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Carotid-femoral pulse wave velocity is an established method for characterizing aortic stiffness, an individual predictor of cardiovascular mortality in adults. Normal pulse wave velocity values for the pediatric population derived from a large data collection have yet to be available. The aim of this study was to create a reference database and to characterize the factors determining pulse wave velocity in children and teenagers. Carotid-femoral pulse wave velocity was measured by applanation tonometry. Reference tables from pulse wave velocities obtained in 1008 healthy subjects (aged between 6 and 20 years; 495 males) were generated using a maximum-likelihood curve-fitting technique for calculating SD scores in accordance with the skewed distribution of the raw data. Effects of sex, age, height, weight, blood pressure, and heart rate on pulse wave velocity were assessed. Sex-specific reference tables and curves for age and height are presented. Pulse wave velocity correlated positively (P1000 children, is the first to provide reference values for pulse wave velocity in children and teenagers, thereby constituting a suitable tool for longitudinal clinical studies assessing subgroups of children who are at long-term risk of cardiovascular disease.

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Assessment of the peripheral vascular system is done to determine the characteristics of the pulse, to ascertain the presence of an arterial bruit(s), and to detect the occurrence of venous inflammation with possible secondary thrombosis of that vein.

Increases in pulse rate (tachycardia) may suggest hyperthyroidism, anxiety, infection, anemia, or arteriovenous fistula. Slowing of the pulse rate (bradycardia) may be seen in heart block, hypothyroidism, or with the use of certain drugs (e.g., propranolol). Irregularities in the pulse suggest the presence of premature beats, and a completely irregular pulse implies the presence of atrial fibrillation. Diminished or absent pulses in the various arteries examined may be indicative of impaired blood flow due to a variety of conditions.

A complete physical examination includes the assessment and recording of arterial pulses in all locations. While examining the pulse, the observer should note its intensity, rate, rhythm, and if any blood vessel tenderness, tortuosity, or nodularity exists. It is unreliable to attempt to estimate blood pressure via arterial palpation without the use of the sphygmomanometer.

The patient should be examined in a warm room with arrangements made so that the patient's pulses can easily be examined from both sides of the bed. A cool environment may cause peripheral vasoconstriction and reduce the peripheral pulse. Palpation should be done using the fingertips and intensity of the pulse graded on a scale of 0 to 4 +:0 indicating no palpable pulse; 1 + indicating a faint, but detectable pulse; 2 + suggesting a slightly more diminished pulse than normal; 3 + is a normal pulse; and 4 + indicating a bounding pulse.

The student examiner must be alert to the possibility that the pulse he or she feels may be due to digital artery pulsations in his own fingertips; this source of confusion can be eliminated by comparing the pulse in question to his own radial pulse or to the patient's cardiac sounds as determined by auscultation over the precordium. In general, it is inadvisable to use the thumb in palpating for peripheral pulses. The thumb carries a greater likelihood of confusion with the examiner's own pulse and generally has less discriminating sensation than the fingers. Frequently, inspection will be an aid to pulse location. The examiner may be able to see the skin rise and fall with each pulsation along the course of an extremity artery, particularly if a bright light is aimed tangentially across the surface of the skin.

The popliteal artery (Figure 30.5) passes vertically through the deep portion of the popliteal space just lateral to the midplane. It may be difficult or impossible to palpate in obese or very muscular individuals. Generally this pulse is felt most conveniently with the patient in the supine position and the examiner's hands encircling and supporting the knee from each side. The pulse is detected by pressing deeply into the popliteal space with the supporting fingertips. Since complete relaxation of the muscles is essential to this examination, the patient should be instructed to let the leg "go limp" and to allow the examiner to provide all the support needed.

The posterior tibial artery (Figure 30.6) lies just posterior to the medial malleolus. It can be felt most readily by curling the fingers of the examining hand anteriorly around the ankle, indenting the soft tissues in the space between the medial malleolus and the Achilles tendon, above the calcaneus. The thumb is applied to the opposite side of the ankle in a grasping fashion to provide stability. Again, obesity or edema may prevent successful detection of the pulse at the location.

The dorsalis pedis artery (Figure 30.7) is examined with the patient in the recumbent position and the ankle relaxed. The examiner stands at the foot of the examining table and places the fingertips transversely across the dorsum of the forefoot near the ankle. The artery usually lies near the center of the long axis of the foot, lateral to the extensor hallucis tendon but it may be aberrant in location and often requires some searching. This pulse is congenitally absent in approximately 10% of individuals.

Frequently the examiner will detect a "thrill" or palpable vibratory sensation over a vessel in which a loud bruit is audible. The thrill is indicative of marked turbulence in local blood flow and suggests significant vascular pathology. If a thrill is noted during examination of the pulses, it should be recorded in the appropriate space on the data base.

Examination of the pulse can provide clues to the presence of systemic diseases. Ancient physicians would diagnose heart, liver, renal, and gastrointestinal problems from assessment of the pulse. Today, other tests have been developed to assist in the work-up of systemic illness, but examination of the pulse is still an important part of patient assessment.

Conditions associated with tachycardia or bradycardia have been discussed, as have the causes of a pulse irregularity. Reduced or absent arterial pulses are a sign of impaired blood flow. The causes include: (1) congenital abnormalities (coarctation of the aorta, anomalous peripheral arteries); (2) intrinsic arterial disease (atherosclerosis, thrombosis, arteritis); (3) vasospastic disorders (Raynaud's phenomenon); or (4) involvement of the vessel by extrinsic compression (thoracic outlet syndrome, trauma, neoplasms). The resultant alteration of pulses, with or without accompanying bruits, may be indicative of either acute or chronic changes in a given patient. The vascular history, together with associated physical findings such as skin color, temperature, and neuromotor status of the extremity, should help to elucidate these points. More refined diagnostic techniques such as Doppler ultrasound examination and arteriography may be required to evaluate abnormalities suspected from the physical examination. In this regard, it is important to understand that significant arterial occlusive disease of the lower extremities may exist in a patient who has almost normal peripheral pulses in the resting state, since collateral circulation can produce pulsatile flow in the peripheral arterial bed in some patients. If such an individual is instructed to exercise to the point of claudication, however, pulse distal to the major vascular occlusion will diminish or disappear.

Much valuable information can be gained from examination of the peripheral pulses in addition to the status of the arterial system itself. The attentive examiner may detect variations in the rate, rhythmicity, intensity, and contour of the pulse wave that yield insight into a variety of disease states. The rapid, thready pulse of hypovolemic shock is a well-known clinical sign, as is the rapid, snapping pulse characteristic of thyrotoxicosis, and the collapsing, "water-hammer" pulse of aortic insufficiency. (Also read Chapter 17, Pulse, and Chapter 20, Carotid Pulse.)

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Heart rate (or pulse rate)[1] is the frequency of the heartbeat measured by the number of contractions of the heart per minute (beats per minute, or bpm). The heart rate can vary according to the body's physical needs, including the need to absorb oxygen and excrete carbon dioxide, but is also modulated by numerous factors, including (but not limited to) genetics, physical fitness, stress or psychological status, diet, drugs, hormonal status, environment, and disease/illness as well as the interaction between and among these factors.[2] It is usually equal or close to the pulse measured at any peripheral point.

Parasympathetic stimulation originates from the cardioinhibitory region of the brain[17] with impulses traveling via the vagus nerve (cranial nerve X). The vagus nerve sends branches to both the SA and AV nodes, and to portions of both the atria and ventricles. Parasympathetic stimulation releases the neurotransmitter acetylcholine (ACh) at the neuromuscular junction. ACh slows HR by opening chemical- or ligand-gated potassium ion channels to slow the rate of spontaneous depolarization, which extends repolarization and increases the time before the next spontaneous depolarization occurs. Without any nervous stimulation, the SA node would establish a sinus rhythm of approximately 100 bpm. Since resting rates are considerably less than this, it becomes evident that parasympathetic stimulation normally slows HR. This is similar to an individual driving a car with one foot on the brake pedal. To speed up, one need merely remove one's foot from the brake and let the engine increase speed. In the case of the heart, decreasing parasympathetic stimulation decreases the release of ACh, which allows HR to increase up to approximately 100 bpm. Any increases beyond this rate would require sympathetic stimulation.[16] 006ab0faaa