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Wide Pulse Pressure

Pulse pressure is the difference between systolic and diastolic blood pressures. Wide pulse pressure is a difference greater than 60–70 mmHg. This often results from conditions that produce an increase in stroke volume.

Differential Diagnosis

  • Atherosclerosis
    –Large arteries stiffen with age, resulting in increased systolic blood pressure and, thus, increased pulse pressure
  • Chronic aortic regurgitation (acute AR does not result in wide pulse pressure)
    –Results in heart failure, syncope, and/or angina
    –Exam may reveal early diastolic murmur
    –Corrigan's pulse: Rapid rise and rapid fall
    –Hill's sign: Systolic blood pressure of lower extremities >20 mmHg more than systolic blood pressure in arms
    –de Musset's sign: Head bobs with each heartbeat
    –Causes include rheumatic heart disease, idiopathic root dilatation, Marfan's disease, and endocarditis
    • Thyrotoxicosis
      –Associated with nervousness, sweating, heat intolerance, tachycardia, weight loss
      –Thyroid nodule(s) may be present
  • Increased cardiac output states
    –Fever
    –Anemia
    –Pregnancy
    –Anxiety
    • Patent ductus arteriosus
      –“Bounding” pulses
      –Continuous murmur through diastole and systole
  • Complete heart block
    –Often secondary to MI or CAD
  • Sinus bradycardia
  • Systemic AV fistula
  • Aortic dissection
  • Endocarditis
  • Increased intracranial pressure

    • Workup and Diagnosis

    • History and physical examination
    • Initial labs may include CBC and TSH
    • Consider blood cultures, lipid panel, free T4, and free T3
    • Evaluate for cardiac causes, especially if murmurs or abnormal pulses are appreciated on exam
    • ECG may reveal LVH, complete heart block (no relationship between P and QRS), irregularly irregular rhythm (atrial fibrillation), and evidence of CAD
    • Echocardiogram (transesophageal and transthoracic) may reveal abnormal valves or regurgitation
      –Transesophageal echocardiography is more useful than transthoracic for evaluation of aortic regurgitation
      –Transesophageal echocardiography is very sensitive and specific for diagnosing aortic dissection because it can evaluate both anatomically (dissection flap) and physiologically (flow between true and false lumen)
  • Chest X-ray will show widening of mediastinum and enlargement of the aortic knob with aortic dissection
  • CT scan may be indicated to evaluate for aortic dissection
  • MRI is as sensitive and specific as TEE for diagnosing aortic dissection
  • Aortography is not as good as transesophageal echocardiography for quantifying the amount of aortic regurgitation and also may not reveal two aortic lumens in cases of aortic dissection
  • If suspect atherosclerosis, evaluate CAD risk stratification, cholesterol screening, stress testing, and cardiac catheterization as necessary

    • Treatment

    • Assess hemodynamic stability
    • Treat emergent causes as necessary
      –Immediate medical or surgical management of aortic dissection
      –Immediate blood cultures and IV antibiotic therapy for endocarditis
    • Chronic atrial regurgitation: Aortic valve replacement may be necessary, especially if patient has a low ejection fraction; medical therapy (e.g., diuretics, vasodilators, pressors) may improve cardiac function
    • Evaluate and treat underlying causes of anemia, fever, hyperthyroidism, increased intracranial pressure, chronic disease
  • Hyperthyroidism: β-blockers for symptoms, antithyroid medications (e.g., PTU), radioactive iodine ablation, or thyroidectomy

    • Book Source Details

    • Book Title: In a Page: Signs and Symptoms
    • Author(s): Scott Kahan, Ellen G. Smith
    • Year of Publication: 2004
    • Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

    Other Book Chapters Related to Pressure

    Read excerpts from these other book chapters related to Pressure:

    Medical Books Excerpts
    • Hypertension
    • "Professional Guide to Diseases (Eighth Edition)" (2005)
    • [ read ]
    • Hypertension
    • "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
    • [ read ]
    • Hypertension
    • "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
    • [ read ]
     

    Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

    More About Causes of Pressure



    More About This Book:
    Title: In a Page: Signs and Symptoms
    Authors: Scott Kahan, Ellen G. Smith
    Publisher: Lippincott Williams & Wilkins
    Copyright: 2004
    ISBN: 1-4051-0368-X

     » Next page: Hypertension (In A Page: Pediatric Signs and Symptoms)

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