{"version":"1.0.0","segments":[{"startTime":0.913,"endTime":3.18,"body":"[upbeat intro music]"},{"startTime":3.18,"endTime":5.59,"body":"[Dr. Handy] Hi, welcome"},{"startTime":3.18,"endTime":5.59,"body":"to Harrison's Podclass"},{"startTime":5.59,"endTime":8.73,"body":"where we discuss important"},{"startTime":5.59,"endTime":8.73,"body":"concepts in internal medicine."},{"startTime":8.73,"endTime":9.86,"body":"I'm Cathy Handy."},{"startTime":9.86,"endTime":11.743,"body":"[Dr. Wiener] And I'm Charlie"},{"startTime":9.86,"endTime":11.743,"body":"Wiener, and we're coming to you"},{"startTime":11.743,"endTime":14.093,"body":"from the Johns Hopkins School of Medicine."},{"startTime":15.8,"endTime":18.42,"body":"Welcome to episode 69, a 65-year-old"},{"startTime":18.42,"endTime":20.09,"body":"with an elevated blood pressure."},{"startTime":20.09,"endTime":23.14,"body":"So a 65-year-old man comes into the clinic"},{"startTime":23.14,"endTime":24.5,"body":"for a routine visit."},{"startTime":24.5,"endTime":26.39,"body":"He last saw you about four years ago"},{"startTime":26.39,"endTime":28.13,"body":"and did not have any medical problems"},{"startTime":28.13,"endTime":30.66,"body":"and was not on any"},{"startTime":28.13,"endTime":30.66,"body":"prescription medications."},{"startTime":30.66,"endTime":32.45,"body":"Before you were even able to see him,"},{"startTime":32.45,"endTime":34.47,"body":"the medical assistant"},{"startTime":32.45,"endTime":34.47,"body":"in your office calls you"},{"startTime":34.47,"endTime":38.09,"body":"because his blood pressure is 194/106."},{"startTime":38.09,"endTime":41.099,"body":"- Now Cathy, before you interrupt me,"},{"startTime":38.09,"endTime":41.099,"body":"- [Dr. Handy chuckles]"},{"startTime":41.099,"endTime":42.65,"body":"[Dr. Wiener] --I'm going"},{"startTime":41.099,"endTime":42.65,"body":"to go right to the question"},{"startTime":42.65,"endTime":44.42,"body":"because it's going to"},{"startTime":42.65,"endTime":44.42,"body":"frame the discussion here."},{"startTime":44.42,"endTime":45.578,"body":"- Okay?"},{"startTime":44.42,"endTime":45.578,"body":"- [Dr. Handy] Okay."},{"startTime":45.578,"endTime":46.97,"body":"[Dr. Handy] So the question asks,"},{"startTime":46.97,"endTime":48.38,"body":"which of the following statements"},{"startTime":48.38,"endTime":51.62,"body":"regarding blood pressure"},{"startTime":48.38,"endTime":51.62,"body":"measurements is true?"},{"startTime":51.62,"endTime":55.37,"body":"Option A. systolic"},{"startTime":51.62,"endTime":55.37,"body":"blood pressure increases"},{"startTime":55.37,"endTime":57.64,"body":"and diastolic blood pressure decreases"},{"startTime":57.64,"endTime":60.43,"body":"when measured in more distal arteries."},{"startTime":60.43,"endTime":64.37,"body":"Option B. systolic leg blood"},{"startTime":60.43,"endTime":64.37,"body":"pressures are generally"},{"startTime":64.37,"endTime":67.18,"body":"as much as 20 mmHg lower"},{"startTime":67.18,"endTime":69.61,"body":"than arm systolic blood pressures."},{"startTime":69.61,"endTime":72.45,"body":"Option C. the difference in blood pressure"},{"startTime":72.45,"endTime":77.02,"body":"measured in both arms"},{"startTime":72.45,"endTime":77.02,"body":"should be less than 20 mmHg."},{"startTime":77.02,"endTime":81.27,"body":"Option D. the concept of"},{"startTime":77.02,"endTime":81.27,"body":"white coat hypertension,"},{"startTime":81.27,"endTime":83.34,"body":"that is blood pressure"},{"startTime":81.27,"endTime":83.34,"body":"measured in the office"},{"startTime":83.34,"endTime":84.44,"body":"or in a hospital setting"},{"startTime":84.44,"endTime":87.5,"body":"being significantly higher"},{"startTime":84.44,"endTime":87.5,"body":"than in non-clinical settings"},{"startTime":87.5,"endTime":89.72,"body":"has been shown to be a myth."},{"startTime":89.72,"endTime":92.788,"body":"And Option E. is using a"},{"startTime":89.72,"endTime":92.788,"body":"blood pressure cuff which is"},{"startTime":92.788,"endTime":96.27,"body":"too small will result in"},{"startTime":92.788,"endTime":96.27,"body":"a marked underestimation"},{"startTime":96.27,"endTime":97.61,"body":"of the true blood pressure."},{"startTime":97.61,"endTime":99.35,"body":"[Dr. Handy] Okay, so this is a good topic."},{"startTime":99.35,"endTime":101.86,"body":"As clinicians, we spend"},{"startTime":99.35,"endTime":101.86,"body":"a lot of time focusing"},{"startTime":101.86,"endTime":104.98,"body":"on the abnormality and what"},{"startTime":101.86,"endTime":104.98,"body":"can be causing the abnormality."},{"startTime":104.98,"endTime":106.39,"body":"So for example, in this case,"},{"startTime":106.39,"endTime":108.88,"body":"going through the differential"},{"startTime":106.39,"endTime":108.88,"body":"diagnosis of hypertension"},{"startTime":108.88,"endTime":111.18,"body":"which is, I think initially"},{"startTime":108.88,"endTime":111.18,"body":"what I was inclined to do"},{"startTime":111.18,"endTime":113.84,"body":"before I let you finish with the question,"},{"startTime":113.84,"endTime":115.15,"body":"but it's important for us to remember"},{"startTime":115.15,"endTime":116.9,"body":"that all tests have limitations"},{"startTime":116.9,"endTime":119.18,"body":"and when performing tests"},{"startTime":116.9,"endTime":119.18,"body":"we must remain cognizant"},{"startTime":119.18,"endTime":121.17,"body":"not only of the test characteristics"},{"startTime":121.17,"endTime":123.56,"body":"but also think about the test methodology."},{"startTime":123.56,"endTime":124.96,"body":"And this is really a great example"},{"startTime":124.96,"endTime":127.13,"body":"of making sure we're"},{"startTime":124.96,"endTime":127.13,"body":"obtaining accurate data"},{"startTime":127.13,"endTime":129.58,"body":"before we make any"},{"startTime":127.13,"endTime":129.58,"body":"therapeutic conclusions."},{"startTime":129.58,"endTime":132.28,"body":"[Dr. Wiener] Okay. So saying that"},{"startTime":129.58,"endTime":132.28,"body":"in addition to understanding things"},{"startTime":132.28,"endTime":135.62,"body":"like sensitivity, specificity,"},{"startTime":132.28,"endTime":135.62,"body":"positive predictive value,"},{"startTime":135.62,"endTime":137.82,"body":"we also must know that we're"},{"startTime":135.62,"endTime":137.82,"body":"making accurate measurements"},{"startTime":137.82,"endTime":139.54,"body":"before we draw any conclusions."},{"startTime":139.54,"endTime":141.658,"body":"[Dr. Handy] Exactly. And for"},{"startTime":139.54,"endTime":141.658,"body":"example, there was a recent"},{"startTime":141.658,"endTime":143.83,"body":"report in the New England"},{"startTime":141.658,"endTime":143.83,"body":"Journal of Medicine,"},{"startTime":143.83,"endTime":145.75,"body":"demonstrating that in Black patients,"},{"startTime":145.75,"endTime":148.13,"body":"pulse oximetry is notably less accurate"},{"startTime":148.13,"endTime":149.96,"body":"compared to arterial blood gas."},{"startTime":149.96,"endTime":151.59,"body":"And they found that Black patients"},{"startTime":151.59,"endTime":154.9,"body":"had nearly three times the"},{"startTime":151.59,"endTime":154.9,"body":"frequency of occult hypoxemia"},{"startTime":154.9,"endTime":158.8,"body":"defined as an arterial oxygen"},{"startTime":154.9,"endTime":158.8,"body":"saturation less than 88%"},{"startTime":158.8,"endTime":161.05,"body":"that was not detected by pulse oximetry"},{"startTime":161.05,"endTime":162.38,"body":"compared to white patients."},{"startTime":162.38,"endTime":163.4,"body":"[Dr. Wiener] So true."},{"startTime":163.4,"endTime":165.41,"body":"We often make such important conclusions"},{"startTime":165.41,"endTime":167.11,"body":"from the vital signs but we seldom think"},{"startTime":167.11,"endTime":169.1,"body":"about the validity of the measurements."},{"startTime":169.1,"endTime":171.62,"body":"In this case we're talking about"},{"startTime":169.1,"endTime":171.62,"body":"blood pressure measurement."},{"startTime":171.62,"endTime":173.22,"body":"What are your thoughts in this case?"},{"startTime":173.22,"endTime":174.8,"body":"[Dr. Handy] All right,"},{"startTime":173.22,"endTime":174.8,"body":"let's go back to the basics."},{"startTime":174.8,"endTime":176.05,"body":"So first let's go through"},{"startTime":176.05,"endTime":177.743,"body":"how to manually check blood pressure"},{"startTime":177.743,"endTime":179.64,"body":"because that is what you"},{"startTime":177.743,"endTime":179.64,"body":"would do here once you brought"},{"startTime":179.64,"endTime":181.63,"body":"the patient back to the exam room."},{"startTime":181.63,"endTime":183.01,"body":"So the length and the width"},{"startTime":183.01,"endTime":184.43,"body":"of the blood pressure cuff/bladder"},{"startTime":184.43,"endTime":188.79,"body":"should be 80% and 40% of the"},{"startTime":184.43,"endTime":188.79,"body":"arm circumference respectively."},{"startTime":188.79,"endTime":190.93,"body":"So a common source of error in practice"},{"startTime":190.93,"endTime":193.3,"body":"is to use an inappropriately small cuff"},{"startTime":193.3,"endTime":195.54,"body":"that would result in a"},{"startTime":193.3,"endTime":195.54,"body":"marked overestimation"},{"startTime":195.54,"endTime":196.77,"body":"of the true blood pressure,"},{"startTime":196.77,"endTime":198.95,"body":"or an inappropriately large cuff"},{"startTime":198.95,"endTime":200.88,"body":"that would result in an underestimation"},{"startTime":200.88,"endTime":202.6,"body":"of the true blood pressure."},{"startTime":202.6,"endTime":205.4,"body":"The cuff should be inflated to 30 mmHg"},{"startTime":205.4,"endTime":207.58,"body":"above the expected systolic pressure,"},{"startTime":207.58,"endTime":209.943,"body":"and then the pressure"},{"startTime":207.58,"endTime":209.943,"body":"release rate should be about"},{"startTime":209.943,"endTime":212.64,"body":"2-3 mmHg per second."},{"startTime":212.64,"endTime":215.11,"body":"And systolic and diastolic"},{"startTime":212.64,"endTime":215.11,"body":"blood pressures are defined"},{"startTime":215.11,"endTime":218.43,"body":"by the first and the fifth"},{"startTime":215.11,"endTime":218.43,"body":"Korotkoff sounds respectively."},{"startTime":218.43,"endTime":220.09,"body":"And blood pressure is best assessed"},{"startTime":220.09,"endTime":221.53,"body":"at the brachial artery level,"},{"startTime":221.53,"endTime":223.86,"body":"though it can be measured"},{"startTime":221.53,"endTime":223.86,"body":"at the radial, popliteal"},{"startTime":223.86,"endTime":225.76,"body":"or even the pedal pulse level."},{"startTime":225.76,"endTime":228.67,"body":"[Dr. Wiener] Okay. So that"},{"startTime":225.76,"endTime":228.67,"body":"makes option E. wrong,"},{"startTime":228.67,"endTime":232.07,"body":"a small blood pressure cuff"},{"startTime":228.67,"endTime":232.07,"body":"will result in an overestimation"},{"startTime":232.07,"endTime":234.53,"body":"not an underestimation"},{"startTime":232.07,"endTime":234.53,"body":"of true blood pressure."},{"startTime":234.53,"endTime":235.9,"body":"You mentioned the other arteries."},{"startTime":235.9,"endTime":237.95,"body":"Are there differences"},{"startTime":235.9,"endTime":237.95,"body":"based on where you measure?"},{"startTime":237.95,"endTime":240.08,"body":"[Dr. Handy] Yeah and just"},{"startTime":237.95,"endTime":240.08,"body":"going through the answers,"},{"startTime":240.08,"endTime":242.76,"body":"so option A. is true and"},{"startTime":240.08,"endTime":242.76,"body":"it's the correct answer."},{"startTime":242.76,"endTime":245.5,"body":"So in general, systolic pressure increases"},{"startTime":245.5,"endTime":247.95,"body":"and diastolic pressure"},{"startTime":245.5,"endTime":247.95,"body":"decreases when measured"},{"startTime":247.95,"endTime":249.51,"body":"in more distal arteries."},{"startTime":249.51,"endTime":250.7,"body":"[Dr. Wiener] Okay. Well,"},{"startTime":249.51,"endTime":250.7,"body":"then why don't you go through"},{"startTime":250.7,"endTime":253.59,"body":"the other answer choices"},{"startTime":250.7,"endTime":253.59,"body":"and why they're incorrect?"},{"startTime":253.59,"endTime":255.195,"body":"[Dr. Handy] Okay. Blood"},{"startTime":253.59,"endTime":255.195,"body":"pressure should be measured"},{"startTime":255.195,"endTime":257.07,"body":"in both arms and the difference should be"},{"startTime":257.07,"endTime":259.45,"body":"less than 10 mmHg."},{"startTime":259.45,"endTime":262.12,"body":"A blood pressure differential"},{"startTime":259.45,"endTime":262.12,"body":"that exceeds this threshold"},{"startTime":262.12,"endTime":264.21,"body":"may be associated with atherosclerotic"},{"startTime":264.21,"endTime":266.67,"body":"or inflammatory subclavian artery disease,"},{"startTime":266.67,"endTime":270.12,"body":"supravalvular aortic stenosis"},{"startTime":266.67,"endTime":270.12,"body":"or aortic coarctation,"},{"startTime":270.12,"endTime":272.399,"body":"or aortic dissection."},{"startTime":272.399,"endTime":274.79,"body":"Option B. talks about the"},{"startTime":272.399,"endTime":274.79,"body":"difference between the arm"},{"startTime":274.79,"endTime":276.03,"body":"and the leg pressures."},{"startTime":276.03,"endTime":278.32,"body":"So systolic blood pressures"},{"startTime":276.03,"endTime":278.32,"body":"are usually as much"},{"startTime":278.32,"endTime":282.412,"body":"as 20 mmHg higher, not lower"},{"startTime":278.32,"endTime":282.412,"body":"as the question mentioned,"},{"startTime":282.412,"endTime":283.96,"body":"than systolic arm pressures."},{"startTime":283.96,"endTime":287.03,"body":"And greater leg and arm"},{"startTime":283.96,"endTime":287.03,"body":"pressure differences are seen"},{"startTime":287.03,"endTime":290.07,"body":"in patients with chronic"},{"startTime":287.03,"endTime":290.07,"body":"severe aortic regurgitation"},{"startTime":290.07,"endTime":291.76,"body":"as well as patients with extensive"},{"startTime":291.76,"endTime":295.13,"body":"and calcified lower extremity"},{"startTime":291.76,"endTime":295.13,"body":"peripheral artery disease."},{"startTime":295.13,"endTime":297.561,"body":"The ankle-brachial index or ABI"},{"startTime":297.561,"endTime":300.91,"body":"should be about 1.0-1.4"},{"startTime":297.561,"endTime":300.91,"body":"and that's lower pressure"},{"startTime":300.91,"endTime":303.769,"body":"in the dorsalis pedis or"},{"startTime":300.91,"endTime":303.769,"body":"posterior tibial artery"},{"startTime":303.769,"endTime":307.09,"body":"divided by the higher of the"},{"startTime":303.769,"endTime":307.09,"body":"two brachial artery pressures."},{"startTime":307.09,"endTime":309.84,"body":"And abnormalities in the"},{"startTime":307.09,"endTime":309.84,"body":"ABI are a powerful predictor"},{"startTime":309.84,"endTime":312.29,"body":"of long term cardiovascular mortality."},{"startTime":312.29,"endTime":313.806,"body":"[Dr. Wiener] Great. What about the myth"},{"startTime":313.806,"endTime":315.52,"body":"of white coat hypertension?"},{"startTime":315.52,"endTime":316.87,"body":"[Dr. Handy] So we do need to acknowledge"},{"startTime":316.87,"endTime":318.23,"body":"that even when properly done,"},{"startTime":318.23,"endTime":319.93,"body":"the blood pressure measured in an office"},{"startTime":319.93,"endTime":322.23,"body":"or hospital setting may"},{"startTime":319.93,"endTime":322.23,"body":"not accurately reflect"},{"startTime":322.23,"endTime":324.03,"body":"the pressure in other venues."},{"startTime":324.03,"endTime":325.66,"body":"White coat hypertension is defined"},{"startTime":325.66,"endTime":328.08,"body":"by at least three separate"},{"startTime":325.66,"endTime":328.08,"body":"clinic-based measurements"},{"startTime":328.08,"endTime":329.81,"body":"above the threshold for hypertension"},{"startTime":329.81,"endTime":332.27,"body":"and at least two"},{"startTime":329.81,"endTime":332.27,"body":"non-clinic-based measurements"},{"startTime":332.27,"endTime":334.07,"body":"below the threshold for hypertension"},{"startTime":334.07,"endTime":337.44,"body":"in the absence of any evidence"},{"startTime":334.07,"endTime":337.44,"body":"of target organ damage."},{"startTime":337.44,"endTime":340.05,"body":"Individuals with white coat"},{"startTime":337.44,"endTime":340.05,"body":"hypertension may not benefit"},{"startTime":340.05,"endTime":342.94,"body":"from drug therapy, usually"},{"startTime":340.05,"endTime":342.94,"body":"lifestyle modifications"},{"startTime":342.94,"endTime":344.96,"body":"and cardiovascular disease risk reduction"},{"startTime":344.96,"endTime":347.16,"body":"should be recommended"},{"startTime":344.96,"endTime":347.16,"body":"though for these patients."},{"startTime":347.16,"endTime":348.41,"body":"[Dr. Wiener] And what"},{"startTime":347.16,"endTime":348.41,"body":"threshold do you have"},{"startTime":348.41,"endTime":349.76,"body":"for considering whether or not patients"},{"startTime":349.76,"endTime":351.46,"body":"are even hypertensive to begin with?"},{"startTime":351.46,"endTime":353.19,"body":"[Dr. Handy] From an"},{"startTime":351.46,"endTime":353.19,"body":"epidemiologic perspective,"},{"startTime":353.19,"endTime":355.19,"body":"there's no obvious level of blood pressure"},{"startTime":355.19,"endTime":357.0,"body":"that defines hypertension."},{"startTime":357.0,"endTime":359.58,"body":"In adults there's a"},{"startTime":357.0,"endTime":359.58,"body":"continuous incremental risk"},{"startTime":359.58,"endTime":362.45,"body":"of cardiovascular disease,"},{"startTime":359.58,"endTime":362.45,"body":"stroke and renal disease"},{"startTime":362.45,"endTime":366.233,"body":"across levels of both systolic"},{"startTime":362.45,"endTime":366.233,"body":"and diastolic blood pressure."},{"startTime":366.233,"endTime":368.21,"body":"The Multiple Risk Factor"},{"startTime":366.233,"endTime":368.21,"body":"Intervention Trial,"},{"startTime":368.21,"endTime":370.2,"body":"or MRFIT as it's more commonly called"},{"startTime":370.2,"endTime":374.01,"body":"which included over"},{"startTime":370.2,"endTime":374.01,"body":"350,000 male participants,"},{"startTime":374.01,"endTime":376.69,"body":"demonstrated a continuous"},{"startTime":374.01,"endTime":376.69,"body":"and graded influence"},{"startTime":376.69,"endTime":379.05,"body":"of both systolic and"},{"startTime":376.69,"endTime":379.05,"body":"diastolic blood pressure"},{"startTime":379.05,"endTime":381.11,"body":"on coronary heart disease mortality"},{"startTime":381.11,"endTime":383.1,"body":"extending down to systolic blood pressures"},{"startTime":383.1,"endTime":385.744,"body":"of 120 mmHg."},{"startTime":385.744,"endTime":388.27,"body":"Similarly, results of a meta-analysis"},{"startTime":388.27,"endTime":389.95,"body":"involving almost a million patients"},{"startTime":389.95,"endTime":392.45,"body":"indicated that ischemic"},{"startTime":389.95,"endTime":392.45,"body":"heart disease mortality,"},{"startTime":392.45,"endTime":395.7,"body":"stroke mortality and mortality"},{"startTime":392.45,"endTime":395.7,"body":"from other vascular causes"},{"startTime":395.7,"endTime":397.99,"body":"are directly related to the"},{"startTime":395.7,"endTime":397.99,"body":"height of the blood pressure"},{"startTime":397.99,"endTime":402.9,"body":"beginning at 115/75, without"},{"startTime":397.99,"endTime":402.9,"body":"evidence of a threshold."},{"startTime":402.9,"endTime":404.84,"body":"Cardiovascular disease risk doubles"},{"startTime":404.84,"endTime":407.95,"body":"for every 20 mmHg increase in systolic"},{"startTime":407.95,"endTime":412.33,"body":"and 10 mmHg increase"},{"startTime":407.95,"endTime":412.33,"body":"in diastolic pressure."},{"startTime":412.33,"endTime":413.71,"body":"And among older individuals,"},{"startTime":413.71,"endTime":415.61,"body":"systolic blood pressure and pulse pressure"},{"startTime":415.61,"endTime":418.21,"body":"are more powerful predictors"},{"startTime":415.61,"endTime":418.21,"body":"of cardiovascular disease"},{"startTime":418.21,"endTime":420.07,"body":"than is diastolic blood pressure."},{"startTime":420.07,"endTime":423.45,"body":"[Dr. Wiener] Wow. You said that"},{"startTime":420.07,"endTime":423.45,"body":"there is a gradation of risk"},{"startTime":423.45,"endTime":426.017,"body":"related to blood pressure."},{"startTime":423.45,"endTime":426.017,"body":"As a result of that,"},{"startTime":426.017,"endTime":427.91,"body":"haven't the recommendations"},{"startTime":426.017,"endTime":427.91,"body":"changed recently"},{"startTime":427.91,"endTime":430.82,"body":"on what is the ideal or"},{"startTime":427.91,"endTime":430.82,"body":"the optimal blood pressure?"},{"startTime":430.82,"endTime":433.267,"body":"[Dr. Handy] Yeah, so some"},{"startTime":430.82,"endTime":433.267,"body":"traditionally acceptable"},{"startTime":433.267,"endTime":435.33,"body":"blood pressures are likely not healthy."},{"startTime":435.33,"endTime":438.33,"body":"The most recent guidelines"},{"startTime":435.33,"endTime":438.33,"body":"define stage one hypertension"},{"startTime":438.33,"endTime":442.7,"body":"as systolic blood pressure"},{"startTime":438.33,"endTime":442.7,"body":"between 130 and 139 mmHg"},{"startTime":442.7,"endTime":445.25,"body":"and diastolic between 80 and 89,"},{"startTime":445.25,"endTime":449.34,"body":"and stage two hypertension"},{"startTime":445.25,"endTime":449.34,"body":"would be at or above 140/90."},{"startTime":449.34,"endTime":451.584,"body":"[Dr. Wiener] Great. So"},{"startTime":449.34,"endTime":451.584,"body":"the teaching points here"},{"startTime":451.584,"endTime":452.97,"body":"are that blood pressure measurements"},{"startTime":452.97,"endTime":454.64,"body":"can vary based on technique,"},{"startTime":454.64,"endTime":457.2,"body":"and it's important to have"},{"startTime":454.64,"endTime":457.2,"body":"the appropriate size cuff,"},{"startTime":457.2,"endTime":459.34,"body":"consider where you're"},{"startTime":457.2,"endTime":459.34,"body":"measuring the blood pressure"},{"startTime":459.34,"endTime":461.72,"body":"and also consider out of"},{"startTime":459.34,"endTime":461.72,"body":"office-based measurements"},{"startTime":461.72,"endTime":463.09,"body":"in the untreated patient."},{"startTime":463.09,"endTime":466.85,"body":"Also, current recommendations"},{"startTime":463.09,"endTime":466.85,"body":"for the goals of treatment"},{"startTime":466.85,"endTime":469.55,"body":"for blood pressure and the"},{"startTime":466.85,"endTime":469.55,"body":"staging of blood pressure"},{"startTime":469.55,"endTime":472.22,"body":"have been changed and require review."},{"startTime":472.22,"endTime":474.27,"body":"[Dr. Handy] And for more"},{"startTime":472.22,"endTime":474.27,"body":"information you can read about this"},{"startTime":474.27,"endTime":477.16,"body":"in Harrison's chapter on"},{"startTime":474.27,"endTime":477.16,"body":"hypertensive vascular disease"},{"startTime":477.16,"endTime":480.21,"body":"and physical examination of"},{"startTime":477.16,"endTime":480.21,"body":"the cardiovascular system."},{"startTime":480.21,"endTime":482.41,"body":"And the article that I"},{"startTime":480.21,"endTime":482.41,"body":"mentioned on pulse oximetry"},{"startTime":482.41,"endTime":485.43,"body":"is from December 17th,"},{"startTime":482.41,"endTime":485.43,"body":"2020 in New England Journal"},{"startTime":485.43,"endTime":487.86,"body":"of Medicine by Michael Sjoding et al."},{"startTime":487.86,"endTime":492.53,"body":"[outro music]"},{"startTime":492.53,"endTime":495.41,"body":"[Mr. Shanahan] This is Jim"},{"startTime":492.53,"endTime":495.41,"body":"Shanahan, publisher at McGraw Hill."},{"startTime":495.41,"endTime":497.02,"body":"Harrison's Podclass is brought to you"},{"startTime":497.02,"endTime":499.02,"body":"by McGraw Hill's Access Medicine,"},{"startTime":499.02,"endTime":501.11,"body":"the online medical resource that delivers"},{"startTime":501.11,"endTime":504.34,"body":"the latest trusted content from"},{"startTime":501.11,"endTime":504.34,"body":"the best minds in medicine."},{"startTime":504.34,"endTime":506.883,"body":"Go to accessmedicine.com to learn more."}]}