# Pulse pressure

Pulse pressure is the difference between the systolic and diastolic pressure readings. It is measured in millimeters of mercury (mmHg). It represents the force that the heart generates each time it contracts. If resting blood pressure is (systolic-diastolic) 120-80 millimeters of mercury (mmHg), pulse pressure is 40.[1]

## Calculation

Formally it is the systolic pressure minus the diastolic pressure.[2]

Theoretically, the systemic pulse pressure can be conceptualized as being proportional to stroke volume, or the amount of blood ejected from the left ventricle during systole and inversely proportional to the compliance of the aorta.[3]

The aorta has the highest compliance in the arterial system due in part to a relatively greater proportion of elastin fibers versus smooth muscle and collagen. This serves the important function of damping the pulsatile output of the left ventricle, thereby reducing the pulse pressure. If the aorta becomes rigid in conditions such as arteriosclerosis or atherosclerosis, the pulse pressure would be very high.

• Systemic pulse pressure = Psystolic - Pdiastolic = 120mmHg - 80mmHg = 40mmHg
• Pulmonary pulse pressure = Psystolic - Pdiastolic = 25mmHg - 10mmHg = 15mmHg

## Values and variation

### Low (Narrow) Pulse Pressure

A pulse pressure is considered abnormally low if it is less than 25% of the systolic value. The most common cause of a low (narrow) pulse pressure is a drop in left ventricular stroke volume. In trauma a low or narrow pulse pressure suggests significant blood loss (insufficient preload leading to reduced cardiac output).[4]

If the pulse pressure is extremely low, i.e. 25 mmHg or less, the cause may be low stroke volume, as in Congestive Heart Failure and/or shock.

A narrow pulse pressure is also caused by aortic valve stenosis and cardiac tamponade.

### High (Wide) Pulse Pressure

#### High values during or shortly after exercise

Usually, the resting pulse pressure in healthy adults, sitting position, is about 30–40 mmHg. The pulse pressure increases with exercise due to increased stroke volume,[5] healthy values being up to pulse pressures of about 100 mmHg, simultaneously as total peripheral resistance drops during exercise. In healthy individuals the pulse pressure will typically return to normal within about 10 minutes.

For most individuals, during aerobic exercise, the systolic pressure progressively increases while the diastolic remains about the same. In some very aerobically athletic individuals, for example distance runners, the diastolic will progressively fall as the systolic increases. This behavior facilitates a much greater increase in stroke volume and cardiac output at a lower mean arterial pressure and enables much greater aerobic capacity and physical performance. The diastolic drop reflects a much greater fall in total peripheral resistance of the muscle arterioles in response to the exercise (a greater proportion of red versus white muscle tissue). Individuals with larger BMIs due to increased muscle mass (body builders) have also been shown to have lower diastolic pressures and larger pulse pressures.[6]

#### Consistently high values

If the usual resting pulse pressure is consistently greater than 100 mmHg, the most likely basis is stiffness of the major arteries, aortic regurgitation (a leak in the aortic valve), arteriovenous malformation (an extra path for blood to travel from a high pressure artery to a low pressure vein without the gradient of a capillary bed), hyperthyroidism or some combination. (A chronically increased stroke volume is also a technical possibility, but very rare in practice.) While some drugs for hypertension have the side effect of increasing resting pulse pressure irreversibly, other antihypertensive drugs, such as ACE Inhibitors, have been shown to lower pulse pressure. A high resting pulse pressure is harmful and tends to accelerate the normal aging of body organs, particularly the heart, the brain and kidneys. A high pulse pressure combined with bradycardia and an irregular breathing pattern is associated with increased intracranial pressure and should be reported to a physician immediately. This is known as Cushing's triad and can be seen in patients after head trauma related to intracranial hemorrhage or edema.

Examples: (these are examples of WIDENING pulse pressure causes)

## Relationship to heart disease

Recent work suggests that a high pulse pressure is an important risk factor for heart disease. A meta-analysis in 2000, which combined the results of several studies of 8,000 elderly patients in all, found that a 10 mm Hg increase in pulse pressure increased the risk of major cardiovascular complications and mortality by nearly 20%.[9] Heightened pulse pressure is also a risk factor for the development of atrial fibrillation.[10] The authors of the meta-analysis suggest that this helps to explain the apparent increase in risk sometimes associated with low diastolic pressure, and warn that some medications for high blood pressure may actually increase the pulse pressure and the risk of heart disease.

## Self measurement

Pulse pressure readings can be taken on a home blood pressure monitoring device. These devices display systolic and diastolic blood pressure, from which pulse pressure can be calculated, and pulse rate readings. Monitoring at home will measure true pulse and blood pressure and is helpful to a medical provider in interpreting in-office results and/or progression of disease processes.

## Treatment

If the patient suffers from elevated pulse pressure, treatment may include medications that address this factor, such as an angiotensin-converting enzyme inhibitor (ACE inhibitor).[11]

### Effect of folic acid

A 2005 study found that 5 mg of folate (Vitamin B9) daily over a three-week period reduced pulse pressure by 4.7 mm of Hg compared with a placebo, and concluded that folic acid is an effective supplement that targets large artery stiffness and may prevent isolated systolic hypertension.[12]

## References

1. A review of educational strategies to improve nurses' roles in recognizing and responding to deteriorating patients. Liaw SY, Scherpbier A, Klainin-Yobas P, Rethans JJ.