Application of Heartbeat and Pulse chapter of BBCR in cardiovascular disorders

Application of Heartbeat and Pulse chapter of BBCR in cardiovascular disorders 

Dr G Supriya Pai
PG Scholar,Department of Practice of Medicine
Government Homoepathic Medical College, Bangalore.

PULSE:
It is the expansion and elongation of the arterial wall imparted by the column of blood and is passively produced by the pressure changes during ventricular systole and diastole.

Commonly pulse is examined in the radial artery of hand which is most accessible peripheral artery. Moreover as soon as the hand is touched of the patient, it builds doctor-patient relationship.

POINTS TO NOTE IN THE EXAMINATION OF PULSE:

  1. Rate 
  2. Rhythm
  3. Volume
  4. Condition of the arterial wall
  5. Comparison between two radial pulses
  6. Radio-femoral delay
  7. Any special character
  8. Palpation of other peripheral arteries.

RATE: Rate is the number of beats per minute. Normally it ranges between 60-100 beats per minute. Usually it remains 140 beats per minute at birth.

Sino-atrial node is the natural pacemaker of the heart.

VARIATION IN PULSE RATE:

  1. TACHYCARDIA: Pulse rate above 100 beats per minute. Normally it is found in children.

Sinus tachycardia: Pulse rate above 100 beats per minute where the impulse is originating from SA node. The heart rate in sinus tachycardia varies between 100-160 beats per minute.

Physiological  Pathological 
Exercise, emotion, excitement Heart failure
Intense pain Thyrotoxicosis
Anxiety Severe anaemia
In children Pyrexia , drugs 
During pregnancy Shock( acute MI)
Smoking  Myocarditis
Acute haemorrhages 
Hypoxia 

Causes:
Relative tachycardia: Here the increase in pulse rate is more than 10 beats per minute with per degree rise of temperature.

Causes: Acute rheumatic carditis 

             Tuberculosis

Diphtheritic myocarditis

Polyarteritis  Nodosa

Paroxysmal tachycardia: Pulse rate above 160 beats per minute. It is divided into two types.

1. Supraventricular 

2. Ventricular 

Causes: Rheumatic carditis 

Ischemic heart disease

Hypertensive heart disease

Cardiomyopathy

WPW syndrome 

RUBRICS RELATED TO TACHYCARDIA IN BBCR: 

Main chapter – FEVER

Subchapter – CIRCULATION

Subsection – PULSE 

  1. Pulse; abnormal in general
  2. Pulse; quick (accelerated)
  3. Pulse; AGGRAVATION-    Ascending (steps)

                   Beer, from

      Coffee, after

      Emotions

Exertion 

Illness, with a sense of

Mental excitement

Motion 

Pains, during the

Tea, after

Tobacco, smoke, smoking

Walking, going about etc.

Whisky, from

Wine, after

Main chapter – FEVER

Sub-chapter – CIRCULATION 

Sub-section – PALPITATION

  1. Palpitation, in general
  2. Anaemia, in 
  3. Anxious
  4. Ascending (steps) on
  5. Climacteric, during
  6. Drinking
  7. Drugging from
  8. Emotions from
  9. Excitement from
  10. Goitre with
  11. Mental exertion agg
  12. Paroxysmal
  13. Rheumatic metastasis from 
  14. Vital loses from
  15. Walking, agg.

Main chapter – FEVER

Sub-chapter – CIRCULATION 

Sub-section – HEARTBEAT 

  1. Heartbeat , rapid (see- pulse-quick)
  2. Heartbeat, tremulous
  3. Heartbeat, vigorous 
  1. BRADYCARDIA:

Pulse rate is below 60 beats per minute, commonly found in 

  1. Athletes, yoga, meditation or during deep sleep.
  2. Myxoedema 
  3. Obstructive jaundice
  4. Increased intra-cranial tension
  5. Drugs like beta blockers/ digitalis
  6. Hypothermia 
  7. Heart block
  8. Sinus sick syndrome
  9. Vasovagal attacks
  10. Severe hypoxia 
  11. Organo-phosphorus poisoning 

Sinus Bradycardia: Pulse rate below 60 beats per minute where the impulse is originating from SA node.

Relative Bradycardia: Here the increase in pulse rate is less than 10 beats per minute with per degree rise of temperature

Causes: Any viral fever

    First week of enteric fever

Sometimes in pyogenic meningitis

Brucellosis, Weil’s disease.

RUBRICS RELATED TO BRADYCARDIA:

Chapter – FEVER

Subchapter – CIRCULATION 

Sub-section – PULSE 

  1. Pulse; slow
  2. Pulse; weak

Chapter – FEVER

Sub-chapter – CIRCULATION 

Sub-section – HEARTBEAT

  1. Heartbeat, ceasing as if
  2. Heartbeat, weak ( see pulse- weak)

Pulse deficit:  It is the difference between the heart rate and the pulse rate. It is commonly found in atrial fibrillation and multiple ectopic beats. It is due to the fact that some weak heart beats are not transmitted to the radial artery.

RUBRIC FOR PULSE DEFICIT: 

Chapter – FEVER, subchapter – CIRCULATION, sub-section – PULSE 

Pulse; slower than heartbeat.

RHYTHM: Rhythm is the spacing of successive beats (pulse waves) in time. Normal pulse is regular in rhythm and is known as ‘Sinus Rhythm’, because it is generated by SA node.

IRREGULARITIES OF RHYTHM:

  1. Regularly Irregular: irregularly comes at regular interval and is seen in extra-systoles, secondary heart block, sinus arrhythmia, pulsus bigeminus
  2. Irregularly Irregular/ completely Irregular: Irregularity between two pulse beats in every aspect (rate, rhythm, volume, totally chaotic)

Commonly seen in atrial fibrillation, multiple ventricular extrasystole, atrial flutter, varying degrees of heart block.

Sinus Arrhythmia:  It is the increase in pulse rate with inspiration and decrease in pulse rate with expiration. It is a physiological phenomenon commonly observed in children and athletes.

Ectopic Beat/Rhythm:

Synonyms: Premature beat, extrasystoles
In ectopic rhythm, the impulse arises from the sites other than SA node that is from atrial wall, AV node or ventricular wall. The ectopic beat is small, occurs prematurely and is followed by a compensatory pause. This pause results in ‘missed beat’ or ‘dropping beat’ in pulse.

Pulse felt in wrist: small pause followed by small beat, big pause followed by big beat.

Causes: overindulgence of tea, coffee, cigarette, alcohol.

Anxiety

Dyspnoea

Rheumatic, ischemic, hypertensive, thyrotoxic and cardiomyopathic heart disease

Digitalis overdose.

RUBRICS RELATED TO IRREGULARITIES OF RHYTHM 

Chapter – FEVER

Subchapter – CIRCULATION 

Sub-section – PULSE 

  1. Pulse; abnormal in general
  2. Pulse; changeable in general
  3. Pulse; double in general
  4. Pulse; irregular 
  5. Pulse; intermittent  – losing 1 to 2 beats

The 3rd beat

The 4th beat

4th to 5th beat

6th beat

10th to 30th beat

  1. Pulse; unequal, uneven
  2. Pulse; AGGRAVATION – ascending steps 

Beer, from

Coffee, after

Emotions 

Exertions

Illness, with a sense of

Inspiration (sinus arrhythmia) 

Mental excitement 

Motion

Pains, during

Tea, after 

Tobacco, smoke, smoking

Walking, going about

Whisky from

Wine, after 

Main chapter – FEVER

Sub-chapter – CIRCULATION 

Sub-section – HEARTBEAT 

  1. Heartbeat; double(see pulse chapter)

          Fluttering

  Intermittent

                Irregular 

Irregular rhythm with normal heart rate:

Causes: multiple extra systoles, sinus arrhythmia 

Rubric: Chapter – FEVER

Subchapter – CIRCULATION 

Sub-section – PULSE 

Pulse; quicker than heartbeat.

VOLUME: It is the amplitude of the pulse wave or the excursion/ uplift felt at the wrist and usually reflects the width of pulse pressure (systolic BP- diastolic BP) which depends on two factors

  • Stroke volume 
  • Compliance of the arteries.

The carotid, brachial or femoral arteries are more useful for assessing pulse volume and character than the radial pulse.

Normal pulse pressure 30-60 mm of Hg (normal pulse volume)

Changes in pulse volume:

  1. High pulse volume: pulse pressure > 60mm of Hg
  1. Hyperkinetic circulatory states: after exercise, severe anaemia, pyrexia, pregnancy, aortic incompetence, thyrotoxicosis, arterio-venous communication (PDA, Paget’s disease), chronic cor pulmonale, hepato-cellular failure, beriberi.
  1. Atherosclerosis: arteries are rigid; less complaint so there is wide pulse pressure as the systolic BP is high or systemic HTN.
  1. Complete heart block, bradycardia due to any cause.

Bounding pulse: It is commonly seen in Hyperkinetic circulatory states where the pulse volume is high with increased blood flow.

RUBRICS RELATED TO HIGH PULSE VOLUME:

Chapter – FEVER

Subchapter – CIRCULATION 

Sub-section – PULSE 

  1. Pulse; full
  2. Pulse; hard
  3. Pulse; large
  4. Pulse; strong
  5. Pulse; tense
  1. Low volume pulse (pulsus parvus): pulse pressure < 30 mm of Hg

Seen in shock (acute MI, massive haemorrhage, hypervolemia, septic shock, cardiogenic shock)

Severe aortic stenosis, mitral stenosis, 

Congestive cardiac failure, pericardial effusion, constrictive pericarditis.

Thready pulse: This is a low volume pulse with rapid pulse rate. This type of pulse is seen in peripheral circulatory failure.

 Ex. Cardiogenic shock, haemorrhage, dehydration

‘Jerky pulse’ felt in Idiopathic hypertrophic subaortic stenosis (IHSS)

RUBRICS RELATED TO LOW VOLUME PULSE:

Chapter – FEVER

Subchapter – CIRCULATION 

Sub-section – PULSE 

  1. Pulse; jerky
  2. Pulse; small
  3. Pulse; soft
  4. Pulse; thin
  5. Pulse; thread

CONDITION OF VESSEL WALL:
Normally the arterial wall is impalpable and may be palpable in old age due to atherosclerosis.

The artery becomes tortuous, thickened, feels like a cord (Monckeberg’s medial sclerosis i.e.  Calcification of medial coat of large arteries)

Absent radial pulse: Anatomical abnormality, severe atherosclerosis, Takayasu’s disease, embolism into radial artery, death.

RUBRICS: Chapter – FEVER

Subchapter – CIRCULATION 

Sub-section – PULSE 

  1. Pulse; contracted
  2. Pulse; empty
  3. Pulse; imperceptible (not felt)
  4. Pulse; suppressed (obliterated)

CHARACTER OF THE PULSE:  The volume, waveform and some special features (ex. Collapsing nature) altogether give rise to character of pulse which is helped in clinical diagnosis of specific diseases or disorders.

  1. Anacrotic pulse: It is a low volume pulse with an upstroke felt in the ascending limb of pulse wave. Anacrotic pulse is found in severe valvular aortic stenosis, typically known as ‘parvus-et-tardus’ (slow rising low volume pulse)
  2. Dicrotic pulse: When the upstroke is felt in the descending limb of pulse wave. The first wave is the percussion wave while the second wave is exaggerated dicrotic wave. It is felt due to hypotonia of vessel wall.

– Second week of typhoid fever (due to circulatory vasculo-toxins)

– Endotoxic shock

– Hypovolemic shock

– Diffuse myocardial disease.

       3.   Pulsus Bisferiens: It is high volume double beating pulse, single pulse wave with two peaks in      systole. Seen in aortic stenosis and incompetence; hypertrophic obstructive cardiomyopathy.

        4.  Pulsus alterans: when the alternate pulse waves are weak i.e. low volume (the rhythm remains regular in contrast to ectopics)

Seen in LVF (severe myocardial failure) where some ventricular muscle fibres are healthy and some degenerated and thus produce normal and weak beat respectively.

  1. Pulsus Bigeminus: Clinically two beats and a pause thereafter recur in regular fashion. The second beat is an ectopic beat and thus there is pause after it. Commonly found in digitalis toxicity and 3:2 heart blocks. In pulsus trigeminus 3 beats and a pause recur in regular fashion.
  1. Water hammer pulse: High volume collapsing pulse characterised by – high volume, sharp rise, ill   sustained, sharp fall. Seen in aortic competence.
  1. Pulsus Paradoxus: Here the pulse volume decreases with inspiration and increase with expiration. The paradox is that the heart sounds may still be audible on auscultation over the time when no pulse is palpable at the radial artery.

Causes: acute severe asthma, cardiac tamponade, chronic constrictive pericarditis, COPD, SVC syndrome, restrictive cardiomyopathy.

In health there is fall in systolic BP in inspiration which is < 10mm of Hg, but in pulsus paradoxus there is exaggerated inspiratory fall in systolic BP > 10 mm of Hg.

RUBRICS RELATED TO DIFFERENT CHARACTER OF PULSE:

Chapter – FEVER

Subchapter – CIRCULATION 

Sub-section – PULSE 

  1. Pulse; abnormal in general
  2. Pulse; changeable
  3. Pulse; double (pulsus bigeminus, dicrotic, anacrotic)
  4. Pulse; irregular
  5. Pulse; jerky
  6. Pulse; jumping (water hammer pulse)
  7. Pulse; slow, alternating with quick pulse (pulsus alterans)
  8. Pulse; spasmodic
  9. Pulse; ticking (like a clock)
  10. Pulse; unequal, uneven

References: 

  1. Boger Boennighausen’s Characteristics & Repertory.
  2. Bedside clinics in medicine – Dr Arup Kumar Kundu 
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