Hypertension ความดันสูง

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Basic technique:

• seat patient in calm, quiet environment with bare arem rest on support so midpoint of upper arm is level with heart
• select appropriate cuff so bladder inside cuff encircles 80% of arm at midpoint between shoulder and elbow
• place cuff so midline of bladder is over aterial pulsation with lower edge of cuff 2.5 cm above antecubital fossa where stethoscope will be placed
• inflate cuff rapidly to 70 mmHg then by 10 mmHg increments while palpating radial pulse to estimate cutoff where pulse disappears (and reappears during deflation)
• place stethoscope over brachial artery pulsation
• inflate bladder rapidly to 20-30 mmHg above cutoff, then deflate at 2 mmHg/second while listening for Kortkoff sounds, note manometer readings at
  • first appearance of repetitive sounds (phase I)
  • muffling of sounds (phase IV)
  • disappearance of sounds (phase V)
• deflate cuff slowly for at least 10 mmHg after no further sounds are audible, then deflate completely
• record systolic/diastolic blood pressure as phase I/phase V sounds
• repeat after at least 30 seconds, record average of 2 readings
• Reference - Circulation 1993 Nov;88(5 Pt 1):2460 in BMJ 2001 Apr 14;322(7291):908
• interpretation of sounds
  • systolic value recorded when pulse appears as clear tapping sound (Korotkoff I)
  • diastolic value when pulse disappears (Korotkoff V)
  • noted that many practitioners use Korotkoff sound phase IV instead of phase V (which is used in trials), and this may falsely suggest diagnosis of hypertension (letter in BMJ 1996 Nov 9;313(7066):1203)

Cuff selection:

• cuff width should be > 2/3 diameter of arm
• cuff length > 2/3 circumference of arm
• small cuff gives falsely high readings
• if regular-sized cuff used in obese patient, BP can be measured as 10-40 mmHg higher than accurate reading (Arch Intern Med 1988 May;148(5):1023 in Cortlandt Forum 1996 Dec;9(12):77,106-9)

Position:

• blood pressure should be measured in consistent arm positions, arm position parallel to torso associated with 8.8-14.4 mmHg higher mean systolic and diastolic blood pressure readings than arm position perpendicular to torso in study of 100 adults with blood pressures measured in standing, sitting and supine positions; study was conducted in convenience sample of emergency department patients who were not hypertensive (Ann Intern Med 2004 Jan 6;140(1):74)
• blood pressure measurement in positions other than chair-seated position (bed-seated, supine, standing) may result in higher readings, based on study of 540 patients with hypertension, but study did not account for order of measurement as all patients had chair-seated measurements before other measurements (Am J Hypertens 2005 Feb;18(2):244)

Additional information:

• shirt sleeve under cuff does not significantly affect normotensive readings but may significantly alter hypertensive readings; 201 patients had 3 blood pressure recordings with digital device in random order with cuff on bare arm, cuff over sleeve, and cuff below rolled-up sleeve; differences between mean blood pressure readings between clothed and bare arm were 0.5/1 mmHg and not statistically significant; mean difference in systolic blood pressure 2 mmHg in hypertensive subjects, but difference ranged from -32 mmHg to +22 mmHg in hypertensive subjects (Fam Pract 2003 Dec;20(6):730)
• waiting 10 minutes after sitting in chair may result in 75% of mean 11.6/4.3 mmHg reduction in blood pressure, based on 16-minute rest in chair in 55 patients with untreated essential hypertension (Am J Hypertens 2006 Jul;19(7):713)
• different methods of blood pressure measurement might produce different results during single office visit
  • study of 223 patients with type 2 diabetes in 5 family practices
  • blood pressure measured at least 4 times with 4 different interpretations for determining blood pressure
    • use of first reading
    • mean of first two readings
    • mean of last 3 readings with < 15% coefficient of variation difference
    • mean of first 2 consecutive readings with maximum 5 mmHg difference
  • most pairwise comparisons showed significant differences ranging with differences up to 7.9/3.3 mmHg
  • Reference - Fam Pract 2006 Feb;23(1):20
• blood pressure difference between arms appears uncommon unless obstructive arterial disease
  • 147 consecutive patients from hypertension clinic had 3 sets of 3 blood pressure readings using different devices, protocol repeated at second visit for 91 patients
  • 2 patients had consistent large interarm systolic blood pressure differences, both had obstructive arterial disease
  • right arm blood pressure readings were slightly higher than left arm by 2-3/1 mmHg for all 3 sets
  • 11 patients (7.5%) had mean interarm difference > 5 mmHg for systolic blood pressure across all 3 sets of readings
  • 4 patients (2.7%) had mean interarm difference > 5 mmHg for diastolic blood pressure across all 3 sets of readings
  • no patient with interam blood pressure difference > 5 mmHg who completed the test had consistent differences across 2 visits
  • Reference - Arch Intern Med 2007 Feb 26;167(4):388

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