CURHAN Base Protocol Cardiovascular Assessment

Adapted from Framingham Heart Study 2013



Essential Equipment

  1. Standard blood pressure cuffs – regular and large
  2. Stethoscope tubing with earpieces and bell, specific manufacturer to be determined but must be moderate quality
  3. Electrocardiograph
    1. MAC 5000 (General Electric) is standard
    2. Leads for acquisition
    3. Adhesives for lead placement
    4. Optimal: CD for storage of digitized ECGs

Blood Pressure Measurement Protocol

1. Equipment:

  • One standard stethoscope tubing and earpieces with bell.
  • One standard mercury column sphygmomanometer:
  • BP cuffs.

2. Blood Pressure Cuff Placement:

  • Bare participant’s left arm to above the point of the shoulder.
  • Determine correct cuff size using guidelines inside the cuff.
  • Palpate the brachial artery.
  • With participant seated, place the appropriate cuff around the upper left arm. The midpoint of the length of the bladder should lie over the brachial artery.  Each cuff has an artery marker. The mid-height of the cuff should be at heart level.
  • Place the lower edge of the cuff, with its tubing connections, about 2.5 centimeters (2.5 cm) above the natural crease across the inner aspect of the elbow.
  • Wrap the cuff snugly about the arm, with the palm of the participant’s hand turned upward.
  • If the subject has had a left-sided mastectomy, the right arm may be used for blood pressure measurement. If right arm is used, note it on the form.

3. Determination of Maximal Inflation For each participant, determine the maximal inflation level, or the pressure to which the cuff is to be inflated for blood pressure measurement. This assures that the cuff pressure at the start of the reading exceeds the systolic blood pressure and thus allows the first Kortokoff sound to be heard.

  • Attach the cuff tubing to the
  • Palpate the radial
  • Inflate the cuff rapidly until the radial pulse is no longer felt (palpated systolic pressure) by inflating rapidly to 70 mmHg, then inflating by 10 mmHg
  • Deflate the cuff quickly and
  • The maximal inflation level is 30 mmHg above the palpated systolic

4. Guidelines for Accurate Blood Pressure Readings:

  • When the pressure is released quickly from a high level, a vacuum is formed above the mercury and the meniscus is Allow a few moments for it to reappear before reading the manometer.
  • All readings are made to the top of the meniscus, the rounded surface of the mercury
  • Any reading which appears to fall exactly between marking on the mercury column should be read to the next higher marking (i.e. 2, 4, 6, 8, or 0).
  • All readings are made to the nearest even
  • The participant should be in a seated position for at least 5 minutes before the blood pressure is

5. Blood Pressure Readings:

  • Following any previous inflation, wait at least 30 seconds after the cuff has completely
  • By closing the thumb valve and squeezing the bulb, inflate the cuff at a rapid but smooth continuous rate to the maximal inflation level (30 mmHg above the palpated systolic pressure).
  • The examiner’s eyes should be level with the mid-range of the manometer scale and focused at the level to which the pressure will be
  • Open the thumb valve Allow the cuff to deflate, maintaining a constant rate of deflation at approximately 2 mmHg per second.
  • Using the bell of the stethoscope, listen throughout the entire range of deflation, from the maximum pressure past the systolic reading (the pressure where the FIRST regular sound is heard), until 10 mmHg BELOW the level of the diastolic reading (that is, 10 mmHg below the level at which the LAST regular sound is heard).
  • Deflate the cuff fully by opening the thumb
  • Remove the Neatly enter systolic and diastolic readings in the spaces provided on the form.

Electrocardiography Protocol

    1. A resting standard 12-lead electrocardiogram (ECG) will be acquired on all study participants using the (GE MAC 500) portable
    2. The ECGs will be recorded according to a standardized study protocol developed by an ECG reading center (EPICARE) and used in previous NHLBI studies.
    3. The records will ideally be transmitted electronically via modem for central
    4. A local ECG screening of the ECG printout for specific abnormalities that require urgent referral will be conducted by trained personnel at the study sites.
    5. ECGs will be recorded after a 12-hour fast and at least one hour after smoking or ingestion of
    6. The ECG recordings will serve to establish the distribution of cardiovascular disease findings (including myocardial infarction, left ventricular hypertrophy, ischemia, prolonged QT interval, and arrhythmias) as well as the development of subclinical ECG findings that are determined to be associated with a poor
    7. The ECG reading center will report classification of ECG abnormalities using Minnesota Code as well as providing continuous measures of the ECG waveforms.
  1. ECG Acquisition
    1. Electrocardiograph
      1. To be determined.
      2. All ECG technicians should become familiar with an operator’s manual.
    2. Equipment and Supplies
  •  HeartSquare
  • Modem or Telephone jack cable for ECG transmission
  • Felt tip non-toxic washable markers
  • ECG paper
  • electrodes
  • Alcohol swabs
  • gauze pads
  • Cotton surgical tape
  1. Preparation for ECG Recording
    1. All ECGs will be conducted on participants while fasting at least 8 hours (overnight fasting).
    2. Examination table/bed should be adequate to comfortably accommodate the
    3. Supply drape for exposed upper
    4. An additional covering may be needed to prevent the participant from becoming
    5. Make sure ankles and wrists are accessible for electrode
    6. ECG electrode placement should be performed with the technician standing to the participant’s left
    7. Reference guide for “Participant Data Entry” instructions (Needs to be developed) should be available to insure
    8. Supplies needed for ECG acquisition should be assembled and arranged
  2. Location of the ECG This involves location of limb electrodes and chest electrodes. Limb electrodes (Figure 1)
  3. RIGHT AND LEFT LEGS(Figure 1)


On the inner side of the right leg (RL), above the ankle, rub briskly an area about 1-2 inches in diameter with an alcohol swab using firm, circular motions.  Mark the position to place the electrode later. Repeat this procedure for the left leg (LL).

In amputees, the leg lead electrode may be placed higher up on the torso.


Rub the inner side of the right arm (RA) above the wrist similar to what you did with the right and left legs. Mark the position to place the electrode later.    Repeat the process for the left arm (LA).  In amputees, the arm electrode may be placed on the shoulder, below the clavicle.


  1. Location of Chest Electrodes
    1. The order of locating chest electrodes is V1 and V2, then V4 and V6, and finally V3 and V5.
    2. V1 and V2: First, locate the sternal angle about the width of your 3 middle fingers below the sternal notch. (Figure 2).
  • Mark a dot over the sternal angle. Feel the sternal angle between the index and middle fingers of your right hand, keeping the fingers wide apart and moving your fingers firmly up and down.
  1. While feeling the sternal angle, move your fingers to the left side of the sternum and feel the 2nd rib between your fingers where it joins the sternal angle.
  2. Move your middle finger to the interspace below the second rib and with your index finger locate the interspace below the next rib (3rd) and again below the next (4th) rib. This is the 4th intercostal space.
  3. Mark an X at this level at the midsternal line. X is the reference level for V1 and V2. Mark their locations at the right and left sternal border (Figures 2 and 3).

Figure 2


Figure 3


  • V4 and V6. From the location of V2, palpate with the middle finger of your right hand the intercostal space and follow it laterally outside the sternal border and at a slight angle down. Feel the 5th rib between your index and middle fingers and then feel the 5th intercostal space with your index finger. At the level of the 5th intercostal space, mark a + sign at the midsternal line below your x mark for V1-V2 level. This + is the reference level “E” for V4, V5, and V6 (Figure 2 and Figure 4).In overweight persons and in women with tender breast tissue, it is often difficult to locate the 5th intercostal space. In such a case, mark the + sign for E point 1 ¼ in (3 cm) below your reference level X for V1 and V2 (in smaller adults, 1 inch (2.5 cm) is enough).

Figure 4


  • APPROXIMATE LOCATION OF Move the left elbow laterally without moving it anteriorly or posteriorly, while observing the anterior and posterior axillary folds. The left elbow must be supported properly. Follow a line exactly in the vertical midplane of the thorax (mid-axillary line) down where the line meets the horizontal plane of E point. Using your marker, make a vertical 1-2 inch long line there as an approximate location of V6 (Figure 5).

Figure 5



Exact location of V6 is determined by using the HeartSquare. Place the HeartSquare horizontally with the wider arm (E arm) at level E point (Figure 6). Slide the V6 arm of the HeartSquare towards the midaxillary line until the arrow points to the mark at the midaxillary line. Mark the exact location of V6 at the level of the arrow on the V6 arm.

Figure 6



While keeping the HeartSquare in the horizontal position with the arrow on the V6 arm pointing toward the V6 position, observe the reading at E point. (Figure 6)

Use this E reading on the centimeter scale on the V6 arm, and follow this same E reading along the 45 degree lines towards the torso to locate the exact position of V4. (Figure 6 and Figure 7)

Now that you have located V6 and V4, secure the V6 arm with your thumb to prevent it from sliding. Note the V6 reading which is the distance from the arrow on the V6 arm to where this arm intersects the E arm at right angles. You may then remove the HeartSquare (Figure 7).

Enter the E and V6 measurements as three digits. Figure 7 shows that the E entry is 160 and the V6 entry is 120 for the readings of 16.0 cm and 12.0 cm, respectively. Enter the 160 for E in the height field of your Mac 1200 and 120 for the V6 measurement in the weight field (DO NOT ENTER THE HEIGHT AND WEIGHT OF THE PARTICIPANT)

Figure 7



Mark V3 exactly halfway between V2 and V4. Mark V5 exactly halfway between V4 and V6. (Figure 8)

Figure 8


  • Attaching the Electrodes.
    • After you have located electrode positions, rubbed them with alcohol swabs and gauze pads, you may apply the electrodes.
    • Attach lead wires in the same, correct order every time to establish routine and to eliminate lead swaps. Position the MULTI-LINK on the participant’s abdomen.
  • Grasp each lead at the MULTI-LINK attachment point.
  • Follow lead wire to the electrode attachment end.
  • Attach wire to electrode, making sure clip is not in contact with electrode adhesive.
  • Make sure lead wires have some slack and are hanging loosely.
  • You may secure the lead wire to the skin by applying paper tape 1-inch below the clip, especially if the ECG shows baseline noise despite careful preparation.


CURHAN Cardiovascular Assessment Protocol, March 9, 2016


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