Tests Of Heart Strength
Categories: UncategorizedSources: Disturbances Of The Heart
If both systolic and diastolic blood pressure are taken, and the
heart strength is more or less accurately determined, mistakes in
the administration of cardiac drugs will be less frequent. Besides
mapping out the size of the heart by roentgenoscopy and studying the
contractions of the heart with the fluoroscope, and a detailed study
of sphygmographic and cardiographic tracings, which methods are not
available to the l
methods of approximately, at least, determining the strength of the
heart muscle.
Barringer [Footnote: Barringer, T. B., Jr.: The Circulatory Reaction
to Graduated Work as a Test of the Heart's Functional Capacity,
Arch. Int. Med., March, 1916, p. 363.] has experimented both with
normal persons and with patients who were suffering some cardiac
insufficiency. He used both the bicycle ergometer and dumb-bells,
and finds that there is a rise of systolic pressure after ordinary
work, but a delayed rise after very heavy work, in normal persons.
In patients with cardiac insufficiency he finds there is a delayed
rise in the systolic pressure after even slight exercise, and those
with marked cardiac insufficiency have even a lowering of blood
pressure from the ordinary level. They all have increase in pulse
rate. He quotes several authorities as showing that during muscle
work the carbon dioxid of the blood is increased in amount, which,
stimulating the nervous centers controlling the suprarenal glands,
increases the epinephrin content of the blood. The consequence is
contraction of the splanchnic blood vessels, with a rise in general
blood pressure. Also, the quickened action of the heart increases
the blood pressure. After a rest from the exercise, the extra amount
of carbon dioxid is eliminated from the blood, the suprarenal glands
decrease their activity, and the blood pressure falls.
Nicolai and Zuntz [Footnote: Nicolai anal Zuntz: Berl. klin.
Wehnschr., May 4, 1914, p. 821.] have shown that with the first
strain of heavy work the heart increases in size, but it soon
becomes normal, or even smaller, as it more strenuously contracts,
and the cavities of the heart will be completely emptied at each
systole. If the work is too heavy, and the systolic blood pressure
is rapidly increased, it may become so great as to prevent the left
ventricle from completely evacuating its content. The heart then
increases in size and may sooner or later become strained; if this
strain is severe, an acute dilatation may of course occur, even in
an otherwise well person. Such instances are not infrequent. A heart
which is already enlarged or slightly dilated and insufficient,
under the stress of muscular labor will more slowly increase its
forcefulness, and we have the delayed rise in systolic pressure.
Barringer concludes that:
The pulse rate and the blood pressure reaction to graduated work is
a valid test of the heart's functional capacity. If the systolic
pressure reaches its greatest height not immediately after work, but
from thirty to 120 seconds later, or if the pressure immediately
after work is lower than the original level, that work, whatever its
amount, has overtaxed the heart's functional capacity and may be
taken as an accurate measure of the heart's sufficiency.
In another article, Barringer [Footnote: Barringer, T. B., Jr.:
Studies of the Heart's Functional Capacity as Estimated by the
Circulatory Reaction to Graduated Work, Arch. Int. Med., May, 1916,
p. 670.] advises the use of a 5-pound dumb-bell extended upward from
the shoulder for 2 feet. Each such extension represents 10 foot-
pounds of work, although the exertion of holding the dumb-bell
during the nonextension period is not estimated. He believes that if
circulatory tire is shown with less than 100 foot-pounds per minute
exercise, other signs of cardiac insufficiency will be in evidence.
He also believes that these foot-pound tests can be made to
determine whether a patient should be up and about, and also that
such graded exercise will increase the heart strength in cardiac
insufficiency.
Schoonmaker, [Footnote: Schoonmaker: Am. Jour. Med. Sc., October,
1915, p. 582.] after studying the blood pressure of 127 patients,
concludes that myocardial efficiency will be shown by a comparison
of the systolic and diastolic blood pressure, with the patient lying
down and standing up, after walking a short distance. Such slight
exercise should not cause any subjective symptoms, either dyspnea,
palpitation or chest pain. If the heart muscle is in good condition,
the systolic pressure should remain the same after this slight
exertion and these changes in posture. When the heart is good, there
may be slight increased pressure when the patient is standing. If,
after this slight exercise in the erect posture, the systolic
pressure is diminished, the heart muscle is defective.
Martinet [Footnote: Martinet: Presse med., Jan. 20, 1916.] tests the
heart strength as follows: He counts the pulse until for two
successive minutes there is the same number of beats, first when the
patient is lying down, and then when he is standing. He also takes
the systolic and diastolic pressures at the same time. He then
causes the person to bend rapidly at the knees twenty times. The
pulse rate and the blood pressure are then taken each minute for
from three to five minutes. The person then reclines, and the pulse
and pressure are again recorded, Martinet says that an examination
of these records in the form of a chart gives a graphic
demonstration of the heart strength. If the heart is weak, there are
likely to be asystoles, and tachycardia may occur, or a lowered
blood pressure.
Rehfisch [Footnote: Rehfisch: Berl. klin. Wehnsehr., Nov. 29, 1915]
states that when a healthy person takes even slight exercise, the
aortic closure becomes louder than the second pulmonic sound,
showing an increased systolic pressure. If the left ventricle is
unable properly to empty itself against the increased resistance
ahead, the left auricle will contain too much blood, and with the
right ventricle sufficient, there will be an accentuation of the
second pulmonic sound and it may become louder than the second
aortic sound, showing a cardiac deficiency. If, on the other hand,
the right ventricle becomes insufficient, or is insufficient, the
second pulmonic sound is weaker than normal, and the prognosis is
bad.
Barach [Footnote: Barach: Am. Jour. Med. Sc., July, 1916, p. 84]
presents what he terms "the energy index of the circulatory system."
He has examined 742 normal persons, and found that the pressure
pulse was anywhere from 20 to 80 percent of the diastolic pressure
in 80 per cent of his cases, while the average of his figures gave a
ratio of 50 percent; but he does not believe that it holds true that
in a normal person the pressure pulse equals 50 percent of the
diastolic pressure. Barach does not believe we have, as yet, any
very accurate method of determining the cardiac strength or
circulatory capacity for work. He does not believe that the estimate
of the pressure pulse is indicative of cardiac strength. He believes
that the important factors in the estimation of the circulatory
strength are the systolic pressure, which shows the power of the
left ventricle, the diastolic pressure, which shows the
intravascular tension during diastole as well as the peripheral
resistance, and the pulse rate, which designates the number of times
the heart must contract during a minute to maintain the proper flow
of blood. He thinks that these three factors are constantly adapting
themselves to each other for the needs of the individual, and he
finds, for instance, that when the left ventricle is hypertrophied
and the output of blood is therefore greater, then the pulse will be
slowed. His method of estimation is as follows: For instance, with a
systolic pressure of 120 mm. and a diastolic pressure of 80 mm.,
each pulse beat will represent an energy equal to lifting 120 mm.
plus 80 mm., which equals 200 mm. of mercury, and with seventy-two
pulse beats the force would be 72 X 200, which equals 14,400 mm. of
mercury. He finds an average circulatory strength based on examining
250 normal individuals by the index, which he terms S, D, R
(systolic, diastolic rate), to be 20,000 mm. of mercury per minute.
Katzenstein [Footnote: Katzenstein: Deutsch. med. Wehnsehr., April
15, 1915.] finds, after ten years of experience, that the following
test of the heart strength is valuable: He records the blood
pressure and pulse, and then compresses the femoral artery at
Poupart's ligament on the two sides at once. He keeps this pressure
up for from two to two and one-half minutes, and then again takes
the blood pressure. With a sound heart the blood pressure will be
higher and the pulse slower than the previous record taken. If the
blood pressure and pulse beat are not changed, it shows that the
heart is not quite normal, but not actually incompetent. When the
blood pressure is lower and the pulse accelerated, he believes that
there is distinct functional disturbance of the heart and loss of
power, relatively to the change in pressure and the increase of the
pulse rate. He further believes that a heart showing this kind of
weakness should, if possible, not be subjected to general
anesthesia.
Stange [Footnote: Stange: Russk. Vrach, 1914, xiii. 72.] finds that
the cardiac power may be determined by a respiratory test as
follows: The patient should sit comfortably, and take a deep
inspiration; then he should be told to hold his breath, and the
physician compresses the patient's nostrils. As soon as the patient
indicates that he can hold his breath no longer, the number of
seconds is noted. A normal person should hold his breath from thirty
to forty seconds without much subsequent dyspnea, while a patient
with myocardial weakness can hold his breath only from ten to twenty
seconds, and then much temporary dyspnea will follow. Stange does
not find that pulmonary conditions, as tuberculosis, pleurisy or
bronchitis, interfere with this test.
Williamson [Footnote: Williamson: Ant. Jour. Med. Sc., April, 1915,
p. 492.] believes that we cannot determine the heart strength
accurately unless we have some method to note the exact position of
the diaphragm, and he has devised a method which he calls the
teleroentgen method. With this apparatus he finds that a normal
heart responds to exercise within its power by a diminution in size.
The same is true of a good compensating pathologic heart. He thinks
that a heart which does not so respond by reducing its size after
exercise has a damaged muscle, and compensation is more or less
impaired.
Practical conclusions to draw from the foregoing suggestions are:
1. An enlargement of the heart after exercise can be well shown only
by fluoroscopic examination, and then best by some accurate method
of measurement.
2. The blood pressure should be immediately increased by exercise,
and after such exercise should soon return to the normal before the
exercise. If it goes below the normal the heart is weak, or the
exercise was excessive.
3. The pulse rate should increase with exercise, but not
excessively, and should within a reasonable time return to normal.
4. The stethoscope will show whether or not the normal sounds of the
heart become relatively abnormal after exercise. If such was the
fact, though the abnormality was not permanent, heart insufficiency
is more or less in evidence.
5. The relation of pulse rate to blood pressure should always be
noted, and the working power of the heart may be estimated according
to Barach's suggestion.
6. The dumb-bell exercise tests suggested by Barringer (only, the
dumb-bells may be of lighter weight) are valuable to note the
gradual improvement in heart strength of patients under treatment.
7. The holding the breath test is very suggestive of heart
efficiency or weakness, but a series of tests must be made before
its limitations are proved.
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