the measurement of blood pressure and hypertension8 8. position the stethoscope over the palpated....
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The measurement of blood pressure and hypertension
Handout Fenyvesi TamásIII.Department of Medicine
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History of the blood pressure measurement
directStephen HALES 1726 horse carotid
indirectRiva-Rocci Scipione 1896 inflatable
bladder
Korotkoff 1905 auscultationKopoткoвъ Николай Сергеевич
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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
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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
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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
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.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 !!!!
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Recording the pressure and the auscultatory gap: range of Korotkoff sounds
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Determining the palpated systolic pressure and the maximum inflation level
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Blood pressure cuff placement and pulse detection
Figures from: www.images.med
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The blood pressure cuff and arm circumference
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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
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Calibrating the manometer
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Measurement of blood pressure in the clinic
Interpretation of ABI
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> 1,30 noncompressible0,95-1,30 normal0,41-0,90 mild-to-moderate peripheral
arterial disease0,00-0,40 severe peripheral arterial
disease
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1979 NY
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Skills a good blood pressure observer must have
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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
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My results mean of 41 measurements
Which was the right measurement?No answer!! Such is the method.
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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
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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
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282003
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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
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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
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.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
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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
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Prevalence of isolated systolic and diastolic blood pressure by age and gender
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Rate and proportion of cardiovascular disease events by systolic blood pressure level
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Risk of myocardial infarction with isolated systolic hypertension in men
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Impact of pulse pressure at specified levels of systolic blood pressure
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Stroke probability in mildly hypertensive men according to associated risk factors
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Risk of peripheral arterial disease by systolic blood pressure and diabetic status
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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)
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Association of heart rate with mortality in hypertensive men
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Cardiovascular disease rates in women according to echocardiogram-left ventricular hypertrophy and hypertensive status