UNEQUAL PULSES

To develop a list of causes of unequal pulses, let’s trace the arterial system from its origin in the heart to its termination in the extremities. Heart. Here is the source of arterial emboli from a mural thrombus in auricular fibrillation or myocardial infarction and subacute bacterial endocarditis (SBE). Aorta. This will bring to mind a coarctation of the aorta and/or dissecting aneurysm (thrombosis of the terminal aorta). Proximal arteries. These suggest thoracic outlet syndrome, subclavian steal syndrome, and femoral artery thrombosis or embolism. Distal arteries. These bring to mind peripheral arteriosclerosis, Buerger disease, arterial embolism, and arteriovenous fistula. A fracture may involve the distal arteries causing pulse inequality.

Approach to the Diagnosis

If there is a history of sudden onset of unequal pulses in either the upper or lower extremity, a diagnosis of arterial embolism or dissecting aneurysm must be ruled out with immediate angiography. If there is a history of trauma, fracture must be ruled out with plain films of the extremity. When the patient complains of ischemic symptoms (intermittent claudication, e.g.) or the pulse inequality is discovered on a routine physical examination, Doppler studies can be used to determine the cause before proceeding with angiography. If you suspect an arterial embolism, order serial electrocardiograms (EKGs) and cardiac enzymes. An EKG may also diagnose auricular fibrillation. If SBE is a possibility, order blood culture. A cardiologist or cardiovascular surgeon may need to be consulted early in the course.

Other Useful Tests

1. Coagulation studies (disseminated intravascular coagulation [DIC])
2. Echocardiography (valvular stenosis)

Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins MD, FACP
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

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More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins MD, FACP Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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