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blood pressure (BP)

Epidemiology: - BP increases more rapidly in women than in men, beginning early in life [19] Physiology: - driving force that moves blood through the circulatory system - systolic blood pressure is the blood pressure when the ventricular muscle contracts - diastolic blood pressure is blood pressure when the ventricular muscle is relaxed between beats. - mean arterial blood pressure of >= 50 mm Hg may be needed to maintain consciousness [12] - ambulatory blood pressure monitoring reveals a significant circadian variation in blood pressure - in healthy people, blood pressure declines 15% in association with parasympathetic responses during sleep [9,20] - an early morning blood pressure surge occurs, that begins before awakening - a small post-prandial decline occurs & a more significant decline in blood pressure occurs during nocturnal sleep [3] - see exercise & blood pressure for effects of exercise on blood pressure * also see sleep & blood pressure Clinical significance: - automated office blood pressure readings are more accurate than manual readings [17,18] - a single blood pressure reading is inadequate; multiple measurements (a minimum of 5-6) are needed [5] - >= 3 BP readings [18] - check home BP monitor in office setting for accuracy [18] - 36% of in clinic blood pressures > 140/90 are < 140/90 with a 2nd measurement - mean systolic BP improvement is 8 mm Hg [15] - systolic blood pressure > 130 mm Hg & diastolic blood pressure > 90 mm Hg are associated with increased long-term early mortality among male adolescents - even slightly elevated blood pressure > 120/80 in adults 20-40 years of age linked to lower gray matter volume [16] - clinic-based blood pressure readings unreliable; ambulatory blood pressure monitoring recommended prior to diagnosis of hypertension & prescription of antihypertensive therapy [6] - long-term elevated blood pressure associated with increased cardiovascular risk [7] - people with the lowest BP levels (90-114)/(60-74) mm Hg with the lowest risk for cardiovascular disease [8]* - association of blood pressure with cardiovascular disease decreases with increasing age [8]* - based on the 33,357-patient ALLHAT trial, there appearsto be a U- or J-shaped association between risk of cardiovascular events & blood pressure [21] - nadir of risk - all-cause mortality: 140-155/70-80 mm Hg - congestive heart failure (CHF): 125-135/70-75 mm Hg - myocardial infarction (MI): 110-120/85-90 mm Hg - stroke: systolic BP of 110-120 mm Hg - systolic blood pressure & diastolic blood pressure peak 14-18 years before death, then progessively decline [13] - attenuation of the decline in blood pressure during sleep is associated with increased amyloid burden in the posterior cingulate gyrus & altered cerebral blood flow of patients with mild cognitive impairment [9] - persons without blood pressure decline with sleep are at increased risk for cardiovascular mortality, heart failure, & stroke [20] - nighttime dosing of antihypertensives may be associated with decreases in cardiovascular events & death [20] === blood pressure variability === - systolic blood pressure variability is associated with cognitive impairment in the elderly [10] - wide variability of blood pressure in hypertensive adults associated with increased cardiovascular risk [11] - variability in systolic BP (> 14 mm Hg) (RR=1.3-1.6) - higher systolic BP variability associated with falls in nursing home residents [26] - variability in diastolic BP also associated with increased risk [11] - diastolic blood pressure variability in subjects 55-64 years but not in subjects >= 65 years of age is associated with cognitive decline [10] - blood pressure variability in elderly may be associated with poorer attention span, psychomotor speed & executive function [24] - systolic short-term blood pressure variability may predict arterial stiffness [24] * huge study, adults age 30 & older, 5 year follow-up [8] Procedure: - caffeine, exercise & smoking should be avoided > 30 minute prior to BP measurement - the patient should be seated quietly for 5 minutes in a chair with feet on the floor (not on an examination table) - if systolic BP < 140 mm Hg, automated office BP can be obtained without rest period & multiple readings may be obtained without intervening delay [22] - bladder of manometer should encircle 80% of arm - lower edge of cuff 2 cm above antecubital fossa - arm should be supported & at the level of the heart - supporting the arm on the lap overestimates systolic BP by 3.9 mm Hg & diastolic BP by 4.0 mm Hg [25] - an unsupported arm at the side overestimates systolic BP by 6.5 mm Hg & diastolic BPby 4.4 mm Hg [25] - inflate cuff 20-30 mm Hg above palpated pressure - listen for Korotkoff sounds deflating cuff at rate of 2 mm Hg/sec - 1st occurrence of repetitive sounds (phase 1) is the systolic blood pressure - muffling of sounds is phase IV - disappearance of sounds is phase V - diastolic blood pressure is phase V - when Korotkoff sounds are heard all the way to 0 mm Hg, record phase 1, phase IV & phase V, for example: 140/70/0 - average of 2 or more measurements [1] - blood pressure monitoring should start at age 3 [2] * see ref [23] for ways measuring blood pressure may go wrong (AMA) Notes: - electronic BP monitors may report systolic BP as slightly lower than that measures intra-arterially & diastolic BP as slightly higher [1]

Related

ambulatory blood pressure monitoring (ABPM) arterial pressure blood pressure cuff exercise & blood pressure home blood pressure monitoring hypertension (HTN, high blood pressure, HBP) hypotension medications that may raise blood pressure sleep & blood pressure venous pressure

Specific

bilateral blood pressure assessment blood pressure > 140/90 blood pressure for HTN/CKD/DM blood pressure in the very old diastolic blood pressure (DBP) early morning blood pressure surge (EMBPS) pulse pressure systolic blood pressure (SBP) toe blood pressure

General

vital signs (V/S)

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 16, American College of Physicians, Philadelphia 2012
  2. Prescriber's Letter 9(11):63 2002
  3. Hermida RC Ambulatory blood pressure monitoring in the prediction of cardiovascular events and effects of chronotherapy: rationale & design of the MAPEC study. Chronobiol Int 2007, 23:749 PMID: 17701685
  4. Sundstrom J et al. Association of blood pressure in late adolescence with subsequent mortality: Cohort study of Swedish male conscripts. BMJ 2011 Feb 22; 342:d643. PMID: 21343202
  5. Powers BJ et al Measuring Blood Pressure for Decision Making and Quality Reporting: Where and How Many Measures? Annals of Internal Medicine: June 20, 2011 154(12):781-788 PMID: 21690592 http://www.annals.org/content/154/12/781.full.pdf+html - Appel LJ et al Improving the Measurement of Blood Pressure: Is It Time for Regulated Standards? Annals of Internal Medicine: June 20, 2011 154(12):838-39 PMID: 21690599 http://www.annals.org/content/154/12/838.extract
  6. Hodgkinson J et al. Relative effectiveness of clinic and home blood pressure monitoring compared with ambulatory blood pressure monitoring in diagnosis of hypertension: Systematic review. BMJ 2011 Jun 24; 342:d3621. PMID: 21705406
  7. Allen NB et al Blood Pressure Trajectories in Early Adulthood and Subclinical Atherosclerosis in Middle Age. JAMA. 2014;311(5):490-497 http://jama.jamanetwork.com/article.aspx?articleid=1820432
  8. Rapsomaniki E et al Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1 25 million people. The Lancet, Volume 383, Issue 9932, pg 1899-1911, 31 May 2014 PMID: 24881994 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2960685-1/abstract#
  9. Tarumi T et al. Amyloid burden and sleep blood pressure in amnestic mild cognitive impairment. Neurology 2015 Dec 1; 85:1922 PMID: 26537049
  10. Qin B, Viera AJ, Muntner P Visit-to-Visit Variability in Blood Pressure Is Related to Late-Life Cognitive Decline. Hypertension. 2016;68:00-00. PMID: 27217401 http://hyper.ahajournals.org/content/early/2016/05/23/HYPERTENSIONAHA.116.07494.full.pdf+html
  11. Stevens SL, Wood S, Koshiaris C et al. Blood pressure variability and cardiovascular disease: Systematic review and meta-analysis. BMJ 2016 Aug 9; 354:i4098 PMID: 27511067 Free PMC Article
  12. Peberdy MA et al. Cardiopulmonary resuscitation in adults and children with mechanical circulatory support: A Scientific Statement from the American Heart Association. Circulation 2017 Jun 13; 135:e1115 PMID: 28533303
  13. Delgado J, Bowman K, Ble A et al Blood Pressure Trajectories in the 20 Years Before Death. JAMA Intern Med. Published online December 4, 2017 PMID: 29204655 https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2663758 - Goodwin JS Decreasing Blood Pressure in Older Patients. JAMA Intern Med. Published online December 4, 2017 PMID: 29204654 https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2663754
  14. Baron RB Treating Blood Pressure Correctly by Measuring It Correctly. JAMA Intern Med. Published online April 16, 2018 PMID: 29710072 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2678451
  15. Einstadter D, Bolen SD, Misak JE et al. Association of repeated measurements with blood pressure control in primary care. JAMA Intern Med 2018 Apr 16; PMID: 29710186 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2678452
  16. Schaare HL, Masouleh SK, Beyer F et al Association of peripheral blood pressure with gray matter volume in 19- to 40-year-old adults. Neurology. Jan 23, 2019 PMID: 30674602 http://n.neurology.org/content/early/2019/01/23/WNL.0000000000006947
  17. Roerecke M, Kaczorowski J, Myers MG Comparing Automated Office Blood Pressure Readings With Other Methods of Blood Pressure Measurement for Identifying Patients With Possible Hypertension. A Systematic Review and Meta-analysis. JAMA Intern Med. Published online February 4, 2019. PMID: 30715088 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2723074
  18. Muntner P, Shimbo D, Carey RM et al Measurement of Blood Pressure in Humans: A Scientific Statement From the American Heart Association. Hypertension. March 4, 2019 PMID: 30827125 https://www.ahajournals.org/doi/10.1161/HYP.0000000000000087
  19. Ji H, Kim A, Ebinger JE et al Sex Differences in Blood Pressure Trajectories Over the Life Course. JAMA Cardiol. Published online January 15, 2020. PMID: 31940010 https://jamanetwork.com/journals/jamacardiology/article-abstract/2758868 - Wenger NK Adverse Cardiovascular Outcomes for Women - Biology, Bias, or Both? JAMA Cardiol. Published online January 15, 2020. PMID: 31940008 https://jamanetwork.com/journals/jamacardiology/article-abstract/2758865
  20. Labos C Is Taking Blood Pressure Medications at Night Really Better? Medscape - Feb 22, 2021. https://www.medscape.com/viewarticle/945200 - Mathur P, Kadavath S, Marsh JD, Mehta JL Chronotherapy for Hypertension: Improvement in Patient Outcomes With Bedtime Administration of Antihypertensive Drugs. Eur Heart J. 2020;41(48):4577-4579 PMID: 31723974 https://www.medscape.com/viewarticle/944367
  21. Lou N The Brain and Heart Want Different Blood Pressure Goals Lower not always better MedPage Today October 18, 2021 https://www.medpagetoday.com/cardiology/prevention/95095 - Itoga NK, Tawfik DS, Montez-Rath ME, Chang TI Contributions of Systolic and Diastolic Blood Pressures to Cardiovascular Outcomes in the ALLHAT Study. J Am Coll Cardiol. 2021 Oct, 78 (17) 1671-1678 PMID: 34674811 https://www.jacc.org/doi/10.1016/j.jacc.2021.08.035
  22. Brady TM, Charleston J, Ishigami J et al. Effects of different rest period durations prior to blood pressure measurement: The Best Rest trial. Hypertension 2021 Nov; 78:1511. PMID: 34601959 Free article https://www.ahajournals.org/doi/10.1161/HYPERTENSIONAHA.121.17496 - Juraschek SP, Ishak AM, Mukamal KJ et al. Impact of 30- versus 60-second time intervals between automated office blood pressure measurements on measured blood pressure. Hypertension 2021 Nov; 78:1502. PMID: 34488436 https://www.ahajournals.org/doi/10.1161/HYPERTENSIONAHA.121.17876
  23. Berg S 4 big ways BP measurement goes wrong, and how to tackle them. American Medical Association. 2023, Jan 3. https://www.ama-assn.org/delivering-care/hypertension/4-big-ways-bp-measurement-goes-wrong-and-how-tackle-them
  24. Gutteridge DS, Tully PJ, Smith AE, Loetscher T, Keage HA. Cross-sectional associations between short and mid-term blood pressure variability, cognition, and vascular stiffness in older adults. Cereb Circ Cogn Behav. 2023 Sep 1;5:100181. eCollection 2023. PMID: 37711969 PMCID: PMC10497990 Free PMC article
  25. Liu H, Zhao D, Sabit A et al Arm Position and Blood Pressure Readings: The ARMS Crossover Randomized Clinical Trial. JAMA Intern Med. 2024 Oct 7:e245213. PMID: 39373998 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2824754
  26. Soultan EH, Hara A, Knutson P et al Blood pressure variability associated with falls in nursing home residents. Geriatr Gerontol Int. 2024 Nov 3. PMID: 39489161 https://onlinelibrary.wiley.com/doi/full/10.1111/ggi.15014