Blood Pressure

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Blood pressure (BP) is the mm Hg). Normal resting blood pressure for an adult is approximately 120/80 mm Hg.

Blood pressure varies depending on situation, activity, and disease states, and is regulated by the stroke. Chronic hypertension is more common than chronic hypotension in Western countries. Chronic hypertension often goes undetected because of infrequent monitoring and the absence of obvious symptoms.

Classification

Systemic arterial pressure

Classification of blood pressure for adults[2]
Category mm Hg diastolic, mm Hg
Hypotension
< 90
< 60
Desired
90–119
60–79
Prehypertension
120–139
80–89
Stage 1 hypertension
140–159
90–99
Stage 2 hypertension
160–179
100–109
Hypertensive emergency
≥ 180
≥ 110

The table on the right shows the classification of blood pressure adopted by the American Heart Association for adults who are 18 years and older.[4]

In the [6]

Blood pressure fluctuates from minute to minute and normally shows a circadian rhythm over a 24-hour period, with highest readings in the afternoons and lowest readings at night.[9]

Various factors, such as age and sex, influence a person’s blood pressure and variations in it. In children, the normal ranges are lower than for adults and depend on height.circadian rhythm.

Differences between left and right arm blood pressure measurements tend to be random and average to nearly zero if enough measurements are taken. However, in a small percentage of cases there is a consistent difference greater than 10 mm Hg which may need further investigation, e.g. for [15]

The risk of cardiovascular disease increases progressively above 115/75 mm Hg.[16] In the past, hypertension was only diagnosed if secondary signs of high arterial pressure were present, along with a prolonged high systolic pressure reading over several visits. Regarding hypotension, in practice blood pressure is considered too low only if noticeable symptoms are present.[2]

Clinical trials demonstrate that people who maintain arterial pressures at the low end of these pressure ranges have much better long term cardiovascular health. The principal medical debate concerns the aggressiveness and relative value of methods used to lower pressures into this range for those who do not maintain such pressure on their own. Elevations, more commonly seen in older people, though often considered normal, are associated with increased mortality.

Reference ranges for blood pressure in children[17]
Stage Approximate age Systolic Diastolic
Infants 1 to 12 months 75–100 50–70
Toddlers and preschoolers 1 to 5 years 80–110 50–80
School age 6 to 12 years 85–120 50–80
Adolescents 13 to 18 years 95–140 60–90

Mean arterial pressure

The mean arterial pressure (MAP) is the average over a cardiac cycle and is determined by the cardiac output (CO), systemic vascular resistance (SVR), and central venous pressure (CVP),[18]

! text{MAP} = (text{CO} cdot text{SVR}) + text{CVP}.

MAP can be approximately determined from measurements of the systolic pressure  ! P_{text{sys}}  and the diastolic pressure  ! P_{text{dias}} [18]

! text{MAP} approxeq P_{text{dias}} + frac{1}{3} (P_{text{sys}} - P_{text{dias}}).

Pulse pressure

Curve of the arterial pressure during one cardiac cycle. The closing of the aortic valve causes the notch in the curve.

The pulse pressure is the difference between the measured systolic and diastolic pressures,[19]

! P_{text{pulse}} = P_{text{sys}} - P_{text{dias}}.

The up and down fluctuation of the arterial pressure results from the pulsatile nature of the cardiac output, i.e. the heartbeat. Pulse pressure is determined by the interaction of the stroke volume of the heart, the compliance (ability to expand) of the arterial system—largely attributable to the aorta and large elastic arteries—, and the resistance to flow in the arterial tree. By expanding under pressure, the aorta absorbs some of the force of the blood surge from the heart during a heartbeat. In this way, the pulse pressure is reduced from what it would be if the aorta were not compliant.[19] The loss of arterial compliance that occurs with aging explains the elevated pulse pressures found in elderly patients.

Systemic venous pressure

Site Normal
pressure range
(in mmHg)[20]
Central venous pressure 3–8
Right ventricular pressure systolic 15–30
diastolic 3–8
Pulmonary artery pressure systolic 15–30
diastolic 4–12
Pulmonary vein/Pulmonary capillary wedge pressure 2–15
Left ventricular pressure systolic 100–140
diastolic 3-12

Blood pressure generally refers to the arterial pressure in the catheter.

Venous pressure is the vascular pressure in a vein or in the atria of the heart. It is much less than arterial pressure, with common values of 5 mm Hg in the right atrium and 8 mm Hg in the left atrium.

Variants of venous pressure include:

  • Central venous pressure, which is a good approximation of right atrial pressure,[21] which is a major determinant of right ventricular end diastolic volume. (However, there can be exceptions in some cases.)[22]
  • The lung disease.
  • The [23]

Pulmonary pressure

Normally, the pressure in the [24]

Increased blood pressure in the capillaries of the lung cause [25]

Disorders

Disorders of blood pressure control include: low blood pressure, and blood pressure that shows excessive or maladaptive fluctuation.

High

Main article: Hypertension

Overview of main complications of persistent high blood pressure.

hypertensive emergency.

Levels of arterial pressure put mechanical stress on the arterial walls. Higher pressures increase heart workload and progression of unhealthy tissue growth (heart muscle tends to thicken, enlarge and become weaker over time.

Persistent hypertension is one of the risk factors for strokes, heart attacks, heart failure and arterial aneurysms, and is the leading cause of chronic kidney failure. Even moderate elevation of arterial pressure leads to shortened life expectancy. At severely high pressures, mean arterial pressures 50% or more above average, a person can expect to live no more than a few years unless appropriately treated.[26]

In the past, most attention was paid to diastolic pressure; but nowadays it is recognised that both high systolic pressure and high pulse pressure (the numerical difference between systolic and diastolic pressures) are also risk factors. In some cases, it appears that a decrease in excessive diastolic pressure can actually increase risk, due probably to the increased difference between systolic and diastolic pressures (see the article on pulse pressure). If systolic blood pressure is elevated (>140) with a normal diastolic blood pressure (<90), it is called “isolated systolic hypertension” and may present a health concern.[27][28]

For those with heart valve regurgitation, a change in its severity may be associated with a change in diastolic pressure. In a study of people with heart valve regurgitation that compared measurements 2 weeks apart for each person, there was an increased severity of aortic and mitral regurgitation when diastolic blood pressure increased, whereas when diastolic blood pressure decreased, there was a decreased severity.[29]

Low

Main article: Hypotension

Blood pressure that is too low is known as hypotension. Hypotension is a medical concern if it causes signs or symptoms, such as dizziness, fainting, or in extreme cases, shock.[4]

When arterial pressure and blood perfusion of the brain becomes critically decreased (i.e., the blood supply is not sufficient), causing lightheadedness, dizziness, weakness or fainting.

Sometimes the arterial pressure drops significantly when a patient stands up from sitting. This is known as orthostatic hypotension (postural hypotension); gravity reduces the rate of blood return from the body veins below the heart back to the heart, thus reducing stroke volume and cardiac output.

When people are healthy, the veins below their heart quickly constrict and the heart rate increases to minimize and compensate for the gravity effect. This is carried out involuntarily by the autonomic nervous system. The system usually requires a few seconds to fully adjust and if the compensations are too slow or inadequate, the individual will suffer reduced blood flow to the brain, dizziness and potential blackout. Increases in G-loading, such as routinely experienced by aerobatic or combat pilots ‘pulling Gs‘, greatly increases this effect. Repositioning the body perpendicular to gravity largely eliminates the problem.

Other causes of low arterial pressure include:

perfusion. The usual mechanisms are loss of blood volume, pooling of blood within the veins reducing adequate return to the heart and/or low effective heart pumping. Low arterial pressure, especially low pulse pressure, is a sign of shock and contributes to and reflects decreased perfusion.

If there is a significant difference in the pressure from one arm to the other, that may indicate a narrowing (for example, due to artery.

Fluctuating blood pressure

Normal fluctuation in blood pressure is adaptive and necessary. Fluctuations in pressure that are significantly greater than the norm are associated with greater [31]

Physiology

During each heartbeat, blood pressure varies between a maximum (systolic) and a minimum (diastolic) pressure.[33]

Hemodynamics

Main article: Hemodynamics

There are many physical factors that influence arterial pressure. Each of these may in turn be influenced by physiological factors, such as: diet, exercise, disease, drugs or alcohol, stress, and obesity.[35]

Some physical factors are:

  • Volume of fluid or [38]
  • Resistance. In the circulatory system, this is the resistance of the blood vessels. The higher the resistance, the higher the arterial pressure upstream from the resistance to blood flow. Resistance is related to vessel radius (the larger the radius, the lower the resistance), vessel length (the longer the vessel, the higher the resistance), blood viscosity, as well as the smoothness of the blood vessel walls. Smoothness is reduced by the buildup of fatty deposits on the arterial walls. Substances called Poiseuille’s Law.
  • Viscosity, or thickness of the fluid. If the blood gets thicker, the result is an increase in arterial pressure. Certain medical conditions can change the viscosity of the blood. For instance, anemia (low red blood cell concentration), reduces viscosity, whereas increased red blood cell concentration increases viscosity. It had been thought that aspirin and related “blood thinner” drugs decreased the viscosity of blood, but instead studies found[39] that they act by reducing the tendency of the blood to clot.

In practice, each individual’s autonomic nervous system responds to and regulates all these interacting factors so that, although the above issues are important, the actual arterial pressure response of a given individual varies widely because of both split-second and slow-moving responses of the nervous system and end organs. These responses are very effective in changing the variables and resulting blood pressure from moment to moment.

Moreover, blood pressure is the result of cardiac output increased by peripheral resistance: blood pressure = peripheral resistance. As a result, an abnormal change in blood pressure is often an indication of a problem affecting the heart’s output, the blood vessels’ resistance, or both. Thus, knowing the patient’s blood pressure is critical to assess any pathology related to output and resistance.

Regulation

The endogenous regulation of arterial pressure is not completely understood, but the following mechanisms of regulating arterial pressure have been well-characterized:

These different mechanisms are not necessarily independent of each other, as indicated by the link between the RAS and aldosterone release. When blood pressure falls many physiological cascades commence in order to return the blood pressure to a more appropriate level.

  1. The blood pressure fall is detected by a decrease in blood flow and thus a decrease in GFR.
  2. Decrease in GFR is sensed as a decrease in Na+ levels by the macula densa.
  3. The Macula Densa cause an increase in Na+ reabsorption, which causes water to follow in via plasma volume. Further, the macula densa releases adenosine which causes constriction of the afferent arterioles.
  4. At the same time, the renin.
  5. Renin converts angiotensin I (active form).
  6. Angiotensin I flows in the bloodstream until it reaches the capillaries of the lungs where angiotensin II.
  7. Angiotensin II is a vasoconstrictor which will increase bloodflow to the heart and subsequently the preload, ultimately increasing the cardiac output.
  8. Angiotensin II also causes an increase in the release of adrenal glands.
  9. Aldosterone further increases the Na+ and H2O reabsorption in the nephron.

Currently, the RAS is targeted pharmacologically by ACE inhibitors and angiotensin II receptor antagonists. The aldosterone system is directly targeted by spironolactone, an aldosterone antagonist. The fluid retention may be targeted by diuretics; the antihypertensive effect of diuretics is due to its effect on blood volume. Generally, the baroreceptor reflex is not targeted in hypertension because if blocked, individuals may suffer from orthostatic hypotension and fainting.

Measurement

A medical student checking blood pressure using a sphygmomanometer and stethoscope.

Right position for taking blood pressure

Arterial pressure is most commonly measured via a sphygmomanometer, which historically used the height of a column of mercury to reflect the circulating pressure.[41] Blood pressure values are generally reported in millimetres of mercury (mm Hg), though aneroid and electronic devices do not contain mercury.

For each heartbeat, blood pressure varies between systolic and diastolic pressures. Systolic pressure is peak pressure in the arteries, which occurs near the end of the cardiac cycle when the ventricles are contracting. Diastolic pressure is minimum pressure in the arteries, which occurs near the beginning of the cardiac cycle when the ventricles are filled with blood. An example of normal measured values for a resting, healthy adult human is 120 mm Hg systolic and 80 mm Hg diastolic (written as 120/80 mm Hg, and spoken as “one-twenty over eighty”).

Systolic and diastolic arterial blood pressures are not static but undergo natural variations from one heartbeat to another and throughout the day (in a circadian rhythm). They also change in response to stress, nutritional factors, drugs, disease, exercise, and momentarily from standing up. Sometimes the variations are large. Hypertension refers to arterial pressure being abnormally high, as opposed to hypotension, when it is abnormally low. Along with body temperature, respiratory rate, and pulse rate, blood pressure is one of the four main vital signs routinely monitored by medical professionals and healthcare providers.[42]

Measuring pressure invasively, by penetrating the arterial wall to take the measurement, is much less common and usually restricted to a hospital setting.

Noninvasive

The noninvasive auscultatory and oscillometric measurements are simpler and quicker than invasive measurements, require less expertise, have virtually no complications, are less unpleasant and less painful for the patient. However, noninvasive methods may yield somewhat lower accuracy and small systematic differences in numerical results. Noninvasive measurement methods are more commonly used for routine examinations and monitoring.

Palpation

A minimum systolic value can be roughly estimated by [43]

A more accurate value of systolic blood pressure can be obtained with a sphygmomanometer and palpating the radial pulse.[44] The diastolic blood pressure cannot be estimated by this method. The American Heart Association recommends that palpation be used to get an estimate before using the auscultatory method.

Auscultatory

Auscultatory method aneroid sphygmomanometer with stethoscope

Mercury manometer

The auscultatory method (from the Latin word for “listening”) uses a stethoscope and a sphygmomanometer. This comprises an inflatable (Riva-Rocci) cuff placed around the upper arm at roughly the same vertical height as the heart, attached to a mercury or aneroid manometer. The mercury manometer, considered the gold standard, measures the height of a column of mercury, giving an absolute result without need for calibration and, consequently, not subject to the errors and drift of calibration which affect other methods. The use of mercury manometers is often required in clinical trials and for the clinical measurement of hypertension in high-risk patients, such as pregnant women.

A cuff of appropriate size is fitted smoothly and also snugly, then inflated manually by repeatedly squeezing a rubber bulb until the artery is completely occluded. Listening with the stethoscope to the Korotkoff sound). The pressure at which this sound is first heard is the systolic blood pressure. The cuff pressure is further released until no sound can be heard (fifth Korotkoff sound), at the diastolic arterial pressure.

The auscultatory method is the predominant method of clinical measurement.[45]

Oscillometric

The oscillometric method was first demonstrated in 1876 and involves the observation of oscillations in the sphygmomanometer cuff pressuretransducer) to observe cuff pressure oscillations, electronics to automatically interpret them, and automatic inflation and deflation of the cuff. The pressure sensor should be calibrated periodically to maintain accuracy.

Oscillometric measurement requires less skill than the auscultatory technique and may be suitable for use by untrained staff and for automated patient home monitoring.

The cuff is inflated to a pressure initially in excess of the systolic arterial pressure and then reduced to below diastolic pressure over a period of about 30 seconds. When blood flow is nil (cuff pressure exceeding systolic pressure) or unimpeded (cuff pressure below diastolic pressure), cuff pressure will be essentially constant. It is essential that the cuff size is correct: undersized cuffs may yield too high a pressure; oversized cuffs yield too low a pressure. When blood flow is present, but restricted, the cuff pressure, which is monitored by the pressure sensor, will vary periodically in synchrony with the cyclic expansion and contraction of the brachial artery, i.e., it will oscillate.

Over the deflation period, the recorded pressure waveform forms a signal known as the cuff deflation curve. A bandpass filter is utilized to extract the oscillometric pulses from the cuff deflation curve. Over the deflation period, the extracted oscillometric pulses form a signal known as the oscillometric waveform (OMW). The amplitude of the oscillometric pulses increases to a maximum and then decreases with further deflation. A variety of analysis algorithms can be employed in order to estimate the systolic, diastolic, and mean arterial pressure.

Oscillometric monitors may produce inaccurate readings in patients with heart and circulation problems, which include arterial sclerosis, citation needed].

In practice the different methods do not give identical results; an algorithm and experimentally obtained coefficients are used to adjust the oscillometric results to give readings which match the auscultatory results as well as possible. Some equipment uses computer-aided analysis of the instantaneous arterial pressure waveform to determine the systolic, mean, and diastolic points. Since many oscillometric devices have not been validated, caution must be given as most are not suitable in clinical and acute care settings.

Recently, several coefficient-free oscillometric algorithms have developed for estimation of blood pressure. These algorithms do not rely on experimentally obtained coefficients and have been shown to provide more accurate and robust estimation of blood pressure,[50]

The term NIBP, for non-invasive blood pressure, is often used to describe oscillometric monitoring equipment.

Continuous noninvasive techniques (CNAP)

Continuous Noninvasive Arterial Pressure (CNAP) is the method of measuring arterial blood pressure in real-time without any interruptions and without cannulating the human body. CNAP combines the advantages of the following two clinical “gold standards”: it measures blood pressure continuously in real-time like the invasive arterial catheter system and it is noninvasive like the standard upper arm sphygmomanometer. Latest developments in this field show promising results in terms of accuracy, ease of use and clinical acceptance.

Non-occlusive techniques: The Pulse Wave Velocity (PWV) principle

Since the 1990s a novel family of techniques based on the so-called [52]

The main advantage of these techniques is that it is possible to measure PWV values of a subject continuously (beat-by-beat), without medical supervision, and without the need of inflating brachial cuffs. PWV-based techniques are still in the research domain and are not adapted to clinical settings.

Home monitoring

[56]

Aside from the white-coat effect, blood pressure readings outside of a clinical setting are usually slightly lower in the majority of people. The studies that looked into the risks from hypertension and the benefits of lowering blood pressure in affected patients were based on readings in a clinical environment.

When measuring blood pressure, an accurate reading requires that one not drink coffee, smoke cigarettes, or engage in strenuous exercise for 30 minutes before taking the reading. A full bladder may have a small effect on blood pressure readings; if the urge to urinate arises, one should do so before the reading. For 5 minutes before the reading, one should sit upright in a chair with one’s feet flat on the floor and with limbs uncrossed. The blood pressure cuff should always be against bare skin, as readings taken over a shirt sleeve are less accurate. During the reading, the arm that is used should be relaxed and kept at heart level, for example by resting it on a table.[57]

Since blood pressure varies throughout the day, measurements intended to monitor changes over longer time frames should be taken at the same time of day to ensure that the readings are comparable. Suitable times are:

  • immediately after awakening (before washing/dressing and taking breakfast/drink), while the body is still resting,
  • immediately after finishing work.

Automatic self-contained blood pressure monitors are available at reasonable prices, some of which are capable of Korotkoff’s measurement in addition to oscillometric methods, enabling irregular heartbeat patients to accurately measure their blood pressure at home.

White-coat hypertension

For some patients, blood pressure measurements taken in a doctor’s office may not correctly characterize their typical blood pressure.[61]

Invasive

Arterial blood pressure (BP) is most accurately measured invasively through an brachial).

The cannula must be connected to a sterile, fluid-filled system, which is connected to an electronic pressure transducer. The advantage of this system is that pressure is constantly monitored beat-by-beat, and a waveform (a graph of pressure against time) can be displayed. This invasive technique is regularly employed in human and veterinary anesthesiology, and for research purposes.

Cannulation for invasive vascular pressure monitoring is infrequently associated with complications such as bleeding. Patients with invasive arterial monitoring require very close supervision, as there is a danger of severe bleeding if the line becomes disconnected. It is generally reserved for patients where rapid variations in arterial pressure are anticipated.

Invasive vascular pressure monitors are pressure monitoring systems designed to acquire pressure information for display and processing. There are a variety of invasive vascular pressure monitors for trauma, critical care, and operating room applications. These include single pressure, dual pressure, and multi-parameter (i.e. pressure / temperature). The monitors can be used for measurement and follow-up of arterial, central venous, pulmonary arterial, left atrial, right atrial, femoral arterial, umbilical venous, umbilical arterial, and intracranial pressures.

Fetal blood pressure

In pregnancy, it is the fetal heart and not the mother’s heart that builds up the fetal blood pressure to drive its blood through the fetal circulation.

The blood pressure in the fetal aorta is approximately 30 mm Hg at 20 weeks of gestation, and increases to approximately 45 mm Hg at 40 weeks of gestation.[62]
The average blood pressure for full-term infants:
Systolic 65–95 mm Hg
Diastolic 30–60 mm Hg[63]

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