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Blood Pressure Basics and Beyond


by Barbara A. Bushman, Ph.D., FACSM

Can you identify the 10 errors in this picture of resting

Q:
Blood pressure is such a routine measure
that the nuances often are taken for granted.
BP measurement? See page 9 for the answer.
What aspects of blood pressure measure-
ment are important for the health and fit-
ness professional?

A:
The measurement of blood pressure (BP) is one of
the most commonly performed health-related assess-
ments, and with good reason. BP is an independent
risk factor for cardiovascular disease (13), and the relationship
between BP and cardiovascular health is continuous across a
broad blood pressure range (10). For example, the risk of cardio-
vascular disease in later adulthood has been found to double for
each 20-mmHg increase in systolic blood pressure (SBP) greater
than 115 mmHg (up to 185 mmHg) and for each 10-mmHg in- Consistent methods should be used when assessing resting
crease in diastolic blood pressure (DBP) greater than 75 mmHg BP. The following procedures should be followed (1):
(up to 115 mmHg) (10). Thus, regular and accurate assessment • Pretest behaviors: the client should avoid smoking ciga-
of BP is crucial. rettes or consuming caffeine for at least 30 minutes prior;
BP is defined as the force of the blood against the walls of the the client should be seated quietly for at least 5 minutes
blood vessels created by the pumping action of the heart (3). before BP is measured.
Two values are reported: SBP, which is the highest pressure in • Body position: the client should be seated in a chair with
the arteries when the heart is contracting (systole) and DBP, back support, feet on the floor, and the arm supported at
which is the lowest pressure in the arteries when the heart is heart level.
relaxing (diastole). BP is measured in units of mmHg (millime- • Cuff selection: the bladder of the cuff should encircle at
ters of mercury). least 80% of upper-arm circumference.
The direct measurement of BP using an intra-arterial cathe- • Cuff location: the cuff should be placed snugly around
ter is not practical in most circumstances (9). Instead, a relatively the upper arm at heart level and should allow for the
cost-efficient and simple indirect way to measure BP involves stethoscope head to be placed below the bottom edge
using a cuff with an inflatable bladder and sphygmomanometer of the cuff over the brachial artery (note: either side of
to measure pressure. A stethoscope is used to listen to the blood the stethoscope can be used; both the bell and dia-
moving through the vessel; various sounds associated with phragm side have been found to be equally effective);
changes in blood movement are referred to as Korotkoff sounds the cuff should be placed so that the bladder is centered
(Table 1) (3). The indirect method requires the cuff to be placed over the brachial artery.
around the upper arm (Figure 1), and then the bladder of the • Cuff pressure: the pressure should be inflated to 20 mmHg
cuff is inflated to block blood flow temporarily through the bra- more than the first sound and then released at a rate of
chial artery. As pressure is reduced in the cuff, blood is able to approximately 2 to 5 mmHg per second.
pass through the artery at the highest pressure point (SBP) and Attention to these procedures will help ensure that BP mea-
then returns to smooth flow once the cuff pressure drops below sures are accurate and consistent. Typically, BP is recorded to
the lowest pressure point (DBP). Thus, SBP is recorded as the the nearest 2 mmHg (i.e., nearest even number) (13). An average
point when the first Korotkoff sounds are heard, and the DBP of two measurements should be recorded, with the two measures
is determined at the point of disappearance of the sounds. taken at least 1 minute apart (13).

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TABLE 1: Korotkoff Sounds (3)


BOX 1:
Phase Sound Activity in Vessel Record
1 First tapping sound Pressure in the cuff SBP
Lifestyle Modifications Can Make a Difference
drops below the highest Although medications often are warranted in the treatment
pressure in vessel so of hypertension, lifestyle modifications can have a positive
blood flow is intermit-
impact. Maintaining normal body weight, defined as a body
tent and turbulent.
mass index of 18.5 to 24.9 kg/m2, is recommended; a
2 Soft tapping or Turbulent blood flow weight loss of 10 kg can reduce SBP by 5 to 20 mmHg (6).
swishing sound continues. Physical activity, including at least 30 minutes per day on
3 Loud crisp tapping most days of the week, has been found to provide a 4- to
sound 9-mmHg reduction in SBP (6). With regard to nutrition, con-
suming a diet rich in fruits, vegetables, and low-fat dairy
4 Muffled tapping DBP (true) while reducing intake of saturated fat and total fat (i.e., the
5 Complete Pressure in the cuff is DBP (clinical) DASH diet (Dietary Approaches to Stop Hypertension)) pro-
disappearance below the lowest motes an SBP reduction of 8 to 14 mmHg (6). Limiting alco-
of sound pressure, and thus hol consumption (<2 drinks per day in most men and 1 drink
blood flow is per day in women and lighter-weight individuals) is associ-
smooth (laminar). ated with a 2- to 4-mmHg reduction in SBP (6). In addition,
keeping sodium intake to less than 2,400 mg/day is recom-
mended for a potential SBP reduction of 2 to 8 mmHg (and
note that lowering sodium intake down to 1,500 mg/day is
The normal resting BP for adults is a SBP of less than
associated with even greater BP reductions) (7).
120 mmHg and a DBP of less than 80 mmHg (1). Prehypertension
is defined as a SBP between 120 and 139 mmHg or a DBP
between 80 and 89 mmHg (1). Stage 1 hypertension is con-
sidered for a SBP between 140 and 159 mmHg or a DBP ○ Stage 1 hypertension: SBP and/or DBP greater than
between 90 and 99 mmHg; stage 2 includes a SBP of the 95th percentile to less than the 99th percentile plus
160 mmHg or higher or a DBP of 100 mmHg or higher (1). 5 mmHg
Lifestyle modifications including physical activity, weight man- ○ Stage 2 hypertension: SBP and/or DBP greater than
agement, and nutritional considerations (e.g., sodium reduction, the 99th percentile plus 5 mmHg
moderation of alcohol consumption, and a healthy eating pat- A pocket guide (including tables for percentiles for boys and
tern), are key for helping to manage BP (6,7). For insights on girls) can be found at bp_child_pocket.pdf (11), and for more de-
the potential benefits of lifestyle factors on BP, see Lifestyle Modifi- tailed information related to BP in children, see The Fourth Report
cations Can Make a Difference (Box 1). on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in
Unlike the specific values used to define hypertension, hypo- Children and Adolescents (14).
tension does not have numerical standards and typically is not In addition to the assessment of BP at rest, health and fit-
a problem unless an individual is experiencing symptoms ness professionals often measure BP responses to exercise. For
of chronically low BP (e.g., dizziness, fatigue, nausea, among
others) (4). If symptoms are present, consulting with a health
care provider is recommended to determine if there is an under- Figure 1. Resting BP.
lying cause (4). Although the focus often is on elevated BP, un-
usually low BP readings also should be evaluated (1).
The measurement of BP in children and adolescents is similar
to the procedures in adults with some considerations, including
the following (11,14):
• Correct cuff selection is typically made by using the largest
cuff that still provides room for correct positioning of the
stethoscope head below the cuff.
• BP is classified by percentiles for age, sex, and height, as
follows:
○ Normal: SBP and DBP are less than the 90th
percentile.
○ Prehypertension: SBP or DBP greater than the 90th
percentile to less than the 95th percentile or BP greater
than 120/80 mmHg to less than the 95th percentile
6 ACSM’s Health & Fitness Journal ® May/June 2016

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appropriate comparison, in such situations, resting BP should considered to be a low-risk condition compared with sustained
be obtained in the exercise position (e.g., standing position for a hypertension (12).
treadmill test) (1). Normal responses to increases in workload In light of concerns with white coat effects, some clients may
include (1) use home BP monitoring (i.e., when an individual measures BP
• Increase in SBP outside of the clinical setting). Self-measured BP monitoring has
• No change or a slight decrease in DBP been found to improve adherence and health outcomes for hy-
SBP increases linearly with increases in workload — approximately pertensive individuals (5). The American Medical Association
10 mmHg per MET (MET is a metabolic equivalent, equal to (AMA) recommends that the following features be considered
3.5 mL/kg/min) (3). An abnormal response would be consid- when recommending a device for self-monitoring (5):
ered if SBP drops by 10 mmHg or more or if SBP does not in-
crease along with increases in workload (1). Concerns associated • Check if the device is certified (e.g., Association for the Ad-
with this type of exertional hypotension include myocardial vancement of Medical Instrumentation, British Hyper-
ischemia, left ventricular dysfunction, and an increased risk of tension Society, European Society of Hypertension).
a future cardiac event (1). Excessive increases in BP also are a • The device should use the upper arm rather than the
concern; exercise testing termination criteria include an SBP wrist.
greater than 250 mmHg or a DBP exceeding 115 mmHg (1).
Various medications may impact BP at rest and during exercise
BOX 2:
(e.g., beta-blockers lower BP) (1); this underscores the impor-
tance of a complete healthy history, including awareness of all Exercise Termination Criteria Related to BP
medications, to anticipate any potential impact on BP. Among a number of other criteria, BP responses to exercise
Accurately assessing BP during exercise can be a challenge may warrant exercise testing termination. General
because of client movement, physical location on exercise equip- indications for stopping a nondiagnostic exercise test
ment, and general noise associated with the testing environment. (assuming no direct physician involvement or monitoring of
Some considerations when assessing BP during exercise include electrocardiogram result) include (1):
the following: • A drop in SBP of 10 mmHg or more with an increase in work
• Support the client's arm rather than allowing the client to rate or if the SBP decreases below the value obtained in the
grasp the treadmill rails or bike handlebars (1). same position before testing
• Hold the client's arm in a relatively straight position; do • An excessive rise in BP: systolic pressure is greater than
not allow the client to flex at the elbow (1). 250 mmHg and/or diastolic pressure is greater than
• Maintain appropriate physical orientation to the client; 115 mmHg.
for example, consider using a step stool when assessing
BP for a client engaging in treadmill walking on a grade.
• Control the movement of tubing; avoid allowing tubing to In addition, other practical features include ease of use, visual
rub against one another or to make contact with the commands, clear readouts, storage of readings, calculation of
stethoscope head because both of these situations can in- Figure 2. Exercise BP.
troduce noise artifact and impair one's ability to hear the
Korotkoff sounds.
Attention to one's orientation to the client as well as the equip-
ment are key factors in taking BP during exercise (Figure 2). The
accurate assessment of exercise BP is vital given the inclusion of
abnormal BP responses in exercise testing termination criteria
(see Exercise Termination Criteria Related to BP).
Although BP measurement seems to be a simple measure-
ment, various factors can impact one's accuracy. Table 2 in-
cludes some issues associated with BP measurement along with
tips on minimizing the impact of those issues (1–3,8,9,12). In ad-
dition, the location of the BP assessment as well as the person
taking the measurement can have an impact. White coat hyperten-
sion refers to situations where an individual has an increased rest-
ing BP when in the clinic or doctor's office (12). The impact of
physician-measured BP has been found to be as much as
30 mmHg higher than similar measures at home (12). White
coat hypertension differs from true hypertension in that the
BP is normal when outside of the clinical setting; this is
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TABLE 2: Issues Associated With Blood Pressure Measurement (1–3,8,9,12)


Measurement Issue How to Address the Issue
Determining the correct value Be attentive during the measurement.
Maintain appropriate placement of the gauge to allow optimal viewing of the reading (e.g., eye level, in direct line of sight).
Deflation issues Do not overtighten the valve to the extent that it becomes stuck in the closed position.
Very slow rate of deflation (2 mmHg/second or less) can cause Korotkoff sounds to be diminished; release pressure
at a rate of approximately 2 to 5 mmHg per second.
Difficulty in hearing the BP sounds Ensure that the stethoscope earpieces are facing somewhat forward; a simple memory cue to help remember to
orient the earpieces toward the nose: “you KNOWS (nose!) which way it goes.”
Place the stethoscope head over the brachial artery (medial side of the antecubital space).
Reduce background noise whenever possible and avoid any talking during the measurement because talking or active
listening can increase BP.
Cuff size Ensure that the bladder encircles at least 80% of the upper arm (note: most cuffs have markings to help determine if
the cuff is too large or too small); using too small a cuff will lead to an overestimate of BP and too large a cuff will
lead to an underestimate of BP.
Cuff location The middle of the bladder of the cuff should be centered over the brachial artery with the lower edge of the cuff 2 to
3 cm above the antecubital fossa (i.e., the front of the elbow).
Apply the cuff to bare skin to optimize the ability to hear the Korotkoff sounds.
Placement of stethoscope Ensure that the stethoscope is placed over the brachial artery (medial aspect of the antecubital space) and is below
the bottom of the cuff rather than under the cuff (to decrease artifact).
Arm position Provide for adequate support of the arm being used for measurement to avoid a potential elevation of DBP caused by
the isometric muscle contraction of an unsupported arm.
Ensure that the arm is maintained at heart level; a lower arm position may result in SBP and DBP being overestimated
because of changes in hydrostatic pressure; elevating the arm may lead to an underestimation of SBP and DBP.

Body position For resting BP measures, the back should be supported and feet placed flat on the ground; DBP can be elevated if the
back is not supported, and SBP may be raised if the legs are crossed.

averages, ability to transmit information to other devices or 2. American College of Sports Medicine. ACSM's Health-Related Physical Fitness
Assessment Manual. 3rd ed. Philadelphia (PA): Lippincott Williams & Wilkins;
apps, and, of course, cost (5). For more detailed information, 2010. 172 p.
see the link to the AMA in the Web Resources found at the 3. American College of Sports Medicine. ACSM's Resource Manual for Guidelines for
end of this article. Exercise Testing and Prescription. 7th ed. Philadelphia (PA): Lippincott Williams &
Wilkins; 2014. 862 p.
4. American Heart Association Web site [Internet]. Dallas (TX): American Heart
SUMMARY Association; [cited 2015 December 2]. Available from: http://www.heart.org/
HEARTORG/Conditions/HighBloodPressure/AboutHighBloodPressure/
BP measures are routinely performed and, to ensure correct Low-Blood-Pressure_UCM_301785_Article.jsp#.Vl9Jnr-b1B4.
values are reported, attention must be given to the methods 5. American Medical Association. Measuring accurately: self-measured blood
used. Specific techniques, including selection of an appropri- pressure monitoring. American Medical Association Web site [Internet].
Chicago (IL): American Medical Association and The Johns Hopkins University;
ately sized cuff along with correct positioning of the client in re- [cited 2015 December 2]. Available from: http://www.ama-assn.org/ama/pub/
lation to the equipment, are foundational to providing accurate about-ama/strategic-focus/improving-health-outcomes/improving-blood-
measures at rest and during exercise. Health and fitness profes- pressure-control.page.

sionals need to be aware of normal versus hypertensive BP read- 6. Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National
Committee on Prevention, Detection, Evaluation, and Treatment of High Blood
ings at rest and also be aware of normal versus abnormal BP Pressure: the JNC 7 report. JAMA. 2003;289(19):2560–72.
changes with exercise.
7. Go AS, Bauman MA, Coleman SM, et al. An effective approach to high blood
pressure control: A science advisory from the American Heart Association, the
Acknowledgment American College of Cardiology, and the Centers for Disease Control and
The author thanks the Kinesiology Department students at Prevention. Hypertension. 2014;63(4):878–85.
Missouri State University for their assistance with the BP dem- 8. Handler J. The importance of accurate blood pressure measurement. Perm J.
onstration photos. 2009;13(3):51–4.

9. Jahangir E. Blood pressure assessment. Medscape. 2015


1. American College of Sports Medicine. ACSM's Guidelines for Exercise Testing and [cited 2015 Nov 20]. Available from: http://emedicine.medscape.com/
Prescription. 9th ed. Philadelphia (PA): Lippincott Williams & Wilkins; 2014. 456 p. article/1948157-overview.

8 ACSM’s Health & Fitness Journal ® May/June 2016

Copyright © 2016 American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
10. Lewington S, Clarke R, Qizilbash N, Peto R, Collins R; Prospective studies Answer from photo quiz:
collaboration. Age-specific relevance of usual blood pressure to vascular
mortality: a meta-analysis of individual data for one million adults in 61 Looking closely, at least 10 errors are present in the assessment of
prospective studies. Lancet. 2002;360(9349):1903–13. resting BP photograph on page 5 including:
11. National High Blood Pressure Education Program Working Group on High Blood
Pressure in Children and Adolescents. A Pocket Guide to Blood Pressure
1. The examiner is talking/laughing during the measurement.
Measurement in Children. U.S. Department of Health and Human Services; 2. The client is talking/laughing during the measurement.
National Institutes of Health; National Heart, Lung, and Blood Institute; 2007. 4 p.
Available from http://www.nhlbi.nih.gov/files/docs/bp_child_pocket.pdf. NIH
publication 07-5268; cited 2015 Nov 30.
3. The examiner is not looking at the gauge.
12. Ogedegbe G, Pickering T. Principles and techniques of blood pressure 4. The client is not seated in a chair with back support.
measurement. Cardiol Clin. 2010;28(4):571–86.
5. The client's arm is not supported.
13. Pickering TG, Hall JE, Appel LJ, et al. Recommendations for blood pressure
measurement in humans and experimental animals: part 1: blood pressure 6. The stethoscope head is under the bottom edge of the cuff.
measurement in humans: a statement for professionals from the
Subcommittee of Professional and Public Education of the American Heart 7. The stethoscope head is placed over the bicep rather than
Association Council on High Blood Pressure Research. Circulation.
2005;111(5):697–716.
over the brachial artery in antecubital space.
14. U.S. Department of Health and Human Services; National Institutes of 8. The stethoscope ear pieces are facing backward rather than
Health; National Heart, Lung, and Blood Institute. The Fourth Report forward.
on the Diagnosis, Evaluation, and Treatment of High Blood Pressure
in Children and Adolescents. U.S. Department of Health and Human 9. The cuff is inside out with the bladder toward the outside,
Services; National Institutes of Health; National Heart, Lung,
and Blood Institute; 2005. 60 p. Available from: http://www.nhlbi.nih.gov/ which will result in the cuff unwrapping itself when the bladder
files/docs/resources/heart/hbp_ped.pdf. NIH Publication is inflated.
No. 05-5267; cited 2015 Nov 30.
10. The cuff is askew and has not been placed securely on the arm.
Web Resources:
• American Heart Association — general information on BP, risk assessment Disclosure: The author declares no conflict of interest and does not have any
calculator, prevention/treatment information, and much more:
http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/High-Blood- financial disclosures.
Pressure-or-Hypertension_UCM_002020_SubHomePage.jsp
• Target:BP™ program from the American Heart Association and AMA — resources Barbara A. Bushman, Ph.D., FACSM, is a pro-
and tools to help individuals control BP
http://connectingcommunities.heart.org/targetbp/
fessor at Missouri State University. She holds four
• ACSM Position Stand: Exercise and Hypertension
ACSM certifications: Program Director, Clinical
http://journals.lww.com/acsm-msse/Fulltext/2004/03000/Exercise_and_ Exercise Specialist, Health Fitness Specialist,
Hypertension.25.aspx and Personal Trainer. Dr. Bushman has authored
• ACSM downloadable brochure: Exercising your way to lower BP papers related to menopause, factors influencing ex-
http://acsm.org/docs/brochures/exercising-your-way-to-lower-blood-pressure.
pdf?sfvrsn=2 ercise participation, and deep water run training;
• American Medical Association: downloadable charts with common errors, quick-check she authored ACSM’s Action Plan for Men-
tool to help promote accurate technique, and helpful guide for self-measuring BP opause (Human Kinetics, 2005), edited ACSM’s Complete Guide to
monitoring (free account registration required to access resources)
http://www.ama-assn.org/ama/pub/about-ama/strategic-focus/improving-health- Fitness & Health (Human Kinetics, 2011) and promotes health/fitness at
outcomes/improving-blood-pressure-control.page www.Facebook.com/FitnessID.

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