1

The measurement of blood pressure and hypertension

Handout Fenyvesi TamásIII.Department of Medicine

2

3

History of the blood pressure measurement

directStephen HALES 1726 horse carotid

indirectRiva-Rocci Scipione 1896 inflatable

bladder

Korotkoff 1905 auscultationKopoткoвъ Николай Сергеевич

4

5

The Korotkoff phases

I. Appearance of the first tapping sound

II. Murmur is heard

III. The sounds are crisper and increase inintensity

IV. Distinct, definite muffling of the sound

V. Disappearance of the sound

3

6

Technique of measurement

systolic bp : the first phasediastolic bp : the fifth phase

it used to be a matter of debatethe equipment

sphygmomanometer rubber bladder and covering cuff( mercury, aneroid,electronic)

width 40-50 % of arm circumferenceif too narrow overestimatesif too wide underestimates

length 80% of arm circumference

7

1.quiet environment, 5 minute rest

2. Arm at heart level3. Manometer at eye level

4. Locate brachial artery by palpation5. Center the bladder over brachial artery,the

lower margin 2,5 cm above antecubital space6. Inflate the bladder and determine the

disappearance of the radial pulse

7. Rapidly deflate

8

.8. Position the stethoscope over the palpatedbrachial artery

9. Inflate rapidly 30 mmHg above determinedlevel

10. Release the cuff at 2-3 mmHg/s speed11. Note the systolic BP at the onset of two

consecutive beats (Korotkoff I )12. Note muffling : Korotkoff IV

disappearance : Korotkoff Vas diastolic pressure

repeat after 2 minutes!!measure by even digits (note the scale!)right down before you forget !!!!

9

10

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

11

Determining the palpated systolic pressure and the maximum inflation level

12

Blood pressure cuff placement and pulse detection

Figures from: www.images.med

13

The blood pressure cuff and arm circumference

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 BLADDER LENGTH, cm

Newborn >6 3 6 Infant 6-15 5 15 Child 16-21 8 21 Small adult 22-26 10 24 Adult 27-34 13 30 Large adult 35-44 16 38 Adult thigh 45-52 20 42

15

Calibrating the manometer

16

Measurement of blood pressure in the clinic

Interpretation of ABI

17

> 1,30 noncompressible0,95-1,30 normal0,41-0,90 mild-to-moderate peripheral

arterial disease0,00-0,40 severe peripheral arterial

disease

18

1979 NY

19

Skills a good blood pressure observer must have

20

The measurement is subjective

1. the observer : hand-eye-ear differences2. the patient : environment, time of the day3. Interaction : “white-coat hypertension"4. Equipment : calibration, random zero etc5. ABPM : 24 hours monitoring

Special pitfalls: absent phase V, auscultatory gaparrhythmias, obesity

Measure on both arms and legsupine and standing

21

22

My results mean of 41 measurements

Which was the right measurement?No answer!! Such is the method.

23

Special pitfalls

absent phase V: aortic insufficiencyauscultatory gaparrhythmias,obesity

Measure on both arms and one legsupine and standing

In outpatients : sitting, on the right arm

24

Classification of hypertension by JNCVI (1997)

class systolic diastolic

optimal <120 <80normal <130 <85high normal 130-139 85-89

hypertension1 stage 140-159 90-992 stage 160-179 100-1093 stage > 180 > 110

This is the presently accepted classification

10

26

27

282003

29

30

31

32

Blood pressure thresholds (mmHg) for definition ofhypertension with different types of measurement

SBP DBP

Office or clinic 140 9024-hour 125–130 80Day 130–135 85Night 120 70Home 130–135 85

33

Aetiological classification of hypertension

A. Essential hypertension >90%prevalence 10-20%

B.Renal hypertension1. parenchymal: acut glomerulonephritis,

chr.nephritis, pyelonephritis2. renovasular fibromusc., atheroscler3. trauma: periren haematoma,

art.ren thr.,dissection

11

34

.C.Endocrine

1. thyroid : hyperthyreosis2. adrenal gland :phaeo,primery hyperaldo,

congen hyperplasia, Cushing syD. Neurogenic: brain tumor, resp acidosis,

encephalitisE. Mechanical: coarctation of aorta, AIF. gravidityG. mixed: polycythaemia vera,carcinoid sy

burning

35

A hypertension as a risk factor

Cardiachypertrophy, coron disease , infarction

Vascular:aortic sclerosis , aneurysm, dissectionperipheral arteries, carotid !!!

Kidney:decrease of GFR, renal failure

Neurological: encephalopathy, stroke !!!Retinal: retinopathy

36

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

37

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

38

Risk of myocardial infarction with isolated systolic hypertension in men

39

Impact of pulse pressure at specified levels of systolic blood pressure

40

Stroke probability in mildly hypertensive men according to associated risk factors

41

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

42

43

44

A most serious epidemy.Unresolved problemsEstimated No. of hypertensives in the USA: 41,9 M(RR > 140/90!!)unaware of 31% 13,1 Maware but not treated 17% 7,0 Minefficiently treated 29% 12,0 Mwell 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;345:479-486)

45

46

Association of heart rate with mortality in hypertensive men

47

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