Proper Technique For Measurement Of Blood Pressure .

Proper Technique forMeasurement of Blood PressurePatient Conditions:Hypertensionno caffeine during preceding hour, nosmoking for 30 minutes prior to readingscomfortable, warm surroundingspt sitting with feet on ground (orsupported)arm is supported at the level of the heartSusan R. DiGiovanni, M.D.Associate ProfessorVCU School of Medicine1Proper Technique forMeasurement of Blood PressureEquipment:2Proper Technique forMeasurement of Blood PressureTake at least 2 readings each visit,separated by as much time aspossible, if readings vary by morethan 5 mm Hg, take additionalreadings until two consecutivereadings are closeInflate the bladder to 20 mm Hgabove the systolic blood pressure asestimated by the radial pulseCuff size: the cuff should cover at least1/2 of the length of the arm andcompletely surround the armThe bladder should be positioned overthe brachial arteryManometers should be calibrated every6 months against a mercury manometer3Proper Technique forMeasurement of Blood PressureDeflate the bladder at a rate of 3 mm Hgper secondNote the position of the patient, which armand the cuff size usedFor the diagnosis of hypertension, takethree readings at least one week apart(except for severe hypertension)Take BP in both arms initially, then in thefuture always use the arm with the higherreading54Hypertension: The Problem60 million Americans have high bloodpressureVirginia has the 7th highest stroke rate inthe USThe prevalence of hypertension in Blackmales in our region is about 35%, manyare not aware of their diagnosisMost patients with hypertension haveadditional risk factors for cardiovasculardisease and thus early intervention iscrucial61

Classification of Blood Pressure forAdults Aged 18 years and olderHypertension: EpidemiologyNational Health & Nutrition Examination SurveyIIIII (Phase 1)III (Phase 92734PrehypertensionSystolic And/Or Diastolic 120and 80120-139or80-89HypertensionStage 1140-159or90-99Stage 2 160or 10078Evaluation of Hypertension:The HistoryEvaluation of HypertensionDuration of hypertensionPrior treatment, if any (includingassessment of any side effects frommedications resulting indiscontinuation)Assess ingestion of substancesknown to influence blood pressure:e.g. Estrogens, adrenal steroids,sympathomimetics, excess sodiumPurpose:Assess end- organ damageAssess cardiovascular riskr/o secondary causes of hypertension9Evaluation of Hypertension:The History - 210Evaluation of Hypertension:The History - 3Family history: hypertension,premature cardiovascular disease,familial diseases, renal disease,diabetesSymptoms of secondaryhypertension: muscle weakness,spells of tachycardia, sweating,tremor, thinning of the skin, flank pain11Symptoms of End-Organ Damage:headaches, transient or permanentweakness or blindness, loss of visualacuity, chest pain, dyspnea,claudicationPresence of other risk factors:smoking, diabetes, hyperlipidemia,physical inactivity, obesity122

Evaluation of Hypertension:The History - 4Evaluation of Hypertension:The Physical ExamDietary history: sodium, alcohol,saturated fatsPsychological factors: familystructure, work status, educationallevelSexual functionFundoscopyNeck: palpation and auscultation ofthe carotid pulses, thyroid palpationHeart: size, rhythm, soundsLungs: listen for ralesAbdomen: assess for renal masses,bruits over aorta or renal arteries13Evaluation of Hypertension:The Physical Exam - 214Evaluation of Hypertension:Laboratory TestingExtremities: palpate peripheralpulses, assess for edemaNeurologic Assessment: evidence ofCVACBCChem 7UrinalysisLipid Profile15Evaluation of Hypertension:The Electrocardiogram16Retinal Disease In HypertensionDiagnosis of LVH made by:Arteriolar ThickeningR wave in I S wave in lead III 25mmR wave in aVL 11 mmR wave in aVF 20 mmS wave in aVR 14 mmR wave in V5 or V6 26 mmR wave in V5 or V6 S wave in V1 35 mmLargest R wave largest S wave in precordialleads 45Grades I & II: enhanced prominence oflight reflex, vascular tortuosity, -A VnickingGrades III & IV: copper- wire, then silverwire changes of arterioles17183

Retinal Disease In HypertensionRetinal Disease In HypertensionHypertensive RetinopathyGrades I & II: focal then generalizedarteriolar constriction representing theautoregulatory response to increasedblood pressureGrades III: flame- shaped hemorrhages,fluffy, white cotton wool spots, yellowwhite exudatesGrade IV Hypertensive RetinopathyHemorrhages and exudatesPapilledema (blurring of disk margins)1920Retinal Disease In HypertensionRetinal Disease In Hypertension2122Retinal Disease In Hypertension23Left Ventricular Hypertrophy244

Secondary HypertensionSecondary HypertensionEtiologyEtiologies ContinuedRenal Artery StenosisHyperaldosteronism or GlucocorticoidResponsive HypertensionCushing’s SyndromeHypothyroidismCoarctation of the AortaRenal Parenchymal DiseasePheochromocytomaOral Contraceptives25Secondary Hypertension:Renovascular DiseaseRenal Artery StenosisNew onset hypertension 20 or 50y.o.No family history of hypertensionSevere or refractory hypertensionAsymmetric renal size (Sono, IVP orCT)Abdominal Bruit (esp. if diastolic)Acute rise in Serum creatinine poststarting ACE inhibitor26Screening Tests“Hypertensive Urogram”Renal artery ultrasoundCaptopril Renal ScanMagnetic Resonance AngiographySpiral CTAngiogram27Secondary Hypertension:Renovascular Disease28Secondary Hypertension:Renovascular DiseaseCaptopril Renal ScanDTPA Nuclear Medicine scan postadministration of Captopril 25 mg poCriteria for “positive” test:Decrease relative uptake of onekidney in which that kidney accountsfor 40% GFRDelayed uptake by both kidneys thatis improved on a “resting” scan29305

Secondary Hypertension:Primary Renal DiseaseSecondary Hypertension:Primary Renal DiseaseMechanisms of Hypertension in RenalParenchymal Disease:Screening/Detection:Activation of RAASIncreased Sodium & Water RetentionActivation of the Sympathetic NervousSystem? Secondary HyperparathyroidismAbnormal UrinalysisElevated serum creatinineRenal Ultrasound31Secondary Hypertension:Oral Contraceptives32Secondary Hypertension:Pheochromocytoma2-5% of women on oralcontraceptives develop hypertensionParoxysmal elevations of bloodpressureTriad of symptoms:It is thought that these women aresusceptible to hypertension geneticallyHeadachePalpitationsSweatingMechanisms not well understood ?Increase renin substrateStopping therapy should return BP tonormal in 2-3 monthsWeight Loss33Secondary Hypertension:Pheochromocytoma34Secondary Hypertension:Primary HyperaldosteronismUnexplained hypokalemia withaccompanying renal potassiumwastingMetabolic Alkalosis35366

Secondary Hypertension:Coarctation of the aortaUsually picked up by the pediatrician/family practitioner3-5% of all congenital heart diseaseMore common in malesDifferential blood pressures andpulses between the upper and lowerextremities is the hallmark of thedisorder3738Secondary Hypertension:Sleep ApneaObesity is a common denominator inmany patients with Sleep ApneaSyndrome and HypertensionEven if correct for BMI, bloodpressure is higher in apneic patientsTreatment of sleep apnea willalleviate the hypertension in many butnot all patients39Secondary Hypertension:Sleep Apnea40Hypertension: TherapyWhy Treat?Hypertension increases risk forcardiovascular disease, stroke,blindness, renal diseaseStudies indicate that control of BPreduces risk of MI or stroke41427

Drug Guidelines for “CompellingIndications”Antihypertensive onEncourageRecommended DrugsInitial Drug TherapyBBACEiARBCHFXXXXXXW/ CompellingIndicationNo AnithypertensiveDrug IndicatedDrug(s) forcompelling indicationPost MIDrug(s) forcompelling indicationCADXXXDMXXXXXXYesNo AnithypertensiveDrug IndicateStage 1YesDiuretics, considerDrug(s) forACEi,ARB, BB, CCB compellingor comboindications and otherdrugs as neededTwo-drugs: Thiazide& ACEi or ARB orBB or CCBYESDW/O CompellingIndicationPrehypertensiveStage tagXXXXX4344Hypertension: TherapyThiazide DiureticsHypertension: TherapyStill recommended as initial treatment ofhypertensionParticularly useful in AA malesUse low dose (12.5- 25 mg)Cheap (about 4.00/month)Disadvantages: hypokalemia, alteredglucose metabolism (increases insulinresistance), increase lipids (& decreaseHDL), increase uric acid, sexualdysfunctionNonpharmacologic TreatmentsWeight- reducing dietExerciseStop smokingLimit caffeineLow sodium diet“Stress” reduction45Hypertension: TherapyBeta Blockers46Hypertension: TherapyBeta ease insulin resistanceDecrease HDL, increases LDL &triglyceridesWithdrawal syndromeVery effectiveOlder preparations are inexpensiveEspecially useful to decrease reflextachycardia seem from otherantihypertensivesPreferred drug in patients withmigraines, h/o recent MI, angina,glaucoma47488

Hypertension: TherapyACE InhibitorsHypertension: TherapyANG II Receptor InhibitorsMajor advantage in patients withCRF, DM, CHFFew side effectsMany can be given once or twice dailyHigher doses may be required for AAptsDisadvantages: cough, angioedema,contraindicated in pts with bilateralrenal artery stenosisNo cough or angioedema, so bettertolerated than ACE inhibitorsDisadvantage: No experience withlong-term benefits49Hypertension: TherapyCalcium Channel Blockers50Hypertension: TherapyAlpha -1 Blockers3 classes: dihydropyridines (e.g.nifedipine)Modest antihypertensive effectGood drug in older men with prostatichypertrophyDisadvantages: fatigue, drowsiness,dizzinessverapamildiltiazemVery effective as monotherapy in AAHypotensive effect partiallyattenuated by RAA and sympatheticnervous system (esp.dihydropyridines)51Hypertension: TherapyCentral Sympathetic Blockers52Hypertension: TherapyVasodilatorsE.g. Clonidine, methyldopa,guanabenz, guanfacineDo not effect lipid metabolismMethyldopa has the best track-recordfor pregnant womenMost cause severe withdrawalhypertension53E.g. Minoxidil, hydralazineExcellent antihypertensive agentsDisadvantages: fluid retention,minoxidil causes hair growth andhydralazine has been shown to causedrug-induced lupus in some patients549

HypertensionSusan R. DiGiovanni, M.D.Associate ProfessorVCU School of Medicine5510

Secondary Hypertension Etiology Renal Artery Stenosis Hyperaldosteronism or Glucocorticoid Responsive Hypertension Cushing’s Syndrome Hypothyroidism Coarctation of the Aorta 26 Secondary Hypertension Etiologies Continued Renal Parenchymal Disease Pheochromocytoma Oral Contraceptives 27 Renal Artery Stenosis New