Blood Pressure Hypertension Orthostatics Sina Raissi, MD, FACP, FASN

Blood Pressure Wave Form

Cardiovascular events Hypertension Atherosclerosis Cardiovascular events

Cardiovascular complications of uncontrolled hypertension Stroke: Ischemic/hemorrhagic

Cardiovascular complications of uncontrolled hypertension Stroke: Ischemic/hemorrhagic Heart disease: Left ventricular hypertrophy, heart failure, myocardial infarction

Cardiovascular complications of uncontrolled hypertension Stroke: Ischemic/hemorrhagic Heart disease: Left ventricular hypertrophy, heart failure, myocardial infarction Aortic dissection

Cardiovascular complications of uncontrolled hypertension Stroke: Ischemic/hemorrhagic Heart disease: Left ventricular hypertrophy, heart failure, myocardial infarction Aortic dissection Kidney failure: dialysis

Cardiovascular complications of uncontrolled hypertension Stroke: Ischmeic/hemorrhagic Heart disease: Left ventricular hypertrophy, heart failure, myocardial infarction Aortic dissection Kidney failure: dialysis Peripheral arterial occlusive disease

Blood Pressure Measurement Office-based measurement Home BP monitoring Ambulatory blood pressure monitoring

Office Blood Pressure Measurement

Office Blood Pressure Measurement Time of measurement

Office Blood Pressure Measurement Time of measurement Type of instrument

Office Blood Pressure Measurement Time of measurement Type of instrument Cuff size

Office Blood Pressure Measurement Time of measurement Type of instrument Cuff size Patient position

Office Blood Pressure Measurement Time of measurement Type of instrument Cuff size Patient position Cuff placement

Office Blood Pressure Measurement Time of measurement Type of instrument Cuff size Patient position Cuff placement Technique of measurement

Office Blood Pressure Measurement Time of measurement Type of instrument Cuff size Patient position Cuff placement Technique of measurement Number of measurements

Patients should avoid the following for 30 minutes before measurement Exercise Caffeine Smoking Food intake Decongestants

The wrong size cuff results in higher systolic blood pressure reading than patient’s real blood pressure.

Cuff Size by AHA Arm circumference 22-26 cm: SMALL ADULT cuff 12 x 22 cm Arm circumference 27-34 cm: ADULT cuff 16 x 30 cm Arm circumference 35-44 cm: LARGE ADULT cuff 16 x 36 cm Arm circumference 42-52 cm: ADULT THIGH cuff 16 x 42 cm

Office Blood Pressure Measurement -Seated -No talking -Back is supported -Arm at the level of heart -Cuff 3 cm above fold of elbow -Keep legs uncrossed -5 minutes of rest

Blood Pressure Measurement Technique Inflate the cuff up to 30 mmHg above systolic BP as detected by disappearance of brachial pulse.

Blood Pressure Measurement Technique Inflate the cuff up to 30 mmHg above systolic BP as detected by disappearance of brachial pulse. Place the stethoscope LIGHTLY on brachial artery. Otherwise increased turbulence may result in artificial reduction in measured diastolic BP by 10-15 mmHg.

Blood Pressure Measurement Technique Inflate the cuff up to 30 mmHg above systolic BP as detected by disappearance of brachial pulse. Place the stethoscope LIGHTLY on brachial artery. Otherwise increased turbulence may result in artificial reduction in measured diastolic BP by 10-15 mmHg. Deflate the cuff slowly (about 5 seconds for each 10 mmHg decline). Fast deflation results in lower SBP and higher DBP reading.

Blood Pressure Measurement Technique Inflate the cuff up to 30 mmHg above systolic BP as detected by disappearance of brachial pulse. Place the stethoscope LIGHTLY on brachial artery. Otherwise increased turbulence may result in artificial reduction in measured diastolic BP by 10-15 mmHg. Deflate the cuff slowly (about 5 seconds for each 10 mmHg decline). Fast deflation results in lower SBP and higher DBP reading. The first pulse sound (Korotkoff phase I)  SBP Sudden muffling of pulse sounds (phase IV) DBP

Blood Pressure Measurement

Blood Pressure Measurement Blood pressure must be measured in both arms, the arm with the higher BP recording should be used for measurement.

Blood Pressure Measurement Blood pressure must be measured in both arms, the arm with the higher BP recording should be used for measurement. Blood pressure must be measured at least twice on each office visit.

Blood Pressure Measurement Blood pressure must be measured in both arms, the arm with the higher BP recording should be used for measurement. Blood pressure must be measured at least twice on each office visit. BP should be measured in standing position when indicated.

Blood Pressure Measurement Blood pressure must be measured in both arms, the arm with the higher BP recording should be used for measurement. Blood pressure must be measured at least twice on each office visit. BP should be measured in standing position when indicated. In the absence of end organ damage, BP should be measured over the course of 3-6 visits (1-6 weeks) before a diagnosis of hypertension is made.

Pitfalls of Office BP measurement White coat syndrome Masked Hypertension

Ambulatory Blood Pressure Monitoring

Definition of Hypertension Office BP measurement: systolic BP > 140 mmHg or diastolic BP > 90 mmHg. (with an automated oscillometric BP device AOBP threshold of > 135/85 mmHg is acceptable.) Home BP monitoring: systolic BP > 135 mmHg or diastolic BP > 85 mmHg. Ambulatory BP monitoring: Average daytime SBP > 135 mmHg or DBP > 85 mmHg, or Average 24 hour SBP >130 mmHg or DBP > 80 mmHg.

Orhtostatic Hypotension

Baroreceptor Reflex

Causes of Orthostatic Hypotension Hypovolemia Bleeding GI losses Cardiac Heart Failure Valvular disease Neurally mediated Degenerative diseases Autonomic neuropathy Other Endocrine

Orthostatic Blood Pressure Assess the need for orthostatics.

Orthostatic Blood Pressure Assess the need for orthostatics. Obtain patient’s pulse rate and blood pressure while supine.

Orthostatic Blood Pressure Assess the need for orthostatics. Obtain patient’s pulse rate and blood pressure while supine. Have the patient sit up for ONE minute.

Orthostatic Blood Pressure Assess the need for orthostatics. Obtain patient’s pulse rate and blood pressure while supine. Have the patient sit up for ONE minute. Obtain the patient’s pulse rate and blood pressure while sitting.

Orthostatic Blood Pressure Assess the need for orthostatics. Obtain patient’s pulse rate and blood pressure while supine. Have the patient sit up for ONE minute. Obtain the patient’s pulse rate and blood pressure while sitting. If positive orthostatic changes occur while sitting, DO NOT continue to standing position.

Orthostatic Blood Pressure Assess the need for orthostatics. Obtain patient’s pulse rate and blood pressure while supine. Have the patient sit up for ONE minute. Obtain the patient’s pulse rate and blood pressure while sitting. If positive orthostatic changes occur while sitting, DO NOT continue to standing position. Have patient stand up for ONE minute. Free standing, not leaning.

Orthostatic Blood Pressure Assess the need for orthostatics. Obtain patient’s pulse rate and blood pressure while supine. Have the patient sit up for ONE minute. Obtain the patient’s pulse rate and blood pressure while sitting. If positive orthostatic changes occur while sitting, DO NOT continue to standing position. Have patient stand up for ONE minute. Free standing, not leaning. Obtain patient’s blood pressure and pulse while standing up.

Orthostatic Blood Pressure Assess the need for orthostatics. Obtain patient’s pulse rate and blood pressure while supine. Have the patient sit up for ONE minute. Obtain the patient’s pulse rate and blood pressure while sitting. If positive orthostatic changes occur while sitting, DO NOT continue to standing position. Have patient stand up for ONE minute. Free standing, not leaning. Obtain patient’s blood pressure and pulse while standing up. Watch for possibility of orthostatic symptoms or syncope.

Orthostatics Result Orthostatics are considered POSITIVE if:

Orthostatics Result Orthostatics are considered POSITIVE if: Patient becomes severely symptomatic

Orthostatics Result Orthostatics are considered POSITIVE if: Patient becomes severely symptomatic Pulse increases by more than 20 bpm

Orthostatics Result Orthostatics are considered POSITIVE if: Patient becomes severely symptomatic Pulse increases by more than 20 bpm Systolic BP falls by more than 20 mmHg

Orthostatics Result Orthostatics are considered POSITIVE if: Patient becomes severely symptomatic Pulse increases by more than 20 bpm Systolic BP falls by more than 20 mmHg Increase in pulse by 10 bpm AND decrease in systolic BP by more than 10 mmHg in a symptomatic patient

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