Avoiding Pitfalls in Clinic BP measurement

How we can measure BP better

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

that can influence accurate BP measurement . take additional readings if marked differences (> 5 mmHg) between initial measurements are found Measure BP in both arms at the initial visit. 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. eating.ESSENTIAL DOs AND DON’Ts IN BP MEASUREMENT • • • • • • • Ask patient to avoid smoking. it may be worthwhile to read the entire booklet for understanding the numerous factors – some known and some not so commonly known -. back and feet of the subject are supported whilst measuring BP. the cuff deflation rate should be 22 mmHg per second Use phase I and V (disappearance) Korotkoff sounds to identify systolic and diastolic BP. avoid tight or thick clothes under the cuff For manual determinations. If aneroid devices are used. 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. The arm must be horizontal at the level of the heart as denoted by the midsternal level Use a properly maintained. diabetic patients. consuming alcohol. 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. 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. However. A mercury manometer is preferable. 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. calibrated and validated device. 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. If significant difference (>20/10 mmHg) is found.

On the other hand. even in patients living in a stable environmental temperature. • A longer rest period of >25 minutes was found to further slightly decrease the BP values. These differences seem to be inversely associated with the body mass index. . 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. chronic smoking induces tolerance. 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. respectively.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. which are dependent on one common feature. business). It mostly involves devices. The indirect method is widely used in both daily practice and research. or by detection of Korotkoff sounds. c) Stimulants • Smoking the first cigarette of the day may acutely induce a rise in BP that lasts for 15 to 30 minutes. but this may not be feasible in general practice. or leg) with an inflatable cuff to measure BP either oscillometrically. possibly due to the increased thermoregulatory requirements of leaner individuals. the equipment used and the observer. finger. which is likely due to the acute release of norepinephrine. They collected and contributed to most of the information on BP levels in arterial hypertension over more than a century. occluding the artery of an extremity (arm. have been reported after a rest period of four and eight minutes prior to BP measurement. namely. PATIENT-RELATED FACTORS a) Rest period • Average drops in the systolic BP (SBP) of 9 and 14 mmHg. wrist. especially the SBP. showing on an average 3 to 8 mmHg higher BP values during the winter than during the summer. Hypertensive patients may require a lower dose of antihypertensive medication during periods of fever or if they move to (sub) tropic countries (holidays. FACTORS AFFECTING BP MEASUREMENT The accurate measurement of BP in clinical practice is dependent on the individual.

When this phenomenon is suspected. • Advise patients to empty their bladder before BP measurement as a distended bladder has been reported to increase BP. a certain degree of tolerance may occur with repeated consumption. Hence. • Twenty four-hour ambulatory BP monitoring (ABPM) or self-measurement at home can be employed before patients are labeled “hypertensive” or treatment is initiated. Other ingredients in coffee apart from caffeine may also be responsible for the cardiovascular (CV) activation. after at least three readings. however a postprandial decrease in BP can also be noted. • If. Further. 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). eating. . however. or resistant to treatment in the absence of target organ damage. probably due to increased sympathetic activity. • Inform patients about a minor discomfort caused by the inflation of the cuff. • Explain the procedure adequately beforehand. measure BP routinely in the arm with the higher value. especially in elderly patients. there is evidence associating an inter-arm difference with peripheral vascular disease. d) Sympathetic stimulators • Pain and anxiety acutely increase the BP. • White coat hypertension should be considered when clinic BP is consistently elevated. but pressures then settle to normal outside the medical environment. it is known as the white coat effect. significant systematic difference (> 20/10 mmHg) is found. raising the possibility that its presence may predict cardiovascular (CV) events. smoking. especially in nervous patients. Eating as an activity increases BP by 8 to 9 mmHg. • A reasonable policy is to measure BP at the initial visit in both arms. • If the BP is higher when measured by a physician than by a nurse or a medical student. Ingestion of alcohol can also acutely increase BP.• • • Ingestion of caffeine-containing beverages may induce an acute rise in BP. nurses rather than physicians should measure the BP. • 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. f) ‘White coat hypertension’ and ‘white coat’ effect • White coat hypertension is a condition in which a normotensive subject becomes hypertensive during BP measurement. consumption of alcohol or caffeine containing beverages and chocolate should be avoided for at least an hour before the measurement of BP.

transportation. a mean difference of 3 mm Hg is considered to be acceptable. replacement of the glazed tube in case of mercury precipitation and replacement of the rubber connections in case of leak. or electronic -. Mercury Sphygmomanometer • Use properly maintained. reflecting the decrease in sympathetic tone. regular maintenance concerns three points: adequate filling of the mercury reservoir. • When calibrated against a mercury sphygmomanometer. although they are notoriously difficult to maintain in an accurate state over time. Activities accompanied by increases in BP of up to 5 mmHg include deskwork. • Talking results in approximately a 7 mmHg increase in BP and should thus be avoided during BP measurement. • Various daytime activities induce increases in BP of different magnitude.whether aneroid. Talking should be avoided during BP measurement. 58% of aneroid sphygmomanometers . Aneroid Manometers • Aneroid devices are used widely. The equipment -. Activities accompanied by a large increase in BP of between 10 and 20 mm Hg include meetings. as a result of both sleep and inactivity. FACTORS RELATED TO THE INSTRUMENT a) Instrument used The measuring device used can induce large variations in BP. walking and dressing. usually leading to falsely low readings with the consequent underestimation of BP. • Maintain the equipment properly. physical work. mercury. Hence activities that induce increases in BP should be avoided before/during BP measurement.g) Routine activities • There is a substantial diurnal BP variation. 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. reading and watching television.should be regularly inspected and validated. calibrated and validated device. with a clear fall in BP during the night of up to 15%. however.

be in a comfortable and relaxed position. . BP 154/92. • Faults in the control valve may be corrected easily by simply cleaning the filter or replacing the control valve. • If any interruption occurs. poor hearing. verbally and in writing. They are susceptible to carelessness in maintenance. The jolts and bumps of everyday use affect their accuracy. because if hurried. sitting position • Provide to patients. with about one third of these having errors >7 mm Hg. Connections should be airtight and easily disconnected.• • have been shown to have errors >4 mm Hg. this leads to underestimation of SBP and overestimation of DBP. or interpret the Korotkoff sounds differently. R arm. their specific BP numbers and the BP goal of their treatment. The observer may fail to interpret the Korotkoff sounds accurately. b) Rubber Tubing • Leaks due to cracked or perished rubber cause inaccurate BP measurement. The arm in which the pressure is being recorded and the position of the subject should also be noted. confusion of auditory and visual cues. • A number of factors can cause a bias in the BP reading. especially for DBP. • Defective valves cause leakage. • 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. the exact measurement may be forgotten and an approximation made. o Observers very often have a terminal digit preference (observer rounds off the BP reading). c) Control Valve • A very common source of error is the control valve. the pressure will be released too rapidly. • Whilst taking the patient’s BP. 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. resulting in underestimation of SBP and overestimation of DBP. for eg. especially when air filter rather than a rubber valve is used. making control of pressure release difficult. as the fall in mercury cannot be controlled. check the aneroid devices regularly against mercury. which in the majority of cases is 0 (75%) or 5 (25%). and therefore not recommended for routine use. The rubber should be in good condition and free from leaks. so the BP should always be written down as soon as it has been measured. etc. If used. o Systematic error may be caused by lack of concentration.

but deflate it slowly at a rate of 2 mm Hg per beat or per second. The lower edge of the cuff should be 2-3 cm above the point of brachial artery pulsation. but it is now recommended that they should be placed superiorly or. its centre must be over the brachial artery. • • • Place the cuff on the bare arm. • The British Hypertension Society (BHS) recommends three different bladder sizes depending on arm circumference. posteriorly. the smallest bladder should be used. with completely encircling bladders. Inflate the bladder rapidly to avoid prolonged discomfort for the patient.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. In children. • If the bladder does not completely encircle the arm. • Use cuffs of the appropriate size such that the bladder encircles at least 80% of the upper arm. to accurately . The rubber tubes from the bladder are usually placed inferiorly. tight or thick clothes under the cuff should be avoided. Undercuffing has the effect in clinical practice of over-diagnosing hypertension and overcuffing leads to hypertensive subjects being diagnosed as normotensive. The physician should have a larger and smaller bladder available for fat and thin arms. respectively.” and too wide or too long a bladder (overcuffing) may cause underestimation of BP. • As per the European Society of Hypertension 2003 guidelines for management of hypertension. so that the antecubital fossa is easily accessible for auscultation. so called “cuff hypertension. often at the site of the brachial artery. • The width of the bladder should be equal to about two-thirds the distance from the axilla to the antecubital space. a standard bladder 12-13 cm long and 35 cm wide should be used.

it is unclear if there are significant differences between BP measured in the sitting vs the supine position. On the other hand. It is . DBP may be raised by as much as 10%. or which position best approximates intra-aortic pressure. • Measure BP one and five min after assumption of the standing position in elderly. However. deflation can be speeded up in the second or third readings. a lower BP will be read when watching from above the scale. diabetics and in other conditions in which orthostatic hypotension may be frequent or suspected. which can be easily adjusted to suit the height of the observer. c) Stethoscope placement • During auscultatory measurement. especially in those at risk for postural hypotension and in those who report symptoms consistent with reduced BP upon standing. • The arms. 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. b) Position of Manometer • The manometer should be no further than three feet (92 cm) away so that the scale can be read easily. hold the stethoscope firmly and evenly but without excessive pressure • Too much pressure might distort the artery. a higher BP will be read if the observer is watching from below the scale and vice versa. It is more convenient in most instances to measure the BP in the sitting position. as tends to happen if the subject is sitting or standing. • 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. the back and feet of the patients should be supported to avoid any isometric physical exercise that might increase the BP.record BP to the nearest 2mm Hg. • Measurement of BP in the standing position is indicated periodically. Arm postion • If the arm in which measurement is being made is unsupported. According to this effect. • The mercury column should be vertical (some models are designed with a tilt) — this is achieved most effectively with stand-mounted models. and virtually all the evidence related to hypertension and CV outcomes is derived from studies that measured sitting BPs. 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.

recommendations on BP measurement have been uncertain about the diastolic endpoint. • Take a mean of at least two readings spaced by 1-2 min. • Phase IV (muffling) may coincide with or be as much as 10 mm Hg higher than phase V (disappearance). • There has been resistance to general acceptance of the silent endpoint until recently. f) Number of measurements • Decisions based on single measurements will result in erroneous diagnosis and inappropriate management due to variability of BP measurements. pregnant women. phase V correlates best with intra-arterial pressure. because the silent endpoint can be greatly below the muffling of sounds in some groups of patients— children. OTHER FACTORS • • Perform BP measurements in a quiet environment. However. anemic or elderly. as noisy rooms make it difficult for the patient to relax and the observer to concentrate and adequately hear Korotkoff sounds.• • 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. but usually the difference is <5 mm Hg. 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). sounds may even be audible when cuff pressure is deflated to zero. e) Diastolic Dilemma • For many years. In some patients. additional recordings are needed if marked differences between initial measurements are found. it has been demonstrated that even in the supine position. 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. The arm must be horizontal at the level of heart as denoted by the midsternal level. anemic or elderly patients. pregnant women. Dependency of the arm below heart level leads to an overestimation of BP and raising the arm above heart level leads to underestimation. . an error of 5 mm Hg for DBP may occur if the arm is not supported at heart level. • There is now a general consensus that disappearance of sounds (phase V) should be taken as diastolic pressure except in children. 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. The magnitude of this error can be as great as 10 mm Hg for BP.

Follow-up of patients with various stages of hypertension BP MEASUREMENTS IN SPECIAL POPULATIONS Certain populations merit special consideration for BP measurement. elevated BP may be a sign of underlying disease or it may represent early onset of primary hypertension. 10-18 cm. 1. the estimated prevalence is 1-2%. • Cuff dimensions are most important and three cuffs with bladders measuring 4-13 cm. to normal levels.• • In cases of slight BP elevation. • Korotkoff sounds are not reliably audible in all children under one year and in many under five years of age. . either because of age. over time. • The variability of BP is greater in children than in adults. or oscillometry must be used. or disturbances of BP related to hemodynamic alterations in other parts of the CV system. Also. • SBP is preferred to DBP because of greater accuracy and reproducibility. because of the possibility of a spontaneous regression. conventional sphygmomanometry is impossible and more sensitive methods of detection such as Doppler. and thus any one BP reading is less likely to represent the true value. In such cases. body habitus. before a clinical decision is taken. although it is often an under-recognized clinical entity. Children and Adolescents • Hypertension during childhood is not rare. evidence of hypertension-related organ damage or a high/very high CV risk profile. If a patient has a more marked BP elevation. repeated measurements should be obtained over shorter periods of time. 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. repeated measurements have to be obtained over several months before a final diagnosis of hypertension can be made. such as weeks or days. ultrasound.

Patients with arrhythmias • The BP measurement can be particularly difficult in patients with arrhythmias. these rapid changes might be best assessed by 24 h ABPM. • In patients with bradyarrhythmias. when the heart rate is extremely slow. BP measurement in pregnancy represents one of the key points in the diagnosis of preeclampsia. for e. 5. with the proviso that in those rare instances in which sounds persist to zero. especially atrial fibrillation. soft Korotkoff sounds or a ‘silent gap’ due to marked beat-to-beat variability. there are large day-to-day variations in body fluid status. Pregnancy • Clinically relevant hypertension occurs in more than 10% of pregnant women.2. In principle. • Whenever continuous BP monitoring is essential. • 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. when ABPM is not possible. 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. BP obtained in the dialysis unit can be used in a qualitative sense for prediction of hypertension in these patients. 3. 6. Dialysis patients • In dialysis patients (hemodialysis and peritoneal dialysis). Elderly • The elderly are subject to considerable BP variability. • In patients with arrhythmias. which can lead to a number of circadian BP patterns that are best identified using ABPM. • A composite of BP measurements over a period of 1 to 2 weeks rather than isolated readings should be used for guidance. • However. The timing of BP measurement in relation to dialysis. changes in interdialytic weight gain. the fourth phase of muffling of sounds should be used. a traditional sphygmomanometric technique is sufficient (palpation is recommended whenever an auscultatory measurement is impossible. and inconsistent BP measurement technique in dialysis units contribute to the variability of BP readings.g. use of intra-arterial catheters is a common procedure. auscultatory measurements and multiple readings are recommended. 40 beats/minute. • Interdialytic BP monitoring with an ambulatory BP monitor is the most reproducible method and is thought to best represent BP in dialysis patients. 4. automated methods are required). when prolonged monitoring is to be performed. Critical-care setting • In an emergency situation. . and therefore also in BP level.

This has led to the concept of “pseudohypertension” to describe patients with a large discrepancy between cuff and direct BP measurement.• It has been postulated that as a consequence of the decrease in arterial compliance and arterial stiffening with ageing. Resistant hypertension Evaluation of the patient with resistant hypertension should include 24-hour ABPM or home measurements and a search for secondary causes. 62: 297-303 3. 322: 981-5 2. 289: 2560-72. 2003. 18: 139-85 5. indirect sphygmomanometry becomes inaccurate. Netherlands J Med 2004. J Hum Hypertens 2004. BMJ 2001. 13: 343-57 4. J Hypertens. 7. 21: 1011-53 6. JAMA 2003. Curr Opin Nephrol Hypertens 2004. . REFERENCES 1.

Sign up to vote on this title
UsefulNot useful