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measurement
The above summarise the essential points to be borne in mind whilst measuring BP.
However, it may be worthwhile to read the entire booklet for understanding the
numerous factors – some known and some not so commonly known -- that can
influence accurate BP measurement
BP MEASUREMENT METHODS
Scipione Riva-Rocci and Nikolaij Korotkoff were among the first to introduce the
measurement of ‘BP’ during the morning round in their hospital wards. They collected
and contributed to most of the information on BP levels in arterial hypertension over
more than a century. The combination of the Riva-Rocci and Korotkoff techniques has
given us the auscultatory sphygmomanometric BP measurement – a method that has
allowed us to identify arterial hypertension as an important factor in CV risk and to
demonstrate that its treatment can markedly improve a patient’s prognosis
PATIENT-RELATED FACTORS
a) Rest period
• Average drops in the systolic BP (SBP) of 9 and 14 mmHg, respectively, have been
reported after a rest period of four and eight minutes prior to BP measurement.
• A longer rest period of >25 minutes was found to further slightly decrease the BP
values, especially the SBP; but this may not be feasible in general practice.
Hence it has been recommended that at least five minutes of rest should be allowed
in a quiet room in a chair (rather than on an examination table) with feet on the
floor before the measurement of BP
b) Seasonal variability
Studies have suggested a seasonal variation of the BP, showing on an average 3 to 8
mmHg higher BP values during the winter than during the summer, even in patients
living in a stable environmental temperature. These differences seem to be inversely
associated with the body mass index, possibly due to the increased thermoregulatory
requirements of leaner individuals.
c) Stimulants
• Smoking the first cigarette of the day may acutely induce a rise in BP that lasts for 15
to 30 minutes, which is likely due to the acute release of norepinephrine. On the other
hand, chronic smoking induces tolerance.
• Ingestion of caffeine-containing beverages may induce an acute rise in BP; however,
a certain degree of tolerance may occur with repeated consumption. Other ingredients
in coffee apart from caffeine may also be responsible for the cardiovascular (CV)
activation.
• Eating as an activity increases BP by 8 to 9 mmHg; however a postprandial decrease
in BP can also be noted, especially in elderly patients.
• Ingestion of alcohol can also acutely increase BP.
d) Sympathetic stimulators
• Pain and anxiety acutely increase the BP, probably due to increased sympathetic
activity.
• Explain the procedure adequately beforehand, especially in nervous patients.
• Inform patients about a minor discomfort caused by the inflation of the cuff.
• Advise patients to empty their bladder before BP measurement as a
distended bladder has been reported to increase BP.
Mercury Sphygmomanometer
• Use properly maintained, calibrated and validated device.
• Maintain the equipment properly; regular maintenance concerns three points:
adequate filling of the mercury reservoir, replacement of the glazed tube in case of
mercury precipitation and replacement of the rubber connections in case of leak.
Aneroid Manometers
• Aneroid devices are used widely, although they are notoriously difficult to maintain
in an accurate state over time, usually leading to falsely low readings with the
consequent underestimation of BP.
• When calibrated against a mercury sphygmomanometer, a mean difference of 3 mm
Hg is considered to be acceptable; however, 58% of aneroid sphygmomanometers
have been shown to have errors >4 mm Hg, with about one third of these having
errors >7 mm Hg.
• They are susceptible to carelessness in maintenance. The jolts and bumps of everyday
use affect their accuracy; and therefore not recommended for routine use.
• If used, check the aneroid devices regularly against mercury.
b) Rubber Tubing
• Leaks due to cracked or perished rubber cause inaccurate BP measurement, as the fall
in mercury cannot be controlled. The rubber should be in good condition and free
from leaks.
• The minimum length of tubing should be 70 cm between the cuff and manometer
and at least 30 cm in length between the inflation source and cuff. Connections
should be airtight and easily disconnected.
c) Control Valve
• A very common source of error is the control valve, especially when air filter rather
than a rubber valve is used.
• Defective valves cause leakage, making control of pressure release difficult; this leads
to underestimation of SBP and overestimation of DBP.
• Faults in the control valve may be corrected easily by simply cleaning the filter
or replacing the control valve.
• Place the cuff on the bare arm; tight or thick clothes under the cuff should be
avoided.
• The rubber tubes from the bladder are usually placed inferiorly, often at the site
of the brachial artery, but it is now recommended that they should be placed
superiorly or, with completely encircling bladders, posteriorly, so that the
antecubital fossa is easily accessible for auscultation.
• Inflate the bladder rapidly to avoid prolonged discomfort for the patient, but
deflate it slowly at a rate of 2 mm Hg per beat or per second, to accurately
record BP to the nearest 2mm Hg. On the other hand, deflation can be speeded up
in the second or third readings, especially when there is an increase in pulse pressure
(eg 224/62 mmHg) since otherwise the procedure may become too painful and pain
may increase the BP further.
b) Position of Manometer
• The manometer should be no further than three feet (92 cm) away so that the
scale can be read easily.
• The mercury column should be vertical (some models are designed with a tilt) —
this is achieved most effectively with stand-mounted models, which can be easily
adjusted to suit the height of the observer.
• View the scale straight on with the eye on a line perpendicular to the centre of
the face of the gauge in order to avoid the parallax effect. According to this effect,
a higher BP will be read if the observer is watching from below the scale and vice
versa, a lower BP will be read when watching from above the scale.
c) Stethoscope placement
• During auscultatory measurement, hold the stethoscope firmly and evenly but
without excessive pressure
• Too much pressure might distort the artery, producing sounds below diastolic
pressure
• The stethoscope end-piece should not touch the cuff or rubber tubes to avoid friction
sounds
Arm postion
• If the arm in which measurement is being made is unsupported, as tends to happen if
the subject is sitting or standing, DBP may be raised by as much as 10%. It is
essential that the arm is supported during BP measurement and this is best
achieved in practice by having the observer hold the subject's arm at the elbow.
• Dependency of the arm below heart level leads to an overestimation of BP and raising
the arm above heart level leads to underestimation. The magnitude of this error can be
as great as 10 mm Hg for BP. Such errors can occur in a patient who is standing with
his arm hanging parallel to the body or in a sitting patient whose arm is supported by
the armrest of the chair or by a regular office desk. However, it has been
demonstrated that even in the supine position, an error of 5 mm Hg for DBP may
occur if the arm is not supported at heart level.
• The arm must be horizontal at the level of heart as denoted by the midsternal
level. The level of the fourth intercostal space or the midsternum have been proposed
as practical approximation of the right atrium level in the sitting and standing
positions.
e) Diastolic Dilemma
• For many years, recommendations on BP measurement have been uncertain about the
diastolic endpoint.
• Phase IV (muffling) may coincide with or be as much as 10 mm Hg higher than phase
V (disappearance), but usually the difference is <5 mm Hg; phase V correlates best
with intra-arterial pressure.
• There has been resistance to general acceptance of the silent endpoint until recently,
because the silent endpoint can be greatly below the muffling of sounds in some
groups of patients— children, pregnant women, anemic or elderly patients. In some
patients, sounds may even be audible when cuff pressure is deflated to zero.
• There is now a general consensus that disappearance of sounds (phase V) should
be taken as diastolic pressure except in children, pregnant women, anemic or
elderly.
f) Number of measurements
• Decisions based on single measurements will result in erroneous diagnosis and
inappropriate management due to variability of BP measurements.
• Take a mean of at least two readings spaced by 1-2 min; additional recordings
are needed if marked differences between initial measurements are found.
OTHER FACTORS
• Perform BP measurements in a quiet environment, as noisy rooms make it
difficult for the patient to relax and the observer to concentrate and adequately hear
Korotkoff sounds.
• Room temperature should not be too high or too low either
FOLLOW-UP BP MEASUREMENTS
• Repeated office BP measurements in standard conditions have a prognostic value
similar to that of 24 hour ambulatory BP monitoring (ABPM).
• In cases of slight BP elevation, repeated measurements have to be obtained over
several months before a final diagnosis of hypertension can be made, because of the
possibility of a spontaneous regression, over time, to normal levels.
• If a patient has a more marked BP elevation, evidence of hypertension-related
organ damage or a high/very high CV risk profile, repeated measurements
should be obtained over shorter periods of time, such as weeks or days, before a
clinical decision is taken.
3. Critical-care setting
• In an emergency situation, a traditional sphygmomanometric technique is sufficient
(palpation is recommended whenever an auscultatory measurement is impossible;
when prolonged monitoring is to be performed, automated methods are required).
• Whenever continuous BP monitoring is essential, use of intra-arterial catheters is a
common procedure.
5. Dialysis patients
• In dialysis patients (hemodialysis and peritoneal dialysis), there are large day-to-day
variations in body fluid status, and therefore also in BP level. The timing of BP
measurement in relation to dialysis, changes in interdialytic weight gain, and
inconsistent BP measurement technique in dialysis units contribute to the variability
of BP readings. In principle, these rapid changes might be best assessed by 24 h
ABPM.
• Interdialytic BP monitoring with an ambulatory BP monitor is the most
reproducible method and is thought to best represent BP in dialysis patients.
• A composite of BP measurements over a period of 1 to 2 weeks rather than
isolated readings should be used for guidance.
• However, when ABPM is not possible, BP obtained in the dialysis unit can be used in
a qualitative sense for prediction of hypertension in these patients.
6. Elderly
• The elderly are subject to considerable BP variability, which can lead to a number of
circadian BP patterns that are best identified using ABPM.
• It has been postulated that as a consequence of the decrease in arterial compliance and
arterial stiffening with ageing, indirect sphygmomanometry becomes inaccurate. This
has led to the concept of “pseudohypertension” to describe patients with a large
discrepancy between cuff and direct BP measurement.
7. Resistant hypertension
Evaluation of the patient with resistant hypertension should include 24-hour ABPM or
home measurements and a search for secondary causes.
REFERENCES
1. BMJ 2001; 322: 981-5
2. Netherlands J Med 2004; 62: 297-303
3. Curr Opin Nephrol Hypertens 2004; 13: 343-57
4. J Hum Hypertens 2004; 18: 139-85
5. J Hypertens. 2003; 21: 1011-53
6. JAMA 2003; 289: 2560-72.