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blood pressure (BP)

Classification: - American College of Cardiology/American Heart Association (ACC/AHA) definitions of blood pressure (BP) for adults: [1] - Normal: <120 systolic, <80 mm Hg diastolic - Elevated: 120-129 systolic, <80 mm Hg diastolic - Stage 1 hypertension: 130-139 systolic or 80-89 mm Hg diastolic - Stage 2 hypertension: >= 140 mm Hg systolic or >= 90 mm Hg diastolic [1] - masked hypertension: <130/80 mm Hg in office - home BP < 130/80 mm Hg or ambulatory BP monitoring >= 125/75 mm Hg - white-coat hypertension: >= 3 separate office BP measurements > 130/80 mm Hg - home BP < 130/80 mm Hg or ambulatory BP < 125/75 mm Hg - no evidence of target organ damage [1] * masked hypertension overides other classifications [1] - no suggestion of how forcing this classification effects management [1] * based on average of >= 2 BP readings measured on >= 2 separate occasions * classified according to highest systolic or diastolic BP category [1] 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] - short & long protocols of multiple unattended BP measurements correlate with 24-hour ambulatory monitoring [28] - 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) - BP measurement in public places with noise level of 74 dB not different from BP in private quiet environment 37 dB [27] - 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] - few available data in U.S. populations to support these classifications [1,29]

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) elevated blood pressure 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 - Medical Knowledge Self Assessment Program (MKSAP) 20 American College of Physicians, Philadelphia 2025
  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
  27. Ishigami J, Liu H, Zhao D et al Effects of Noise and Public Setting on Blood Pressure Readings : A Randomized Crossover Trial. Ann Intern Med. 2025 Jan 28. PMID: 39869911 https://www.acpjournals.org/doi/10.7326/ANNALS-24-00873
  28. Lynn-Green EE et al. Clinical impact of 3- vs. 5-minute delay and 30- vs. 60-second intervals on unattended automated office blood pressure measurements. Am J Hypertens 2025 Mar; 38:168 PMID: 39387134 PMCID: PMC11833244 https://academic.oup.com/ajh/article/38/3/168/7816888
  29. Whelton PK, Carey RM, Aronow WS et al 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines J Am Coll Cardiol. 2018 May 15;71(19):e127-e248. PMID: 29146535 Free article - Whelton PK, Carey RM, Aronow WS et al 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2017. Nov 3, 2017 PMID: 29133356