Nadi Pariksha
Nadi Pariksha
Review Article
a r t i c l e i n f o a b s t r a c t
Article history: The significance of Nadi Pariksha is well understood and effectively used by Ayurveda practioners for
Received 4 May 2017 assessing Tridoshas and various physiological and psychological states of the patient. The traditional texts
Received in revised form Sarangadhara Samhita, Yoga Ratnakara, Basavarajeeyam and Bhavaprakasha have discussed the details of
12 October 2017
Nadi Pariksha in succinct set of slokas. Ayurveda has thousands of years of rich experience in Nadi Par-
Accepted 16 October 2017
Available online 10 August 2018
iksha with strong literature support but is subjective in nature and the need for studying nadi with a
scientific approach is well understood. Recently, pulse wave velocity has gained significant research
interest as it is considered to be a strong indicator of cardiovascular disease; however, the relevance of
Keywords:
Gati
pulse wave analysis to Nadi Pariksha has not been studied. In this review, traditional methods of Nadi
Kathinya Pariksha as defined in Ayurveda classics and the recent advances in pulse wave analysis are discussed. As
Pulse wave velocity per classical texts, qualities or properties of pulse such as pulse movement (gati), speed of the pulse
(vega), stability of the pulse (sthiratva) and hardness of the artery (kathinya) play major role in Nadi
Pariksha and in the current review these properties were analyzed and compared with the modern pulse
parameters namely pulse wave velocity, pulse rate variability and arterial stiffness. The significance of
pulse wave velocity in cardiovascular studies is discussed and the need for extending these studies to
Ayurveda is highlighted.
© 2017 Transdisciplinary University, Bangalore and World Ayurveda Foundation. Publishing Services by
Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).
1. Introduction of Nadi Pariksha [3]. The speed, stability and gati of the pulse vary
with the aggravated doshas and assessing such variations with Nadi
Ayurveda is well known for Nadi Pariksha and classical texts Pariksha is an art and science of its own. The traditional ayurvedic
have emphasized its significance in assessment of Tridoshas which practitioners were adept in pulse based diagnosis and used to di-
are the basis of disease diagnosis and prognosis [1e4]. There is a agnose the diseases effectively by just placing fingers on the radial
precise description of dosha predominance in the texts which can artery.
be sensed from specific locations on radial artery and accordingly Ayurveda has rich experience in pulse based diagnosis but it is
vata dosha is felt at the root of the thumb which can be sensed with subjective in nature and is highly dependent on skill of the physi-
index finger, next to it is pitta dosha which can be sensed with cian. In recent past there is a growing research interest in acquiring
middle finger followed by kapha dosha sensed by ring finger. As per the pulse from Tridosha locations and analyzing the pulse wave
ayurveda balanced Tridoshas represent the sound health and viti- forms scientifically in the context of ayurveda. The pulse patterns of
ated doshas lead to diseases. According to Yoga Ratnakara all the vata, pitta and kapha doshas were studied in detail by Upadhyaya as
diseases can be diagnosed from Nadi and it was compared with part of the clinical and experimental studies on Nadi Pariksha using
strings of veena playing all the ragas which signifies the importance Dudgeon Sphygmograph [5]. It was a detailed study covering the
systematic review of ayurvedic literature, hemodynamics and sta-
tistical analysis of pulse patterns representing vata, pitta and kapha
doshas of normal and diseased persons. The mean pulse rate and
* Corresponding author.
E-mail address: [email protected] (P.V.G. Kumar).
mean pulse pressure were studied across vata, pitta and kapha
Peer review under responsibility of Transdisciplinary University, Bangalore. doshas and the significance of pulse parameters rate, rhythm,
https://doi.org/10.1016/j.jaim.2017.10.007
0975-9476/© 2017 Transdisciplinary University, Bangalore and World Ayurveda Foundation. Publishing Services by Elsevier B.V. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
P.V.G. Kumar et al. / Journal of Ayurveda and Integrative Medicine 10 (2019) 308e315 309
volume, force, tension, character and hardness of the artery were evidence based research. This necessitates the review of pulse
analyzed in the context of ayurveda. In similar lines Vasant has properties defined in classical texts with a view to understand the
analyzed the physiological significance of pulse parameters gati physiological significance of the pulse and identify the modern
(movement), vega (rate), tala (rhythm), bala (force), tapamana pulse parameters which can be associated to the traditional pulse
(temperature), akruti (volume and tension) and kathinya (consis- properties.
tency of the vessel wall) across vata, pitta and kapha doshas [6]. The qualities manda (slow), vega (fast), sthira (stable), capala
These initial studies accentuated the importance of the pulse (unstable) and kathina (hard) are of research significance as these
parameters in analyzing Tridoshas in more scientific way compared qualities or properties are measurable and can be associated to
to qualitative analysis. In this review the pulse measuring locations modern pulse parameters. The terms manda (slow) and vega (fast)
used in Tridosha analysis were highlighted and qualities or prop- correspond to the speed or velocity of the pulse and in Sar-
erties of Nadi as explained in ayurveda classics were discussed. The angadhara Samitha while explaining Nadi Pariksha vidhi the term
physiological significance of qualities of Nadi was analyzed and vega is used for increased pulse rate and ksheena and manda are the
compared them with the modern pulse parameters which includes terms used for decreased pulse rate [4]. The term vega can be
pulse wave velocity, arterial stiffness and pulse rate variability. closely associated to speed of velocity of the pulse and can be
Recent advances in pulse wave analysis were highlighted and the associated to modern pulse parameters such as pulse rate and pulse
relevance of pulse wave analysis techniques to Nadi Pariksha was wave velocity.
underscored. As part of the review various pulse measuring in- The stability of the pulse has been dealt with in detail in the
struments used in current research and its application to Tridosha texts while explaining Nadi Pariksha and the texts have used terms
analysis were discussed. Traditional practices in Nadi Pariksha were sthir (stable) and capal (unstable) while explaining the stability of
manual and there were no instruments available for measuring the the pulse [3,4]. The stability is referred as sthiratva in doshadi vij-
pulse whereas modern pulse wave analysis makes use of in- naniya adhyaha (sutrasthana) of Ashtanga Hridayam while
struments both in clinical and research applications. In this review explaining prakruta dosha karma [14]. The texts have not used the
the role of modern instruments in studying the traditional pulse term sthiratva while explaining Nadi Pariksha but this term can be
parameters was discussed. used to represent the stability of the pulse and can be closely
The ancient texts of ayurveda were included in the study of Nadi associated to modern parameter pulse rate variability. As stable
Pariksha. The ayurveda texts included were Sarangadhara Samhita, pulse is more rhythmic in nature the term tala which corresponds
Yoga Ratnakara, Basavarajeeyam and Bhavaprakasha. Nadi Vijnana to rhythm can also be used to represent stability of the pulse and
by Upadhyaya and Secrets of the Pulse by Vasant were also included Vasant has used the term tala in Secrets of the Pulse [6]. In this re-
in the study of traditional practices of Nadi Pariksha. A detailed view the term sthiratva has been used to represent the stability of
search was undertaken using key words Nadi, Nadi Pariksha in the pulse as it is used in most of the classical texts.
pubmed, google scholar, science direct and google. The search The texts have used the term kathinya to explain the hardness of
yielded only six papers which discussed Nadi Pariksha [7e13] as per the artery and reference to kathinya is available only in Basavar-
classical texts and there were no papers discussing the relevance of ajeeyam. In dviteeya prakarana of Basavarajeeyam while explaining
recent advances in pulse wave analysis to Nadi Pariksha which the signs of mrityu nadi the term kathinya has been used and in
underlines the need for a comprehensive review of Nadi Pariksha. triteeya prakarana of Basavarajeeyam the term kathinya is used to
explain the nature of kapha [1]. The term kathin (hard) represented
2. Pulse parameters as kathinya corresponds to hardness of the artery and can be closely
associated to modern pulse parameter arterial stiffness. Vasant [6]
Traditionally Nadi Pariksha was done by sensing the pulse at has used the term consistency of the vessel wall to explain kathi-
three locations on radial artery and assessing doshas from palpation nya whereas Upadhyaya [5] has used the term condition of the
of the pulse. The qualities or properties of the Nadi are vital in vessel wall for the same. In this review the term hardness of the
assessing doshas as part of Nadi Pariksha. The classical texts have artery is used to represent kathinya and is associated to arterial
emphasized the significance of gati, a unique quality of the pulse, as stiffness which is measurable and has research significance.
part of Nadi Pariksha and as per texts gati plays a key role in disease In summary gati (pulse movement), vega (speed of the pulse),
diagnosis [1e4]. There is no equivalent term for gati in modern sthiratva (stability of the pulse) and kathinya (hardness of the ar-
medicine and pulse movement is the closely matching term in tery) are identified as measurable qualities of Nadi which can be
modern medicine which can be associated to gati. There are many closely associated to modern pulse parameters pulse movement,
other qualities of pulse apart from gati (pulse movement) which pulse wave velocity, pulse rate variability and arterial stiffness
texts have highlighted and in this review the gati and other quali- respectively. In this review the qualities of Nadi have been dis-
ties of pulse were discussed in detail. cussed in line with the modern pulse parameters with a view to
As per Ashtanga Hridayam guru (heavy), manda (slow), hima bring out the physiological significance behind Nadi Pariksha.
(cold), snigdha (unctuous), slakshna (smooth), sandra (solid), mridu
(soft), sthira (stable), sukshma (subtle), visada (non slimy) and their 2.1. Gati (pulse movement)
opposites laghu (light), tikshna (quick, fast), usna (hot), ruksha (dry),
khara (roughness) drava (liquid), kathina (hard), cala (moving), The dosha predominance can be well assessed with gati which is
sthula (big), picchila (slimy) are twenty qualities or gunas which a very unique way of diagnosis in ayurveda wherein the movement
play key role in disease diagnosis and specifically in assessing of the pulse has been compared with the movement of animals,
doshas [14]. The qualities of pulse also need to be understood from birds and reptiles. According to the texts the movement of vata
these properties and the review of classical texts revealed that the pulse, well known as sarpa gati, will be curved resembling move-
texts have used the terms manda (slow), vega (fast), sthira (stable), ment of snake (sarpa) and leech (jaluka). The curved and zigzag
capala (unstable), kathina (hard), sukshma (subtle) and picchila nature of movement is the significance of vata pulse and in Basa-
(slimy) while explaining the qualities of pulse [1e4]. The texts have varajeeyam the vata pulse has been explained to be of vakra and
explained the significance of the pulse properties, but in qualitative kutil in nature which signifies the curved movement [1]. Bhavap-
manner which is subjective in nature and the need for quantitative rakasha has not compared the gati with the movement of animals
description of these properties is well understood in the light of or birds but similar to Basavarajeeyam explained it to be of vakra in
310 P.V.G. Kumar et al. / Journal of Ayurveda and Integrative Medicine 10 (2019) 308e315
nature [2]. The movement of pitta pulse, well known as manduka to 15 m/s. In the recent past pulse wave velocity (PWV) is consid-
gati, was compared with the movement of frog which will be ered as an indicator of cardiovascular risk and has gained signifi-
hopping and jumping in nature and was explained with the words cant research interest [15]. The longitudinal studies have shown
capal and utplutya which signifies the jumping nature. The slow that aortic PWV is a strong predictor of future cardiovascular events
movement (manda gati) is the significance of kapha pulse, well and all cause mortality [16]. The longitudinal studies on aortic and
known as hamsa gati, which has been compared with the move- carotid stiffness in predicting the cardio-vascular disease are listed
ment of swan. The ayurveda texts have explained the gati of the in Table 1 [17]. The European Society of Hypertension and European
pulse when more than one dosha is present and according to the Society of Cardiology has suggested a threshold exceeding 12 m/s as
texts gati will be of sarpa and manduka in nature if both vata and a conservative estimate of significant alterations in aortic function
pitta doshas are in aggravation, similarly it will be of sarpa and of hypertensive patients and later the threshold has been adjusted
hamsa in nature if vata and kapha doshas are in aggravation and will to 10 m/s considering the true anatomical distance traveled by
be of manduka and hamsa in nature if pitta and kapha doshas are in pulse wave [18]. The studies on the subjects with hypertension, end
aggravation. It is quite evident from the texts that gati plays a sig- stage renal disease and geriatrics have confirmed the predictive
nificant role in assessing the dosha predominance and traditional value of aortic PWV especially in assessing the cardiovascular
ayurveda doctors were adept in assessing gati from nadi. events [19e21].
The studies have shown significant results with pulse wave
2.1.1. Pulse movement velocity in modern medicine and in the context of ayurveda the role
The traditional practice of assessing gati has been in practice for of PWV in Tridosha analysis need to be explored. The pulse wave
thousands of years but it is very subjective in nature and in the velocity may not be directly related to vega defined in traditional
current context of evidence based research it is important to assess text but can be closely associated to it and the variations in doshas
the nature of gati in scientific manner with a clear understanding of can be studied by measuring the pulse wave velocity. The dosha
its physiological significance. Upadhyaya as part of his clinical and predominance has been discussed in classical texts of ayurveda and
experimental studies on Nadi Pariksha discussed the physiological according to the texts kapha dominance can be seen in childhood,
significance of gati from rate, volume and character of the pulse and pitta dominance in middle age and vata dominance in old age.
according to him vata pulse signifies the rate of the pulse to be fast, Secondly as per ayurveda nature of vata corresponds to fastness,
volume to be small and character to be curvilinear resembling sarpa pitta corresponds to medium speed and kapha corresponds to
gati, if the rate is slow, volume to be high and character is of slowness. The studies have shown that the pulse wave velocity
jumping in nature it resembles pitta pulse and slow rate with vol- measured using carotid femoral technique increases with age and
ume in between vata and pitta resembles kapha pulse [5]. In hence pulse wave velocity can be considered as an important pulse
another study by Joshi, nadi patterns of healthy and diseased per- parameter in studying dosha dominance and classifying doshas.
sons were analyzed using computational models with promising Carotid femoral technique is gold standard and as a first step it can
results [12]. These initial studies highlight the physiological sig- be used to study the pulse wave velocity in the context of Tridosha
nificance of gati but needs thorough validation to establish the analysis.
physiological significance of gati and its nature across Tridoshas in
various states of the health. As it is quite evident from the texts that 2.3. Sthiratva (stability of the pulse)
gati plays an important role in assessing dosha, it is utmost
important that current research in ayurveda should focus on the The ayurveda classics have discussed the stability of the pulse in
ways of validating gati in a measurable way. detail with a mention of intermittent nadi which will be sometimes
slow, sometimes fast and sometimes stops in between. Basavar-
2.2. Vega (speed of the pulse) ajeeyam has used the term sthitva sthitva to explain the intermittent
pulse while explaining the qualities of sannipatha nadi [1]. As per
The speed of the pulse is another aspect which ayurveda has laid the texts nadi which is intermittent in nature and is sensed in the
much importance in understanding various physiological, psycho- locations other than the specified place indicates to be fatal which
logical and pathological states of the person. According to Sar- may lead to early death of the patient. Basavarajeeyam [1] and Yoga
angadhara and Bhavaprakasha [2,4], the increase in lust and anger Ratnakara [3] have termed it as asadhya nadi and as per Basavar-
result into fast nadi and on the other hand nadi will be slow due to ajeeyam it is the nature of mrityu nadi also. The stability of the pulse
the increase in sorrow and fear. Sarangadhara has related the speed
of the nadi to digestive fire and said nadi will be fast when the
digestive fire is active and will be slow when the digestive fire is Table 1
Longitudinal studies on aortic and carotid stiffness.
weak. Traditionally ayurveda doctors used to assess speed of the
pulse from nadi but now with the advent of bio medical in- Measurement site Type of patient (Reference) Follow Mean
struments measuring the speed of pulse has become simple and up (years) age
sophisticated. The pulse rate is well known measure of the speed of Aortic PWV (Regional End Stage Renal Disease [19] 6 51
pulse and has been widely used in clinical practice which gives arterial stiffness) Hypertension [21] 9.3 50
initial assessment of state of the health but warrants the need for Elderly (>70) [20] 2.5 87
End Stage Renal Disease [48] 5.2 55
further investigations to diagnose the disease. Pulse wave velocity Hypertension [29] 5.7 51
is another parameter with significant research interest and can be Impaired Glucose Tolerance [49] 10.7 51
associated to vega and there is a need to study this parameter in the Hypertension [50] 7.9 51
context of ayurveda. Elderly [51] 4.6 74
General Population [15] 10 64
General Population [52] 9.4 55
2.2.1. Pulse wave velocity Elderly [53] 4.1 72
The blood flows faster in aorta compared to peripheral network Ascending aorta Recurrent acute Coronary Heart 3 55
and the speed varies from meters per second in aorta to mm per (invasive) Disease [54]
second in peripheral network. The velocity of the pulse wave is Carotid stiffness End Stage Renal Disease [55] 2.1 58
(local stiffness) End Stage Renal Disease [56] 7.9 43
termed as pulse wave velocity (PWV) and normally ranges from 5
P.V.G. Kumar et al. / Journal of Ayurveda and Integrative Medicine 10 (2019) 308e315 311
also depends on various physiological and psychological states of The stiffness index (SI) is a measure of arterial stiffness and is
the person. According to Sarangadhara Samhita nadi will be strong measured from radial artery which closely corresponds to the
and steady in healthy persons and the nadi of a hungry person will volume pulse measured using photoplethysmograph (PPG). The SI
be irregular when compared to that of a person who has just taken measured from digital volume pulse (DVP) of PPG is strongly
the food [4]. associated to cardiovascular risk score emphasizing the significance
of its utility in cardiovascular risk stratification [30]. In our previous
2.3.1. Pulse rate variability study we have seen that the SI measured from radial artery using
Traditionally rhythm of the pulse is felt from the palpation of the Nadi Tarangini, a pulse acquisition system, has shown significantly
pulse which is more qualitative in nature but with instruments it is high values at vata location for diabetes compared to non-diabetes
possible now to acquire the pulse as time series enabling the and SI was negatively correlated to fasting plasma glucose in non
rhythm of the pulse to be analyzed in quantitative manner. In the diabetes subjects [31]. The study has shown SI at pitta location was
recent past there is a growing research interest in studying pulse significantly high compared to vata and kapha locations which
rate variability (PRV) as surrogate marker of heart rate variability might be due to the fact that the average age of the subjects both in
(HRV) [22e24]. There are no equivalent terms in traditional texts diabetes and non-diabetes groups is around 50 years a pitta
which can be compared with PRV but intermittent nadi can be dominant age. Nadi Tarangini has three linearly placed pressure
closely associated to PRV as the nature of intermittent nadi can be transducers which can be placed on the Tridosha locations of radial
well understood by looking into pulse rate variability and missing artery and the pulse will be acquired from vata, pitta and kapha
peaks, beat to beat alterations in pulse interval are some of the locations. The advantage of such a system is that the arterial stiff-
important parameters which can explain the intermittent nadi. The ness measured from three locations can be analyzed simulta-
beat to beat alterations of the pulse wave acquired using Nadi neously and initial studies with Nadi Tarangini have shown that the
Tarangini showed significant variations across different age groups arterial stiffness varies significantly across vata, pitta and kapha
and disorders [25]. The arterial pulse intervals (API), analyzed locations. The pressure wave as it propagates from central to pe-
across time domain, frequency domain and non linear measures ripheral arteries gets amplified at peripheral artery due to multiple
showed significant variations across age and disorders [26]. The reflections from various reflection sites and the reflection sites are
stability or rhythm of the pulse has a significant role in Nadi Par- closer to peripheral arteries when compared to central arteries. As a
iksha but there was no detailed description in the texts about its result due to the pulse amplification, peripheral arteries do not give
association with Tridoshas. As the pulse acquisition has become accurate results in cardiovascular studies and hence the arterial
much more sophisticated there is a need to study the association of stiffness measured from peripheral arteries was not used as a sur-
pulse rate variability with Tridoshas. An indepth study of inter- rogate for aortic and carotid stiffness [17] and there are very limited
mittent nadi is the need of the day as it is considered to be serious cardiovascular studies with radial artery. As radial artery plays a
as per the texts and extending PRV analysis to Tridoshas can be a major role in ayurveda, SI measured from radial artery can be
significant step in Nadi Pariksha. considered as significant parameter in Tridosha analysis. As the
significance of arterial stiffness is well understood from the texts of
2.4. Kathinya (hardness of artery) ayurveda and also from the recent studies, there is a need to study
the arterial stiffness in the context of Tridosha analysis.
The hardness of the artery is closely associated to kathinya and
only Basavarajeeyam has discussed the nature of kathin nadi in 3. Pulse locations
detail [1]. As per Basavarajeeyam vata nadi will be hard and the
hardness of the artery has been explained with the words kathor Ayurveda has laid much emphasis on sensing the pulse at radial
and kathin whereas the hardness of the artery due to pitta and artery primarily to assess doshas but it has not limited the pulse
kapha doshas was not mentioned. The hardness (kathin) and location to just radial artery but has clearly defined that the pulse
roughness (khara) of the artery corresponds to vata dosha as per can be sensed from eight locations. The classical text Basavar-
ayurveda and Basavarajeeyam compared vata nadi with string of ajeeyam has mentioned about eight locations to sense nadi and
veena which signifies the hardness of the vata nadi. The blood flow accordingly there are two at radial artery, two at ankle, two at neck
in hardened arteries will be fast compared to normal arteries which region and two at nasal region [1]. It is also mentioned that the
implies that vata pulse will be fast which is in agreement with knowledge of vata, pitta and kapha doshas can be obtained from
ayurveda. According to Basavarajeeyam if nadi is kathin, very slow radial artery and Nadi Pariksha based on radial artery has been
moving in a curved manner, if it is displaced from its original po- widely practiced as it is important to assess Tridoshas for any dis-
sition then it is considered as mrityu nadi and is an indicator for ease diagnosis and treatment. Though radial artery plays a major
early death of the patient. role in disease diagnosis and treatment, nadi at neck and nasal
regions was also considered as important nadi in diagnosis and
2.4.1. Arterial stiffness prognosis of disease. The fear, sorrow, anger, lust and fever are
The arteries stiffen due to age and atherosclerosis and recently some of the symptoms which can be sensed from the nadi at neck
the arterial stiffness measured from pulse wave velocity (PWV) has and similarly the diseases pertaining to head, eyes and ears can be
gained significant research importance as it is considered to be diagnosed from the nadi at nose. The status of life and health, fever
strong predictor of cardio-vascular events [16,27] and Alberto et al. and its relief are sensed from nadi at ankle. It is evident from the
have discussed in detail the role of arterial pulse wave analysis in literature of Ayurveda that nadi pariksha has a major role in disease
cardiovascular risk assessment [28]. A longitudinal study by Bou- diagnosis and is not limited to radial artery but extended to other
touyrie provides the first direct evidence that the aortic stiffness is arteries.
an independent predictor of primary coronary events in hyper- As per modern physiology pulse is palpated at radial, carotid,
tensive patients [29] and in another independent study by Laurent, femoral, brachial and ankle arteries and this is in line with the
the aortic stiffness is confirmed to be in an independent predictor description in ayurveda except that there was no mention of
of all cause and cardiovascular mortality in hypertensive patients femoral artery in ayurveda and arteries at nasal region in modern
[21]. The pulse wave velocity, a surrogate measure of arterial physiology are not highlighted. The significance of radial artery
stiffness, closely corresponds to the description of mrityu nadi. based pulse diagnosis is well understood in ayurveda and has been
312 P.V.G. Kumar et al. / Journal of Ayurveda and Integrative Medicine 10 (2019) 308e315
widely practiced but the nadi at other locations are not explored 4.2. Carotid femoral pulse wave velocity (cfPWV) measuring
much. On the other hand the radial artery has a very limited role in instruments
modern medicine and is limited to just measuring the pulse rate
whereas they have given much emphasis on carotid, femoral, There are number of devices available today to measure the pulse
brachial and ankle arteries which were widely used in measuring wave velocity using cfPWV technique. Complior from Alam Medical,
the pulse wave velocity. SphygmoCor from Atcor Medical, PulsePen from Dia Tecne, Vasera
from Fucuda Denshi Co Ltd, Vicorder from Skidmore Medical Ltd are
4. Pulse measurement techniques and instruments some of the instruments used for measuring the pulse wave velocity
[34]. Complior and SphygmoCor are widely used in PWV based
The pulse parameters and their analysis play key role in disease studies [35] and the way pulse transit time and distance between
diagnosis in both ayurveda and modern medicine. In the evidence arteries are computed varies between these two devices.
based research, pulse measurement techniques and the in- The Complior (Alam-Medical, France) is based on pressure
struments used for such measurements are very critical. There are transducers and the pulse at carotid and femoral arteries is ac-
multiple pulse measurement techniques for assessing arterial quired simultaneously. The correlation algorithm is applied be-
stiffness from central and peripheral arteries. The pulse wave ve- tween the two simultaneous pulse recordings to determine the
locity and stiffness index are measures of arterial stiffness and pulse transit time. The distance traveled by pulse is obtained by
techniques are developed to assess arterial stiffness from pulse directly measuring the distance between carotid and femoral ar-
wave velocity and stiffness index. The standard pulse wave velocity teries [32,35].
measurement techniques are carotid femoral pulse wave velocity In the SphygmoCor system (Artcor, Sydney, Australia) high fi-
(cfPWV) and brachial ankle pulse wave velocity (baPWV). The ca- delity applanation tonometers are used for pulse acquisition and
rotid and femoral arteries are used for pulse wave velocity mea- the pulse is acquired at carotid artery along with the ECG recording
surement in carotid femoral pulse wave velocity (cfPWV) technique followed by femoral pulse acquisition with simultaneous ECG
whereas brachial and ankle arteries are used for pulse wave ve- recording. The pulse transit time is computed by subtracting the
locity measurement in brachial ankle pulse wave velocity (baPWV) time difference between ECG and carotid pulse peak from the time
technique. Stiffness Index (SI) is measured from the radial artery. In difference between ECG and femoral pulse peak. The distance
this section pulse measurement techniques and instruments used traveled by the pulse is computed by subtracting the distance be-
for measurement were discussed. tween sternal notch to carotid artery from the distance between
sternal notch to femoral artery [32,35].
4.1. Carotid femoral pulse wave velocity (cfPWV) technique The PulsePen [34] is another device which uses two methods in
assessing the pulse wave velocity. In the first method two tonom-
The measurement of pulse wave velocity using carotid femoral eters are used and the pulse is acquired simultaneously at both
pulse wave velocity is the standard technique and is considered to carotid and femoral arteries. This is similar to the method used in
be non invasive, robust and reproducible method for assessing the Complior. In the second method only one tonometer is used
arterial stiffness [32]. The carotid femoral pulse wave velocity wherein pulse is acquired from carotid and femoral arteries sepa-
(cfPWV) has gained significant research interest in the recent past rately and synchronized with ECG. This method is similar to
and the pulse wave velocity measured with cfPWV technique is SphygmoCor.
considered as gold standard [18]. In cfPWV technique pulse wave The Vasera [34] uses cardio-ankle vascular index (CAVI) as an
will be obtained at carotid and femoral arteries and the distance index for arterial stiffness measurement but this device needs
between these two arteries will be recorded. The pulse wave ve- further validation. The Vicorder [34] is similar to Complior but the
locity, a surrogate measure of arterial stiffness, is considered as the algorithms used are not clear and this device also needs further
ratio of distance between carotid and femoral arteries to the time validation.
taken for the pulse to travel from carotid to femoral arteries [32]. There are many other devices and methods used in assessing
arterial stiffness and the abridged version of expert consensus
Pulse Wave Velocity ¼ Distance/pulse transit time from carotid to document on arterial stiffness has summarized them [32]. Apart
femoral from the standard non imaging techniques the ultrasound and
Magnetic Resonance Imaging (MRI) are the imaging methods used
The advantage with the cfPWV is that it is a gold standard but in assessing pulse wave velocity using which the path length can be
the process of measuring the arterial stiffness requires good directly measured which is the biggest advantage but is very
amount of skill in acquiring the pulse [33]. The cfPWV technique is expensive solution [36]. Recently many devices have come to the
a non invasive, robust and reproducible method and is widely used market but it is important to verify the scientific validity of such
in epidemiological studies [32]. instruments before using them in research [34].
The pulse transit time and measurement of distance between
carotid and femoral arteries need to be understood while assessing 4.3. Brachial ankle pulse wave velocity (baPWV) technique
pulse wave velocity using cfPWV. The pulse transit time is
measured using foot to foot method wherein foot is considered to The brachial ankle pulse wave velocity (baPWV) is another
be the end of the diastole. The distance between carotid and technique introduced in Japan in 2000 to measure the pulse wave
femoral arteries is measured physically and is considered as an velocity from brachial and ankle arteries [37] The complexities
estimate of the true distance traveled by the pulse wave but the involved in arterial stiffness measurement with cfPWV technique
inaccuracies in the distance measured may lead to errors in the have been addressed in baPWV. The pulse wave velocity is
absolute value of PWV. As the true distance traveled by the pulse is measured in baPWV by connecting volume plethysmographic
critical for PWV it is recommended that the distance from carotid sensors to the cuffs connected to brachial and ankle locations. The
artery to sternal notch is subtracted either from the total distance pulse wave velocity is computed as the ratio of virtual arterial
between carotid and femoral arteries or from the distance between length between these two arteries to the pulse transit time from
sterna notch to femoral artery [32]. brachial to ankle arteries [37]. The virtual arterial length is
P.V.G. Kumar et al. / Journal of Ayurveda and Integrative Medicine 10 (2019) 308e315 313
estimated from the height of the subject which eliminates the need
for physically measuring the distance between arteries [38].
The virtual arterial length is computed as shown below.
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