1. Measurement of Blood Pressure: Issues and Challenges
Sadhana Bhagwat, NPO WCO India
13 December 2018

2. Silent killer
Most hypertensive people have no symptoms Under-diagnosis Under-treatment

3. Hypertension Prevalence, Awareness, Treatment
China: Age Liu J, Lancet Dec 9;390(10112):

4. Most with Hypertension in India Are Not Aware and Hence Not treated
Barely 1 in 10 of the 218 million adults with hypertension in India have it under control
74M
60M
Despite the heavy burden of illness and death from hypertension, many countries have been slow to respond. Just over half with HTN know they have it and just 1 in 7 globally have it under control. These proportions are significantly higher in LMICs. Yet HTN is probably the easiest to treat and effective treatment is available and can be relatively inexpensive.
24M
<11%
Roy A et al. BMJ Open. 2017;7:e Data for Delhi National Capital Region weighted and applied nationally.

5. WHO Guidance on Hypertension
FDC, Blood Pressure Device, Self care
Best buys, Global action plan
CVD, risk factors
Advocacy
Surveillance
Capacity Monitoring
Diagnosis
Assess CVD risk
Innovations
Essential Medicines and Technology
Treatment Protocol
Data System
Technical package
Risk stratification
-STEP survey
-WHS plus
Invest 1 USD on drug therapy and counselling to high CVD risk, return 3.29 USD
-Screen

6. Diagnosis Confirmation of hypertension:
after two visits ideally 1 to 4 weeks apart
Systolic blood pressure on both days is ≥140 mmHg and/or Diastolic blood pressure on both days is ≥90 mmHg
Patients with SBP ≥160 mmHg or DBP ≥100 mmHg may be indicated for immediate treatment based on one assessment
High blood pressure, according to the WHO-ISH guidelines, includes both hypertension (defined as 140/90 mmHg or above) and ``high normal'' (between 130/85 mmHg and 140/90 mmHg). The WHO-ISH guidelines class optimal blood pressure as less than 120/80 mmHg, 105/60

7. Essential technology (device and lab)
Blood pressure measurement device, Stethoscope
Weighing scales
Measuring tapes
Urine albumin strips
Urine ketones test strips
Glucometer, blood glucose test strips
Blood cholesterol, electrolyte, creatinine, ECG
BP> From Mercury, to Aneroid, to Electronic. Cost of essential technology, point of care, validation
-Affordable technology blood pressure measuring devices for low resource settings, WHO 2005
Challenges at PHC at low resource settings

8. Diagnosis confirmation
Diagnosis and treatment of hypertension
Diagnosis confirmation
Detection
Prolonged Treatment

9. Challenges in Diagnosis
Three sources of error in the measurement of blood pressure (AHA)
Observer bias
Faulty equipment
Failure to standardize the technique of measurement
Diagnosis confirmation

10. Three sources of error in the measurement of blood pressure (AHA)
Observer bias
Faulty equipment
Failure to standardize the technique of measurement

11. Common errors…. Raise the pressure to 30mm above pulse palpation
Lower at 2mm/sec (faster rate: lower SBP and higher DBP)
Terminal digit preference: rounding off to the zero: over estimation
*Office blood pressure measurement practices among community health providers (medical and paramedical) in northern district of India; Bishav Mohan a,*, Naved Aslam a, Upma Ralhan b, Sarit Sharma et al, India Heart Journal 6 6 ( )

12. Three sources of error in the measurement of blood pressure (AHA)
Observer bias
Faulty equipment
Failure to standardize the technique of measurement

13. Common errors….*
The best equipment????
Calibration interval

14. Three sources of error in the measurement of blood pressure (AHA)
Observer bias
Faulty equipment
Failure to standardize the technique of measurement

15. Common errors….
Supporting the arm: lower SBP/DBP by 11 and 12mm as compared to unsupported arm
Right cuff sizes: if small (obese people) SBP can rise by 8mm
Resting the patient: food, cold weather, stress, activity, coffee, tobacco
Auscultation: 1st appearance of sound: systolic
Complete disappearance of sound: diastolic

16. Common errors…. Minimum two readings
Sitting is better than supine: 3mm SBP raised and 3mm DBP lowered in supine
Centre of the bladder: Heart level: Increases if above, decreases if below that

17. WHO Guidance

18. Objectives of the workshop
Present the available guidelines and preliminary progress on guidance updating
Solicit practical country-level inputs from representatives on the most suitable devices for different levels of health care
Purchasing and maintaining blood pressure devices at different levels of health care provision