Blood pressure is the net result of stroke volume and vascular resistance or impedance. Blood pressure can increase with an increase in stroke volume as occurs with exercise or with adrenaline. Blood pressure can also increase with an increase in arterial tone, which is the usual cause of essential hypertension. Blood pressure increases with vasoconstrictors such as phenylephrine or angiotensin which raise blood pressure solely by increasing vascular stiffness.
It would be very useful to be able to quantify the relative contribution of stroke volume and arterial stiffness to blood pressure. For example, if the oscillometrically measured blood pressure is 150/80, are these high numbers due to increases in stroke volume or from arterial stiffness? The decision to treat or not to treat, and/or the determination of what agent to use, could vary, depending upon the result.
Similarly, the response to the treatment to be followed can vary with the result. For example, if a vasodilator such as an angiotensin receptor blocker (ARB) is used, the change in vascular stiffness may be more important to follow, rather than blood pressure alone, as arterial stiffness is the primary pathology.
In the acute care setting, a non-invasive measure would help in decision-making to diagnose and manage heart failure or sepsis with vasoactive drugs and fluid.
There is also a large group of people with normal blood pressure but increased vascular stiffness. A non-invasive way of assessing the degree of vasoconstriction and cardiac performance would be helpful in diagnosing and treating such patients. Other patients have unrecognized vascular stiffness yet their blood pressure does not reach the 140/90 threshold of treatment. How to treat (or not to treat) these patients is unclear. The ability to further characterize those patients who may have so-called “pre-hypertension” into those with and without vascular stiffness could provide a way forward in therapy and prevention of premature vascular death.
The principal object of the present invention is to provide a method and apparatus for identifying the various components of the arterial pulse, and from these components to determine a cardiovascular profile, from a common non-invasive clinical test—a simple oscillometric blood pressure measurement.
Most arterial wave analysis is presently based upon intra-arterial pulse waves or waveforms obtained from Doppler or tonometry techniques. The present invention makes possible the assessment of such waveforms obtained using a normal blood pressure cuff.
This object, as well as other objects which will become apparent from the discussion that follows, are achieved, according to the present invention, by providing a method of, and apparatus for, determining a cardiovascular status of a mammal having a cardiovascular system that includes a brachial artery, by:
Apparatus is also provided for carrying out the method.
The various cardiac medical parameters are defined, and their values are determined, from the representative waveform, as follows:
Reflection Wave Ratio (RWR)
The “reflection wave ratio” provides a measure of large arterial tone or arterial stiffness. The RWR is determined as the ratio of peak amplitude of the reflected wave to that of the initial, incident wave.
Reflected Wave Transit Time (RWTT)
Measurement of the time delay between the initial, incident wave and the subsequent reflected wave provides a surrogate measure of pulse wave velocity. Changes in this value in a patient over time, or with treatment, reflect a change in pulse wave velocity and a change in large arterial stiffness or compliance. The RWTT can be assessed by measuring the start-to-start or peak-to-peak time period of the successive incident and reflection waves. The peak-to-peak time period is also called “time of reflection” (TR).
Peak Pressure (PS1) of Incident Wave
The maximum amplitude of the initial, incident wave (PS1) serves as a surrogate for cardiac stroke volume. Increases or decreases in this peak amplitude of the incident wave in a patient over time, or with therapy, represent changes in stroke volume. The measured area under the incident wave curve may also be used to measure these changes.
Maximum Rate of Increase (Slope) of PS1 (dp/dt)
The rate of change in pressure of the incident wave over time (Dp/dt), or the maximum slope of the rise in this wave, represents a change in cardiac performance or “contractility”.
Systolic Ejection Period (SEP)
The total systolic ejection period is measured from the beginning of the incident wave to the end of the reflected wave. This parameter is useful for assessing vascular compliance.
For a full understanding of the present invention, reference should now be made to the following detailed description of the preferred embodiments of the invention as illustrated in the accompanying drawings.
a and 4b are time diagrams showing pulse waveforms of a patient on 50 mg/day of Losartan (
a and 5b are time diagrams showing pulse waveforms of a patient both before (
a and 6b are time diagrams showing pulse waveforms of a patient both before (
a and 7b are time diagrams showing pulse waveforms of a patient both before (
a and 8b are time diagrams showing pulse waveforms of a patient both before (
a and 9b are time diagrams showing pulse waveforms of a patient both before (
a and 10b are time diagrams showing pulse waveforms of a patient both before (
The preferred embodiments of the present invention will now be described with reference to
This invention concerns the measurement, processing and display of certain cardiac medical parameters obtained, using a blood pressure cuff on the brachial artery, by sensing pressure pulse waveforms with a wideband pressure transducer during a plurality (e.g. from 5 to 15) cardiac ejection cycles and taking the average.
Oscillometric Blood Pressure System
The Tahoe 32 comprises a dedicated CPU which averages the multiple digitized pulse waveform signals received from the A/D converter to produce, store and display a single, representative cadiac pulse waveform of the type shown in
Standard Cardiac Pulse Waveform
Determining Medical Parameters
Various cardiac medical parameters which are determined by the method and apparatus of the present invention are set forth and illustrated in
Reflection Wave Ratio (RWR)=(d−a)/(b−a);
Reflected Wave Transit Time (RWTT)=Tc−Ta;
Peak Pressure of Incident Pressure Wave (PS1)=b−a;
Peak slope of Incident Pressure Wave (dp/dt)=Max dp/dt;
and
Systolic Ejection Period (SEP)=Te−Ta;
where a, b, etc. are the pressures in mm Hg, and Ta, Tc and Te are times at points a, c and e, respectively.
The remaining figures illustrate how the cardiac medical parameters may be used, with and without drug therapy, to assess the cardiac performance of a patient. As will be explained below, the parameters provide useful information especially when they are determined multiple times to generate historical data.
Supra-systolic recordings can be used to characterize the physiology underlying blood pressure, which is the next result of stroke volume and large arterial impedance or vascular resistance. An increased blood pressure can be secondary to increased stroke volume or increased vascular resistance or a combination. Treatment decisions are better defined by knowing what causes the increased blood pressure. For example, if the cause is increased arterial resistance, a vasodilator is indicated. If the cause is increased stroke volume, either no treatment is indicated or a beta blocker can be used.
If someone's blood pressure is marginally elevated, due to increased arterial resistance, it may be appropriate to treat the blood pressure with a vasodilator thus providing a more rational basis upon when to treat patients with prehypertension.
Many patients with blood pressure of 130/80 kg may have increased vascular stiffness (MW RWR) and benefit from vasodilator therapy decreasing their chance of stroke, myocardial infarction and renal failure.
Similarly, low blood pressure (hypotension) can be due to a reduction in stroke volume or vasodilatation. The treatment and prognosis are therefore different. Low stroke volume and low cardiac output are poorly tolerated and cardiac stimulation is preferred. Conversely, a low blood pressure from vasodilatation is well tolerated requiring less urgent (and different) treatment.
Thus, the present invention, by measuring RWR and PS1, can be used to analyze blood pressure and improve clinical decision making in both ambulatory and critical care environments.
PS1 represents the intensity or energy of the incident waveform upon cardiac ejection. It is dependent upon both blood pressure and stroke volume. An increase in stroke volume (due, e.g., to fluid, ephedrine or epinephrine) or of blood pressure (ephedrine) increases PS1. Conversely, a reduction in stroke volume (phenylephrine plus epidural anesthesia) results in a decrease in PS1.
Thus PS1 is a measure of pulse wave amplitude and can be used to assess stroke volume if blood pressure and reflection wave ratio (RWR), a measure of vascular tone, are known.
For example, with propofol, if RWR decreases but PS1 is maintained, stroke volume should be increased. With epidural anesthesia with phenylephrine, where RWR increases and PS1 decreases, stroke volume should be decreased. PS1 increases and RWR decreases with exercise and epinephrine, therefore, stroke volume must be enhanced.
1. An example of an increase in blood pressure from vasoconstriction (increase in reflection wave ratio (RWR)) is shown with discontinuation of a vasopressor Losartan (
2. An example of an increase in blood pressure secondary to an increase in stroke volume, with an increase in PS1 but no increase in RWR, is shown in
3. An example of a reduction in blood pressure due to vasodilatation is shown in
4. An example of a reduction on blood pressure due to cardiac depression is shown in
5. The effect of low dose epinephrine (
Calculating an Average Pulse Waveform
The average cardiac pulse waveform or “beat” is calculated from measurement of supra-systolic (SS) signals for approximately 10 seconds. The raw SS signal is sampled at 200 Hz. This sampled signal is then processed in the manner shown in the flowcharts of
As illustrated in these figures, the process measurement proceeds as follows:
where B is the number of beats, N is the number of samples in each beat, pb,n is the nth sample on beat b, and qn is the nth sample on the average beat.
The SNR is used to gauge the quality of the processed signal. If the patient moves, or experiences arrhythmias, the SNR will decrease. If all the beats are very similar to the average beat, the SNR is high. Generally, a good signal has an SNR greater than 12 dB, whereas a poor signal has an SNR less than 3 dB.
The SNR of the signal is preferably displayed to the user as a cue to the reliability of the measurement.
Feature points on the “average beat” are found as follows:
There has thus been shown and described a novel method and apparatus for determining cardiac medical parameters from supra-systolic signals obtained from a blood pressure cuff which fulfills all the objects and advantages sought therefor. Many changes, modifications, variations and other uses and applications of the subject invention will, however, become apparent to those skilled in the art after considering this specification and the accompanying drawings which disclose the preferred embodiments thereof. All such changes, modifications, variations and other uses and applications which do not depart from the spirit and scope of the invention are deemed to be covered by the invention, which is to be limited only by the claims which follow.
This present application claims benefit of priority from U.S. patent application Ser. No. 11/358,283, filed Feb. 21, 2006 (now U.S. Patent Publication No. 2006/0224070-A1, published Oct. 5, 2006); U.S. patent application Ser. No. 12/157,854, filed Jun. 13, 2008 (now U.S. Patent Publication No. 2009/0012411-A1, published Jan. 8, 2009) and U.S. Provisional Application Ser. No. 61/132,120, filed Jun. 16, 2008. The invention disclosed and claimed herein is related in subject matter to that disclosed in U.S. Pat. No. 5,913,826, issued Jun. 22, 1999; U.S. Pat. No. 6,994,675, issued Feb. 7, 2006; and the aforementioned U.S. Patent Publication No. 2006/0224070-A1 and U.S. Patent Publication No. 2009/0012411-A1, all of which are incorporated herein by reference.
Number | Date | Country | |
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61132120 | Jun 2008 | US |