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A simple clinical method of estimating arterial pulse rise time
A simple clinical method arterial pulse rise time Thomas A. Preston, London, England
of estimating
M.D.*
A
rterial pulse contours give much useful information, particularly in the presence of aortic valve disease. Carotid artery palpation is the simplest means of assessment of the arterial pulse; carotid artery external pulse tracings are more objective and may be diagnostic of aortic valvular disease. The problem commonly arises of differentiating the murmurs of supravalvular stenosis, valvular aortic stenosis, fixed or dynamic subaortic stenosis, and aortic sclerosis. Rodbard and Libanoffr have reported a method for describing the brachial artery pulse contour by means of analysis of Korotkoff sounds during indirect measurement of the brachial artery pressure. This is a report of a simple method of analysis of the upstroke time of the brachial arterial pressure pulse using a stethoscope and a sphygmomanometer. By noting the interval between the audible first heart sound and the palpable brachial artery pulse, and comparing it with the corresponding interval when a sphygmomanometer cuff applied to the arm is inflated to just below brachial artery
systolic pressure, it is possible to detect a prolonged arterial pulse rise time in those patients with fixed left ventricular outflow tract obstruction-specifically severe aortic valve stenosis. Methods Twenty-five patients were studied with simultaneous recording of electrocardiogram, phonocardiogram (lower left sternal edge), and external brachial artery pulse tracings from the antecubital area. A sphygmomanometer cuff was applied to the arm proximal to the brachial artery recording device, and all recordings were made before and after inflation of the sphygmomanom,eter to just below systolic pressure. Three intervals were determined for each patient: (1) from the beginning of the first heart sound complex to the time when the brachi.al pulse attained one third of its maximum height with the cuff uninflated (Sl-1/3P); (2) from the onset of the first heart sound complex to the time when the brachial pulse reached its maximum height with sphygmomanometer cuff inflated to just below systolic
From the National Heart Hospital, London. W.l., England This work was done while Dr. Preston was a Special Research Fellow, working ander the United States Public Health Service. Received for publication April 22, 1970. Address for reprints: Department of Cardiology, Veterans Administration Hospital, Mich. 48105. *Present position: Chief, Section of Cardiology, Ann Arbor Veterans Administration Medicine, University of Michigan Medical Center.
Vol.
80, No.
4, pp. 475-478
October,
1970
American
Grant
2215 Hospital;
Heart
I-F3-HE-35,
Fuller
Road, Assistant
Journal
368-01
Ann
from
Arbor,
Professor
of
475
476
Preston
Fig. 1. Patient with calcific aortic stenosis. A, Sphygmomanometer cuff inflated to just below peak systolic pressure. Distance between dotted lines represents the time interval between the audible onset of the first heart sound and the palpable brachial artery pulse. 23, Sphygmomanometer cuff deflated. Time interval between onset of first heart sound and palpable brachial artery pulse is about half of the interval presented in A.
pressure (Sl-I’); and (3) the difference between (2) and (1). Ten patients were normal, ten patients had valvular aortic stenosis, and five patients had idiopathic hypertrophic subaortic stenosis (IHSS). Resrslts In normal subjects the interval from the onset to peak of the indirectly recorded
brachial artery pressure pulse ranged from 0.04 to 0.07 sec. (mean 0.055 sec.). In patients with valvular aortic stenosis the interval ranged from 0.10 to 0.20 sec. (mean 0.16 sec.) and in those with IHSS the interval ranged from 0.03 to 0.08 sec. (mean 0.07 sec.). The values in patients with valvular stenosis are significantly different from those in the normal group (p < 0.001)) whereas the findings in patients with
Volume Number
80 4
Afethod of estimating
477
arterial @ulse rise time
Table I. I / Subjects
Aortic gradient (mm. f4d
Normal
Patients
with
IHSS
Patients
with
valvular
aortic
stenosis
110 80 90 120 70 50 90 100 95 115
Sl-1/3P is the time in seconds from the onset of the first heart sound onset of the first heart sound to the peak of the brachial pulse.
IHSS are not different group.
from the normal
Discussion
Measurements derived from simultaneous phonocardiograms and external brachial artery pulse tracings show that if the interval from the first heart sound to the upstroke of the pulse tracing is compared to the same interval with a blood pressure cuff on the arm inflated to near systolic pressure, the difference is 0.04 to 0.07 sec. in normal subjects. A similar interval is observed (0.03 to 0.08) in patients with IHSS but the value is significantly greater (0.10 to 0.20) in patients with valvular aortic stenosis. An experienced examiner can judge the time of impulse transmission from left ventricle to the brachial artery by noting the interval between the audible heart
0.14 0.22 0.18 0.19 0.19 0.20 0.18 0.17 0.17 0.18
0.21 0.28 0.22 0.23 0.24 0.26 0.22 0.23 0.24 0.24
0.07 0.06 0.04 0.04 0.05 0.06 0.04 0.06 0.07 0.06
0.12 0.10 0.14 0.12 0.13
0.20 0.18 0.22 0.15 0.20
0.08 0.08 0.08 0.03 0.07
0.11 0.16 0.12 0.22 0.17 0.16 0.25 0.24 0.18 0.24
0.25 0.36 0.32 0.38 0.30 0.24 0.40 0.41 0.34 0.43
0.14 0.20 0.20 0.16 0.13 0.10 0.15 0.17 0.16 0.19
to onset
of brachial
pulse
upstroke.
Sl-P
ia the time
from
the
sound and the palpable brachial artery pulse. As the brachial pulse is felt by the time the pulse has reached one third its peak, measurement of the Sl-1/3P interval (as described above) correlates with the time between hearing the first heart sound and feeling the brachial pulse. Similarly, when the sphygmomanometer cuff is inflated to just below systolic pressure, the time between the two clinically sensed events is measured by the Sl-P interval. The difference between the two intervals is an estimate of the upstroke time of the brachial arterial pulse. This difference can easily be appreciated by inflating the sphygmomanometer cuff to near the systolic pressure level, fixing in mind the time interval from the first heart sound to the palpable pulse, and then comparing it with the corresponding interval immediately after the sphygmomanometer cuff is
fnhw. Hewt i. October. 1970
suddenly deflated. In normal persons and patients with IHSS, the change in this interval is slight or not detectable, whereas in patients with severe valvular aortic stenosis the change in the interval when the sphygmomanometer is deflated is marked. Thus, if there is a distinct change in the interval between the first heart sound and the palpable brachial pulse, the patient probably has severe aortic valvular stenosis (or other fixed left ventricular outflow tract obstruction) and does not have IHSS. Although the experienced examiner can sometimes gain as much information by carotid artery palpation alone, there are individuals in whom the carotid pulse is difficult or impossible to palpate because of the anatomy of the neck or disease of the vessel. The method reported here is a convenient, simple, and semiquantitative one for analysis of peripheral artery upstroke time,
and is a useful adjuact to the physical examination and has proven to be a useful aid in the teaching of physical diagnosis,
By comparing the interval between the audible first heart sound and the palpable brachial pulse before and after deflation of a sphygmomanometer cuff on the arm, an examiner can estirnate the brachial pulse rise time. With this method the differentiation between valvular aortic stenosis (or other fixed severe left ventricular outflow tract obstruction) and IHSS (or nonobstructive lesions) can be accomplished easily at the bedside. REFERENCE 1.
Rodbard, S., and Libanoff, A.: Differentiation of aortic valve stenosis from subaortic muscular stenosis by means of arterial-sound recordings, New Eng. J. Med. X3:780, 1955.
of estimating
M.D.*
A
rterial pulse contours give much useful information, particularly in the presence of aortic valve disease. Carotid artery palpation is the simplest means of assessment of the arterial pulse; carotid artery external pulse tracings are more objective and may be diagnostic of aortic valvular disease. The problem commonly arises of differentiating the murmurs of supravalvular stenosis, valvular aortic stenosis, fixed or dynamic subaortic stenosis, and aortic sclerosis. Rodbard and Libanoffr have reported a method for describing the brachial artery pulse contour by means of analysis of Korotkoff sounds during indirect measurement of the brachial artery pressure. This is a report of a simple method of analysis of the upstroke time of the brachial arterial pressure pulse using a stethoscope and a sphygmomanometer. By noting the interval between the audible first heart sound and the palpable brachial artery pulse, and comparing it with the corresponding interval when a sphygmomanometer cuff applied to the arm is inflated to just below brachial artery
systolic pressure, it is possible to detect a prolonged arterial pulse rise time in those patients with fixed left ventricular outflow tract obstruction-specifically severe aortic valve stenosis. Methods Twenty-five patients were studied with simultaneous recording of electrocardiogram, phonocardiogram (lower left sternal edge), and external brachial artery pulse tracings from the antecubital area. A sphygmomanometer cuff was applied to the arm proximal to the brachial artery recording device, and all recordings were made before and after inflation of the sphygmomanom,eter to just below systolic pressure. Three intervals were determined for each patient: (1) from the beginning of the first heart sound complex to the time when the brachi.al pulse attained one third of its maximum height with the cuff uninflated (Sl-1/3P); (2) from the onset of the first heart sound complex to the time when the brachial pulse reached its maximum height with sphygmomanometer cuff inflated to just below systolic
From the National Heart Hospital, London. W.l., England This work was done while Dr. Preston was a Special Research Fellow, working ander the United States Public Health Service. Received for publication April 22, 1970. Address for reprints: Department of Cardiology, Veterans Administration Hospital, Mich. 48105. *Present position: Chief, Section of Cardiology, Ann Arbor Veterans Administration Medicine, University of Michigan Medical Center.
Vol.
80, No.
4, pp. 475-478
October,
1970
American
Grant
2215 Hospital;
Heart
I-F3-HE-35,
Fuller
Road, Assistant
Journal
368-01
Ann
from
Arbor,
Professor
of
475
476
Preston
Fig. 1. Patient with calcific aortic stenosis. A, Sphygmomanometer cuff inflated to just below peak systolic pressure. Distance between dotted lines represents the time interval between the audible onset of the first heart sound and the palpable brachial artery pulse. 23, Sphygmomanometer cuff deflated. Time interval between onset of first heart sound and palpable brachial artery pulse is about half of the interval presented in A.
pressure (Sl-I’); and (3) the difference between (2) and (1). Ten patients were normal, ten patients had valvular aortic stenosis, and five patients had idiopathic hypertrophic subaortic stenosis (IHSS). Resrslts In normal subjects the interval from the onset to peak of the indirectly recorded
brachial artery pressure pulse ranged from 0.04 to 0.07 sec. (mean 0.055 sec.). In patients with valvular aortic stenosis the interval ranged from 0.10 to 0.20 sec. (mean 0.16 sec.) and in those with IHSS the interval ranged from 0.03 to 0.08 sec. (mean 0.07 sec.). The values in patients with valvular stenosis are significantly different from those in the normal group (p < 0.001)) whereas the findings in patients with
Volume Number
80 4
Afethod of estimating
477
arterial @ulse rise time
Table I. I / Subjects
Aortic gradient (mm. f4d
Normal
Patients
with
IHSS
Patients
with
valvular
aortic
stenosis
110 80 90 120 70 50 90 100 95 115
Sl-1/3P is the time in seconds from the onset of the first heart sound onset of the first heart sound to the peak of the brachial pulse.
IHSS are not different group.
from the normal
Discussion
Measurements derived from simultaneous phonocardiograms and external brachial artery pulse tracings show that if the interval from the first heart sound to the upstroke of the pulse tracing is compared to the same interval with a blood pressure cuff on the arm inflated to near systolic pressure, the difference is 0.04 to 0.07 sec. in normal subjects. A similar interval is observed (0.03 to 0.08) in patients with IHSS but the value is significantly greater (0.10 to 0.20) in patients with valvular aortic stenosis. An experienced examiner can judge the time of impulse transmission from left ventricle to the brachial artery by noting the interval between the audible heart
0.14 0.22 0.18 0.19 0.19 0.20 0.18 0.17 0.17 0.18
0.21 0.28 0.22 0.23 0.24 0.26 0.22 0.23 0.24 0.24
0.07 0.06 0.04 0.04 0.05 0.06 0.04 0.06 0.07 0.06
0.12 0.10 0.14 0.12 0.13
0.20 0.18 0.22 0.15 0.20
0.08 0.08 0.08 0.03 0.07
0.11 0.16 0.12 0.22 0.17 0.16 0.25 0.24 0.18 0.24
0.25 0.36 0.32 0.38 0.30 0.24 0.40 0.41 0.34 0.43
0.14 0.20 0.20 0.16 0.13 0.10 0.15 0.17 0.16 0.19
to onset
of brachial
pulse
upstroke.
Sl-P
ia the time
from
the
sound and the palpable brachial artery pulse. As the brachial pulse is felt by the time the pulse has reached one third its peak, measurement of the Sl-1/3P interval (as described above) correlates with the time between hearing the first heart sound and feeling the brachial pulse. Similarly, when the sphygmomanometer cuff is inflated to just below systolic pressure, the time between the two clinically sensed events is measured by the Sl-P interval. The difference between the two intervals is an estimate of the upstroke time of the brachial arterial pulse. This difference can easily be appreciated by inflating the sphygmomanometer cuff to near the systolic pressure level, fixing in mind the time interval from the first heart sound to the palpable pulse, and then comparing it with the corresponding interval immediately after the sphygmomanometer cuff is
fnhw. Hewt i. October. 1970
suddenly deflated. In normal persons and patients with IHSS, the change in this interval is slight or not detectable, whereas in patients with severe valvular aortic stenosis the change in the interval when the sphygmomanometer is deflated is marked. Thus, if there is a distinct change in the interval between the first heart sound and the palpable brachial pulse, the patient probably has severe aortic valvular stenosis (or other fixed left ventricular outflow tract obstruction) and does not have IHSS. Although the experienced examiner can sometimes gain as much information by carotid artery palpation alone, there are individuals in whom the carotid pulse is difficult or impossible to palpate because of the anatomy of the neck or disease of the vessel. The method reported here is a convenient, simple, and semiquantitative one for analysis of peripheral artery upstroke time,
and is a useful adjuact to the physical examination and has proven to be a useful aid in the teaching of physical diagnosis,
By comparing the interval between the audible first heart sound and the palpable brachial pulse before and after deflation of a sphygmomanometer cuff on the arm, an examiner can estirnate the brachial pulse rise time. With this method the differentiation between valvular aortic stenosis (or other fixed severe left ventricular outflow tract obstruction) and IHSS (or nonobstructive lesions) can be accomplished easily at the bedside. REFERENCE 1.
Rodbard, S., and Libanoff, A.: Differentiation of aortic valve stenosis from subaortic muscular stenosis by means of arterial-sound recordings, New Eng. J. Med. X3:780, 1955.