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Radial pulse analysis, central blood pressure and cardiovascular health: an historical curiosity makes a comeback. Tom Archer, MD, MBA UCSD Anesthesiology May 9, 2011. Pulse analysis was practiced in Chinese medicine thousands of years ago. http://www.itmonline.org/image/pulse2.jpg.

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slide1

Radial pulse analysis, central blood pressure and cardiovascular health: an historical curiosity makes a comeback.

Tom Archer, MD, MBA

UCSD Anesthesiology

May 9, 2011

slide2

Pulse analysis was practiced in Chinese medicine thousands of years ago.

http://www.itmonline.org/image/pulse2.jpg

pulse analysis was also serious business in the 19 th century in europe and the usa
Pulse analysis was also serious business in the 19th century in Europe and the USA
  • Sphygmographs in common use.
  • Insurance companies relied on their results.
slide4

Etienne-Jules Marey (1830-1904) invented the sphygmograph to record the arterial pulse on smoked paper. It was used by Engelmann, Mackenzie and Wenckebach.

Sphygmograph 1876

http://www.mamweb.org/modules.php?name=Content&pa=showpage&pid=32000

slide7

Tom Archer, 58 y.o., good general health. Takes Crestor for high cholesterol.

Radial and predicted ascending aortic pressure waveform when subject is cold.

slide9

Harvey Cushing used it.

Korotkoff introduced auscultation for diastolic pressure in 1905.

history.library.ucsf.edu/.../chapter2_03.html

in the 20th century riva rocci and korotkoff s sphygmomanometer eclipsed pulse analysis
In the 20th century, Riva-Rocci and Korotkoff’s sphygmomanometer eclipsed pulse analysis
  • Two simple numbers: systolic / diastolic.
  • Easy to use.
  • Pulse analysis fell into disuse.
  • 20th century saw tremendous gains from simple sphygmomanometry: dangers of high BP.
but simple sphygmomanometry ignores valuable information within the pulse trace
But simple sphygmomanometry ignores valuable information within the pulse trace.
  • Extra information can be extracted from the pulse using high fidelity transducers, computers and a “generalized transfer function”, which has been validated.
  • Specifically, the Central Blood Pressure (CBP) can be calculated using the radial pulse contour and the non-invasive brachial blood pressure.
  • CBP is the pressure in the ascending aorta.
slide12

LV “sees” the SBP in the ascending aorta.

With normal aortic valve, LV wall tension depends on pressure in ascending aorta

(and diameter of LV chamber).

health.yahoo.com/topic/heart/overview/article...

central blood pressure cbp
Central blood pressure (CBP)
  • Diastolic and mean pressures are very similar at radial / brachial and central sites, but
  • Systolic CBP is not the same as brachial or radial systolic BP!
slide15

What creates central BP?

#2 Stiffness of aorta (“windkessel”)

AIR

BLOOD

heart

Central BP

#1 SV

veins

arteries

#4 Wave reflection–

timing and amount

#3 Systemic vascular resistance (resistance arterioles)

Muscular arteries

slide16

If reflected wave travels fast and arrives during systole it creates “augmentation pressure”, extra pressure work for the heart during systole.

Augmentation Index (AIx) =

Augmentation Pressure /

Pulse Pressure

Kozo Hirata, MD; Masanobu Kawakami, MD; Michael F O’Rourke, MD, DSc*Circ J 2006; 70: 1231–1239

run animation
Run animation
  • Wave reflection animation can be found at:
  • http://atcormedical.com/wave_reflection.html
augmentation index aix
Augmentation Index (AIx)
  • High AIx = unnecessary heart work.
  • High AIx leads to LVH and cardiomyopathy.
  • Lower AIx is better.
  • Treatments that lower AIx help the patient.
when is aix high chronically
When is AIx high-- chronically?
  • Normal aging
  • Obesity
  • Atherosclerosis
  • Diabetes
  • Pre-eclampsia
  • Inflammatory arthritis
  • Renal failure
slide21

As healthy individuals age, reflected wave arrives at ascending aorta earlier and increases augmentation index and central pulse pressure. Three members of same family.

WW Nichols Curr Opin Cardiol 2002, 17:543–551

central bps ascot cafe study
Central BPs– ASCOT / CAFE study
  • Lower central BPs are associated with better CV outcomes.
  • Amlodipine achieved lower central BPs and had better CV outcomes than atenolol, despite achieving the same brachial artery BPs.

CAFE / ASCOT study, M. O’Rourke (Circulation. 2006;113:1213-1225.)

slide23

Four months Rx with lisinopril decreased central aortic pulse pressure and augmentation index.

WW Nichols Curr Opin Cardiol 2002, 17:543–551

slide24

6 months Rx with atorvastatin decreased central aortic pulse pressure and augmentation index.

WW Nichols Curr Opin Cardiol 2002, 17:543–551

slide25

ACE inhibitors and aldosterone antagonists reverse LV hypertrophy– via central BP effects?.

Adams KF, Am J Health-Syst Pharm—Vol 61 May 1, 2004 Suppl 2

slide26

ACE inhibitors, statins and aldosterone antagonists can reverse LV hypertrophy—is this due to decreased AIx and strain on the heart?

what makes aix go down chronically
What makes AIx go down-- chronically?
  • Exercise
  • Weight loss
  • Red wine
  • Statins
  • Control of blood pressure (ACEI and CCB)
  • NTG
slide29

Ultra-marathon runner, 30 yo, at rest, seated. AIx = -14%.Note high diastolic radial and CBP.

when is aix high acutely
When is AIx high– acutely?
  • Arterial compression in legs (squatting)
  • Cold body temperature.
  • Nicotine ingestion
slide33

Exposure of healthy young adults to cold air for 30 min increases augmentation index.

David G. Edwards,1 Amie L. Gauthier,2 Melissa A. Hayman,2 Jesse T. Lang,2 and Robert W. Kenefick2J Appl Physiol 100: 1210–1214, 2006.

what makes aix decrease acutely
What makes AIx decrease-- acutely?
  • Exercise
  • Alcohol
  • Lowering blood pressure
  • NTG
perioperative hypothermia increases cardiac event rate

Perioperative hypothermia increases cardiac event rate.

Is this due to increased AIx with hypothermia?

could aix guide therapies in anesthesia and intensive care
Could AIx guide therapies in anesthesia and intensive care?
  • NTG in low doses may work by decreasing wave reflection, CBP and afterload.
  • First trial of AIx guided treatment would seem to be afterload reduction for the depressed LV– as in coming off CPB.
  • SphygmoCor Mx does analysis on arterial line tracing, so it is continuous and hands-free.