Where is peripheral pulse

Blood pressures are typically taken with a blood pressure cuff. But blood pressure can be measured using catheters placed inside the arteries. Because the arteries are punctured, this is known as invasive blood pressure monitoring. In most people, the resting ankle pressure is greater than the pressure at the crook of the arm, known as the brachial blood pressure. The ratio of the ankle pressure to the brachial pressure is called the ankle-brachial index ABI.

Toe pressures can be measured with miniature blood pressure cuffs to check for poor blood flow in the toes. Arterial pressure can be estimated in the upper thigh, above the knee, and in the upper calf by placing blood pressure cuffs at the appropriate levels. The pressures can be compared between the two legs or at different levels in the same leg. Blood pressures can be measured at the elbow brachial , forearm, or wrist.

Large differences between pressures at the various levels suggest arterial blockage. As with toes, finger pressures can be measured. Author: Healthwise Staff.

Medical Review: Rakesh K. Systematic cardiovascular examination can provide a diagnosis quickly without need for invasive or expensive tests. Such routine examination can reveal an unexpected and timely diagnosis. Historically, in the Middle or Far East, doctors were expected to make many diagnoses on examination of the radial pulse alone. Still today, thorough examination of the pulse can provide a lot of information and help form an accurate diagnosis. It is important to develop a reliable routine for examining the pulse and to refine and improve the technique throughout a career.

As with all clinical examination, there are aspects of the history which are particularly relevant to abnormalities in the pulse. There are many symptoms which may be relevant; however, some examples include:.

Arterial pulses can be examined at various sites around the body. Systematic examination normally involves palpating in turn radial, brachial, carotid, femoral and other distal pulses. Palpation of the abdominal aorta would also form part of this systematic examination to identify abdominal aortic aneurysms for example. Other sites may be examined for pulses, in special circumstances - for example, the temporal artery for tenderness in temporal arteritis and the ulnar artery if the radial cannot be felt or before arterial access at the radial site.

Finally, note the character of the pulse. This incorporates an assessment of the pulse volume the movement imparted to the finger by the pulse and what has been described as the 'form of the pulse wave'. The pulse character must be interpreted in the light of pulse rate. Studies have correlated markers of arterial stiffness eg, pulse-wave velocity and pulse pressure with risk for the development of fatal and non-fatal cardiovascular events [ 3 , 4 ].

This systematic examination of the pulse will give a great deal of information. Systematic examination of the pulse remains an essential part of clinical practice. Examination of the rest of the cardiovascular system should give a very clear idea of the diagnosis or at least put the examiner in a position to make a rational request for further investigations. See also the separate Cardiovascular History and Examination article. Khasnis A, Lokhandwala Y ; Clinical signs in medicine: pulsus paradoxus.

J Postgrad Med Eur Respir J. Epub Dec 6. Liao J, Farmer J ; Arterial stiffness as a risk factor for coronary artery disease. Curr Atheroscler Rep. Boutouyrie P, Fliser D, Goldsmith D, et al ; Assessment of arterial stiffness for clinical and epidemiological studies: methodological considerations for validation and entry into the European Renal and Cardiovascular Medicine registry.

Nephrol Dial Transplant. Epub Sep Hi, I recently had a limb lead test for my arms and legs. Leads 2 and 3 were both healthy and normal but lead 1 had a regularity.

It was a slow weak signal. Peripheral arterial disease PAD is most commonly a manifestation of systemic atherosclerosis in which the arterial lumen of the lower extremities becomes progressively occluded by atherosclerotic plaque.

Patients with PAD are at triple the risk of all-cause mortality and at more than 6 times the risk of death from coronary heart disease as those without the disease, yet PAD is probably the most underdiagnosed and least aggressively managed atherosclerotic disease. In the diagnosis of PAD, a detailed history and physical examination are extremely important, although limited by a lack of consistent sensitivity and specificity.

Other office-based noninvasive tests, including the ankle-brachial index, can be easily performed to confirm the diagnosis and help stratify the risk. The ankle-brachial index correlates well with disease severity and functional symptoms and can also be used to assess disease progression and to predict cardiovascular and cerebrovascular mortality. Once diagnosed, risk factor modification, symptomatic relief, and secondary prevention strategies with antiplatelet agents form the core of medical management of PAD.

The most important implication of PAD in terms of morbidity and mortality is that PAD serves as a strong surrogate marker for the severity of atherosclerotic disease in other vascular territories.

Despite the importance of early detection of atherosclerotic disease, the diagnosis of PAD is often overlooked during routine physical examinations. A comprehensive patient history is a valuable first step in the examination of the patient with suspected PAD. Physical examination should include measurement of blood pressure, auscultation of pulses and bruits, palpation of pulses bilateral , exploration of skin tone, texture, color, and temperature and pattern of hair distribution, and presence of skin lesions or ulcers.

Claudication, characterized by cramping, tightness, tiredness, or aching in the lower extremities, is brought on by exercise and relieved with rest. The patient interview can provide important clues to the potential location of an arterial occlusion, since the discomfort occurs in the muscle group just distal to the obstruction.

A thorough history can help differentiate symptomatic PAD from symptoms of pseudoclaudication, which are due to lumbar canal stenosis or lumbar radiculopathy rather than PAD. A patient's report of pain at rest or the presence of ischemic ulcerations or gangrene indicates severe arterial disease, referred to as critical limb ischemia. One important limitation of the medical history in patients with PAD is that many patients subsequently diagnosed as having PAD on the basis of noninvasive testing do not initially present with classic symptoms of claudication.

This is exemplified by the Rose claudication questionnaire for detecting PAD. In some patients who do report symptoms, the disease has already become severe, affecting multiple arterial segments, before the patient notices a problem. The lower extremities should be inspected for the obvious appearance of ulcers, gangrene, edema, and atrophy as well as for less obvious changes in nail thickness, absence of hair growth and perspiration, dry skin, and cool temperature.

For example, a diminished femoral pulse coupled with a pronounced bruit over the iliac artery indicates significant iliac stenosis. Atherosclerosis is not a focal disease. For this reason, the physical examination should be conducted with attention to its multisystemic nature.

Assessment of the circulatory and cardiovascular systems should begin with blood pressure BP measurement in both arms. The sensitivity, specificity, and predictive values of traditional clinical evaluation methods, such as pulse palpation, for the detection of PAD were compared in the San Diego Lipid Research Clinics Program Prevalence Study population.

The ABI is a simple, inexpensive, noninvasive tool that correlates well with angiographic disease severity and functional symptoms. The ABI can be measured in a primary care or hospital setting, since the equipment required is inexpensive and portable 26 , 33 , 39 Figure 2.

A Doppler ultrasonic velocity signal probe is then placed over the brachial artery to detect the resumption of blood flow with cuff deflation.

Measurement of SBP is repeated on the other arm. If a discrepancy exists, the higher of the 2 SBP values is used. For measurement of ankle SBP, the BP cuff is moved to the ankle and blood flow resumption is detected with the Doppler probe over the posterior tibial artery and then over the dorsalis pedis artery. Again, if there is a discrepancy in SBP between the 2 arteries, the higher value is used.

The process should be repeated for the other leg. The major limitation of the ABI to establish the diagnosis of PAD is that calcific tibial peroneal arteries may be rendered noncompressible, especially in patients with diabetes, resulting in erroneously high ABI values.

Patients with incompressible arteries should be referred to an accredited vascular laboratory for measurement of a toe-brachial index or other noninvasive testing. Furthermore, the ABI is dependent on the brachial pressure being a true measure of central systolic pressure. This may not be the case in patients with bilateral subclavian artery stenosis, occasionally seen in diabetic patients or those with advanced vascular disease.

Changes in the ABI over time can also be used to monitor disease progression. During an average 4. Several studies have shown that the ABI is independently associated with impaired lower extremity functioning, even in asymptomatic patients.

The Women's Health and Aging Study, an observational study of disabled women 65 years or older living in and around Baltimore, Md, used the ABI as a measure of lower extremity function. Results showed that 82 patients 5. The ABI is well established as an independent predictor of cardiovascular morbidity and mortality.

In the Cardiovascular Health Study, adults 65 years or older were monitored for cardiovascular events after establishing a baseline cardiovascular disease status and ABI measurement. Similar findings concerning the relationship between ABI and morbidity and mortality were found in the Edinburgh Artery Study of men and women 55 years and older.

A subgroup of patients have been found to have a reduced ABI but no complaints of claudication pain. Results of several studies highlight the importance of the ABI as a predictor of cardiovascular or all-cause mortality in these asymptomatic patients. After excluding subjects with a history of cardiovascular disease at baseline, the RR of death from coronary heart disease did fall from 6. These findings confirm that PAD as diagnosed by ABI is a strong and independent predictor of subsequent mortality, especially deaths due to coronary heart disease.

In terms of risk of mortality and degree of PAD symptoms, results showed that unilateral, moderately severe, asymptomatic disease and disease isolated to the posterior tibial artery increased the risk of death from coronary heart disease and cardiovascular disease from 3- to 6-fold when compared with patients without evidence of disease.

This suggests that substantial risk exists for patients who would not usually demand clinical attention. Kaplan-Meier survival curves based on mortality from all causes among normal subjects and subjects with symptomatic and asymptomatic large-vessel PAD confirm the overall poor prognosis with advancing disease and the alarmingly high risk in asymptomatic patients whose disease would not be detected clinically Figure 3. The Systolic Hypertension in the Elderly Program study was originally designed to study the effect of treatment in patients with systolic hypertension, but it also provides mortality data for a subset of patients without evidence of cardiovascular disease or symptoms of PAD.

Given these data and those from other studies in symptomatic and asymptomatic patients with PAD, strong evidence now argues for the more widespread use of the ABI in routine clinical practice 20 , 31 , 34 , 49 , 51 , 52 Table 2. At least 2 studies have specifically examined the ability of ABI measurement to predict ischemic stroke.

Measurement of ABI coupled with exercise testing can provide additional information on the dynamics of claudication. An alternative method of exercise testing that requires no special equipment is active pedal plantarflexion heel raises.

Keeping knees straight, the patient raises his or her heels as high as possible and then immediately lowers them; the cycle is repeated 30 to 50 times. As with treadmill testing, the ankle SBP is measured with the patient in a supine position immediately after completing the exercise sequence. When further detection, localization, or characterization of potential arterial lesions is necessary, other noninvasive or invasive tests are required.

The measurement of segmental pressures and pulse volume recordings can localize occlusions of limb segments by comparing the differences in the SBPs and the magnitude and contour of pulse volumes to segments located most proximally and distally to the site of occlusion. When it is necessary to localize occlusions more precisely than arterial segments or to more fully characterize the severity and morphologic features of occlusions, ultrasonic duplex scanning is a noninvasive preliminary alternative to angiography.

Once patients with clinical or subclinical PAD are identified, the primary aim of medical management is to reduce morbidity and mortality through aggressive risk factor reduction, initiate antiplatelet therapy, and provide symptomatic relief where possible.

Risk factors for developing PAD include advanced age, cigarette smoking, diabetes mellitus, an elevated homocysteine level, hyperlipidemia, and hypertension. Risk factor reduction is of utmost importance in patients with PAD, as the risk factors for the development PAD are common to the development of other manifestations of atherothrombotic disease, including MI and stroke. Antiplatelet therapy for prevention of secondary vascular events is the cornerstone of pharmacologic intervention in PAD.

Combination antiplatelet therapy using 2 synergistic yet mechanistically different agents may further reduce platelet activity.