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Here are Pulse 4 Pulse we place the patient’s prevention at the primary point of our interest in taking care of that patient. Pulse 4 PUlse has developed an algorithm that is embedded within a software program that that will actually tell you if you have silent peripheral vascular disease.

Good afternoon everyone. This is Mary. She is our medical assistant today. We have Patrick who is sitting who is our patient. I’m Dr. PHil MOngelluzzo and we are about to perform 3 different tests.

Autonomic Nervous System Test

Our first test is the Autonomic Nervous System test. You can think of the ANS Test as simply a balance of your nervous system. Very simple. When you get scared or cut off on the highway your heart starts to race. That’s your sympathetic nervous system. The other thing this tests for is your parasympathetic system. When you eat a large meal you get tired and you want to fall asleep.

So that is what this test does. It’s primarily based on a couple of different parameters. As we go through this test you’ll see Patrick go through it, a couple of different maneuvers; standing up, bearing down, sitting back down.

Heart Rate Variability

What this test is a Heart Rate Variability. The best way to explain Heart Rate Variability (HRV) is that when you run up the stairs your heart rate needs to pick up.  It needs to beat faster, so that you can get more oxygen to your muscles, to your legs to your arms. If that doesn’t happen that could be a problem and that is one of the things that this test, tests for. That is called Cardiac Autonomic Neuropathy. That is one of the many things that we’ll go over at some point. It’s based on Heart Rate Variability.

People that have diabetes, people that have high cholesterol, people that even have hypertension, sometimes their ability to pick up their heart rate during exercise is compromised and that is a problem that we need to find out. That is what this test is for. When you can’t find that out it’s a silent issue. Meaning we don’t know that it’s there And if you don’t know its there and your healthcare practitioner doesn’t know it’s there that could be a problem for you. When we identify it there a number of ways to treat it.

So as you can see, Patrick is setup here. He has a blood pressure cuff on his upper arm and his lower leg. So what we’re doing now is we are going to check his blood pressure in the sitting position. And later we’ll test his blood pressure when he stands up as well. Again, all about the aforementioned heart-rate variability. Are really unique way to find out if there is a silent problem.

One of the things that I love to talk about in my own practice is preventative medicine. What we’re really after is asymptomatic disease in the asymptomatic patient, meaning silent disease. Disease that hasn’t manifested itself. Wouldn’t it be great if you knew there was going to be a problem two years from now, five years from now?

When you build a house you want a strong foundation. You want to make sure there are no cracks in the cement because if there are and there is a leak in your basement, you’d rather know about it on day one, that five years from now. What this test does it allows us to quantify silent disease. We are allowed to pick up small blood vessel disease before it ever becomes a problem.

In medicine, we’re really good at a couple of things. We know how to treat reactively. Someone comes into the hospital with a heart attack, someone comes into the hospital with a stroke. WE know what protocols to run. We know how to treat them. We know how to treat them aggressively so that they survive. What I want to ask you is, imagine if there is a way to identify small blood vessel disease, the same way we identify large vessel disease? That is the difference between micro-vascular (meaning small blood vessel) and macro-vascular disease (meaning large blood vessel). Again, very good at determining when someone has a heart attack and how to treat them. Not very good at determining the five-years-prior to a heart attack. And that’s one of the things that this test helps us do, risk stratify.

So right now, Pat is having his blood pressure taken and you can see the screen. There is an EKG tracing above, which is right here. Here we have a couple of pulse wave velocities going on which allows us to look at the blood flow between his upper arm, his heart, and his legs and his heart. Based on this an algorithm is written within the software, we’re able to identify if there is a problem with the autonomic nervous system.

Deep Breathing

So while Patrick is deep breathing I will just tell you that when you take a deep breath in it increases the intrathoracic pressure inside of your chest and will actually compress the heart. So it’s a way to measure the HRV under stress. So what I’ve mentioned before having your heart rate change as you run up the stairs or (decrease) as you meditate.

Same way, so as we’re running up the stairs our heart rate should pick up, if we’re doing something relaxing, meditating, tai chi sleeping, our heart rate should drop. This is measuring his autonomic nervous system from the heart rate variability. And that is really the backbone of the autonomic nervous system.

Valsalva Maneuver

You just witnessed Patrick doing a Valsalva maneuver that holds pressure in the intrathoracic cavity and pushes on the heart. How that differ from his deep breathing? When we breathe we have respirations and our heart rate should change with respirations, like running up the stairs, or running a marathon The faster you run the heavier you breathe. You want your heart rate to pick up sometimes that’s not the case. THat’s one of the things that this test can pick up. When Patrick had that Valsalva it really increases his intrathoracic pressure putting a lot of pressure on the heart. So we’re measuring his heart rate variability to make sure that the changes that are happening are appropriate.

Stand Up Maneuver

In this next segment, Patrick is going to stand up and again we’ll look at his HRV.

Ankle-Brachial Index TestingSo as you see Patrick standing this is really a very interesting part of the test. When you’re sitting down you don’t need high blood pressure to profuse your brain because you’re sitting and you’re relaxed. The moment we stand up or the moment we get out of bed from a lying position a lot of things have got to happen correctly to our body so we don’t get dizzy or pass out So when we stand up forcibly and quickly blood pressure tends to pool in our legs and not go to our brain. We need blood pressure in our brain. It’s called brain profusion. Without it, you’ll get dizzy or light-headed. So these tests for something called orthostatic hypotension. Another thing that we test for. If it is present it alerts us that there is an issue and we need to work that issue up.

In a normal individual what we would expect when they stand up is that the blood pressure stays stable and it doesn’t drop and the heart rate stays stable and does not drop. Because the body is smart enough to know that it needs vasoconstriction (or tight the blood vessels of the lower extremities to send blood back up towards the brain. So that is what Patrick was just demonstrating.

So as you’re seeing the tracing, on the system here, one of the things we always caution patients here is not to worry so much about what the blood pressures are reading because we are so used to getting blood pressures in our arm and we’re so used to numbers like 120/80 the blood pressures in the lower extremities we’ll be different. I always caution patients not to worry.

What I do once this test is complete is that we will be able to take the ratio of the blood pressure in the ankle and put it over the blood pressure in the arm and see if there is an issue. As I said earlier (medical) literature as stood the test of time as back as far as dirt, if there is a problem with that number it is very easy to ascertain and the next step would be looking at that blood pressure in the leg more carefully an ultrasound.

Ankle-Brachial Index Test

As you can see Mary is preparing Patrick for another part of our testing. She is moving the blood pressure cuffs to the other side. As we go through the same parameters that we just spoke about in terms of taking the blood pressure of the arm and ankle. The ratio will give us a number that has stood the test of time. Once we complete Patrick’s left side of the body we will then complete his right side. We’d love for their results to be mirror images, but sometimes what goes on on the right is not is what is going on in the left. You can have a normal Ankle-Brachial Index on the right and, meaning normal blood flow and the left can be compromised. That is why we test both. The importance of this is that if there is compromise on either side we need to start looking for other disease patterns that also suggest peripheral vascular disease. This testing has many clinical benefits but probably the most important, the one clinical benefit above all is that it will help diagnose asymptomatic peripheral artery disease

Sudomotor Test

Now we are going to start the third and final part of the testing. Sudomotor testing is important because it will actually test your sweat glands. As Patrick is showing he has his feet and hands on glass plates. There will be a small electrical impulse that will go through the palms of his hands and the soles of his feet. Patrick won’t feel it. But what that does is stimulate the sweat glands. it doesn’t matter if your 10 or 100, or if black or white, yellow, green or orange is your favorite color we all have a characteristic sweat response and that has a voltage attached to it. That voltage is measure in this test. If that voltage is abnormal then you have a problem in the smallest blood vessels of your body called microvascular blood vessels, or you have a problem in the smallest nerve fibers in your body called micro-neuropathy disease. That is a silent disease pattern, you will never know that it exists, not at this level. It’s one of the things our we’re testing for and alerts us to a potential problem.

So as you can see the screen here Patrick is now undergoing this test. One of the parameters that we test for, because of the electrical impulse, if you have a pacemaker or defibrillator you should alert your technician to that because you will be skipping this part of the test.


So what if there was a way now that we could actually look at the smallest blood vessel problems in your body from an arterial standpoint? or the smallest nerve problems in your body? We would be able to identify asymptomatic disease. That is what Pulse 4 Pulse does. We are much more interested in the asymptomatic patient with the asymptomatic disease because we know that today that patient is healthy, or so it seems. But in two or five years that patient may not be as healthy they are today and our tests help determine what other testing may need to be done. And simple lifestyle modifications, if there is an underlying vascular disease issue, simple lifestyle modifications, walking, can improve their health so incredibly.

Medicine has changed a lot in my last 20 years. We are stressed with so many different priorities now, to care for the patient, insurance issues, prior authorizations.. We’ve really lost touch with why we went into medicine in the first place This makes me a better doctor and will make those doctors looking at it, and mid-level practitioners, it will make them better practitioners because it allows us to uncover silent disease. Prevent is where the key is in today’s medicine. We need to be able to identify today if there is going to be a problem in the next year. Think about it. If I was walking around and I knew I was going to have a heart attack in two years I think I might take some precautions today. I would change the way I eat. I would change the way that I exercise. I would change the way I treat my body.

We need to become better doctors. We need to uncover more truths. We need to uncover those hidden truths we don’t know. It’s far too hard to do that in the 15-minute visit. But through our preventative screening, we do that for the doctor and that will allow him or her to become a better doctor.