血管检查

血管检查,北京安贞医院十五病房 李昭,血管检查是心血管检查的重要组成部分，分为以下几个部分：脉搏(Pulse)血压(Blood pressure)血管杂音(Vascular bruit)周围血管征(Peripheral vascular sign),脉搏(Pulse),A persons pulse is the arterial palpation of a heartbeat. It can be felt in any place that allows for an artery to be compressed against a bone, such as at the neck (Carotid Artery), at the wrist(Radial artery), behind the knee (Popliteal aretery), on the inside of the elbow (Brachial artery), and near the ankle joint(Posterior tibial artery). The pulse rate can also be measured by measuring the heart beat directly (Auscultation), usually using a stethoscope.主要用触诊(Palpation)：桡动脉(Radial artery)、肱动脉(Brachial artery)、股动脉(Femoral artery)、颈动脉(Carotid Artery)及足背动脉(Dorsalis pedis artery)。正常人两侧脉搏差异很小，某些疾病可有明显不同：缩窄性大动脉炎(Constrictive Aortoarteritis)或无脉症(Pulseless disease)。,脉率(Pulse rate)类似心率(Heart rate)。A normal pulse rate for a healthy adult, while resting, can range from 60 to 100 beats per minute (BPM) .Generally, pulse rates are higher in infants and young children. 生理、病理及药物影响可使脉率增快或减慢。还应观察脉率与心率是否一致。某些心律失常如心房颤动(Atrial fibrillation)或频发期前收缩(Extrasystole)，脉率可少于心率。,脉律(Pulse Rhythm)反应心脏节律(Heart Rhythm) 正常人脉律规整，窦性心律不齐(Sinus arrhythmia)可随呼吸(Breath)改变，吸气(Inspiratory)时增快，呼气(Expiration)时减慢Respiratory Sinus Arrhythmia(RSA): is a naturally occurring variation in heart rate that occurs during a breathing cycle. Heart rate increases during inspiration and decreases during expiration.,房颤(Atrial fibrillation)患者脉律绝对不规则(Irregular)，脉搏强弱不等，脉率少于心率，后者称之为脉搏短绌(Pulse shortage)；期前收缩(Extrasystole)呈二联律，三联律可形成二联脉(Pulsus bigeminus )，三联脉。二度房室传导阻滞(Atrioventricular block)可有脉搏脱落，称脱落脉(dropped pusle)。Atrial fibrillation is usually accompanied by symptoms related to a rapid heart rate.,Conduction,Sinus rhythm,Atrial fibrillation,In AF, the normal electrical impulses that are generated by the sinoatrial node(窦房结) are overwhelmed by disorganized electrical impulses that originate in the atria(心房) and pulmonary veins(肺静脉), leading to conduction of irregular impulses to the ventricles that generate the heartbeat.,紧张度与动脉壁状态脉搏的紧张度与动脉硬化(Arteriolosclerosis)程度有关。检查方法：两个手指指腹置于桡动脉(Radial artery)上，近心端手指用力按压阻断血流，使远心端触不到脉搏，通过施加压力的大小及感觉的血管壁弹性状态判断脉搏紧张度。,强弱与心搏出量(Cardiac output) 、脉压(Pulse pressure)及外周血管阻力(Peripheral vascular resistance)有关。脉搏增强及振幅大，由于心搏量大、脉压宽和外周阻力低有关，见于高热(High fever )、甲状腺功能亢进(Hyperthyroidism)、主动脉瓣关闭不全(Aortic insufficiency)；脉搏减弱及振幅低，由于心搏量少、脉压小和外周阻力高有关，见于心力衰竭(Heart failure )、主动脉瓣狭窄(Aortic stenosis)与休克(Shock)等。,The strength of the pulse can also be reported:0 = Absent 1 = Barely palpable 2 = Easily palpable 3 = Full 4 = Aneurysmal(动脉瘤) or Bounding pulse(洪脉) Bounding pulse is a medical sign characterized as a bounding and forceful pulse that quickly disappears. Occurs normally with heavy exercise剧烈运动, pregnancy怀孕, alcohol consumption饮酒, or high anxiety焦虑. A bounding pulse is also often associated with high blood pressure and large stroke volume(每搏输出量), and can occur with many pathological conditions, including:Heart failure 心衰, Aortic regurgitation 主动脉瓣关闭不全, Atherosclerosis动脉粥样硬化 , Anemia贫血 , Fever发热.,脉波正常脉波，由升支（叩击波）ascending、波峰（潮波）和降支（重搏波）descending组成。升支，左室收缩早期，左室射血(Left ventricular ejection)冲击动脉壁(Arterial wall)所致；波峰，收缩中、晚期，血液向动脉远端运行同时，部分逆反，冲击动脉壁引起；降支，左室舒张期，源于主动脉瓣关闭，血液由外周向近端折回后又向前，以及主动脉壁弹性回缩(Recoil) ，使血流持续流向外周动脉所致。明显主动脉硬化(Atherosclerosis)者，重搏波趋于不明显。,水冲脉（Water hammer pusle）：骤起骤落，犹如潮水涨落，故名水冲脉。是由于周围血管扩张(Peripheral vasodilation)或存在分流、反流(Shunt, reflux)所致。前者见于甲亢(Hyperthyroidism )、严重贫血(Severe anemia )、脚气病(Beriberi )；后者见于主动脉关闭不全(Aortic valve regurgitation )，先心病动脉导管未闭(Patent ductus arteriosus )，动静脉瘘(Arteriovenous fistula)。检查时，握紧手掌腕面(Palm side of wrist )，前臂(Forearm)高举过头，可明显感觉桡动脉(Radial artery)犹如水冲的急促而有力的脉搏冲击。Watsons water hammer pulse is the medical sian which describes a pulse that is bounding and forceful, as if it were the hitting of a water hammer that was causing the pulse.This is associated with increased stroke volume(每搏输出量) of the left ventricle and decrease in the peripheral resistance leading to the widened pulse pressure(脉压) of aortic regurgitation(主动脉瓣关闭不全 ).,交替脉（Pulsus alternans）：节律规整(Regular rhythm)而强弱交替(Alternating strong and weak)的脉搏，必要时需患者在呼气中期屏住呼吸(Hold breath) ，以排除呼吸变化影响的可能性。Pulsus alternans is a physical finding with arterial pulse waveform showing alternating strong and weak beats. It is almost always indicative of left ventricular systolic impairment(左室收缩功能受损), and carries a poor prognosis(预后).一般认为交替脉为左室收缩力(Left ventricular contractility)强弱交替所致，为左心衰竭(Left heart failure)的重要体征之一。常见于高血压性心脏病(Hypertensive heart disease )、急性心肌梗死(Acute myocardial infarction)和主动脉瓣关闭不全(Aortic insufficiency)等。,Pulsus alternans,Pulse pressure waveform displaying the variation in pressure between beats in pulsus alternans.,D.H.Lawrence, in his famous novel, “sons and lovers elegantly describes pulsus alternans:Then he felt her pulse. There was a strong stroke and a weak one, like a sound and its echo. That was supposed to betoken the end.,奇脉（Paradoxical pulse）：吸气时脉搏明显减弱或消失，左心室搏出量减少所致。当有心脏压塞(Cardiac tamponade)或心包缩窄(Pericardial constriction)时，吸气时右心舒张受限(Limited right ventricular diastolic )，回心血量减少(Reduction of venous return)而影响右心排量(Right cardiac output )，右心室排入肺循环血量(Pulmonary blood volume)减少，另一方面肺循环受吸气时胸腔负压(Thoracic negative pressure)的影响，肺血管扩张，致使肺静脉(Pulmonary vein)回流左心房(Left atrium)血量减少，左心排血减少。这些因素形成吸气时脉搏减弱，甚至不能触及，故又称“吸停脉”。明显的奇脉触诊时即可按知。,Paradoxical pulse (PP), also paradoxic pulse and pulsus paradoxus, is an exaggeration of the normal variation in the pulse during the inspiratory phase of respiration, in which the pulse becomes weaker as one inhales and stronger as one exhales. It is a sign that is indicative of several conditions including cardiac tamponade, pericarditis, chronic sleep apnea, croup, and obstructive lung disease (e.g. asthma, COPD).,无脉（pulseless）：即脉搏消失，可见于严重休克(Severe shock)及多发大动脉炎(Multiple arteritis )，后者为某一部位动脉闭塞(Artery occlusion)而致相应部位脉搏消失。,血压（Blood pressure）,Blood pressure (BP) is a force exerted by circulating blood on the walls of blood vessels, and is one of the principal vital signs. During each heartbeat, BP varies between a maximum (systolic) and a minimum (diastolic) pressure. The mean BP, due to pumping by the heart and resistance in blood vessels, decreases as the circulating blood moves away from the heart through arteries.,测量方法 (Measurement) 直接测压法(Invasive measurement)：经皮穿刺(Percutaneous)将导管(Catheter)从周围动脉(Peripheral artery)送入主动脉(Aorta)，末端接监护测压系统(Pressure Monitoring System)。优点：精确；缺点：有创操作。仅适用于危重、疑难病例。Arterial blood pressure (BP) is most accurately measured invasively through an arterial line. Invasive arterial pressure measurement with intravascular cannulae(套管) involves direct measurement of arterial pressure by placing a cannula needle(套管针 ) in an artery (usually radial, femoral, dorsalis pedis or brachial). This procedure can be done by any licensed doctor or a respiratory Therapist.,间接测量法(Noninvasive measurement)：袖带加压法(Cuff pressure method)，以血压计测量(Sphygmomanometer )。The non invasive auscultatory and oscillometric measurements(示波测量) are simpler and quicker than invasive measurements, require less expertise in fitting, have virtually no complications(几乎没有任何并发症), and are less unpleasant and painful for the person. However, noninvasive methods may yield somewhat lower accuracy and small systematic differences in numerical results. Non-invasive measurement methods are more commonly used for routine examinations and monitoring.,操作规程：椅子上休息至少15分钟，取坐位或仰卧位测血压，被检者上肢裸露并轻度外展，肘部置于心脏同一水平，将气袖均匀紧贴皮肤缠于上臂，使其下缘在肘窝以上约23cm，气袖之中央位于肱动脉表面，检查者触及肱动脉搏动后，将听诊器体件置于搏动上准备听诊。然后，向袖带内充气，边充气边听诊，待肱动脉搏动消失后再升高30mmHg，缓慢放气，双眼随汞柱下降，平视汞柱表面，根据听诊结果得出血压值。,Auscultatory methodThe auscultatory method (from the Latin word for listening) uses a stethoscope(听诊器) and a sphygmomanometer(血压计). This comprises an inflatable cuff(袖带) placed around the upper arm at roughly the same vertical height as the heart, attached to a mercury or aneroid manometer(无液血压计). The mercury(水银) manometer measures the height of a column of mercury, giving an absolute result without need for calibration(校准), and consequently not subject to the errors and drift of calibration which affect other methods. The use of mercury manometers is often required in clinical trials and for the clinical measurement of hypertension in high risk patients, such as pregnat women.A cuff of appropriate size is fitted smoothly and snugly(紧贴), then inflated manually by repeatedly squeezing a rubber bulb until the artery is completely occluded(闭塞). Listening with the stethoscope to the brachial artery at the elbow, the examiner slowly releases the pressure in the cuff. When blood just starts to flow in the artery, the turbulent flow creates a “whooshing” or pounding (first korotkoff sound). The pressure at which this sound is first heard is the systolic BP(收缩压). The cuff pressure is further released until no sound can be heard (fifth Korotkoff sound), at the diastolic arterial pressure(舒张压).,血压至少应测量两次，间隔12分钟，如收缩压或舒张压2次读数差别5mmHg以上，应再测量，3次读数的平均值作为测量结果。脉压(Pulse pressure):收缩压与舒张压的差值。平均动脉压(Mean arterial pressure, MAP)：舒张压加1/3脉压。偶尔会出现听诊间隙（在收缩压与舒张压之间出现的无声间隔），可能因未能识别导致收缩压被低估，主要见于重度高血压或主动脉瓣狭窄等。需注意向袖带内充气时肱动脉搏动声消失后，再升高30mmHg，气袖宽度：大小应适合患者的上臂臂围，至少应包裹80%的上臂。手臂过于粗大或大腿血压，用标准气袖测值会过高；反之，手臂太细或儿童测压时用标准气袖，数值会偏低。为保证数值准确，需使用适当大小的气袖。,Korotkoff 5期法：第1期 代表收缩压 首先听到的响亮的拍击音第2期 随后拍击有所减弱和带有柔和的吹风样杂音第3期 拍击音增强和杂音消失第4期 音调变为沉闷第5期 代表舒张压 声音消失妊娠妇女、严重贫血、甲状腺功能亢进、主动脉瓣关闭不全及Korotkoff不消失者，可以第4期作为舒张压读数，或者记录两个数值，如血压160/8050mmHg,Five types of Korotkoff sounds:The first Korotkoff sound is the snapping sound first heard at the systolic pressure. Clear tapping, repetitive sounds for at least two consecutive beats is considered the systolic pressure. The second sounds are the murmurs heard for most of the area between the systolic and diastolic pressures. The third = A loud, crisp tapping sound.The fourth sound, at pressures within 10 mmHg above the diastolic blood pressure, were described as thumping and muting. The fifth Korotkoff sound is silence as the cuff pressure drops below the diastolic blood pressure. The disappearance of sound is considered diastolic blood pressure- two points below the last sound heard.,血压标准,中国高血压防治指南（2005）,若患者收缩压与舒张压分属于不同级别时，以较高的分级为准；单纯收缩期高血压也可按照收缩压水平分为1、2、3级。,血压变动的临床意义,高血压(Hypertension)：Hypertension is a chronic medical condition in which the blood pressure is elevated. It is also referred to as high blood pressure or shortened to HT, HTN or HPN. The word hypertension, by itself, normally refers to systemic,arterial hypertension. 情绪激动(Emotional )、紧张(Tension )、运动(Sports)等。安静清醒的条件下采用标准测量方法，至少3次非同日血压值达到或超过收缩压140mmHg和（或）舒张压90mmHg，即可认为有高血压，如果仅收缩压达到标准成为单纯收缩期高血压(Isolated systolic hypertension )。,Hypertension can be classified as either essential (primary)(原发性高血压)or secondary(继发性或症状性高血压). Essential or primary hypertension means that no medical cause can be found to explain the raised blood pressure and represents about 90-95% of hypertension cases.Secondary hypertension indicates that the high blood pressure is a result of (i.e., secondary to) another condition, such as kidney disease or tumours (adrenal adenoma 肾上腺腺瘤 or pheochromocytoma嗜铬细胞瘤 ). 高血压是动脉粥样硬化(Atherosclerosis)和冠心病(Coronary Heart Disease)重要危险因素，也是心力衰竭(Heart failure)的重要原因。,低血压(Hypotension)： If blood pressure is lower than normal then it is called as low blood pressure or hypotension.Low blood pressure causes can be due to hormonal changes（激素变化）, widening of blood vessels, medicine side effects, anemia（贫血）, heart & endocrine problems（内分泌失调）. 凡血压低于90/60mmHg时称低血压，持续低血压状态多见于严重病症，如休克(shock)、心肌梗死(Myocardial infarction)、急性心脏压塞(Acute cardiac tamponade)等。也可是体质因素，一般无症状。另外，如果患者平卧5分钟以上后站立1min和5min，收缩压下降20mmHg以上，伴有头晕或晕厥，为直立性低血压(Orthostatic hypotension).,双上肢血压差别显著：正常双侧上肢血压差别510mmHg，超过此范围属于异常，见于多发性大动脉炎(Takayasu)或先天性动脉畸形(Congenital arterial malformation)等。,上下肢血压差异常：正常下肢血压(Lower extremity blood pressure)高于上肢血压(Upper extremity blood pressure)2040mmHg，如下肢血压低于上肢血压应考虑主动脉缩窄(Coarctation of the aorta )，或胸腹主动脉型大动脉炎(Aortic arteritis)等。,脉压改变：脉压明显增大，结合病史，可考虑甲状腺功能亢进(Hyperthyroidism )、主动脉瓣关闭不全(Aortic insufficiency)和动脉硬化(Arteriosclerosis)等。若脉压减少，可见于主动脉瓣狭窄(Aortic stenosis )、心包积液(Pericardial effusion)和严重的心力衰竭(Severe heart failure )。If pulse pressure is consistently greater than 40 mmHg, e.g. 60 or 80 mmHg, the most likely basis is stiffness of the major arteries, aortic regurgitation (a leak in the aortic valve), hyperthyroidism or some combination. If the pulse pressure is genuinely low, e.g. 25 mmHg or less, the cause may be low stroke volume(每搏输出量), as in Congestive Heart Failure(充血性心力衰竭) and/or shock,aortic or pericardial effusion(心包积液).,动态血压监测,ABPM measures blood pressure at regular intervals throughout the day and night. It is believed to be able to reduce the white coat hypertension effect.24小时记录血压白昼时间6am10pm，15或20min测量一次晚间为10pm次晨6am，30min测量一次国内正常参考标准：24小时平均血压值130/80mmHg；白昼平均值135/85mmHg；夜间平均值125/75mmHg。正常情况下，夜间血压值较白昼低1015%。疑有诊所高血压（Hypertension Clinic,白大衣高血压white coat hypertension) 、隐蔽性高血压(Hidden hypertension )、顽固难治性高血压(refractory hypertension )、发作性高血压或低血压以及降压治疗效果差的患者，均应考虑做动态血压监测作为常规血压的补充手段。,Ambulatory blood pressure monitoring，ABPM,血管杂音及周围血管征,静脉杂音(Venous hum)：静脉压力低，一般多不明显，临床上较有意义的有颈静脉营营声（无害性杂音），在颈根部近锁骨处，甚至在锁骨下，尤其右侧，低调、柔和、连续性杂音，坐位及站立位明显，为颈静脉血液快速回流至上腔静脉(Superior vena cava )。以手指轻轻压迫颈静脉暂时中断血流，杂音即可消失，属无害性杂音。需与甲亢之血管杂音和某些先心病的杂音鉴别。此外，肝硬化门静脉高压(Portal hypertension)引起腹壁静脉曲张(Abdominal wall veins)时，可在脐周或上腹部闻及连续性静脉营营声。Venous hum is a benign(良性) medical condition where 20% of the blood flow travels to the brain and back to the heart. Due to the large amount of blood it can move quite fast causing the vein walls to vibrate which can create a humming nois