The measurement of blood pressure and hypertension. Handout Fenyvesi Tamás III.Department of Medicine

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1 The measurement of blood pressure and hypertension Handout Fenyvesi Tamás III.Department of Medicine 1

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3 History of the blood pressure measurement direct Stephen HALES 1726 horse carotid indirect Riva-Rocci Scipione 1896 inflatable bladder Korotkoff 1905 auscultation KopoткoвъНиколайСергеевич 3

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5 3 The Korotkoff phases I. Appearance of the first tapping sound II. Murmur is heard III. The sounds are crisper and increase in intensity IV. Distinct, definite muffling of the sound V. Disappearance of the sound 5

6 Technique of measurement systolic bp : the first phase diastolic bp : the fifth phase it used to be a matter of debate the equipment sphygmomanometer rubber bladder and covering cuff ( mercury, aneroid,electronic) width % of arm circumference if too narrow overestimates if too wide underestimates length 80% of arm circumference 6

7 1.quiet environment, 5 minute rest 2. Arm at heart level 3. Manometer at eye level 4. Locate brachial artery by palpation 5. Center the bladder over brachial artery,the lower margin 2,5 cm above antecubital space 6. Inflate the bladder and determine the disappearance of the radial pulse 7. Rapidly deflate 7

8 8.. Position the stethoscope over the palpated brachial artery 9. Inflate rapidly 30 mmhg above determined level 10. Release the cuff at 2-3 mmhg/s speed 11. Note the systolic BP at the onset of two consecutive beats (Korotkoff I ) 12. Note muffling : Korotkoff IV disappearance : Korotkoff V as diastolic pressure repeat after 2 minutes!! measure by even digits (note the scale!) right down before you forget!!!! 8

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10 Recording the pressure and the auscultatory gap: range of Korotkoff sounds 10

11 Determining the palpated systolic pressure and the maximum inflation level 11

12 Blood pressure cuff placement and pulse detection Figures from: 12

13 The blood pressure cuff and arm circumference 13

14 Blood pressure cuff sizes, arm circumference ranges, and bladder widths and lengths Blood pressure cuff sizes, arm circumference ranges, and bladder widths and lengths CUFF SIZES ARM CIRCUMFERENCE RANGE AT MIDPOINT, cm BLADDER WIDTH, cm Newborn >6 3 6 Infant Child Small adult Adult Large adult Adult thigh BLADDER LENGTH, cm 14

15 Calibrating the manometer 15

16 Measurement of blood pressure in the clinic 16

17 Interpretation of ABI > 1,30 noncompressible 0,95-1,30 normal 0,41-0,90 mild-to-moderate peripheral arterial disease 0,00-0,40 severe peripheral arterial disease 17

18 1979 NY 18

19 Skills a good blood pressure observer must have 19

20 The measurement is subjective 1. the observer : hand-eye-ear differences 2. the patient : environment, time of the day 3. Interaction : white-coat hypertension" 4. Equipment : calibration, random zero etc 5. ABPM : 24 hours monitoring Special pitfalls: absent phase V, auscultatory gap arrhythmias, obesity Measure on both arms and leg supine and standing 20

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22 My results mean of 41 measurements Which was the right measurement? No answer!! Such is the method. 22

23 Special pitfalls absent phase V: aortic insufficiency auscultatory gap arrhythmias, obesity Measure on both arms and one leg supine and standing In outpatients : sitting, on the right arm 23

24 10 Classification of hypertension by JNCVI (1997) class systolic diastolic optimal <120 <80 normal <130 <85 high normal hypertension 1 stage stage stage > 180 > 110 This is the presently accepted classification 24

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32 Blood pressure thresholds (mmhg) for definition of hypertension with different types of measurement SBP DBP Office or clinic hour Day Night Home

33 Aetiological classification of hypertension 11 A. Essential hypertension >90% prevalence 10-20% B.Renal hypertension 1. parenchymal: acut glomerulonephritis, chr.nephritis, pyelonephritis 2. renovasular fibromusc., atheroscler 3. trauma: periren haematoma, art.ren thr.,dissection 33

34 . C.Endocrine 1. thyroid : hyperthyreosis 2. adrenal gland :phaeo,primery hyperaldo, congen hyperplasia, Cushing sy D. Neurogenic: brain tumor, resp acidosis, encephalitis E. Mechanical: coarctation of aorta, AI F. gravidity G. mixed: polycythaemia vera,carcinoid sy burning 34

35 A hypertension as a risk factor Cardiac hypertrophy, coron disease, infarction Vascular: aortic sclerosis, aneurysm, dissection peripheral arteries, carotid!!! Kidney: decrease of GFR, renal failure Neurological: encephalopathy, stroke!!! Retinal: retinopathy 35

36 Prevalence of isolated systolic and diastolic blood pressure by age and gender 36

37 Rate and proportion of cardiovascular disease events by systolic blood pressure level 37

38 Risk of myocardial infarction with isolated systolic hypertension in men 38

39 Impact of pulse pressure at specified levels of systolic blood pressure 39

40 Stroke probability in mildly hypertensive men according to associated risk factors 40

41 Risk of peripheral arterial disease by systolic blood pressure and diabetic status 41

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44 A most serious epidemy.unresolved problems Estimated No. of hypertensives in the USA: 41,9 M (RR > 140/90!!) unaware of 31% 13,1 M aware but not treated 17% 7,0 M inefficiently treated 29% 12,0 M well treated 23% 9,7 M 19% of population 65 years, still 45% of all patient who are unaware, are in this age group. ( NEJM 2001;345: ) 44

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46 Association of heart rate with mortality in hypertensive men 46

47 Cardiovascular disease rates in women according to echocardiogram-left ventricular hypertrophy and hypertensive status 47

AFFORDABLE TECHNOLOGY

World Health Organization AFFORDABLE TECHNOLOGY BLOOD PRESSURE MEASURING DEVICES FOR LOW RESOURCE SETTINGS CARDIOVASCULAR DISEASES Blood Pressure Measurement in Low Resource Settings Annex 1: Blood Pressure