Sie sind auf Seite 1von 13

Avoiding Pitfalls in Clinic BP

measurement

How we can measure BP better


Blood pressure (BP) measurement is one of the most commonly performed
clinical procedures. However, BP is a variable hemodynamic phenomenon,
which is influenced by many factors – some known and some not so commonly
known. These influences on BP can be significant, often accounting for rises
in systolic BP (SBP) > 20 mmHg. An effect of such magnitude can result in
erroneously labeling a healthy individual as 'hypertensive' for life.
Conversely, incorrect BP measurement may also result in missing a diagnosis
of hypertension. Also, good control of hypertension begins with accurate BP
measurement. Hence it goes without saying that accurate BP measurement is
imperative. This publication highlights the possible errors and pitfalls in BP
measurement and emphasizes the right techniques for accurate BP
measurement.
ESSENTIAL DOs AND DON’Ts IN BP MEASUREMENT

• Ask patient to avoid smoking, eating, consuming alcohol, caffeine containing


beverages or chocolate for at least an hour before BP measurement
• Allow patient to rest for at least 5 minutes
• Ensure that the arms, back and feet of the subject are supported whilst measuring
BP. The arm must be horizontal at the level of the heart as denoted by the
midsternal level
• Use a properly maintained, calibrated and validated device. A mercury
manometer is preferable. If aneroid devices are used, they should be checked
regularly against the mercury device
• Use cuffs of the appropriate size such that the bladder encircles at least 80% of
the subject’s arm
• Place cuff on the bare arm; avoid tight or thick clothes under the cuff
• For manual determinations, use palpated radial pulse obliteration pressure to
estimate systolic BP – the cuff should then be inflated 20-30 mmHg above this
level for the auscultatory determinations; the cuff deflation rate should be 22
mmHg per second
• Use phase I and V (disappearance) Korotkoff sounds to identify systolic and
diastolic BP, respectively
• Note down the BP as soon as it has been measured. The arm in which the pressure
is being recorded and the position of the subject should also be noted
• Take a mean of at least two readings spaced by 1-2 minutes; take additional
readings if marked differences (> 5 mmHg) between initial measurements are
found
• Measure BP in both arms at the initial visit. If significant difference (>20/10
mmHg) is found, measure BP routinely in the arm with the higher value
• Measure BP 1 and 5 minutes after assumption of the standing position in elderly
subjects, diabetic patients, and in other conditions in which orthostatic
hypotension may be frequent or suspected

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

BP can be measured directly (intra-arterially) or indirectly. The indirect method is widely


used in both daily practice and research. It mostly involves devices, which are dependent
on one common feature, namely, occluding the artery of an extremity (arm, wrist, finger,
or leg) with an inflatable cuff to measure BP either oscillometrically, or by detection of
Korotkoff sounds.

FACTORS AFFECTING BP MEASUREMENT


The accurate measurement of BP in clinical practice is dependent on the individual, the
equipment used and the observer.

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.

Hypertensive patients may require a lower dose of antihypertensive medication


during periods of fever or if they move to (sub) tropic countries (holidays, business).

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.

Hence, smoking, eating, consumption of alcohol or caffeine containing beverages


and chocolate should be avoided for at least an hour before the measurement of 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.

e) Anatomy: one arm or both the arms?


• There has been much controversy in various studies as to whether there is a
difference between the BP readings in the two arms (inter-arm difference).
Further, there is evidence associating an inter-arm difference with peripheral
vascular disease, raising the possibility that its presence may predict
cardiovascular (CV) events.
• A reasonable policy is to measure BP at the initial visit in both arms.
• If, after at least three readings, significant systematic difference (> 20/10
mmHg) is found, measure BP routinely in the arm with the higher value.

f) ‘White coat hypertension’ and ‘white coat’ effect


• White coat hypertension is a condition in which a normotensive subject becomes
hypertensive during BP measurement, but pressures then settle to normal outside the
medical environment.
• If the BP is higher when measured by a physician than by a nurse or a medical
student, it is known as the white coat effect. When this phenomenon is suspected,
nurses rather than physicians should measure the BP.
• White coat hypertension should be considered when clinic BP is consistently
elevated, or resistant to treatment in the absence of target organ damage.
• Twenty four-hour ambulatory BP monitoring (ABPM) or self-measurement at
home can be employed before patients are labeled “hypertensive” or treatment
is initiated.
• Physicians should diagnose white coat hypertension whenever office BP is
>140/90 mmHg at several visits while 24-hour ambulatory BP is <125/80 mmHg.
g) Routine activities
• There is a substantial diurnal BP variation, with a clear fall in BP during the night of
up to 15%, as a result of both sleep and inactivity, reflecting the decrease in
sympathetic tone.
• Various daytime activities induce increases in BP of different magnitude.
Activities accompanied by a large increase in BP of between 10 and 20 mm Hg
include meetings, physical work, transportation, walking and dressing. Activities
accompanied by increases in BP of up to 5 mmHg include deskwork, reading and
watching television.
• Talking results in approximately a 7 mmHg increase in BP and should thus be
avoided during BP measurement.

Hence activities that induce increases in BP should be avoided before/during BP


measurement. Talking should be avoided during BP measurement.

FACTORS RELATED TO THE INSTRUMENT


a) Instrument used
The measuring device used can induce large variations in BP. There is a wide range of
BP measuring devices in the market but unfortunately only a few of these devices have
been validated according to official standards.

The equipment -- whether aneroid, mercury, or electronic -- should be regularly


inspected and validated.

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.

FACTORS RELATED TO THE OBSERVER


The person who is measuring the BP (the observer) requires meticulous and repeated
theoretical and practical training and validation of his/her ability to measure the BP
accurately.
• Whilst taking the patient’s BP, be in a comfortable and relaxed position, because
if hurried, the pressure will be released too rapidly, resulting in underestimation
of SBP and overestimation of DBP.
• If any interruption occurs, the exact measurement may be forgotten and an
approximation made, so the BP should always be written down as soon as it has
been measured. The arm in which the pressure is being recorded and the
position of the subject should also be noted, for eg, BP 154/92, R arm, sitting
position
• Provide to patients, verbally and in writing, their specific BP numbers and the
BP goal of their treatment.
• A number of factors can cause a bias in the BP reading.
o Systematic error may be caused by lack of concentration, poor hearing, confusion
of auditory and visual cues, etc. The observer may fail to interpret the Korotkoff
sounds accurately, especially for DBP; or interpret the Korotkoff sounds
differently.
o Observers very often have a terminal digit preference (observer rounds off the
BP reading), which in the majority of cases is 0 (75%) or 5 (25%).
o Observers may be influenced by the knowledge of previous BP values during
serial readings (observer prejudice or expectation bias) and simply adjust the BP
to meet his/her preconceived notion of what the BP should be.

FACTORS RELATED TO TECHNIQUES

a) Bladder size/Cuff placement


• There is unequivocal evidence that either too narrow or too short a bladder
(undercuffing) will cause overestimation of BP, so called “cuff hypertension,” and
too wide or too long a bladder (overcuffing) may cause underestimation of BP.
Undercuffing has the effect in clinical practice of over-diagnosing hypertension
and overcuffing leads to hypertensive subjects being diagnosed as normotensive.
• Use cuffs of the appropriate size such that the bladder encircles at least 80% of
the upper arm.
• If the bladder does not completely encircle the arm, its centre must be over the
brachial artery. The lower edge of the cuff should be 2-3 cm above the point of
brachial artery pulsation.
• The width of the bladder should be equal to about two-thirds the distance from the
axilla to the antecubital space.
• As per the European Society of Hypertension 2003 guidelines for management of
hypertension, a standard bladder 12-13 cm long and 35 cm wide should be used.
• The British Hypertension Society (BHS) recommends three different bladder
sizes depending on arm circumference. The physician should have a larger and
smaller bladder available for fat and thin arms, respectively. In children, the smallest
bladder should be used.

• 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

d) Position of the body and arm


Posture of subject
• Most official guidelines recommend that BP should be routinely measured with
the patient in the sitting position. However, it is unclear if there are significant
differences between BP measured in the sitting vs the supine position, or which
position best approximates intra-aortic pressure. It is more convenient in most
instances to measure the BP in the sitting position; and virtually all the evidence
related to hypertension and CV outcomes is derived from studies that measured
sitting BPs.
• The arms, the back and feet of the patients should be supported to avoid any
isometric physical exercise that might increase the BP.
• Measurement of BP in the standing position is indicated periodically, especially
in those at risk for postural hypotension and in those who report symptoms
consistent with reduced BP upon standing.
• Measure BP one and five min after assumption of the standing position in
elderly, diabetics and in other conditions in which orthostatic hypotension may
be frequent or suspected.

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.

Follow-up of patients with various stages of hypertension

BP MEASUREMENTS IN SPECIAL POPULATIONS


Certain populations merit special consideration for BP measurement, either because of
age, body habitus, or disturbances of BP related to hemodynamic alterations in other
parts of the CV system.

1. Children and Adolescents


• Hypertension during childhood is not rare; the estimated prevalence is 1-2%, although
it is often an under-recognized clinical entity. Also, elevated BP may be a sign of
underlying disease or it may represent early onset of primary hypertension.
• The variability of BP is greater in children than in adults, and thus any one BP
reading is less likely to represent the true value.
• SBP is preferred to DBP because of greater accuracy and reproducibility.
• Cuff dimensions are most important and three cuffs with bladders measuring 4-13
cm, 10-18 cm, and the adult dimensions 12-26 cm are required for the range of arm
sizes likely to be encountered in the age range 0-14 years.
• Korotkoff sounds are not reliably audible in all children under one year and in
many under five years of age. In such cases, conventional sphygmomanometry is
impossible and more sensitive methods of detection such as Doppler, ultrasound,
or oscillometry must be used.
2. Pregnancy
• Clinically relevant hypertension occurs in more than 10% of pregnant women. BP
measurement in pregnancy represents one of the key points in the diagnosis of pre-
eclampsia.
• A general consensus from obstetricians based on careful analysis of the evidence
is that disappearance of sounds (fifth phase) is the most accurate measurement
of DBP, with the proviso that in those rare instances in which sounds persist to
zero, the fourth phase of muffling of sounds should be used.

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.

4. Patients with arrhythmias


• The BP measurement can be particularly difficult in patients with arrhythmias,
especially atrial fibrillation, soft Korotkoff sounds or a ‘silent gap’ due to marked
beat-to-beat variability.
• In patients with arrhythmias, auscultatory measurements and multiple readings
are recommended.
• In patients with bradyarrhythmias, when the heart rate is extremely slow, for
e.g. 40 beats/minute, it is important that the deflation rate used is less than for
normal heart rates as too rapid deflation will lead to underestimation of SBP
and overestimation of DBP.

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.

Das könnte Ihnen auch gefallen