intensive care since the 1970s.
The rate of the pulse is observed and measured by tactile or visual
means on the outside of an artery and is recorded as beats per
minute or BPM.
The pulse may be further indirectly observed under Light absorbances
of varying wavelengths with assigned and inexpensively reproduced
mathematical ratios. Applied capture of variances of light signal from
the Blood component Hemoglobin under oxygenated vs.
deoxygenated conditions allows the technology of Pulse Oximetry.
[edit]Normal Pulse Rates
Normal pulse rates in beats per minute (BPM):
newborn

1 12 months

1 2 years

2 6 years

6 12 years

12 years -
adults
adult athletes

120 - 160 80 - 140 80 - 130 75 - 120 75 - 110 60 - 100 40 - 70
[edit]Evaluation
A collapsing pulse is a sign of hyperdynamic circulation.
Several pulse patterns can be of clinical significance. These include:
Pulsus alternans
Pulsus bigeminus
Pulsus bisferiens
Pulsus tardus et parvus
Pulsus paradoxus
Sinus Tachycardia
The strength of the pulse can also be reported:
[3][4]

0 = Absent
1 = Barely palpable
2 = Easily palpable
3 = Full
4 = Aneurysmal or Bounding pulse
[edit]Common pulse sites
[edit]Upper limb


Front of right upper extremity
Axillary pulse: located inferiorly of the lateral wall of the axilla
Brachial pulse: located on the inside of the upper arm near the
elbow, frequently used in place of carotid pulse in infants (brachial
artery)
Radial pulse: located on the lateral of the wrist (radial artery). It
can also be found in the anatomical snuff box.
Ulnar pulse: located on the medial of the wrist (ulnar artery).
[edit]Lower limb
Femoral pulse: located in the inner thigh, at the mid-inguinal point,
halfway between the pubic symphysis and anterior superior iliac
spine (femoral artery).
Popliteal pulse: Above the knee in the popliteal fossa, found by
holding the bent knee. The patient bends the knee at approximately
124, and the physician holds it in both hands to find the popliteal
artery in the pit behind the knee (Popliteal artery).
Dorsalis pedis pulse: located on top of the foot, immediately
lateral to the extensor of hallucis longus (dorsalis pedis artery).
Tibialis posterior pulse: located on the medial side of the ankle,
2 cm inferior and 2 cm posterior to the medial malleolus (posterior
tibial artery). It is easily palpable over Pimenta's Point.
[edit]Head/neck


Arteries of the neck.
Carotid pulse: located in the neck (carotid artery). The carotid
artery should be palpated gently and while the patient is sitting or
lying down. Stimulating its baroreceptors with low palpitation can
provoke severe bradycardia or even stop the heart in some
sensitive persons. Also, a person's two carotid arteries should not
be palpated at the same time. Doing so may limit the flow of blood
to the head, possibly leading to fainting or brain ischemia. It can be
felt between the anterior border of the sternocleidomastoid muscle,
above the hyoid bone and lateral to the thyroid cartilage.
Facial pulse: located on the mandible (lower jawbone) on a line
with the corners of the mouth (facial artery).
Temporal pulse: located on the temple directly in front of the ear
(superficial temporal artery).
[edit]Torso
Apical pulse: located in the 4.5th or 5th left intercostal space, just
outside the mid-clavicular line. In contrast with other pulse sites,
the apical pulse site is unilateral, and measured not under an
artery, but below the heart itself (more specifically, the apex of the
heart).
[edit]

Pulse: The rhythmic contraction and expansion of an artery due to the surge of blood from the beat of
the heart. The pulse is most often measured by feeling the arteries of the wrist. There is also a pulse,
although far weaker, in veins.