Aortic stenosis & BP - right or left arm?

  1. I work on a med-surg floor & the other day I had a pt who had a cardiology consult due to aortic stenosis. She went from being a stable GI bleed to very unstable. Our critical care team assessed her & decided she wasn't sick enough for the ICU.

    We couldn't get a pressure in her left arm at all, either with the auto cuff or manually. The right arm I got a decent pressure manually -120/72. Throughout the night, it varied from oneteens/60's down as low as 108 systolic. I'm not sure what I should do in that situation - the doctor didn't seem very concerned, even when I reminded her of the pt's heart condition and that she was actively bleeding. Was I getting an artificially high reading?

    What do you usually do when the pressures are unequal? No one I worked with that night seemed to have an answer for me, and what I've reasearched just says that there is a difference in the right & left extremities, not which one is the accurate one.
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  2. 9 Comments

  3. by   P_RN
    MIL had aortic stenosis BP left was above 200/
    BP right would be 140/. Maybe you didn't inflate enough. Was her left arm cold, blue?
  4. by   Nurseboy1
    Quote from rnmi2004
    I work on a med-surg floor & the other day I had a pt who had a cardiology consult due to aortic stenosis. She went from being a stable GI bleed to very unstable. Our critical care team assessed her & decided she wasn't sick enough for the ICU.

    We couldn't get a pressure in her left arm at all, either with the auto cuff or manually. The right arm I got a decent pressure manually -120/72. Throughout the night, it varied from oneteens/60's down as low as 108 systolic. I'm not sure what I should do in that situation - the doctor didn't seem very concerned, even when I reminded her of the pt's heart condition and that she was actively bleeding. Was I getting an artificially high reading?

    What do you usually do when the pressures are unequal? No one I worked with that night seemed to have an answer for me, and what I've reasearched just says that there is a difference in the right & left extremities, not which one is the accurate one.
    First off, the difference in the right/left arm comes from the anatomy. The left subclavian artery branches directly off the aortic arch, while on the right the brachiocephalic artery branches later into the right subclavian and the right carotid arteries, this can sometimes account for pressure differences between the arms.

    When I have unequal pressures, I look carefully at the patient condition. Are they A&O x4 without any symptoms or are they unresponsive. Are there other symptoms such as tachycardia, dizziness, lightheadedness, syncope. If you are drawing serial HCTs are they trending down or stable?

    The vitals you posted do show a widened pulse pressure, were IV fluids initiated? If so, did the pressure respond to the volume? Pressure response to volume could indicate hypovolemia and lend credence to a worry about an ustable GIB needing an ICU bed.
    Last edit by Nurseboy1 on Sep 8, '06
  5. by   Dinith88
    Quote from rnmi2004
    I work on a med-surg floor & the other day I had a pt who had a cardiology consult due to aortic stenosis. She went from being a stable GI bleed to very unstable. Our critical care team assessed her & decided she wasn't sick enough for the ICU.

    We couldn't get a pressure in her left arm at all, either with the auto cuff or manually. The right arm I got a decent pressure manually -120/72. Throughout the night, it varied from oneteens/60's down as low as 108 systolic. I'm not sure what I should do in that situation - the doctor didn't seem very concerned, even when I reminded her of the pt's heart condition and that she was actively bleeding. Was I getting an artificially high reading?

    What do you usually do when the pressures are unequal? No one I worked with that night seemed to have an answer for me, and what I've reasearched just says that there is a difference in the right & left extremities, not which one is the accurate one.
    Hold up for a moment!

    Aortic stenosis has nothing to do with your aorta. This diagnosis means the AORTIC VALVE is stenosed. So...disregard what you've just read. Your bp differences were from reasons other than a stenotic heart-valve. ('subclavian steal' more likely...look into that)
  6. by   VickyRN
    Most aortic stenosis patients I have seen over the years had very low diastolic pressures, as opposed to normal systolic. This is due to the pathophysiology of the stenosed valve. And there was a difference in BP's on right versus left arm - sometimes significantly lower on right. We always recorded both pressures. Some of the cardiac surgeons would require BP's on both the right and left arm for all their presurgical patients.
  7. by   rnmi2004
    She did have a hx of rheumatic fever & valve replacement in her H&P; it didn't specify which valve, it also specified aortic stenosis. She had many other issues going on that were being addressed (as much as I could get the docs to address them). I was just wondering for future reference what I should do in a situation where the right & left arm show variable BPs.

    I did let the MDs know about the differences in the BPs; the critical care team was even in the room while we were trying to get her BPs.

    It was one of those nights that was just frustrating because I don't feel like I could get the MD to realize how serious she was--I was with her 3 nights in a row & saw how she deteriorated. I hope she's okay.
  8. by   VickyRN
    Thank you for your persistent patient advocacy
  9. by   Dinith88
    Quote from VickyRN
    . And there was a difference in BP's on right versus left arm - sometimes significantly lower on right. We always recorded both pressures. Some of the cardiac surgeons would require BP's on both the right and left arm for all their presurgical patients.

    If there was a difference in rt-vs-lt bp's it wasnt from the aortic valve stenosis. The jet 'ejected' from the left ventricle is what is effected by a stenosed valve. The pressure from this ejected 'jet' (diminished in AorticStenosis) will not cause a difference in pressure in the arms. This may have a global effect on bp's...but wont cause a difference in the two. If a patient has a difference between lt and rt, it's something else. Aortic stenosis will not effect peripheral resistance or arterial contractility.
  10. by   VickyRN
    Quote from Dinith88
    Aortic stenosis will not effect peripheral resistance or arterial contractility.
    It increases afterload; hence the wide pulse pressures and low diastolic BP's.
    Last edit by VickyRN on Sep 9, '06
  11. by   Dinith88
    Quote from VickyRN
    It increases afterload; hence the wide pulse pressures and low diastolic BP's.
    The reason it increases after-load is because the ventricle is trying to 'push against' an aortic valve that is tight/stenosed. It is not because the periphery/arteries/capillaries are effected. So, yes-ventricular 'afterload' is increased..but not in the vessels. Once the blood gets out of the left venrticle (and into the vessels), aortic stenosis has no effect on peipheral resistance. (or blood pressure...especially differences in right-or-left arm bp's).

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