BP Measurement

HYPERTENSION

HIGH BLOOD PRESSURE

ELEVATED BLOOD PRESSURE

RAISED BLOOD PRESSURE

HYPERTENSION

IN A PATIENT WITH HIGH BLOOD PRESSURE:

4 ISSUES:

1. Is the patient truly hypertensive ?

2. Are there any identifiable secondary causes ?

3. is target organ damage present ?

4. Are there co-existing cardiovascular risk factors associated and/or associated clinical condition present

Routine steps for accurate measurement of blood pressure

• Rest the patient (seated) for at least 5 mins in a quiet con fortable room. Use a calibrated aneroid device (a validated and recently calibrated electronic electronic device may may also be used. Choose cuff with appropriate width of bladder. Record with cuff at heart level. Deflate cuff at 2 mmHg/sec. First sound = systolic reading, disappearance = diastolic reading. Repeat measurement at least x2 (first visit: x3) & take average value. Take BP in both arms at least once; record which arm is used; patient position ( seated, supine, standing) & pulse rate. . Measure BP at + 1 & 5 mins after standing ( especially in older patients and those with diabetes).

BP Measurement TechniquesBP Measurement TechniquesMethod Brief Description

In-office Two readings, 5 minutes apart, sitting in chair. Confirm elevated reading in contralateral arm.

Ambulatory BP monitoring

Indicated for evaluation of “white-coat” HTN. Absence of 10–20% BP decrease during sleep may indicate increased CVD risk.

Self-measurement Provides information on response to therapy. May help improve adherence to therapy and evaluate “white-coat” HTN.

JNC 7 2003

Office BP MeasurementOffice BP Measurement Use auscultatory method with a properly calibrated and validated

instrument.

Patient should be seated quietly for 5 minutes in a chair (not on an exam table), feet on the floor, and arm supported at heart level.

Appropriate-sized cuff should be used to ensure accuracy.

At least two measurements should be made.

Clinicians should provide to patients, verbally and in writing, specific BP numbers and BP goals.

JNC 7 2003

……… sphygmomanometer

Patient should be seated and relaxed, preferably for several minutes prior to to the measurement and in a quiet room.

Appropriate cuff size.

Average the readings. If the first two readings differ by more than 10 mmHg systolic or 6 mmHg diastolic or if the initial readings are high, take several readings after five minutes of quiet rest, until consecutive readings do not vary by greater than these amounts.

Ideally, patients should not take caffeine-containing beverages or smoke for at least two hours before blood pressure is measured, …………………..

How to measure blood pressure accuratelyHow to measure blood pressure accurately

Australia, 2004

Box 2 Procedures for blood pressure measurementBox 2 Procedures for blood pressure measurementWhen measuring blood pressure, care should be taken to ……….. to sit for several minutes in a quiet room before beginning blood pressure

measurements.

Take at least two measurements spaced by 1-2 min, ………….

Use a standard bladder ……. but have a larger and a smaller bladder available for fat and thin arms, respectively.

Have the cuff at the heart level, whatever the position of the patient. Use phase I and V …………….

Measure blood pressure in both arms at first visit to detect possible differences ……………………..

Measure blood pressure 1 and 5 min after assumption of the standing position in elderly subjects, diabetic patients,……………..

Measure heart rate by pulse palpation (30 s) after the second measurement in the sitting position.

ESC/ESH 2003

Box 3 Position statement: Blood Box 3 Position statement: Blood pressure measurementpressure measurement

Blood pressure values measured in the doctor’s office or the clinic should commonly be used as reference.

Twenty-four-hour ambulatory blood pressure monitoring may be considered of additional clinical value, when:- considerable variability of office blood pressure is found over the same or different visits;- high office blood pressure is measured in subjects otherwise at low global cardiovascular risk;- there is marked discrepancy between blood pressure values measured in the office and at home;- resistance to drug treatment is suspected;- research is involved.

Self-measurement of blood pressure at home should be encouraged in order to:- provide more information for the doctor’s decision;- improve patient’s adherence to treatment regimens

Self-measurement of blood pressure at home should be discouraged whenever:- it causes patients anxiety;- it induces self-modification of the treatment regimen.

* Normal values are different for office, ambulatory and home blood pressure.

Are there identifiable secondary causes:

1.Clinical and family history drug intake ( prescription & non-prescription, food supplement)

2. Full physical examination

3. Laboratory investigation: urinalysis ( protein, glucose, blood, microscopy) blood (Hb, creatinin, K+, fasting glucose, lipid profile)

4. ECG

Is target organ damage present?

Target organ damage

Brain Stroke TIA Vascular dementia

Heart CAD LV hypertrophy LV syst. dysfunction

Vascular system Hypertensive retinopathy Aortic aneurysm PVD Overt atherosclerotic

Kidneys Hypertensive

nephropathy

Clinical assessment of target organ damage

Target organ Damage indicators

HEART * History of heart failure, angina pectoris , MI, or coronary revascularization * Physical/ECG findings of LVH (Confirm with Echo)

BRAIN * History of TIA, stroke or impaired cognitive function * Focal neurological impairment: carotid bruits

KIDNEYS * Elevated serum creatinin microalbuminuria or proteinuria

RETINA * Hypertensive retinopathy changes ( copper wiring, a-v nicking etc)

PERIPHERAL * History of intermittent or rest claudication VASCULAR SYSTEM * Abdominal or carotid bruits, reduced peripheral pulses

WHO-ISH Guidelines for WHO-ISH Guidelines for Management of Hypertension: Management of Hypertension:

Stratification of Cardiovascular RiskStratification of Cardiovascular Risk Blood Pressure (mm Hg)

Grade 1 Grade 2 Grade 3

Mildhypertension

Moderatehypertension

Severehypertension

Other risk factors anddisease history

SBP 140–159or DBP 90–99

SBP 160–179or DBP 100–109

SBP 180or DBP 110

I No other risk factors Low risk Med risk High risk

II 1–2 risk factors Med risk Med risk Very high risk

III 3 or more risk factors or TOD or diabetes

High risk High risk Very high risk

IV ACC Very high risk Very high risk Very high risk

TOD = Target-organ damageACC = Associated clinical conditions

Guidelines subcommittee. WHO-ISH Guidelines. J Hypertens 1999;17:151-183.

2003 ESH / ESC Guidelines:Stratification of risk to quantify prognosis

2003 ESH/ESC, J Hypertension 2003;21:1011-1053

Other risk factorsOther risk factors Normal High normal Grade 1 Grade 2 Grade 3 Normal High normal Grade 1 Grade 2 Grade 3& disease history& disease history SBP 120-129 130-139 140-159 160-179 > 180 SBP 120-129 130-139 140-159 160-179 > 180

or DBP 80-84 85-89 90-99 100-109 > 110or DBP 80-84 85-89 90-99 100-109 > 110____No other risk factorsNo other risk factors

1-2 risk factors1-2 risk factors

> 3 risk factors > 3 risk factors or TOD or DMor TOD or DM

ACCACC

Aver. Risk Aver.riskAver. Risk Aver.risk

ACC: associated clinical conditionsACC: associated clinical conditionsTOD: target organ damageTOD: target organ damage

Low addedLow addedriskrisk



Mod. added Mod. addedMod. added Mod. addedrisk riskrisk risk

Mod. addedMod. addedriskrisk

Mod. addedMod. addedriskrisk

High addedHigh addedriskrisk





Very highVery highadded riskadded risk






Threshold for intervention initial blood pressure (mmHg)

>180/110 160/179 100-109

140/159 90-99

<130/85130/139 85-89

† ‡

* Unless malignant phase of hypertensive emergency confirm over 1-2 weeks then treat.

† If can cardiovascular complications, target organ damage, or diabetes is present, confirm over 3-4 weeks then threat, if absent remeasure weekly threat if blood pressure persists at these levels over 4-12 weeks.

‡ If cardiovascular complications, target organ damage, or diabetes is present, confirm over 12 weeks then threat, if absent remeasure monthly and threat if these levels are maintained and estimated 10 year cardiovascular disease risk is ≥20%.

§ Assessed with risk chart for cardiovascular disease.

≥180/110 140/159 90-99

<140/90

Target organ damage or cardiovascular complications or

diabetes or 10 year risk of cardiovascular disease§ ≥20%

No target organ damage and no cardiovascular complications and no diabetes and 10 year risk of cardiovascular disease § <20%

Treat Treat Treat Observe, reassess risk of

cardiovascular disease yearly Reassess

yearlyReassess in 5 years

*

JNC 7: Management of Hypertension JNC 7: Management of Hypertension by Blood Pressure Classificationby Blood Pressure Classification

ACE-I = angiotensin-converting enzyme inhibitor; ARB = angiotensin-receptor blocker; BB = beta blocker; CCB = calcium channel blocker.Chobanian AV et al. Chobanian AV et al. JAMA. JAMA. 2003;289:2560-2572.2003;289:2560-2572.

Drug(s) for the compelling indications; other antihypertensive drugs (diuretics, ACE-I, ARB, BB, CCB) as needed

Drug(s) for the compelling indications; other antihypertensive drugs (diuretics, ACE-I, ARB, BB, CCB) as needed

BP ClassificationLifestyle Modification

Initial Drug Therapy

Without Compelling Indication

With Compelling Indication

Normal<120/80 mm Hg

Prehypertension120-139/80-89 mm Hg

Stage 1 hypertension140-159/90-99 mm Hg

Stage 2 hypertension≥160/100 mm Hg

Encourage

Yes

Yes

Yes

No drug indicated Drug(s) for the compelling indications

Thiazide-type diuretics for most; may consider ACE-I, ARB, BB, CCB, or combination

2-drug combination for most (usually thiazide-type diuretic and ACE-I, ARB, BB, or CCB)

AUSTRALIA 2003

The major classes of anti-hypertensive drugs

1. Diuretics . Loop furosemide, bumetanide . K+-sparing amiloride, spironolactone . Thiazide hydrochlorothiazide, bendrofluazide . Thiazide-like chlorthalodone, indapamide2. Adrenergic inhibitors . Alpha-1 blockers Doxazosin, Prazosin . Beta-blockers Atenolol, Metoprolol, Bioprolol, Carvedilol . Combine Labetalol 3. RAS inhibitots . ACE-inhibitors Captopril, Enalapril, Perindopril etc . ARB Losartan, Valsartan, Candesartan etc 4. Ca-channel blockers (CCB) . Dihydropyridin Nifedipin, Amlodipin . Non-dihydropyridine Diltiazem, Verapamil 5. Imidazoline receptor agonist monoxidine, nilmenidine 6. Vasodilatation hidralazine, minoxidil

Recommended blood pressure targets

Organisation

Patient group

Uncomplicatied hypertension

+ DM or

Renal disease

+ RF with proteinuria*

American Kidney Assiciation (2001)

<130/80 <125/75

British Hypertension Society (1999)

< 140/85 < 140/80 <125/75

Canadian Hypertension Society (1999)

< 140/90 < 130/80 <125/75

European Hypertension Society (2003)

< 140/90 < 130/80 <125/75

JNC-VII (2003) < 140/90 < 130/80 <125/75

National Kidney Foundation US (2000)

< 140/90 < 130/80 <125/75

WHO-ISH (1999) < 140/90 < 130/80 <125/75

*Proteinuria : > 1 gram per 24 hours

Blood pressure treatment thresholds

Recommended for healthy lifestyleLifestyle parameter Health recommendation Diet Eat more whole grain products

Eat more-fresh fruits & vegetarian Use low-fat milk products Use low-fat meat & alternatives Reduce saturated fat content Reduce salth content (6 g per day max. ≈ 1 teaspoon

Exercise 30-60 min of endurance activies x 4-7 days per week (e.g. brisk walking, jogging, cycling)

Body weight Maintain BMI*@ 20-25

Alcohol comsumption Limit to 0-2 standard drinks per day People with elevated triglyceride levels should eliminate alcohol completely

Smoking cessation Smokers should be advised to quit ( ± cessation programmes, nicotine replacement/drug therapy) Encourage young people not to start

*BMI = weigth (kg)/height2(m) (Normal : 20-25; overweight ; 25-30; obese : >30)

Recommendations for healthy lifestyle

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BP Measurement