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`9
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`
`(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 0 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
`
`0 Comparison of d,/—Sota|ol and
`
`iCDs - Laser Doppler Analysis of Free Regurgitant Jets - HLA Matching and
`
`Thoracic Transplantation
`
`a
`
`Basic Science Reports
`
`Estrogen and Progesterone and Atherosclerosis in Rabbits - Nitric Oxide and
`Microvascular Disease -
`Intracellular Mechanism of Coronary Spasm
`
`o Recombinant Staphylokinase With Altered Immunoreactivity, l
`
`- Recombinant Staphylokinase With Altered Immunoreactivity, ll
`
`-
`
`‘
`
`Heart Rate Influence on Refractoriness
`
`In Memoriam
`
`
`
`viii
`
`Lewis Dexter, MD: 1910-1995 - Lewis Dexter, MD: End of an Era
`
`Images in Cardiovascular Medicine
`
`Late Consequences of Kawasaki Disease
`
`“\Wllllliitwwlmmm Apple Inc.
`
`APL 1 068
`US. Patent No. 8,652,040
`
`73-3216(i®:;m§lf$6b23¢822:ifid
`mgr-atriaialigiaim
`
`Apple Inc.
`APL1068
`U.S. Patent No. 8,652,040
`
`0001
`
`

`

`Circulation
`
`Cardiovascular News
`
`New Associate Editor Appointments for Circulation
`James T. WiI/erson, MD .
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`
`90th Anniversary of the Development by Nikolai S. Korotkoff of the Auscultatory Method of
`Measuring Blood Pressure
`Yury L. Shevchenko, MD; Joshua E. Tsit/ik, PhD .
`
`Ed1tor1al
`
`
`Noninvasive Quantification of Valvular Regurgitation: Getting to the Core of the Matter
`Paul A. Grayburn, MD; Ronald M. Peshock, MD .
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`. .119
`
`Brief Rapid Communications
`
`Sex-Related Differences in Autonomic Modulation of Heart Rate in Middle-aged Subjects
`Heikki V. Huikuri, MD; Sirkku M. Pikkujamsa'i, MD; K. E. Juhani Airaksinen, MD; Markku J. lka‘heimo, MD;
`Asko O. Rania/a, MD; Heikki Kauma, MD; Mauno Li/ja, MD; Y. Antero Kesa'niemi, MD .
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`. .122
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`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, PhD .
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`. .126
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`Clinical Investigation and Reports
`
`Coronary Heart Disease
`
`Effects of L-Arginine Supplementation on Endothelium-Dependent Coronary Vasodilation in
`Patients With Angina Pectoris and Normal Coronary Arteriograms
`Kensuke Egashira, MD; Yoshitaka Hirooka, MD; Takeshi Kuga, MD; Masahiro Mohri, MD; Akira Takeshita, MD .
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`. .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; Torn Treasure, FRCS; John R. Hampton, FRCP;
`for the RITA Trial Participants .
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`. .135
`
`Cost-effectiveness of a Coronary Care Unit Versus an Intermediate Care Unit for Emergency
`Department Patients With Chest Pain
`Anna N.A. Tosteson, 800; Lee Goldman, MD; I. Steven Udvarhe/yi, MD; Thomas H. Lee. MD. M50 -
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`V
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`- -143
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`i
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`Arrhythmias/Defibrillators
`Comparison of d,I-Sotalol and Implantable Defibrillators for Treatment of Sustained Ventricular
`Tachycardia or Fibrillation in Patients With Coronary Artery Disease
`Dirk Booker, MD; Wilhelm Haverkamp, MD; Michael Block, MD; Martin Borggrefe, MD; Dieter Hammel, MD;
`GUnter Breithardt, MD .
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`. .151
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`Valvular Heart Disease
`
`In Vitro Flow Mapping of Regurgitant Jets: Systematic Description of Free Jet With
`Laser Doppler Velocimetry
`Benoit Diebo/d, MD, PhD; Annie De/ouche, BSc; Philippe Deiouche; Jean-Paul Guglielmi; Philippe Dumee;
`Alain Herment, PhD .
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`. .158
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`
`
`CIRCULATION (ISSN 0009—7322) is published twice monthl by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231-4596. Individuals
`may subscribe for their personal use at the following rates: 120 for members of an American Heart Association scientific council and $160 for nonmembers,
`Outside the United States, add $126 for postage. Contact AHA for single copy rates and subscription rates for medical professionals in training and for
`libraries, reading rooms, and other multiple~use institutions. Periodicals postage paid at Dallas, Texas, and additional mailing offices. POSTMASTER: Send
`address changes to CIRCULATION, American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231-4596.
`0002
`
`This material w‘inQEppied
`at; the N LM 3 rid may be
`Subject UEzilepyright: Laws
`
`0002
`
`

`

`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-Mo Lin, PhD; 0. Patrick Daily, PhD .
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`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 0. Mick, PhD, MD;
`Friedrich W. Schmahl, MD; Rainer Haasis, MD; Vinzenz Hombach, MD .
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`. .175
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`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 .
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`. .182
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`Coronary Artery Spasm Does Not Depend on the Intracellular Calcium Store but ls
`Substantially Mediated by the Protein Kinase C-Mediated Pathway in a Swine Model With
`Interleukin-1B In Vivo
`Toshiaki Kadokami, MD; Hiroaki Shimokawa, MD; Yoshihiro Fukumoto, MD; Akira lto, MD; Tsuneo Takayanagi, MS;
`Kensuke Egashira, MD; Akira Takeshita, MD .
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`. .190
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`Thrombolytic Agents
`Recombinant Staphylokinase Variants With Altered Immunoreactivity, I:
`Construction and Characterization
`De'sire’ Col/en, MD, PhD; Ria Bernaens, PhD; Paul Declerck, PhD; Frans De Cock; Edward Demarsin; Stephane Jenne’;
`Yves Laroche, PhD; Henri R. Lijnen, PhD; Karen Silence, PhD; Maria Verstreken .
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`. .197
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`Recombinant Staphylokinase Variants With Altered lmmunoreactivity, II:
`Thrombolytic Properties and Antibody Induction
`Désire’ Col/en, MD, PhD; Huberte Moreau; Luc Stockx, MD; Steven Vanderschueren, MD .
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`. .217
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`Arrhythmias
`Rapid Rates During Bradycardia Prolong Ventricular Refractoriness and Facilitate Ventricular
`Tachycardia Induction With Cesium in Dogs
`Tadashi Satoh, MD; Douglas P. lees, MD .
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`. .228
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`Lewis Dexter, MD: 1910-1995
`William Grossman, MD .
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`. .229
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`Lewis Dexter, MD: The End of an Era
`Paul D. Stein, MD .
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`Images in Cardiovascular Medicine
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`Late Consequences of Kawasaki Disease
`Yoshinori L. Doi, MD; Takashi Furuno, MD; Jun Takata, MD; Toshikazu Yabe, MD; Taishiro Chikamori, MD .
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`. A14
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`Annotated Table of Contents .
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`Abstract File Cards .
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`, A68
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`Classified Advertising .
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`Shevc/Ienko and Tsitlik Auscultatory Method of Measuring Blood Pressure
`
`1 l7
`
`
`
`urtesy 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 surgeon to predict an outcome of ligation
`of arteries of the 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 been ligated. He established that certain specific
`sounds could be heard during the decompression of the
`arteries. This specific phenomenon, known in 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“ in Italy in 1896 (Fig 2), which contained
`an arm-encircling inflatable elastic cuff, a rubber bulb to
`inflate the cuff, and a mercury sphygmomanometer to
`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-
`ment of diastolic pressure. Soon after Riva—Rocci’s tech-
`nique was described, Hill and Barnard7 in England in
`1897 reported an apparatus with an arm-encircling in-
`flatable cuff and a needle pressure gauge that allowed
`measurement of the diastolic pressure by the oscillatory
`method. This method used the oscillations transmitted to
`
`the gauge as the pulse wave came through 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
`llow. His
`contribution was the discovery of a new, more accurate
`
`auscultatory technique to identify the times when the
`pressure in the cuff coincided with systolic and diastolic
`arterial pressures. When he examined patients who had
`damaged vessels, Korotkoff gradually compressed the ar—
`teries until the peripheral pulse disappeared. He also re—
`corded sphygmograms while simultaneously listening to
`the sounds in the part of the artery distal to the com-
`pressed arca. He determined that a totally compressed
`artery produced no sounds at all and that while the pres-
`sure in the artery was decreased gradually, certain sounds
`appeared that allowed one to judge the level of arterial
`pressure. 1'2
`t
`To measure blood pressure, Korotkoff applied an elas-
`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 used to listen to the
`pressure in the artery “directly below the cuff.”1 Once
`the pressure fell below a certain level, the first short tones
`could be heard; this indicated the passage of the first pulse
`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 second tones. Finally, all the sounds
`disappeared. The moment all sounds subsided, according
`to Korotkoff, blood was flowing freely through the 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-
`pressed artery revealed the difference in the cuffpressures
`for the appearance of sounds and the formation of the
`pulse wave in a segment distal to the compressed area.
`The first sounds appeared at the cuff pressure, which was
`10 to 12 mm Hg higher than the pressure at which the
`palpable pulse was produced, because generation of the
`pulse required some filling of the vessel.1
`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
`short time interval. Also, vibrations of the “unsticking”
`
`
`
`FIG 2. Riva—Rocci sphygmomanometer used by Korotkoff in his
`measurements (from Korotkoff’s dissertationz). The length of the
`cuff was approximately 1/2 arshin (35.56 cm) and the width was
`at least 2% to 3 inches (6.85 to 7.62 cm).
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`118
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`Circulation V01 94, N0 2
`
`July 15, 1996
`
`vessel walls contributed to the production of the 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 semilunar aortic valves, as
`was hypothesized by some of his critics. In one of the
`experiments, he placed a T—shaped cannula into an ex-
`posed femoral artery. The vertical branch ol‘ the cannula
`was connected to a container filled 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 through the vessel; the sounds produced iirst were
`tones, followed by murmurs, and then the sounds disap-
`peared. Thus, the experiments demonstrated that the K0-
`rotkoff sounds originated at the site of vessel compres—
`sion.8 Korotkoff’s presentation was highly praised by
`Prof M.V. Yanovskiy. He stated that he was in complete
`agreement with Korotkoff’s
`results:
`“. . .with this
`method, I believe, we will achieve quite accurate results
`.
`.
`.
`. I 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“"5°”""“’"’
`Yanovskiy’s clinic produced many studies in support
`of the auscultatory method of measurement of blood pres-
`sure. One of the earliest serious studies was the work by
`Krilov, “Determining Blood Pressure by Using the Sound
`Method of Doctor Korotkoff,”9 which was completed on
`the advice and under the supervision of Yanovskiy. The
`reports presented methods of 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 measurements by use of other methods (Rek-
`lrnghausen, Pal, direct invasive measurements, etc).4'9‘11
`The method of measurement of blood pressure in-
`vented by Korotkofi’ quickly received wide recognition
`
`and became a standard medical procedure?5 This method
`played an important role in the study of various forms of
`disturbance of vascular tone and influenced our under-
`
`standing ol’ the etiology, pathogenesis, and treatment of
`hypertension. This method also made it possible to re-
`search the 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
`
`2.
`
`9.
`
`l. Korntkoff NS. On methods of studying blood pressure [in Russian].
`Bull Imperial Mil Met/Acml. 1905;11:365-367 (with discussions).
`Korotkoff NS. EA‘pert‘mcnls‘fiW Determining the Strength afArteria/
`Col/metals. Saint-Pctersburg, Russia:
`Imperial Military Medical
`Academy; 1910. Dissertation.
`3. Lewis WH Jr. The evolution of clinical sphygmomanomctry. Bill/N
`YAc-udMed. 1941;17:871-881.
`Nikitin VP. 50th anniversary 01’ development by N.S. Korotkot‘l‘ of
`the auscultatory method of measuring the arterial blood pressure [in
`Russian]. Klinic/zeskaya Metlizinu. 1956;34:84-86.
`Segall HN. Dr. N.C. Korotkol‘f: discoverer ofthc auscultatory method
`for measuring arterial pressure. Ann Intern Med. 1965;63:147-149.
`Riva»Rocci S. Un sfigmomanometro nuovo. Gazettu Met/[ca (11' To-
`rino. 1896;47:981-986.
`Hill L, Barnard H. A simple and accurate form of sphygmometer or
`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]. lzv Int/Jet" Vow-Med ACUII. 1906;12:254-257
`(with discussion).
`Krilov DO. Determining blood pressure by using the sound method
`of Doctor Korotkol‘f
`[in Russian].
`Izv lmper Vow-Med Acarl.
`1906;13:113-135. 221-233, 3194328.
`Lebedev AC. [in Russian] Izv lmpcr Vow—Med Acatl. 1911;23:175—
`213.
`Yanovskiy MV. [in Russian] lzv lmper Voen-Mctl/tcml. 1911;22:20—
`25.
`
`10.
`
`11.
`
`
`
`KEY WORDS ' Cardiovascular News - blood pressure - diastole
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