A simple clinical method of estimating

arterial pulse rise time

Thomas A. Preston, M.D.* London, England

A rterial pulse contours give much useful information, particularly in the pres-

ence of aortic valve disease. Carotid artery palpation is the simplest means of assess- ment 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 supravalvu- lar 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 in- direct measurement of the brachial artery pressure.

This is a report of a simple method of analysis of the upstroke time of the brach- ial arterial pressure pulse using a steth- oscope 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 sphygmo- manometer 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 se- vere aortic valve stenosis.

Methods

Twenty-five patients were studied with simultaneous recording of electrocardio- gram, 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 re- cording 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 sphygmoma- nometer 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 Grant I-F3-HE-35, 368-01 from

the United States Public Health Service. Received for publication April 22, 1970. Address for reprints: Department of Cardiology, Veterans Administration Hospital, 2215 Fuller Road, Ann Arbor,

Mich. 48105. *Present position: Chief, Section of Cardiology, Ann Arbor Veterans Administration Hospital; Assistant Professor of

Medicine, University of Michigan Medical Center.

Vol. 80, No. 4, pp. 475-478 October, 1970 American Heart Journal 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 be- tween 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 idio- pathic 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 80 Number 4 Afethod of estimating arterial @ulse rise time 477

Table I.

I

Subjects / Aortic gradient

(mm. f4d

Patients with IHSS

Normal 0.14 0.21 0.07 0.22 0.28 0.06 0.18 0.22 0.04 0.19 0.23 0.04 0.19 0.24 0.05 0.20 0.26 0.06 0.18 0.22 0.04 0.17 0.23 0.06 0.17 0.24 0.07 0.18 0.24 0.06

0.12 0.20 0.08 0.10 0.18 0.08 0.14 0.22 0.08 0.12 0.15 0.03 0.13 0.20 0.07

Patients with valvular aortic stenosis 110 0.11 0.25 0.14 80 0.16 0.36 0.20 90 0.12 0.32 0.20

120 0.22 0.38 0.16 70 0.17 0.30 0.13 50 0.16 0.24 0.10 90 0.25 0.40 0.15

100 0.24 0.41 0.17 95 0.18 0.34 0.16

115 0.24 0.43 0.19

Sl-1/3P is the time in seconds from the onset of the first heart sound to onset of brachial pulse upstroke. Sl-P ia the time from the onset of the first heart sound to the peak of the brachial pulse.

IHSS are not different from the normal group.

Discussion

Measurements derived from simulta- neous 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

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 in- flated 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 sys- tolic 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 immedi- ately 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 ven- tricular outflow tract obstruction) and does not have IHSS. Although the ex- perienced examiner can sometimes gain as much information by carotid artery palpation alone, there are individuals in whom the carotid pulse is difficult or im- possible 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 anal- ysis 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 dif- ferentiation between valvular aortic ste- nosis (or other fixed severe left ventricular outflow tract obstruction) and IHSS (or nonobstructive lesions) can be accom- plished 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.