BDX1  Peripheral Circulation - Venous Pulses

Michael S. Feldman, M.D., F.A.C.C.
Disclosures		The author has no relationships with commercial interests related to the content of the presentation.

Bernard Segal, M.D., F.A.C.C.
Disclosures		The author has no relationships with commercial interests related to the content of the presentation.

Michael S. Feldman, MD, is Clinical Professor of Medicine at the University of Pennsylvania School of Medicine, and Chairman of Graduate Education Foundation. Bernard Segal, MD, is professor of medicine at Thomas Jefferson University Hospital, and director of the Jefferson Heart Institute. In this first of seven parts, they discuss peripheral circulation, venous and arterial pulses.

The authors state that visualization is key to examination of the heart; and they explain how the peripheral circulation contributes to the final evaluation of ausculatory and palpatory findings. They discuss the manifestations of peripheral vasoconstriction and how it is encountered in tight mitral stenosis, aortic stenosis, and ischemic and nonischemic left ventricular dysfunction, and may result in cyanosis of the limbs or arteriolar spasm as in Raynaud's phenomenon.

They then discuss how to observe the phenomenon of peripheral vasodilation and the major causes of central cyanosis and how it can be differentiated from the peripheral type. In a review of the venous and arterial pulses, Drs. Feldman and Segal note that analysis of these is the most informative portion of the physical examination, and they describe the differences between the two. They go on to explain the three positive venous waves – a, c, and v – and their causes and diagnostic value ... noting that alterations and abnormalities in these waves are important clues to cardiac defects and disorders.

The authors state that carotid pulsation generally gives more accurate information about the central aortic pulse than do the peripheral arteries, and note that a sharp upsurge in the pulse followed by an abrupt diastolic collapse is observed in all conditions where there is excessive diastolic filling of the left ventricle – such as aortic and mitral regurgitation, ventricular septal defect and patent ductus arteriosus. They go on to describe the character of the pulse contour in patients with valvular and idiopathic subvalvular aortic stenosis and to explain pulsus paradoxus and pulsus alternans.

The lecture concludes with a discussion of examination of the precordium – a necessary antecedent to cardiac auscultation – and how and why palpation of the precordium is conducted.