ey
`Wl cl74g
`“Ve 94
`1996
`NO-2
`Vite QLeettTT SEQ? C22640000
`WL? CIRCULATION
`12/10/96
`
`American Heart
`Associations:
`Fighting Heart Disease
`and Stroke
`
`"
`
`”
`
`r
`
`Circulation
`
`Volume 94, Number 2
`
`July 15, 1996
`
`Cardiovascular News
`
`New Associate Editors * Auscultatory Method of Measuring Blood Pressure
`Editorial
`Quantifying Valvular Regurgitation
`Brief Rapid Communications
`Autonomic Modulation of Heart Rate in Women and Men « Pulmonary Blood
`Flow After Transcatheter Closure of Arterial Duct
`
`Clinical Investigation and Reports
`L-Arginine in Microvascular Angina « 3-Year Follow-up in RITA
`¢ Cost-effectiveness of the Coronary Care Unit
`* Comparison of d,/-Sotalol and
`iCDs « Laser Doppler Analysis of Free Regurgitant Jets * HLA Matching and
`
`Thoracic Transplantation
`
`Basic Science Reports
`.Estrogen and Progesterone and Atherosclerosis in Rabbits ° Nitric Oxide and
`Microvascular Disease «
`Intracellular Mechanism of Coronary Spasm
`
`¢ Recombinant Staphylokinase With Altered Immunoreactivity,|
`
`e Recombinant Staphylokinase With Altered Immunoreactivity,li «
`
`"
`
`Heart Rate Influence on Refractoriness
`
`In Memoriam
`
`Lewis Dexter, MD: 1910-1995 * Lewis Dexter, MD: End of an Era
`
`Images in Cardiovascular Medicine
`Late Consequences of Kawasaki Disease
`
`&
`
`73-3216(SB)5 RENdabe7aspried
`atthe NLMand may be
`Subject US Copyright Laws.
`
`Apple Inc.
`APL1068
`U.S. Patent No. 8,652,040
`
`{ ie
`
`yeaa
`
`7
`
`wots
`
`IAAT
`
`Apple Inc.
`APL1068
`U.S. Patent No. 8,652,040
`
`0001
`
`

`

`CULCULATION sormess suber suyte,108
`
`Cardiovascular News
`
`New Associate Editor Appointments for Circulation
`JamesT. Willerson, MD oo... ccc cc nnn dren enn b en ene ebb bebe t bE bbb eben ens 115
`
`90th Anniversary of the Development by Nikolai S. Korotkoff of the Auscultatory Method of
`Measuring Blood Pressure
`Yury L. Shevchenko, MD; Joshua E. Tsitlik, PAD 0.000. c ccc ccc nce e eect ec ce ence nent rete tbnteneaeens 116
`
`Editorial
`
`
`Noninvasive Quantification of Valvular Regurgitation: Getting to the Core of the Matter
`Paul A. Grayburn, MD; Ronald M. Peshock, MD oo... oc ccc ccc ccc cet n cece etn een n eter ebenvntennecebnnnya 119
`
`Brief Rapid Communications
`
`
`Sex-Related Differences in Autonomic Modulation of Heart Rate in Middle-aged Subjects
`Heikki V. Hufkuri, MD; Sirkku M. Pikkujémsd, MD; K.E. Juhani Airaksinen, MD; Markku J. Ikiheimo, MD;
`Asko O. Rantala, MD; Heikki Kauma, MD; MaunoLilja, MD; Y. Antero Kesdniemi, MD ..... 0.0.0 occ cc ccc ccc ccc ccee 122
`
`Echocardiographic and Radionuclide Pulmonary Blood Flow Patterns After Transcatheter
`Closure of Patent Ductus Arteriosus
`Hugues Dessy, MD; Joris P.S. Hermus, MD; Freek van den Heuvel, MD; H.Y. Oei, PhD; Eric P. Krenning, MD, PhD;
`John Hess, MD, PAD... ccnn nen e eden ened e bbb tte b bere b ebb tet bbb bbb eeeus 126
`
`Clinical Investigation and Reports
`Coronary Heart Disease
`Effects of L-Arginine Supplementation on Endothelium-Dependent Coronary Vasodilationin
`Patients With Angina Pectoris and Normal Coronary Arteriograms
`Kensuke Egashira, MD; Yoshitaka Hirooka, MD; Takeshi Kuga, MD; Masahiro Mohri, MD; Akira Takeshita, MD ....... 130
`Quality of Life, Employment Status, and Anginal Symptoms After Coronary Angioplasty or Bypass
`Surgery: 3-Year Follow-up in the Randomized Intervention Treatment of Angina (RITA)Trial
`Stuart J. Pocock, PhD; Robert A. Henderson, MRCP; Paul Seed, MSc; Tom Treasure, FRCS; John R. Hampton, FRCP;
`for the RITA Trial Participants 0.0000. ccc ccc ccc ccc cece een n need ender een n ee Erne deen enn e nes 135
`Cost-effectiveness of a Coronary Care Unit Versus an Intermediate Care Unit for Emergency
`DepartmentPatients With Chest Pain
`Anna N.A. Tosteson, ScD; Lee Goldman, MD; I. Steven Udvarhelyi, MD; Thomas H. Lee, MD, MSc «1.1... e eee 143
`
`Arrhythmias/Defibrillators
`Comparison of d,/-Sotalol and Implantable Defibrillators for Treatment of Sustained Ventricular
`Tachycardia or Fibrillation in Patients With Coronary Artery Disease
`Dirk Bécker, MD; Wilhelm Haverkamp, MD; Michael Block, MD; Martin Borggrefe, MD; Dieter Hammel, MD;
`Gunter Breithardt, MD ooo. ccc cee nee nnn tLe nn ene ented ene ete e nent teen nt neeenes 151
`
`Valvular Heart Discasc
`In Vitro Flow Mapping of Regurgitant Jets: Systematic Description of Free Jet With
`Laser Doppler Velocimetry
`Benoit Diebold, MD, PhD; Annie Delouche, BSc; Philippe Delouche; Jean-Paul Guglielmi; Philippe Dumee;
`Alain Herment, PAD ooo. ccc ccc nee nn nen EEE ened en eden een nner nett e tenet nes 158
`
`CIRCULATION (ISSN 0009-7322) is published twice monthly by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231-4596.Individuals
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`

`Heart and Lung Transplantation
`Influence of HLA Matching on Thoracic Transplant Outcomes:An Analysis From the
`UNOS/ISHLT Thoracic Registry
`Jeffrey D. Hosenpud, MD,Erick B. Edwards, PhD; Hung-MoLin, PhD; O. Patrick Daily, PAD .. 0.0.0. cece eens 170
`
`Basic Science Reports
`
`Atherosclerosis/Coronary Reactivity
`Different Effects of Estrogen and Progesterone on Experimental Atherosclerosis in Female
`Versus Male Rabbits: Quantification of Cellular Proliferation by Bromodeoxyuridine
`Hartmut Hanke, MD; Sybille Hanke, MD; Gerald Finking, MD; Alexandra Muhic-Lohrer, MD;Alfred O. Mick, PhD, MD;
`Friedrich W. Schmahl, MD; Rainer Haasis, MD; Vinzenz Hombach, MD «0.06.0... 175
`Altered Serotonin Receptor Subtypes Mediate Coronary Microvascular Hyperreactivity in Pigs
`With Chronic Inhibition of Nitric Oxide Synthesis
`Toshiaki Kadokami, MD; Kensuke Egashira, MD; Kouichi Kuwata, MD; Yoshihiro Fukumoto, MD; Toshiyuki Kozai, MD;
`Hiroshi Yasutake, MS; Takeshi Kuga, MD; Hiroaki Shimokawa, MD; Katsuo Sueishi, MD; Akira Takeshita, MD ....... 182
`Coronary Artery Spasm Does Not Depend onthe Intracellular Calcium Store but Is
`Substantially Mediated by the Protein Kinase C-Mediated Pathway in a Swine Model With
`Interleukin-1£ In Vivo
`Toshiaki Kadokami, MD; Hiroaki Shimokawa, MD; Yoshihiro Fukumoto, MD; Akira Ito, MD; Tsuneo Takayanagi, MS;
`Kensuke Egashira, MD; Akira Takeshita, MD oo... 000 cccen nen ees 190
`
`Thrombolytic Agents
`Recombinant Staphylokinase Variants With Altered Immunoreactivity, I:
`Construction and Characterization
`Désiré Collen, MD, PhD; Ria Bernaerts, PhD; Paul Declerck, PhD; Frans De Cock; Edward Demarsin; Stephane Jenne;
`Yves Laroche, PhD; Henri R. Liinen, PhD; Karen Silence, PhD; Maria Verstreken .... 6.6.06 197
`Recombinant Staphylokinase Variants With Altered Immunoreactivity,II:
`Thrombolytic Properties and Antibody Induction
`Désiré Collen, MD, PhD; Huberte Moreau; Luc Stockx, MD; Steven Vanderschueren, MD ........ 26... e cece eens 207
`
`Arrhythmias
`Rapid Rates During Bradycardia Prolong Ventricular Refractoriness and Facilitate Ventricular
`Tachycardia Induction With Cesium in Dogs
`Tadashi Satoh, MD; Douglas P. Zjpes, MD ooo.EEE EEE EERE nets 217
`
`In Memoriam
`
`
`Lewis Dexter, MD: 1910-1995
`William Grossman, MD ooo. ccc ccc EEE EEE EEE EEE EEE DE EEE EEE EE Ee eee eee 228
`
`Lewis Dexter, MD: The End of an Era
`Paul D. Stein, MD voce ccc ccc ccc ccc EEE EEE EEE EEE E EDD Een EEE EEE EEE eS 229
`
`Images in Cardiovascular Medicine
`
`Late Consequences of Kawasaki Disease
`Yoshinori L. Doi, MD; Takashi Furuno, MD; Jun Takata, MD; Toshikazu Yabe, MD; Taishiro Chikamori, MD .......... 231
`
`
`Annotated Table of Contents. 2.000.000 ee ene nee tree eee A14
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`Shevchenko andTsitlik Auscultatory Method of Measuring Blood Pressure
`
`
`
`
`
`117 "
`
`auscultatory technique to identify the times whenthe
`pressure in the cuff coincided with systolic and diastolic
`arterial pressures. When he examined patients who had
`damaged vessels, Korotkoff gradually compressed thear-
`teries until the peripheral pulse disappeared. He alsore-
`corded sphygmogramswhile simultaneously listening to
`the sounds in the part of the artery distal to the com-
`pressed area. He determined that a totally compressed
`artery produced no soundsatall and that while the pres-
`sure in the artery was decreased gradually, certain sounds
`appeared that allowed one to judge the level ofarterial
`pressure. '?
`To measure blood pressure, Korotkoff applied anclas-
`tic, rubber cuff of the Riva-Rocci apparatus (Fig 2) on
`the middle third of the arm. The pressure in the cuff was
`increased until
`the blood supply to the periphery was
`completely stopped. Then the pressure in the cuff was
`decreased, and a stethoscope was usedto listen to the
`pressure in the artery “directly below the cuff.”! Once
`the pressure fell below a certain level, the first short tones
`could be heard; this indicated the passageofthefirst pulse
`ey®, 2
`
`ve. 1seineknictusane
`wave along the artery below the cuff. The manometer
`reading at which the first tone appeared corresponded to
`the systolic pressure. With a further decrease in pressure
`in the cuff, the tones were replaced by murmurs that were
`followed in turn by secondtones. Finally, all the sounds
`disappeared. The momentall sounds subsided, according
`to Korotkoff, blood was flowing freely throughthe arter-
`ies. The diastolic pressure in the artery at that moment
`slightly exceeded the pressure in the cuff, and the ma-
`nometer reading at the moment the sounds disappeared
`corresponded to the diastolic pressure.'
`Simultaneous auscultation and palpation of the com-
`pressedartery revealedthe difference in the cuffpressures
`for the appearance of sounds and the formation ofthe
`pulse wave in a segmentdistal to the compressed area.
`The first sounds appearedat the cuff pressure, which was
`10 to 12 mm Hg higher than the pressure at which the
`palpable pulse was produced, because generation ofthe
`pulse required somefilling of the vessel.!
`Korotkoff considered the tones and murmurs in the
`vessel to be compression sounds. He thought the tones
`were caused by the rushing “of a minuscule part of the
`pulse wave” through the compressed area during a very
`
`Fia 1. Nikolai Sergeevich Korotkoff. (Photograph courtesy of The
`Russian Military Medical Academy, Saint Petersburg, Russia.)
`
`dissertation for the degree of Doctor of Medical Sciences,
`“Can the Ligation of the Abdominal Aorta During An-
`eurism in Groin Region Be Performed Easily and
`Safely?” While treating wounded soldiers who had an-
`eurysms, Korotkoff set a goal
`to find indications that
`would allow the surgeonto predict an outcomeof ligation
`ofarteries ofthe traumatized limbs,ie, to predict whether
`the limb would recover or die after surgery. While at-
`tempting to resolve this problem, he systematically lis-
`tened to the arteries to estimate the potential strength of
`arterial collaterals after a major vessel of the wounded
`limb had beenligated. He established that certain specific
`sounds could be heard during the decompression of the
`arteries. This specific phenomenon, knownin world lit-
`erature as “Korotkoff sounds,” became the basis of the
`new method of blood pressure measurement.
`In his studies, Korotkoff used the apparatus proposed
`by Riva-Rocci® inItaly in 1896 (Fig 2), which contained
`an arm-encircling inflatable elastic cuff, a rubber bulb to
`inflate the cuff, and a mercury sphygmomanometerto
`measure the cuff pressure. Riva-Rocci measured the sys-
`tolic pressure by registering the cuff pressure at which
`the radial pulse was obliterated as determined by palpa-
`tion. The palpation technique did not allow the measure-
`mentof diastolic pressure. Soon after Riva-Rocci’s tech-
`nique was described, Hill and Barnard’ in England in
`1897 reported an apparatus with an arm-encircling in-
`flatable cuff and a needle pressure gauge that allowed
`measurementof the diastolic pressure by the oscillatory
`method. This method used theoscillations transmitted to
`the gauge asthe pulse wave camethrough the compressed
`artery. When the cuff pressure was reduced slowly from
`the suprasystolic pressure, the appearance of definitive
`oscillations denoted the systolic pressure, whereas the
`change from maximal oscillations to smaller ones de-
`noted the diastolic pressure,
`Similar to Riva-Rocci, Korotkoff used an inflatable
`sphygmomanometer cuff to obstruct arterial flow. His
`contribution was the discovery of a new, more accurate
`
`short time interval. Also, vibrations of the “unsticking”
`
`Fig 2. Riva-Rocci sphygmomanometerused by Korotkoff in his
`measurements(from Korotkoff's dissertation”). The length of the
`cuff was approximately '% arshin (35.56 cm) and the width was
`at least 2'% to 3 inches (6.35 to 7.62 cm).
`0005
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`

`118
`
`Circulation Vol 94, No 2
`
`July 15, 1996
`
`vessel walls contributed to the production ofthe tones.
`Korotkoff believed that the sound phenomenon depended
`on the elastic properties of the arterial walls.
`To prove the local generation of sound, Korotkoffper-
`formed a series of canine experiments. He reported the
`results of these experiments at a scientific seminar on
`December 13, 1905.8 Experiments demonstrated that
`sounds heard during the compression of vessels did not
`originate from the heart or the semilunaraortic valves,as
`was hypothesized by some ofhis critics. In one of the
`experiments, he placed a T-shaped cannula into an ex-
`posed femoral artery. The vertical branch ofthe cannula
`was connectedto a containerfilled with saline. The artery
`was ligated proximal to the cannula and compressed by
`the cuff distal to the cannula. As pressure in the saline
`changed from 40 to 100 mm Hg,
`the wave of liquid
`passed throughthe vessel; the sounds producedfirst were
`tones, followed by murmurs, and then the sounds disap-
`peared. Thus, the experiments demonstrated that the Ko-
`rotkoff sounds originated at the site of vessel compres-
`sion.* Korotkoff’s presentation was highly praised by
`Prof M.V. Yanovskiy. Hestated that he was in complete
`agreement with Korotkoff’s
`results:
`“...with this
`method, I believe, we will achieve quite accurate results
`.... T have to say that through your observations, you
`have demonstrated your talent and sharpness. You have
`noticed the fact that many other researchers who have
`been working on this problem missed.” 8(iscession)
`Yanovskiy’s clinic produced manystudies in support
`of the auscultatory method of measurementof blood pres-
`sure. Oneofthe earliest serious studies was the work by
`Krilov, “Determining Blood Pressure by Using the Sound
`Method ofDoctor Korotkoff,”°? which was completed on
`the advice and underthe supervision of Yanovskiy. The
`reports presented methodsof study, described the types
`of sounds during the termination of the occlusion of the
`arterial vessel, and analyzed the sounds and the reasons
`for their generation and change.
`Later research studies by Krilov, Vesternik, Lebedev,
`Lang, and Mansvetova showed a close correlation be-
`tween arterial pressure measurements by Korotkoff’s
`method and measurementsby use ofother methods (Rek-
`linghausen,Pal, direct invasive measurements, etc).*>'!
`The method of measurement of blood pressure in-
`vented by Korotkoff quickly received wide recognition
`
`and became a standard medical procedure.** This method
`played an importantrole in the study of various forms of
`disturbance of vascular tone and influenced our under-
`standing of the etiology, pathogenesis, and treatment of
`hypertension. This method also made it possible to re-
`searchthe functioning of the cardiovascular system under
`normal conditions and during various diseases.
`Introduced in 1905, the simple and accurate Korotkoff
`method of measuring blood pressure has been used by
`physicians, nurses, researchers, and paramedics around
`the world throughout this century. Korotkoff’s method
`certainly will still be used extensively in the 21st century.
`
`Acknowledgments
`The authors are thankful to Dr Leonid Sakharny, Professor of
`the Saint Petersburg University, who, after extensive search at
`the Leningrad Public Library, provided Dr Tsitlik with copies of
`Korotkoff’s presentations and his 1910 dissertation.
`
`References
`
`1. Korotkoff NS. On methods ofstudying blood pressure [in Russian].
`Bull Imperial Mil Med Acad. 1905311:365-367 (with discussions).
`. Korotkoff NS. Experiments for Determining the Strength ofArterial
`Collaterals. Saint-Petersburg, Russia:
`Imperial Military Medical
`Academy; 1910. Dissertation,
`3, Lewis WHJr. The evolutionofclinical sphygmomanometry. Bull N
`¥ Acad Med. 1941;17:871-881.
`. Nikitin VP. 50th anniversary of development by N.S. Korotkoff of
`the auscultatory method of measuring the arterial blood pressure [in
`Russian]. Klinicheskaya Medizina. 1956;34:84-86.
`. Segall HN. Dr. N.C. Korotkoff: discovererofthe auscultatory method
`for measuringarterial pressure. Ann Intern Med. 1965;63:147-149,
`. Riva-Rocci S. Un sfigmomanometro nuovo. Gazetta Medica di To-
`rino. 1896;47:98 1-986.
`. Hill L, Barnard H. A simple and accurate form of sphygmometeror
`arterial pressure gauge contrived for clinical use. Br Med J. October
`2, 1897:904.
`. Korotkoff NS. On methods of studying blood pressure: second pre-
`sentation [in Russian]. /zv Jniper Voen-Med Acad. 1906;12:254-257
`(with discussion).
`. Krilov DO. Determining blood pressure by using the sound method
`of Doctor Korotkoff [in Russian].
`/zv Jmper Voen-Med Acad.
`1906;13:113-135, 221-233, 319-328,
`. Lebedev AC. [in Russian] /zvper Voen-Med Acad. 1911;23:175-
`213.
`Yanovskiy MV.[in Russian] /zv Jmper Voen-Med Acad. 1911;22:20-
`25,
`
`11.
`
`
`
`Key Worps ¢ Cardiovascular News ¢ blood pressure * diastole
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