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Office and Home Blood Pressure AssessmentHyperte
nsion Diagnosis and Follow up

• 2009

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Blood Pressure Canada and the Canadian
Hypertension Education Program

• This slide set is an initiative aimed at
  enhancing the quality of blood pressure
  measurement. This venture is the result of a
  collaborative effort of the following
  organizations
• - The Canadian Hypertension Education Program
• - Blood Pressure Canada
• Other slide sets and other educational material
  on hypertension can be downloaded from the
  following website http//www.hypertension.ca

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• The Canadian Hypertension Education
• Program (CHEP)
• Overseen by
• The Canadian Hypertension Society
• Blood Pressure Canada
• The Heart and Stroke Foundation of Canada
• The Public Health Agency of Canada
• The College of Family Physicians of Canada
• The Canadian Council of Cardiovascular Nurses
• The Canadian Pharmacy Association.

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Blood Pressure Canada and the Canadian
Hypertension Education Program
Instructions for proper blood pressure
measurement are found in the detailed
recommendations of the CHEP program (Can J
Cardiol 200824(6)455-63) At www.hypertension.ca
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Blood Pressure Measurement and Hypertension
Diagnosis

• 1 in 5 adult Canadians have hypertension
• Over 40 of Canadians at aged 56-65 have
  hypertension
• 90 of normotensive persons aged 55-65 developed
  hypertension in the next 20 years in the
  Framingham study

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Blood Pressure Assessment

• Blood pressure of all adults should be measured
  by a trained healthcare professional at all
  appropriate visits.
• To determine cardiovascular risk
• To monitor antihypertensive treatment
• Blood pressure of adults with high normal blood
  pressure (130-139/80-89 mmHg) should be assessed
  annually

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The percent of Canadians with hypertension
CHHS CMAJ 1992
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Life time risk of Hypertension in Normotensive
Women and men aged 55-65 years
Risk of Hypertension
Risk of Hypertension
100
100
Women
Men
80
80
60
60
40
40
20
20
0
0
Years to Follow-up
Years to Follow-up
JAMA 20022971003-10. Framingham data.
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Modifiable risks for developing hypertension

• Obesity
• Poor dietary habits
• High sodium intake
• Sedentary lifestyle
• High alcohol consumption

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Development of hypertension () in those with
high normal blood pressure
Framingham cohort Vasan. Lancet 20013581682-86
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New onset hypertension in those with high normal
blood pressure

• 772 subjects, over weight, mean age 48.5
• Not receiving treatment for Hypertension
• Average of 3 blood pressures at baseline
• SBP 130-139 and DBP lt 89 OR
• SBP lt 139 and DBP 85-89
• Primary endpoint new onset hypertension

NEJM 20063541685-97
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New onset hypertension in people with high normal
blood pressure
NEJM 20063541685-97
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New onset hypertension in people with high normal
blood pressure

• 40 of overweight patients with systolic 130-139
  or diastolic 85-89 mmHg developed hypertension
  in 2 years and 63 in 4 years
• Annual follow-up of patients with high normal
  blood pressure is recommended by CHEP.

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Blood Pressure AssessmentPatient preparation
and posture
Standardized Preparation Patient 1. No acute
anxiety, stress or pain. 2. No caffeine, smoking
or nicotine in the preceding 30 minutes. 3. No
use of substances containing adrenergic
stimulants such as phenylephrine or
pseudoephedrine (may be present in nasal
decongestants or ophthalmic drops). 4. Bladder
and bowel comfortable. 5. No tight clothing on
arm or forearm. 6. Quiet room with comfortable
temperature 7. Rest for at least 5 minutes
before measurement 8. Patient should stay silent
prior and during the procedure.
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Blood Pressure AssessmentPatient preparation
and posture
Standardized technique Posture The patient
should be calmly seated with his or her back well
supported and arm supported at the level of the
heart. His or her feet should touch the floor
and legs should not be crossed.
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Blood Pressure AssessmentPatient position
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Recommended Equipment for Measuring Blood Pressure

• Use a mercury manometer or a recently calibrated
  aneroid or a validated automated device.
• Aneroid devices should only be used if there is
  an established calibration check every 12 months.

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Recommended Equipment for Measuring Blood Pressure

• Automated oscillometric devices
• Use a validated automated device according to
  BHS, AAMI or IP clinical protocols.
• For home blood pressure measurement devices, a
  logo on the packaging ensures that this type of
  device and model meets the international
  standards for accurate blood pressure measurement.

AAMIAssociation for the Advancement of Medical
Instrumentation BHSBritish Hypertension
Society IP International Protocol.
19
Recommended Technique for Measuring Blood
Pressure (cont.)

• Select a device with an appropriate size
  cuff

20
Use an appropriate size cuff
For automated devices, follow the manufacturers
directions. For manual readings using a
stethoscope and sphygmomanometer, use the table
as a guide.
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Recommended Technique for Measuring Blood
Pressure (cont.)

• Locate the brachial pulse and centre the cuff
  bladder over it
• Position cuff at the heart level
• Arm should be supported

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Recommended Technique for Measuring Blood
Pressure (cont.)

• To exclude possibility of auscultatory gap,
  increase cuff pressure rapidly to 30 mmHg above
  level of disappearance of radial pulse
• Place stethoscope over the brachial artery

with manual or semi automated devices
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Recommended Technique for Measuring Blood
Pressure (cont.)

• Drop pressure by 2 mmHg / beat
• Appearance of sound (phase I Korotkoff)
  systolic pressure
• Drop pressure by 2 mmHg / beat
• Disappearance of sound (phase V Korotkoff)
  diastolic pressure
• Record measurement
• Take at least 2 blood pressure measurements, 1
  minute apart

with manual or semi automated devices
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Korotkoff sounds and auscultatory gaps
Systolic BP
Phase 3
Phase 4
Diastolic BP
25
Recommended Technique for Measuring Blood
Pressure

• Standardized technique
• For initial readings, take the blood pressure in
  both arms and subsequently measure it in the arm
  with the highest reading.
• Thereafter, take two measurements on the side
  where BP is higher.

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Recommended Technique for Measuring Blood
Pressure (cont.)

• Record the blood pressure to the closest 2 mmHg
  on the manometer
• and whether the patient was supine, sitting or
  standing.

Aneroid devices should not be used unless they
are known to be in calibration and are checked
regularly (minimally every 12 months).
For manual blood pressure measurement
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Recommended Technique for Measuring Blood
Pressure (cont.)

• Avoid digit preference for five (5) or zeros (0)
  by not rounding up or down.
• Record the heart rate.

If the needle on an aneroid device does not zero
it is inaccurate however the converse is not
true.
For manual blood pressure measurement
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Recommended Technique for Measuring Blood
Pressure (cont.)

• The seated BP measurement is the standard
  position to determine diagnostic and therapeutic
  treatment decisions
• The standing blood pressure is used to test for
  postural hypotension, if present, which may
  modify the treatment.

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Recommended Technique for Measuring BP Standing
BP
Perform in patients over age 65 with
diabetes if there are symptoms of postural
hypotension Check after 1 to 5 minutes in the
standing position and under circumstances when
the patients complains of symptoms suggestive of
hypotension.
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Diagnostic algorithm for high Blood Pressure
including Office, ABPM and Home Blood Pressure
Measurement
Hypertension Visit 1 BP Measurement, History and
Physical examination
Diagnostic tests ordering at visit 1 or 2
Hypertension Visit 2 within 1 month
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Diagnostic algorithm for high Blood Pressure
including Office, ABPM and Home Blood Pressure
Measurement
32
Diagnostic algorithm for high Blood Pressure
including Office, ABPM and Home Blood Pressure
Measurement
33
The concept of masked hypertension
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True hypertensive
Masked HTN
Home or daytime ABPM SBP mmHg
135
True Normotensive
White Coat HTN
140
Office SBP mmHg
From Pickering, Hypertension 1992
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The prognosis of masked hypertension
Prevalence of masked hypertension is
approximately 10 in the general population
(prevalence is higher in diabetic patients).
J Hypertension 2007252193-98
35
Threshold for Initiation of Treatment and Target
Values
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VII. Home measurement of blood pressure
Home BP measurement should be encouraged to
increase patient involvement in care
Which patients?
For the diagnosis of hypertension Suspected non
adherence White coat hypertension or
effect Masked hypertension
Average BP equal to or over 135/85 mmHg should be
considered elevated
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Benefits of Home Blood Pressure Monitoring

• Rapid confirmation of the diagnosis of
  hypertension
• Better prediction of cardiovascular prognosis
• Diagnosis of white coat and masked hypertension
• Reduced medication use in white coat effect
• Improved adherence to drug therapy
• Better blood pressure

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Not all patients are suited to home measurement

• Undue anxiety in response to high blood pressure
  readings
• Physical or mental disability prevents accurate
  technique or recording
• Arm not suited to blood pressure cuff (e.g.
  conical shaped arm)
• Irregular pulse or arrhythmias prevent accurate
  readings
• Lack of interest

The vast majority of patients can be trained to
measure blood pressure
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Home Measurement of BPUse validated BP
measurement devices
This logo on the packaging ensures that this
type of device and model meets the international
standards for accurate blood pressure measurement
Endorsed by the Canadian Hypertension Society
Average BP gt 135/85 mmHg should be considered
elevated
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VII. Suggested Protocol for Home Measurement of
Blood Pressure for the diagnosis of hypertension

• Home blood pressure values should be based on
• duplicate measures,
• morning and evening,
• for an initial 7-day period.
• Singular and first day home BP values should not
  be considered.
• Daytime average BP equal to or over 135/85 mmHg
  should be considered elevated

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Home Measurement of BPPatient Education
How to?

• Use devices
• appropriate for the individual
• appropriate cuff size
• marked with this symbol
• Adequate patient training in
• measuring their BP
• interpreting these readings
• Regular verification
• measuring techniques

Values gt 135 / 85 mmHg should be considered
elevated
Home measurement can help to improve patient
adherence
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Suggested Protocol for Home Measurement of Blood
Pressure
How?

• Home blood pressure values for assessing white
  coat hypertension or sustained hypertension
  should be based on
• Duplicate measures,
• Morning and evening,
• For an initial 7-day period.
• Single readings and
• First day home BP values should not be
  considered.
• For patients treated for hypertension
• Morning measurement should be done before
  medication taking

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VII. Home Measurement of BP Patient Education
Assist patients select a model with the correct
size of cuff Measure and record the patients mid
arm circumference so they can match it to cuff
size Recommend devices listed at
www.hypertension.ca or marked with this symbol
Ask patients to carefully follow the
instructions with device and to record only those
blood pressure readings where they have followed
recommended procedure Advise patients that
average readings equal to or over 135/85 mmHg are
high a lower threshold is appropriate for those
with diabetes or chronic kidney disease
Values equal to or over 135 / 85 mmHg should
be considered elevated for those without diabetes
or chronic kidney disease
Home measurement can help to improve patient
adherence
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Web based home monitoring

• A new website to assist patients home monitor and
  track blood pressure and to enhance self
  management of lifestyle is now available
• www.heartandstroke.ca/BP

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Advice for patients on when to contact a health
care professional based on high average home
blood pressure readings
Patients with diabetes, chronic kidney disease
or who are at high risk of cardiovascular events
require individualized advice.
(available at www.hypertension.ca/bpc in the
resource section under educational tools for
health care professionals in the Brief
Hypertension Action Tool or at
www.heartandstroke.ca/BP)
46
Home measurement of blood pressure
A poster and instruction sheets can be ordered at
the Heart and Stroke Foundation offices at the
following internet address
http//www.hypertension.ca
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Suggested use of ABPM in the Management of
Hypertension
Office BP gt 140/90 mmHg in low risk patients
(with no target-organ disease)
Home-monitored blood pressure lt135/85mmHg
Home-monitored blood pressure equals or over
135/85mmHg
Perform ABPM
Mean awake BP Less than 135/85 mmHg
Mean awake BP equals or over 135/85 mmHg
Follow-up with periodic home-BP measurement and
or repeated ABPM every 1-2yr.
Initiate antihypertensive therapy
ABPM Ambulatory Blood Pressure Monitoring BP
Blood Pressure
Adapted from White W, NEJM 34824, June 12, 2003
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Recommendations for Follow-up
Diagnosis of hypertension
Non Pharmacological treatment With or without
Pharmacological treatment
Are BP readings below target during 2 consecutive
visits?
No
Yes
Follow-up at 3-6 month intervals
Symptoms, Severe hypertension, Intolerance to
anti-hypertensive treatment or Target Organ Damage
No
Yes
More frequentvisits
Visits every 1-2 Months
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Blood pressure measurement with specific devices

• Mercury Blood Pressure Monitor
• Aneroid Blood Pressure Monitor
• Automated Blood Pressure Monitor

50
Blood Pressure Measurement with Mercury Blood
Pressure Monitor

• The patient should
• Be calmly seated for at least 5 minutes
• Have his or her back supported with a chair back
• Have their arm bare or have thin clothing on
• Have their arm supported at the level of the
  heart.
• Have their feet on the floor and their legs
  should not be crossed.
• Not talk prior and during the procedure.
• The column of mercury must be vertical, and at
  the observers eye level

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Blood Pressure Measurement with Mercury Blood
Pressure Monitor

• Use a cuff with the appropriate size
• Estimate the systolic beforehand
• a) Palpate the brachial artery
• b) Inflate cuff until pulsation disappears
• c) Deflate cuff
• d) Estimate systolic pressure
• Inflate to 30mmHg above the estimated systolic
  level needed to occlude the pulse

52
Blood Pressure Measurement with Mercury Blood
Pressure Monitor

• Place the stethoscope diaphragm over the brachial
  artery and deflate at a rate of 2mmHg/beat until
  you hear regular tapping sounds. Measure systolic
  (first regular sound) to nearest 2mmHg
• Deflate at a rate of 2 mmHg/heart beat to 10 mmHg
  below the last heard Korotkoff sound
• Measure diastolic blood pressure to nearest 2mmHg.

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Blood Pressure Measurement with Aneroid Blood
Pressure Monitor

• The patient should
• Be calmly seated for at least 5 minutes
• Have his or her back supported with a chair back
• Have their arm bare or have thin clothing on
• Have their arm supported at the level of the
  heart.
• Have their feet on the floor and their legs
  should not be crossed.
• Not talk prior and during the procedure.
• The manometer should be easily visible at the
  observers eye level

Aneroid devices should not be used unless they
are known to be in calibration and are checked
regularly (minimally every 12 months).
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Blood Pressure Measurement with Aneroid Blood
Pressure Monitor

• Estimate the systolic beforehand
• a) Palpate the brachial artery
• b) Inflate cuff until pulsation disappears
• c) Deflate cuff
• d) Estimate systolic pressure when the pulse
  reappears
• Inflate to 30mmHg above the estimated systolic
  level needed to occlude the pulse

Aneroid devices should not be used unless they
are known to be in calibration and are checked
regularly (minimally every 12 months).
55
Blood Pressure Measurement with Aneroid Blood
Pressure Monitor

• Place the stethoscope diaphragm over the brachial
  artery and deflate at a rate of 2mmHg/beat until
  you hear regular tapping sounds. Measure systolic
  (first regular sound) to nearest 2mmHg
• Deflate at a rate of 2mmHg/beat until
  disappearance. Measure diastolic blood pressure
  to nearest 2mmHg

Aneroid devices should not be used unless they
are known to be in calibration and are checked
regularly (minimally every 12 months).
56
Blood Pressure Measurement with Aneroid Blood
Pressure Monitor
Aneroid devices should not be used unless they
are known to be in calibration and are checked
regularly (minimally every 12 months). If the
needle on an aneroid device does not zero it is
inaccurate however the converse is not true.
57
Assessing the calibration of an aneroid device

• Attach the aneroid device and cuff to a mercury
  manometer using tubing and if necessary a Y or
  T connection (see diagram). Consider putting
  cotton wool in the T tube to prevent the mercury
  from oxidizing and becoming contaminated.
• Pump the cuff up and assess the pressure of the
  aneroid at 20 mmHg intervals from 300 mmHg to 60
  mmHg.
• The aneroid is out of calibration if the readings
  are 4 or more mmHg different from the mercury
  device.
• Do not use the aneroid device if it reads 4 or
  more mmHg different from the mercury device at
  pressures where diagnosis or therapeutic
  decisions are made.

Note If the aneroid device does not read 0
when there is no pressure in the cuff it is out
of calibration
58
Attaching an aneroid device to a Mercury device
for calibration testing
Note check the mercury column is at zero before
testing.
59
Blood Pressure Measurement with a Fully Automated
Home or Office Automated Blood Pressure Monitor

• The patient should be calmly seated for at least
  5 minutes, with his or her back well supported
  and arm supported at the level of the heart. His
  or her feet should touch the floor and legs
  should not be crossed. The patient should be
  instructed not to talk prior and during the
  procedure.
• Ensure no tight clothing constricts the arm
• Use a cuff with the appropriate size
• Place the cuff on snuggly with the indicator mark
  on the cuff over the brachial artery
• Take at least two blood pressure measurements one
  minute apart
• Record measurement as displayed

60
Recommended automated blood pressure monitors for
home blood pressure measurement
Monitors AD or LifeSource Models 705, 767,
767PAC, 767Plus, 774, 774AC, 779, 787,
787AC Monitors Omron  Models HEM-705 PC,
HEM-711, HEM-741CINT Monitors Microlife or
Thermor (also sold under different brand
names) Models BP 3BTO-A, BP 3AC1-1, BP 3AC1-1
PC, BP 3AC1-2, BP 3AG1, BP 3BTO-1,BP 3BTO-A (2),
BP 3BTO-AP, RM 100, BP A100 Plus, BP A 100