13. When the systolic and diastolic pressures approach, heart failure is imminent either when pressure picture is high or low.
When all these factors are taken into consideration, it becomes apparent that the diastolic pressure is most important, if not the most important part of the pressure picture.
Up to within a very brief time all the statistical evidence of blood pressure was based on systolic readings alone. This data is most valuable and much has been learned as to diagnosis and prognosis, but it is a mass of data based on a one-sided picture and can not be as valuable as the statistics which will undoubtedly be published later when all the pressure picture figures can be analyzed.
Pulse Pressure
The pulse pressure is the actual head of pressure which is forcing the blood to the periphery. At every systole a certain amount of blood 75-90 c.c. (Howell) is thrown violently into an already comfortably filled aorta. The sudden ejection of this blood instigates a wave which rapidly passes down the arteries as the pulse wave. The elastic recoil of the aorta and large arteries near the heart contract upon the blood and keep it moving during diastole. Normally the blood-vessels are highly elastic tubes with an almost perfect coefficient of elasticity. The pulse pressure varies under normal conditions from 30 to 50 mm. Hg. There is a very definite relationship between the velocity of blood and the pulse pressure which is expressed thus; velocity = pulse rate × pulse pressure.[5]
Further it has been demonstrated that under normal conditions and during various procedures—the pulse pressure is a reliable index of the systolic output.[6]
Increased pulse pressure therefore goes hand in hand with greater systolic output. Physiologically this is most ideally seen during exercise. Following exercise the pulse rate increases, the systolic pressure rises greatly, the diastolic slightly or not at all. The pulse pressure therefore is increased. The velocity also is much increased. The call comes for more blood and the heart responds. In the chronic high pulse pressures there are four correlated conditions which, so far as I have studied them, are always present. These are: (1) An increase in size of the cavity of the left ventricle. The ventricle actually by measurement contains more blood than normal, and therefore throws out more blood at every systole. The volume output is greater per unit of time. (2) There is actual permanent increase in diameter of the arch of the aorta. This is a compensating process to accommodate the increased charge from the left ventricle. (3) There are on careful auscultation over the manubrium, particularly the lower half, breath sounds which vary from bronchial to intensely tubular, depending upon the anatomic placing of the aorta, the shape of the chest, and the degree of dilatation. Often there is very slight impairment of the percussion note as well. (4) There is increase in size of all the large distributing arteries, carotids, brachials, femorals, renals, celiac axis, etc., with fibrous changes in the media, loss of some elasticity, and increase in size of the pulse wave. Increased pulse pressure means increased volume output, but does not always mean increased velocity. The proper distribution of blood to the various organs of the body is regulated by the vasomotor system acting upon the small arteries which contain considerable unstriated muscle. When fibrous arteriosclerosis is present there is loss of elasticity in the distributing arteries and a greater volume of blood must be thrown out by the ventricle at every systole in order that every organ shall have its full quota of blood. A force which is sufficient to send blood through elastic normal distributing tubes becomes totally insufficient to send the same amount of blood through tortuous and more or less inelastic tubes.
It is evident then that pulse pressure is exceedingly important. It can only be determined by measuring both the systolic and diastolic pressure. The pulse rate must also be known in order to compute the velocity. It is essential to have the whole pressure picture for all cases if correct conclusions are to be drawn.
In an irregular heart, especially in the cases due to myocardial disease, it is quite impossible to determine the true diastolic pressure. One can only approximate it and say that the pulse pressure is low or high. As a matter of fact the real systolic pressure can not be determined. For this figure the place on the scale where most of the beats are heard may be taken for the average systolic pressure. No one can seriously maintain that he can measure the diastolic pressure under all circumstances.