Blood Pressure Measurements: New Techniques in Automatic and 24-hour Indirect Monitoring
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The preferred blood pressure determination method would be one that reduces variability between measurements and that reflects the true blood pressure level.
Home Blood Pressure Monitoring
In this article, we present the variability of, and agreement between, the blood pressures collected by two indirect methods on the same patients during a hypertensive research project. Data obtained on patients in a typical clinical setting are also provided. Twenty-four-hour diastolic pressures obtained by the automated method demonstrated no regression to a lower mean, while blood pressures obtained casually in the office exhibited such regression.
The magnitudes of the differences in blood pressures obtained on separate occasions in the same subjects were significantly lower with automated vs casual blood pressure determination methods 7. Thus, the variability in mean hour automated blood pressures is less than that for casual office blood pressures. The clinician should understand that the variability of blood pressures measured on an individual may be much greater than that reported for populations of hypertensive patients, and must be considered when applying epidemiologic group data to a specific patient.
Moreover, any methodology of indirect blood pressure measurement that may reduce the variability and improve repeatability of casual office blood pressures deserves further consideration. Arch Intern Med. All Rights Reserved. Twitter Facebook Email. This Issue. Peter B. Bottini, PharmD ; Albert A.
Carr, MD ; Robert B. Rhoades, MD ; et al L. Michael Prisant, MD. Learn more. Save Preferences. Protocols for the validation of noninvasive BP monitors were initially established in the s to characterize the accuracy of new devices. Discrepancies between clinical measurements and oscillometric device measurements, including ABPM and HBPM, led to greater scrutiny and the standardization of the protocols in both Europe and the United States. A minority of BP monitor validation studies have correctly adhered to the relevant protocol, and many studies have biased or misrepresented results.
There are 4 main validation protocols for BP devices Table However, its advantage is that it is thorough and accounts for intradevice variability and consistency in performance after prolonged use. The ESH protocol is on the opposite extreme of complexity, having eliminated some prevalidation steps. It has the smallest sample size requirement and eliminates some of the redundancy seen in the British Hypertension Society protocol.
The validation protocol of the Association for the Advancement of Medical Instrumentation is less complex than the British Hypertension Society protocol but requires a similar sample size and participants with a wide range of BP and asks for specific assessment for special populations. Finally, the Quality Seal Protocol from Germany German Hypertension League requires the largest sample size and the most well-defined age groups. Modified from Beime et al with permission. Some recommend that the device be returned to the manufacturer for recalibration; however, there is often a nontrivial cost for this service.
In hospitals and some other settings, there is usually a biomedical engineering department that can evaluate whether each individual device is taking accurate readings. Because of their lower cost and because they are not used in the office setting, there are no standardized protocols for calibrating HBPM devices once they have left the manufacturer.
An HBPM device validated in a specific population may not always provide an accurate measure of BP for a specific individual. However, this approach may be appropriate for some individuals in whom it is suspected that home BP readings may be inaccurate despite the use of a validated device. Accurately measuring BP is essential for the proper diagnosis of hypertension and monitoring the effect of antihypertensive treatment. In addition, BP is a component of CVD risk prediction equations that, in turn, are used to guide the decision to initiate statins, pharmacological antihypertensive medication, and aspirin therapy.
A list of summary points from each section is provided in Table In the office setting, the use of oscillometric devices provides an approach to obtain a valid BP measurement that may reduce the human error associated with auscultatory measurements. The use of a validated AOBP device that can be programmed to take and average at least 3 BP readings should be considered the preferred approach for evaluating office BP.
Finally, we cannot overstate the importance of using only validated devices, routinely calibrating and maintaining BP measurement devices, and having BP measured by healthcare providers who have been properly trained and retrained. Figure 3. Detection of white-coat effect or masked uncontrolled hypertension in patients on drug therapy. Writing Group Disclosures.
This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. Reviewer Disclosures. This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all reviewers are required to complete and submit.
The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.
To purchase additional reprints, call or e-mail kelle. Measurement of blood pressure in humans: a scientific statement from the American Heart Association. DOI: The expert peer review of AHA-commissioned documents eg, scientific statements, clinical practice guidelines, systematic reviews is conducted by the AHA Office of Science Operations. Home Hypertension Vol. View PDF. Tools Add to favorites Download citations Track citations Permissions. Jump to. Schwartz , PhD Raymond R. Daichi Shimbo Daichi Shimbo Search for more papers by this author.
Robert M. Carey Robert M. Carey Search for more papers by this author. Jeanne B. Charleston Jeanne B. Charleston Search for more papers by this author. Trudy Gaillard Trudy Gaillard Search for more papers by this author. Sanjay Misra Sanjay Misra Search for more papers by this author. Martin G. Myers Martin G. Myers Search for more papers by this author. Gbenga Ogedegbe Gbenga Ogedegbe Search for more papers by this author. Joseph E. Schwartz Joseph E.
Schwartz Search for more papers by this author. Raymond R. Townsend Raymond R. Townsend Search for more papers by this author. Elaine M. Urbina Elaine M. Urbina Search for more papers by this author. Anthony J. Viera Anthony J. Viera Search for more papers by this author.
Ambulatory Blood Pressure Monitoring Techniques
William B. White William B. White Search for more papers by this author. Jackson T. Wright Jr Jackson T. Wright Jr Search for more papers by this author. Abstract The accurate measurement of blood pressure BP is essential for the diagnosis and management of hypertension. Hearing: The observer must be able to hear the Korotkoff sounds. Questionnaires or interviews can be used to assess knowledge of the BP measurement methodology.
Retraining of healthcare professionals every 6 mo to 1 y should be considered. Shirtsleeves should not be rolled up because this may create a tourniquet effect. Individual cuffs should be labeled with the ranges of arm circumferences; lines should be added that show whether the cuff size is appropriate when it is wrapped around the arm. Information on cuff selection for patients with morbid obesity is provided in the Obese Patients section.
When BP measurements are taken in the supine position, the cuffed arm should be supported with a pillow. In the seated position, the right atrium level is the midpoint of the sternum or the fourth intercostal space. The cuffed arm should be held up by the observer or resting on a table at heart level.
If the arm is held up by the patient, BP will be raised. Have the patient relax, sitting in a chair with feet flat on floor and back supported. The patient should be seated for 3—5 min without talking or moving around before recording the first BP reading. A shorter wait period is used for some AOBP devices.
The patient should avoid caffeine, exercise, and smoking for at least 30 min before measurement. Neither the patient nor the observer should talk during the rest period or during the measurement. Remove clothing covering the location of cuff placement. Measurements made while the patient is sitting on an examining table do not fulfill these criteria.
Step 2: Use proper technique for BP measurements 1. Use an upper-arm cuff BP measurement device that has been validated, and ensure that the device is calibrated periodically. Use either the stethoscope diaphragm or bell for auscultatory readings. At the first visit, record BP in both arms. Separate repeated measurements by 1—2 min. For auscultatory determinations, use a palpated estimate of radial pulse obliteration pressure to estimate SBP. Step 4: Properly document accurate BP readings 1. If using the auscultatory technique, record SBP and DBP as the onset of the first of at least 2 consecutive beats and the last audible sound, respectively.
Note the time that the most recent BP medication was taken before measurements. Someone should help the patient interpret the results. For each period daytime, nighttime, and 24 h , the average of all readings should be calculated to determine mean daytime BP, mean nighttime BP, and mean h BP, respectively, and other BP measures eg, dipping. Download figure Download PowerPoint.
Some guidelines and scientific statements recommend excluding the first day of readings. If the first day of readings is excluded, the minimum and preferred periods of HBPM should be 4 and 8 d, respectively. Aneroid sphygmomanometers require frequent calibration every 2—4 wk for handheld devices and every 3—6 mo for wall-mounted devices.
Unattended AOBP has been associated with a lower prevalence of white-coat effect compared with office BP measured through auscultation and reduces the possibility of human error in BP measurement. The main indications for ABPM are to detect white-coat hypertension and masked hypertension. White-coat hypertension may not be associated with an increased risk for CVD. Masked hypertension is associated with a risk for CVD approaching that for individuals with sustained hypertension. Nocturnal hypertension is common among blacks.
ABPM is the preferred approach to assess for nocturnal hypertension. HBPM can be used to detect white-coat hypertension and masked hypertension. There is a tendency for the device not to maintain positioning over the radial artery. The wrist must be kept at heart level to obtain an accurate reading. A preliminary analysis of wireless BP monitors showed poor accuracy compared with auscultatory readings.
Kiosks that are commonly used to measure BP often do not have cuffs that fit large arms. Most normative data are based on auscultatory BP measurements. If elevated BP is present when measured with an oscillometric device, auscultation should be performed to define BP categories. BP should be taken in the right arm to align with normative data. A systematic review has reported devices that have been validated in pregnant women. If a thigh cuff does not fit, BP can be measured at the wrist. Standing BP should be obtained immediately after rising and 1 and 2 min later.
Orthostatic hypotension has been associated with risk for fractures, syncope, and mortality. ABPM may be useful in identifying white-coat hypertension, hypotension in the postprandial state, and after awakening in the morning. Visit-to-visit variability is associated with risk for CVD events. Calcium channel blockers and thiazide-type diuretics are associated with lower visit-to-visit variability of BP. These protocols vary in requirements eg, sample size, range of BP, success criteria. Many device validation studies do not adhere to these protocols.
Biomedical engineering departments can evaluate whether individual devices are taking accurate readings. Whelton Johns Hopkins School of Medicine None None None None None None None This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all reviewers are required to complete and submit. References 1. Siu AL ; U. Preventive Services Task Force. Screening for high blood pressure in adults: U. Preventive Services Task Force recommendation statement. Ann Intern Med. Unmasking masked hypertension: prevalence, clinical implications, diagnosis, correlates and future directions.
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Blood pressure measurement - Wikipedia
Is resistant hypertension really resistant? Clinical features of patients with resistant hypertension classified on the basis of ambulatory blood pressure monitoring. Is white-coat hypertension associated with increased cardiovascular and mortality risk? Setting thresholds to varying blood pressure monitoring intervals differentially affects risk estimates associated with white-coat and masked hypertension in the population.
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Chapter 2. Measurement and clinical evaluation of blood pressure
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