Unequal Pulses

Unequal pulses is a difference in blood pressure measurements between both arms or between the arms and the legs. The presence of unequal pulses can help diagnose significant underlying disease. A thorough vascular examination is an integral part of every cardiac exam.

Differential Diagnosis

• Atherosclerosis
  –Most common cause of unequal pulses
  –Manifestations include claudication, rest pain, ischemic ulcers, and gangrene

• Aortic dissection
  –Sharp, “tearing” chest or back pain
  –Etiologies include hypertension, Marfan's syndrome, bicuspid aortic valve, cocaine, trauma
• Aortic aneurysm
  –Focal or diffuse dilation 50% larger than normal diameter of vessel
  –Etiologies include atherosclerosis (most common for abdominal, descending thoracic aneurysms), cystic medial necrosis (most common for ascending aneurysms), connective tissue disorders (Marfan's, Ehlers-Danlos), congenital abnormalities (bicuspid aortic valve), syphilitic aortitis, spondyloarthropathies, vasculitis
  • Takayasu's disease (“pulseless disease”)
    –Idiopathic inflammatory disorder of aorta
    –Most common in women aged 10–40 years
    –Often presents with systemic complaints (fever, malaise, weight loss, fatigue)
    –Aortic inflammation causes narrowing of aortic branches, ultimately resulting in vascular insufficiency
  • Coarctation of aorta
    –6–8% of all congenital heart disease
    –More common in males
    –May rarely result in diminished left brachial pulse when origin of left subclavian artery is distal to coarctation
    –Narrowing of section of aortic arch resulting in decreased BP in lower extremities, may present as HTN in upper extremities
    –May also have bicuspid aortic valve, ventricular septal defect, patent ductus arteriosus, left ventricular outflow obstruction
  • Subclavian steal syndrome
    –Syncope or dizziness following exercise of the arms
  • Compartment syndrome
    –Increased pressure in a closed compartment may decrease the blood pressure to tissues
    –Look for the “five P's” (pain, pallor, pulselessness, paresthesia, paralysis)

  Workup and Diagnosis

  • History and physical examination
    –Elicit risk factors and identify predisposing conditions
    –Atrophic changes and dependent rubor suggest atherosclerosis
    –Pulsatile abdominal mass and abdominal bruit suggest aortic aneurysm
    –Hypertension, diastolic murmur of aortic insufficiency, and left pleural effusion suggest aortic dissection
    –Continuous murmur suggests coarctation of the aorta
    –Asymmetric blood pressure suggests aortic dissection, coarctation of the aorta, or Takayasu's disease
  • ABI of systolic pressure <0.9 is consistent with peripheral arterial disease; values <0.5 are consistent with severe ischemia
  • Chest X-ray may reveal widened mediastinum, pleural effusion, and tracheal deviation in aortic dissection; “rib notching” is due to intercostal artery collateral channels in coarctation of the aorta
  • CT or MRA may be used to diagnose Takayasu's, aortic aneurysm, and peripheral arterial disease
  • MRA, transesophageal echocardiogram, or CT scan are used to diagnose aortic dissection
  • Angiography is the definitive test for Takayasu's arteritis, peripheral artery disease, aortic dissection, and coarctation of the aorta

  Treatment

  • Atherosclerosis
    –Nonpharmacologic interventions include exercise, smoking cessation, lipid-lowering therapy, aggressive blood sugar control, adequate foot care
    –Medical therapy includes antiplatelet agents (aspirin, dipyridamole, clopidogrel), pentoxifylline, cilostazol
    –Revascularization procedures may be necessary
  • Aortic dissection requires prompt, aggressive therapy to lower BP and decrease left ventricular contractility
    –All patients should be treated with β-blockers
    –Surgery may be indicated
  • Aortic aneurysm: Blood pressure reduction; surgical correction if symptomatic, large, or rapidly expanding
  • Takayasu's disease: Corticosteroids, methotrexate, and possible revascularization procedures
  • Coarctation of aorta is treated with angioplasty or surgical correction
  • Compartment syndrome requires immediate decompression by fasciotomy
'>>

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 Slow heartbeat

Read excerpts from these other book chapters related to Slow heartbeat:

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

More About Causes of Slow heartbeat

• Back to symptom: Slow heartbeat: Introduction (review 48 causes)
• Next Book Extract About Slow heartbeat: Bradycardia (In A Page: Pediatric Signs and Symptoms)
• All Book Extracts: All Online Book Extracts for Slow heartbeat

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: Bradycardia (In A Page: Pediatric Signs and Symptoms)

Rate This Website

What do you think about the features of this website? Take our user survey and have your say:

Website User Survey

Medical Tools & Articles:

Next articles:

• Bradycardia (In A Page: Pediatric Signs and Symptoms)
• MURMURS (Differential Diagnosis in Primary Care)
• BRADYCARDIA (Differential Diagnosis in Primary Care)
• Murmurs (Handbook of Signs & Symptoms (Third Edition))
• Pulse rhythm abnormality (Handbook of Signs & Symptoms (Third Edition))

Tools & Services:

• Bookmark this page
• Take a survey relating to Slow heartbeat
• Symptom Search
• Symptom Checker
• Medical Dictionary
• Give your feedback

Medical Articles:

• Disease & Treatments Search
• Misdiagnosis Center
• Full list of interesting articles

Forums & Message Boards

• Ask or answer a question at the Boards:
• I cannot get a diagnosis. Please help.
• Tell us your medical story.
• Share your misdiagnosis story.
• What is the best treatment for my condition?
• See all the Boards.

Enter your search terms Submit search form
Search The Web Search wrongdiagnosis.com

Common Health Mistakes

Symptom
Checker

Search Specialists by State and City