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http://www.zora.uzh.ch
Year: 2010
Evaluation of high-definition and conventional oscillometricblood pressure measurement in anaesthetised dogs using ACVIM
guidelines
Wernick, M; Doherr, M; Howard, J; Francey, T
Wernick, M; Doherr, M; Howard, J; Francey, T (2010). Evaluation of high-definition and conventionaloscillometric blood pressure measurement in anaesthetised dogs using ACVIM guidelines. Journal of Small AnimalPractice, 51(6):318-324.Postprint available at:http://www.zora.uzh.ch
Posted at the Zurich Open Repository and Archive, University of Zurich.http://www.zora.uzh.ch
Originally published at:Journal of Small Animal Practice 2010, 51(6):318-324.
Wernick, M; Doherr, M; Howard, J; Francey, T (2010). Evaluation of high-definition and conventionaloscillometric blood pressure measurement in anaesthetised dogs using ACVIM guidelines. Journal of Small AnimalPractice, 51(6):318-324.Postprint available at:http://www.zora.uzh.ch
Posted at the Zurich Open Repository and Archive, University of Zurich.http://www.zora.uzh.ch
Originally published at:Journal of Small Animal Practice 2010, 51(6):318-324.
1
Evaluationofhigh‐definitionandconventionaloscillometricbloodpressuremeasurement1
inanaesthetiseddogsusingACVIMguidelines2
M.Wernick1,2,M.Doherr3,J.Howard4,5,T.Francey1,53
4 1SmallAnimalClinic,DepartmentofSmallAnimalinternalMedicine,VetsuisseFaculty,5
UniversityofBern,Switzerland6
7 2Currentaddress:ClinicforZooAnimals,ExoticPetsandWildlife,VetsuisseFaculty,8
UniversityofZurich,Switzerland9
10 3DepartmentofClinicalResearch&VeterinaryPublicHealth,VetsuisseFaculty,Universityof11
Bern,Switzerland12
13 4ClinicalLaboratory,DepartmentofVeterinaryMedicine,VetsuisseFaculty,Universityof14
Bern,Switzerland15
16 5Theseauthorscontributedequally17
18
Correspondenceto:MorenaWernick,ClinicforZooAnimals,ExoticPetsandWildlife,19
Winterthurerstr.260,8057Zurich,Switzerland,[email protected]
21
Runninghead:Evaluationofstandardandhigh‐definitionoscillometricdevices22
23
2
Summary23
24
Objectives:25
Toevaluatehigh‐definitionandconventionaloscillometryincomparisonwithdirectblood26
pressuremeasurementsinanaesthetiseddogs.27
Methods:28
Eightsimultaneousreadingsforsystolic,diastolicandmeanpressurewereobtaineddirectly29
andwitheachoftwodevicesin9anaesthetiseddogs.Measurementprocedureand30
validationwerebasedonthe2007ACVIMguidelines.31
Results:32
Sixty‐threesimultaneousreadingswereevaluatedforeachdeviceanddirectmeasurements.33
Themeandifferences(bias)todirectvalueswerewithin10mmHgforbothdevicesalthough34
biasforSAPandDAPwashigherforMemodiagnostic.Thestandarddeviationsofdifferences35
(precision)werewithin15mmHgforDinamapbutexceededforMemodiagnostic.36
CorrelationcoefficientswerehigherforDinamapthanMemodiagnosticbutbothfailedto37
reachacorrelationof0.9.Over50%ofvalueslaywithin10mmHgofdirectmeasuresfor38
bothdevicesbutthispercentagewasgreaterforDinamapthanMemodiagnostic.Over80%39
ofvalueslaywithin20mmHgofdirectmeasuresforDinamapbutnotforMemodiagnostic.40
Clinicalsignificance:41
BothdevicesfailedtomeetACVIMguidelinevalidation.However,Dinamaponlyfailedwith42
regardstocorrelation.Memodiagnosticfailedonseveralrequirementsand,basedonpoor43
correlation,accuracyandprecision,thisdevicecannotbecurrentlyrecommendedfordogs44
underanaesthesia.45
46
Keywords:47
Dog,bloodpressure,directarterialpressure,oscillometry,high‐definitionoscillometry,48
validation49
3
Introduction50
Theimportanceofdetectingalterationsinsystemicbloodpressure(BP)isincreasingly51
recognisedinveterinarymedicine.Asearlydetectionandtreatmentofhypertensionmay52
avertseriousandpotentiallyfatalsequela,measurementofBPindogsandcatsaffectedbya53
varietyofdisordersisfrequentlyperformedinclinicalpractice(Brownandothers2007,54
Habermanandothers2006).Inaddition,continuousBPmonitoringofdogsandcatsunder55
generalanaesthesiahaslongsincebecomeroutine,inparticularbecauseoftheimportance56
ofrecognisinghypotension(Sawyerandothers2004).Directintra‐arterialBPmeasurement57
istheacceptedgoldstandardbutisnotcommonlyusedinclinicalpracticebecauseitis58
technicallydemandingandinvasive.Instead,avarietyofnoninvasivedevicesarein59
widespreaduse(Brownandothers2007,DeflandreandHellebrekers2008,Grandyand60
others1992,Habermannandothers2006,Mandigers2005,Sawyerandothers2004,61
Stepienandothers2003).62
Cliniciansexpectthatcomparativestudiesshowingthatmeasurementsare63
meaningfulareperformedwhennewnoninvasiveBPdevicesareintroduced.Priorto64
evaluatingdevicesinconsciousclinicalpatients,initialstudiesareoftenperformed65
comparingresultswithdirectBPmeasurementsinanimalsunderanaesthesia(Bodeyand66
others1994,Gainsandothers1995,Geddesandothers1980,Meursandothers1996,67
Sawyerandothers1991,Sawyerandothers2004)butnospecificrequirementsfor68
validationofveterinaryBPdevicesexist.Asaresult,themannerinwhichdevicesare69
assessedvariesgreatlyfromstudytostudy,makingdifficultdirectcomparisonsbetween70
assessmentsofdifferentdevicesindifferentreports.71
InanattempttoofferveterinarypractitionersguidelinestostandardiseBP72
assessment,theACVIMissuedaconsensusstatementfortheidentification,evaluation,and73
4
managementofsystemichypertensionindogsandcatsin2007(Brownetal.2007).These74
guidelinesincluderecommendationsfordevicecalibration,patientrestraint,cuffsizeand75
position,andpatientpositioningforbloodpressuremeasurement.Instructionsforthe76
validationofBPdevicesinanaesthetisedandconsciousanimals,basedonguidelinesofthe77
AssociationfortheAdvancementofMedicalInstrumentation(AAMI),arelistedinthe78
ConsensusStatementappendixandincludespecificconditionsunderwhichsystemic79
efficacyofadevicearesatisfied.80
OscillometricBPdeviceshavebeeninwide‐spreadclinicaluseformanyyearsinsmall81
animals.Recently,anewhigh‐definitionoscillometricdevice,theMemodiagnostic(S+B82
MedVETGmbH,Germany)wasintroducedandismarketedinEuropeandtheUSA.This83
deviceholdspromisefordeliveringaccurateandreliablemeasuresofbloodpressureindogs84
andcats,however,noreportsonthevalidityofBPreadingswiththisdevicehavebeen85
published.Ifcliniciansaretooptforuseofthisdevice,theywouldexpecttoknowhow86
measurementscomparewithagoldstandardaswellaswithconventionaloscillometry.87
Oneofthemostwidelyassessedconventionaloscillometricdeviceshasbeenthe88
Dinamap(Critikon,Tampa,Fl,USA).AvarietyofstudiesevaluatingtheDinamap1846sx,89
Dinamap8100,andtheDinamap8300,specificallydevelopedforclinicalveterinarypatients90
in1993,havebeenpublished(Binnsandothers1995,Bodeyandothers1994,Bodeyand91
others1996,BodeyandMitchell1997,Gainsandothers1995,Habermanetal.2004,92
Habermanandothers2006,Meursandothers1996,GrosenbaughandMuir1998,Sawyer93
andothers2004)butnostudyhasevaluatedthisdeviceinaccordancewiththe2007ACVIM94
guidelinessodirectcomparisonwithfuturedevicesisdifficult.95
Theaimofthisstudywastoevaluatethehigh‐definitionoscillometricdevice,96
MemodiagnosticMD_15/90Pro,andtheconventionaloscillometricdevice,DinamapModel97
5
8300,comparedwithdirectarterialBPmeasurementinanesthetiseddogsbasedonthe98
guidelinesofthe2007ACVIMConsensusStatement.99
MaterialsandMethods100
Nineclient‐owneddogswererecruitedfrompatientsrequiringanaesthesiafor101
reasonsunrelatedtothestudyintheSmallAnimalClinic,DepartmentofClinicalVeterinary102
Medicine,VetsuisseFaculty,UniversityofBerne.Thestudyprotocolwasevaluatedand103
approvedbytheinstitution’sEthicsCommittee.Dogswererecruitedbyrequestingowner104
consentforparticipationinthestudyofdogsscheduledforasurgicalprocedure.The105
measurementswereperformedafterreachingastableplaneofanaesthesia,butpriortoany106
otherprocedures,inthesurgerypreparationroomwiththedogsindorsalrecumbency.For107
oscillometricdevices,theBPcuffwasplacedaroundthemidleftorrightantebrachium108
overlyingthemedianartery.Forconventionaloscillometricmeasurements,cuffsizewas109
selectedtoaccountforapproximately40%ofthecircumferenceofthelimbatplacement110
site.Forhigh‐definitionoscillometricmeasurement,thecuffusedwasselectedfromoneof111
thoseprovidedwiththedeviceaccordingtothemanufacturer’sguidelines.Carewastaken112
toensurethatmeasurementsweretakenattheleveloftheheartbaseandthatECG113
readingsshowedasinusrhythm.Fordirectarterialpressuremeasurement,theskinoverthe114
leftorrightdorsalhindpawwassurgicallyprepared,anda20‐or22‐gauge,1‐inchfluoro‐115
ethylene‐propylenecatheter(Jelco®2i.v.,SmithsMedicalInternationalLtd.,Kent,UK)was116
placedinthedorsalpedalartery.Thearterialcatheterwasconnectedtoadisposable117
transducerviaanon‐compliantsaline‐filledtubing.Thetransducerwasconnectedtoa118
monitorandattachedtoapressurised(300mmHg)bagofsaline(0.9%NaCl)solution.The119
catheterwasflushedintermittentlytoavoidbloodclots,andthesystemclearedofair120
bubbles.Thetransducerwasplacedattheleveloftheheartandzeroedtoatmospheric121
6
pressurebeforestartingtheprocedure.Priortoallmeasurements,thedirectBPmonitor122
andtheoscillometricdeviceswerecalibratedfrom0to200mmHgusingastandardaneroid123
manometerthatmetthestandardsfornonautomatedsphygmomanometersestablishedby124
theAAMI.Attheendofthestudy,thecalibrationwasrecheckedtoensurethattheir125
accuracywasmaintained.126
AtotalofeightconsecutivereadingsweretakensimultaneouslybydirectBP127
measurementandwitheachoftheoscillometricdevices(DinamapModel8300and128
MemodiagnosticMD_15/90Pro).Foreachsinglemeasurement,thesystolic(SAP),diastolic129
(DAP)andmean(MAP)bloodpressuresandtheheartratewererecorded.Otherdata130
recordedincludeddate,starttimeofthemeasurementsession,thecircumferenceofthe131
dog’slimb,thesizeofthebloodpressurecuff,anddrugsandintravenousinfusions132
administeredtothepatient.Atleastfivesecondselapsedbetweenconsecutive133
measurements.134
Throughouttheentirestudy,allmeasurementsweretakenbyasingleinvestigator,135
familiarisedwithalldevices,andtheprotocolforBPmeasurementsconformedtothe136
ACVIMconsensusstatement(Brownandothers,2007,Table2).Basedontheseguidelines,137
thefirstintheseriesof8consecutiveBPmeasurementswasdiscardedandnotusedfordata138
comparison.139
Statisticsandvalidation140
Simplelinearregressionanalysiswasusedtoevaluatetherelationshipsbetweenthe141
directvaluesandtheindirectvaluesobtainedwitheachoftheoscillometricdevices.The142
agreementbetweenoscillometricandsimultaneousdirectBPmeasurementsforSAP,DAP143
andMAPwereevaluatedusingBland‐Altmanplots(BlandandAltman1986,Blandand144
Altmann1995)inwhichthedifferencesbetweenthetwomeasurementswasplottedagainst145
7
themeanofthetwomeasurementsforeachsetofsimultaneousmeasurements.Thebias146
(meandifferencefromdirectBPvalues),precision(standarddeviationofdifferences)and147
the95%limitsofagreement(mean±2SD)werecalculated.Thepercentagesof148
measurementswithin5mmHg,10mmHgand20mmHgofthedirectmeasuresforboth149
indirectdeviceswerecalculated.Theindirectdeviceswereconsideredtopassvalidationif150
theymetallofthefollowingconditions(Brownandothers,2007):themeandifferenceof151
pairedmeasurementsforSAPandDAPtreatedseparatelyis±10mmHgorlesswitha152
standarddeviationof15mmHgorless;thecorrelationbetweenpairedmeasuresforSAP153
andDAPtreatedseparatelyis≥0.9acrosstherangeofmeasuredvaluesofBP;50%ofall154
measurementsforSAPandDAPtreatedseparatelyliewithin10mmHgofthedirectvalues;155
80%ofallmeasurementsforSAPandDAPtreatedseparatelyliewithin20mmHgofdirect156
values;dataareobtainedfornofewerthan8animals.Inaddition,thedeviceswere157
consideredtogivereliablereadingsonlyifthecoefficientofvariationforeachsetof7158
measurementsforSAPwasbelow20%(Brownandothers,2007).Analyseswereperformed159
usingstatisticalsoftware(Medcalc®v11.0.1,MedcalcSoftwarebvba,Belgium).160
Results161
Dogsrecruitedwerebetween3and11yearsold(meanage6.5±2.87years)andweighed162
between11.8and45.0kg.Readingswereobtainedforall72measurementswithboththe163
DinamapandtheMemodiagnosticdevice.AllsetsofvaluesforSAPhadacoefficientof164
variationof<20%foralldevices;therangesofcoefficientsofvariationforSAPwere1.09‐165
12.11%(median2.3%)fordirect,1.15‐13.22%(median3.07%)forDinamap,and1.87‐9.24%166
(median4.89%)forMemodiagnostic.Comparativestudiesofvaluesobtainedwith167
oscillometricanddirectmeasurementswereperformedafterdiscardingthefirstvalue168
8
(Brownandothers,2007),givingatotalof63simultaneousdataforeachofthetwo169
oscillometricdevices.170
Bland‐AltmanplotsrevealedaslightunderestimationofSAPandDAPand171
overestimationofMAPwiththeDinamap(Fig.1,Table1).ValuesforSAP,DAPandMAP172
werealloverestimatedwiththeMemodiagnosticandoverestimationincreasedforSAPand173
DAPwithincreasingpressures(Fig.2,Table1).Apositivecorrelationwasfoundbetweenall174
indirectandsimultaneouslymeasureddirectvalues(Figs.3,4).Thecorrelationwaspoor175
withtheMemodiagnostic(Table2,Fig.4).Althoughastrongcorrelationwasfoundwiththe176
Dinamap,thiswasslightlybelow0.9,requiredforvalidation(Table2,Fig.3).Themean177
differences(bias)betweendirectandindirectmeasuresweregreaterforthe178
MemodiagnosticthantheDinamap(Table2)althoughallwerewithin10mmHgrequiredfor179
validation.Theprecision(standarddeviationofthedifferences)waslessthan10mmHgfor180
theDinamapbutexceededthe15mmHgthresholdrequiredforvalidationwiththe181
MemodiagnosticforbothSAPandDAP(Table2).Thelimitsofagreementwerelikewisevery182
largefortheMemodiagnostic(Table2).Greaterthan75%ofoscillometricreadingswere183
within10mmHgandthevastmajoritywerewithin20mmHgofdirectvaluesfortheDinamap184
(Table2).However,onlybetween50and60%werewithin10mmHgfortheMemodiagnostic185
(Table2).Moreover,theMemodiagnosticdidnotfulfiltherequirementofover80%of186
valueswithin20mmHgforDAP.187
Discussion188
ThisstudycomparedBPbetweentwooscillometricdevicesanddirectmeasurements189
inanaesthetiseddogsbasedontheACVIMguidelines.Thisincludedastandardisedapproach190
tomeasurements(samepositionofanimals,samecuffsiteandsize,serialmeasurements191
withdiscardofthefirstmeasurement,asingleexaminer)withvalidationaccordingtothe192
9
suggestedguideline.Althoughdiseasestateandanaestheticprotocolmightsignificantly193
affectbloodpressure,thiswasconsideredirrelevanttotheaimofthestudyandnostudy194
inclusionlimitationswereenforcedinthisrespect.Ashortcomingofthisstudyisthatdogs195
wereevaluatedunderanaesthesiaandtherangeofBPswasrelativelynarrow(directSAP196
between76and137mmHg).Resultsofthisstudyarethereforeonlyvalidforanaesthetised197
dogswithpressureswithinthisrange.198
TheMemodiagnosticoscillometricdeviceisarelativelynewdeviceusinghigh199
definitionoscillometry.Therearecurrentlynopublicationsevaluatingthisdeviceindogsbut200
thedeveloperclaimsmanyadvantagestoconventionalindirectBPdevices(Egner2006a;201
Egner2006b,S+BMedVet1998).Contrarytoconventionaloscillometry,inwhichtheMAPis202
measured,andSAPandDAParecalculatedusinganalgorithmbasedontheoscillation203
curve,theMemodiagnosticperformsreal‐timeanalysisofarteryoscillationstoobtainpulse204
amplitudes.Otherpurportedbenefitsaretheelectronically‐controlledvaluesthatadaptto205
maintainlinearityduringdeflation,permittingreadingsfrom5to300mmHg,highsensitivity206
thatallowsmeasurementsfromminimalsignalsandheartfrequenciesofupto500beats207
perminute,andhigh‐speedanalysisthatallowsthedetectionofarrhythmias(S+BMedVet208
1998).Inapreviouslypublishedstudy,thisdevicewastestedforitsapplicationinthe209
cynomolgusmonkey(Schmeltingetal.2009),bothundergeneralanaesthesiaincomparison210
withtelemetryandinconsciousanimals.Inthisstudy,MAPwaslowerwiththe211
Memodiagnosticthanwithtelemetry.However,thisstudydidnotevaluatesimultaneously212
obtainedpairedreadingsandtheaccuracyofthereadingswasthereforenotassessed.213
TheDinamaphasbeenpreviouslyevaluatedinanesthetiseddogsinseveralstudies,214
mostofwhichfoundfavourableresultscomparedwithdirectmeasurements(Bodeyand215
others1994;Gainsandothers1995;GrosenbaughandMuir1998;Hamlinandothers1982;216
10
Meursandothers1996).However,thesestudieswereperformedpriortotheACVIM217
consensus,andevaluationprocedurevariedwidelybetweenstudies.218
Inthisstudy,theDinamapunderestimatedSAPandDAP,aswasfoundinprevious219
reports(GrosenbaughandMuir1998;Habermannandothers2006;Bodeyandothers1996).220
Incontrast,theMemodiagnosticoverestimatedSAPandDAP.Thecoefficientofvariationof221
consecutivevaluesforSAPsineachdogwasbelow20%withbothdevices,showing222
adequateconsistencyinreadingswitheachdevice.ThecorrelationbetweenDinamapand223
directmeasureswasnotcalculatedinsomepreviousstudiesandvariedsogreatlyinothers224
(RforSAPbetween0.24and0.908),notleastbecauseofvariationincuffsite,numberof225
consecutivemeasurements,positionofdogs,andBPranges,thatdirectcomparisonofdata226
betweenstudiesisdifficult(Bodeyandothers1994;Gainsandothers1995;Grosenbaugh227
andMuir1998;Hamlinandothers1982;Meursandothers1996).Asthisstudyusedthe228
sameprocedureforbothdevices,correlationcanbecomparedbetweenthetwodevices.229
NeitherdevicefulfilledthevalidationrequirementofR≥0.9.However,contrarytothe230
Memodiagnostic,theDinamapachievedhighcorrelationsandfelljustshortofthisvalidation231
criterion.232
Themeandifferences(bias)betweenSAPandDAPvaluesobtainedwiththeDinamap233
anddirectmeasurementswasgreaterthanthe10mmHgrequirementintwoprevious234
studies(Bodeyandothers1994;GrosenbaughandMuir1998).However,thiswasonlythe235
caseforhypertensivedogsbutnotfornormo‐orhypotensivedogsinoneofthesestudies236
(GrosenbaughandMuir1998),andonlyfortailanddistalhindlimbbutnotforproximal237
hindlimbcuffsitesintheotherstudy(Bodeyandothers1994).Bias(meandifference)for238
DAPrangedtovaluesupto13mmHginthesestudies.Wefoundaverylowbiasforthe239
11
DinamapandsomewhathighervaluesfortheMemodiagnostic,indicatingbetteraccuracy240
withtheDinamap.241
Thestandarddeviationsofthedifferences(precision)forSAPandDAPwerewithin242
15mmHgfortheDinamapaswasthecaseinapreviousstudyevaluatingBPoverawide243
pressurerangeinanaesthetiseddogs(GrosenbaughandMuir1998).However,standard244
deviationsfortheMemodiagnosticdeviceweregreaterthan15mmHg,indicatinga245
relativelypoorprecision.246
Thevalidationcriteriathat>50%and>80%ofSAPandDAPvaluesmustliewithin10247
and20mmHgofdirectmeasurements,respectively,hasnotbeenpreviouslyevaluatedfor248
theDinamapindogsunderanaesthesia.Inonestudywithconsciousbeagles,neitherthe249
DinamapnorDopplermetthisstandardfor10mmHg(Habermannandothers2006)despite250
thefactthatthiscriterionislessstringentthanAAMIrequirementsofhumanindirectBP251
devices.Inthepresentstudy,theDinamapfarsurpassedthisrequirementbutthe252
Memodiagnosticfellshort.253
DespitethepurportedadvantagesoftheMemodiagnostic,thisdevicedidnotmeet254
theACVIMrequirementsforbloodpressuredevicevalidationinthepresentstudy,and255
demonstratedpoorcorrelationwithdirectmeasuresinanaesthetiseddogs.Moreover,256
accuracyandprecisionwerepoorerthanwithDinamap,leadingtolimitsofagreementthat257
maybeclinicallyunacceptable.Furthermore,thepercentagesofmeasuredvalueswithin5,258
10or20mmHgofthoseobtaineddirectlywereverylowcomparedwiththoseachievedwith259
theDinamap.AlthoughtheDinamapmetalmostallvalidationcriteria,bothdevicesarelikely260
tofairlesswellinsatisfyingcriteriawhenmeasurementsaretakeninconsciousdogsand261
acrossagreaterrangeofBPvalues.TheACVIMConsensusStatementpanelrecognizesthat262
theguidelinesmaybesorigorousastoexcludeanydevicepresentlyinusewhenappliedto263
12
consciousdogsandcats(Brownandothers2007).Theresultsofthepresentstudysuggest264
thatthecriterionforcorrelationmayindeedbetoohighasitcouldnotbesatisfiedunder265
thenarrowconditionsofcontrolledmeasurementsinanaesthetiseddogsinthepresent266
study.However,thecriteriaforthepercentageofvalueslyingwithin10and20mmHgof267
directmeasurementsmaybetoolenient,inparticularbecauseadifferenceof20mmHgmay268
significantlyaffecttheclinicalinterpretationofresultsinpatients.269
270
13
270
Acknowlegements271
TheauthorswouldliketothankDr.MarcusClaussforhisassistance.272
14
273
References274
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15
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343
16
Table1:Agreementandcorrelationofbloodpressuresmeasuredbyuseoftwo343 oscillometricdevicesandthosemeasureddirectlyin9anaesthetiseddogs.344
345 Dinamap MemodiagnosticParameter ACVIM
recommendedlimitsfor
systolicanddiastolicvalues(Brownandothers2007)
Systolic Diastolic Mean Systolic Diastolic Mean
Correlation(R) ≥0.9 0.8850* 0.8734* 0.8605* 0.5546* 0.7186* 0.5671*Bias(meandifference,mmHg)1
≤±10 1.78 1.82 ‐3.90 ‐5.80 ‐5.19 ‐2.90
Precision(Standarddeviation,mmHg)1
≤15 7.56 7.30 8.14 17.76 15.33 10.45
Limitsofagreement(mmHg)
none ‐13.0to16.6
‐12.5to16.1
‐19.9to12.1
‐40.6to29.0
‐35.2to24.9
‐23.4to17.6
≤5mmHg2 none 57.1% 47.6% 49.2% 22.2% 42.8% 26.9%≤10mmHg2 ≥50% 76.2% 88.9% 76.2% 52.4% 58.7% 61.9%≤20mmHg2 ≥80% 100% 98.4% 98.4% 82.5% 76.2% 96.8%Range3(mmHg) 76‐137 41‐83 53‐97 64‐124 36‐81 45‐96*Significantlinearrelationship(P<0.001)346 1.Direct–indirectmethod347 2.Percentageofindirectlyobtainedvalueswithin5,10or20mmHgofthedirectvalues348 3.Rangeofvaluesobtainedbydirectarterialmeasurements349 350
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