Practical semantics of "heart rate" and "pulse"

As part of further exploration of the problem space discussed in this topic, we’ve run into question on clinical semantics that we can’t answer ourselves, so I’d like to ask the community for their opinions and observations:

We know it’s fairly common to use the phrase “heart rate” to name measurements which in reality measures the (peripheral) pulse.

But are there any cases where the word “pulse” is used to name measurements which in reality measures the (central) heart rate? Exclude the devices often called “pulse belts”, since these are devices and not a measurement practice in general.

Hi Silje

As a clinical member of this community, I’ll share my point of view on this issue.

In clinical practice, arterial pulse rate measurements are commonly used to infer the heart rate. Other than that, I can’t find any similarities between both concepts, and would thus recommend modeling them as different archetypes.

There is, however, at least in Portugal, a common - but wrong, IMHO - confusion of terms, mainly in non-clinical scenarios. On clinical grounds, and specially in clinical informatics, disambiguation is critical.

Best regards,

A terça, 21/05/2024, 12:19, Silje Ljosland Bakke via openEHR <discourse@openehr.org> escreveu:

1 Like

Hi Silje

People do all sorts of strange things, so inevitably, someone, somewhere, will use the term ‘pulse’ when actually referring to ‘ventricular rate’. I cannot think of any consistent clinical scenarios or processes where this may happen.

Does that matter from a modelling perspective? If someone wants to call VR ‘Pulse’ then they could change the name in a Template. We should clearly refer to the thing we are measuring in the archetype though. As @Leuschner states, disambiguation is our job. The clinician can ‘re-ambiguate’ if they really feel the need for their specific use case!

As I was thinking about this issue - separation of pulse rate from ‘heart rate’ - Atrial Fibrillation probably presents the classic use case where the peripheral pulse rate may/will not correspond to the Apical/Ventricular rate. That probably does increase the value in separating these things out. VR can be measured from clinical examination, whereas Atrial Rate can only really be determined from ECGs.

‘Heart rate’ is itself an ambiguous term, because hearts have Atrial Rates and Ventricular Rates.

I am not a cardiologist, by way of disclaimer!

Paul

Here a reference:

Blockquote * Radial-apical deficit: this is important to assess because each ventricular contraction may not be sufficiently strong enough to transmit a pulse to the radial artery and palpating only the radial artery can miss tachycardia."

:speech_balloon:2 - Atrial Fibrillation (AF) | AF | Summary | Geeky Medics

"

I fully endorse this statement. One of the usual situations in which central pulse and peripheral pulse must be distinguished is in peripheral arterial disease. For example in an acute right femoral arterial embolism, there will be no peripheral pulse in the right lower extremity, but there will be a central pulse and a peripheral pulse in the rest of the extremities.

Thanks for re-opening this discussion @Silje, as I think this is does require quite careful consideration, and thanks to the others contributors on the thread.

I doubt if there is much disagreement that physiologically (or from a biomedical ontology pov) , these concepts are quite different

  1. Electrical heart rate
  2. Heart beat
  3. Pulse as a proxy for heart rate/heart beat and sometimes rythm. It may be taken peripherally but only if it is felt to be a accurate reflection of 1 and/or 2 above
  4. Peripheral pulse as a measure of that peripheral pulse itself, not as a proxy of 1 and/or 2. I think that is
    already explicitly out of scope of the current and proposed archetypes.

And of course there are very definitely clinical situations where 1,2,3 are disassociated and do need to be measured/labelled explicitly.

However, and I think at the core of Silje’s question, is the issue that by ‘volume of recording’, these kinds of events are extremely rare and that in the vast majority of cases where ‘pulse’ or ‘heart rate’ is measured, clinical recording practice makes no distinction. I had a look for example paper ‘vital signs
charts’ on Google and of the first 10 that I found, 8 described ‘pulse’ and 2 described ’ heart rate’. None talked about ‘heart beat’.

Even more specialised ICU charts talk about heart rate with no separate category for ‘heart beat’ or ‘pulse’.

So ‘routine recording practice’ very much blurs the different physiological concepts of heart rate, pulse and heart beat , mostly for the very good reason that they are, in practice, only very rarely disassociated.

I would prefer to find a means of accepting that ‘blurred’ reality of clinical recording practice, whilst allowing the disassociated concepts to be used, in the more rare circumstances that these are needed.

A very typical trajectory of ‘pulse’ recording might be a manual pulse, then a pulse oximeter is used to record ‘pulse’ then a single lead ECG is applied and measures heart rate.

‘Heart beat’ as the base concept does make some sense but paradoxically, in low tech environments, it is much more likely to be captured using a peripheral pulse or oximeter, with the need to record location or body position etc. If the new designs are accepted, I would probably recommend that people use the pulse specialisation be default, otherwise both heart beat and pulse specialisation will need to be carried in every simple vital signs template to cope with switching between the various measurement modalities.

I’d much prefer the base archetype to be extended so that it could be used for all the modalities, and then if required could be explicitly templated/specialised for the edge cases where the concepts are actually disassociated.

Of course, we need to be able to capture unusual clinical conditions, but I think we need to be able to reflect the ‘ontology of clinical record-keeping’ as well as the ‘ontology of biomedical concepts’.

2 Likes

I have just spoken to professor Hisdal OUH - Scientists (ous-research.no) in my hospital, and he’s quite clear that we should represent heart rate and pulse on scientific grounds, as separate concepts.

The pulse tells us more than the heart rate (sorry for my layman English on the medical phrases):

  • Indirectly the blood volume
  • Indirectly how the heart pumps
  • Indirectly on dilatation/constriction of vessels
  • Occlusion
  • Ruptured/torn vessel

In addition, the pulse wave has more information, as analysis of the amplitude to calculate stroke volume, peripheral resistance, etc.

See the proposed solution in the other thread: https://discourse.openehr.org/t/heartbeat-and-pulse/5092/26