1. Blood Pressure Hypertension Orthostatics
Sina Raissi, MD, FACP, FASN

3. Blood Pressure Wave Form

4. Cardiovascular events
Hypertension
Atherosclerosis
Cardiovascular events

5. Cardiovascular complications of uncontrolled hypertension
Stroke: Ischemic/hemorrhagic

6. Cardiovascular complications of uncontrolled hypertension
Stroke: Ischemic/hemorrhagic
Heart disease: Left ventricular hypertrophy, heart failure, myocardial infarction

7. Cardiovascular complications of uncontrolled hypertension
Stroke: Ischemic/hemorrhagic
Heart disease: Left ventricular hypertrophy, heart failure, myocardial infarction
Aortic dissection

8. Cardiovascular complications of uncontrolled hypertension
Stroke: Ischemic/hemorrhagic
Heart disease: Left ventricular hypertrophy, heart failure, myocardial infarction
Aortic dissection
Kidney failure: dialysis

9. Cardiovascular complications of uncontrolled hypertension
Stroke: Ischmeic/hemorrhagic
Heart disease: Left ventricular hypertrophy, heart failure, myocardial infarction
Aortic dissection
Kidney failure: dialysis
Peripheral arterial occlusive disease

10. Blood Pressure Measurement
Office-based measurement
Home BP monitoring
Ambulatory blood pressure monitoring

11. Office Blood Pressure Measurement

12. Office Blood Pressure Measurement
Time of measurement

14. Office Blood Pressure Measurement
Time of measurement
Type of instrument

16. Office Blood Pressure Measurement
Time of measurement
Type of instrument
Cuff size

18. Office Blood Pressure Measurement
Time of measurement
Type of instrument
Cuff size
Patient position

19. Office Blood Pressure Measurement
Time of measurement
Type of instrument
Cuff size
Patient position
Cuff placement

20. Office Blood Pressure Measurement
Time of measurement
Type of instrument
Cuff size
Patient position
Cuff placement
Technique of measurement

21. Office Blood Pressure Measurement
Time of measurement
Type of instrument
Cuff size
Patient position
Cuff placement
Technique of measurement
Number of measurements

22. Patients should avoid the following for 30 minutes before measurement
Exercise
Caffeine
Smoking
Food intake
Decongestants

23. The wrong size cuff results in higher systolic blood pressure reading than patient’s real blood pressure.

24. Cuff Size by AHA
Arm circumference cm: SMALL ADULT cuff 12 x 22 cm
Arm circumference cm: ADULT cuff 16 x 30 cm
Arm circumference cm: LARGE ADULT cuff 16 x 36 cm
Arm circumference cm: ADULT THIGH cuff 16 x 42 cm

25. Office Blood Pressure Measurement
-Seated
-No talking
-Back is supported
-Arm at the level of heart
-Cuff 3 cm above fold of elbow
-Keep legs uncrossed
-5 minutes of rest

26. Blood Pressure Measurement Technique
Inflate the cuff up to 30 mmHg above systolic BP as detected by disappearance of brachial pulse.

27. Blood Pressure Measurement Technique
Inflate the cuff up to 30 mmHg above systolic BP as detected by disappearance of brachial pulse.
Place the stethoscope LIGHTLY on brachial artery. Otherwise increased turbulence may result in artificial reduction in measured diastolic BP by mmHg.

28. Blood Pressure Measurement Technique
Inflate the cuff up to 30 mmHg above systolic BP as detected by disappearance of brachial pulse.
Place the stethoscope LIGHTLY on brachial artery. Otherwise increased turbulence may result in artificial reduction in measured diastolic BP by mmHg.
Deflate the cuff slowly (about 5 seconds for each 10 mmHg decline). Fast deflation results in lower SBP and higher DBP reading.

29. Blood Pressure Measurement Technique
Inflate the cuff up to 30 mmHg above systolic BP as detected by disappearance of brachial pulse.
Place the stethoscope LIGHTLY on brachial artery. Otherwise increased turbulence may result in artificial reduction in measured diastolic BP by mmHg.
Deflate the cuff slowly (about 5 seconds for each 10 mmHg decline). Fast deflation results in lower SBP and higher DBP reading.
The first pulse sound (Korotkoff phase I)  SBP
Sudden muffling of pulse sounds (phase IV) DBP

30. Blood Pressure Measurement

31. Blood Pressure Measurement
Blood pressure must be measured in both arms, the arm with the higher BP recording should be used for measurement.

32. Blood Pressure Measurement
Blood pressure must be measured in both arms, the arm with the higher BP recording should be used for measurement.
Blood pressure must be measured at least twice on each office visit.

33. Blood Pressure Measurement
Blood pressure must be measured in both arms, the arm with the higher BP recording should be used for measurement.
Blood pressure must be measured at least twice on each office visit.
BP should be measured in standing position when indicated.

34. Blood Pressure Measurement
Blood pressure must be measured in both arms, the arm with the higher BP recording should be used for measurement.
Blood pressure must be measured at least twice on each office visit.
BP should be measured in standing position when indicated.
In the absence of end organ damage, BP should be measured over the course of 3-6 visits (1-6 weeks) before a diagnosis of hypertension is made.

35. Pitfalls of Office BP measurement
White coat syndrome
Masked Hypertension

36. Ambulatory Blood Pressure Monitoring

39. Definition of Hypertension
Office BP measurement: systolic BP > 140 mmHg or diastolic BP > 90 mmHg. (with an automated oscillometric BP device AOBP threshold of > 135/85 mmHg is acceptable.)
Home BP monitoring: systolic BP > 135 mmHg or diastolic BP > 85 mmHg.
Ambulatory BP monitoring: Average daytime SBP > 135 mmHg or DBP > 85 mmHg, or
Average 24 hour SBP >130 mmHg or DBP > 80 mmHg.

40. Orhtostatic Hypotension

41. Baroreceptor Reflex

42. Causes of Orthostatic Hypotension
Hypovolemia
Bleeding
GI losses
Cardiac
Heart Failure
Valvular disease
Neurally mediated
Degenerative diseases
Autonomic neuropathy
Other
Endocrine

43. Orthostatic Blood Pressure
Assess the need for orthostatics.

44. Orthostatic Blood Pressure
Assess the need for orthostatics.
Obtain patient’s pulse rate and blood pressure while supine.

45. Orthostatic Blood Pressure
Assess the need for orthostatics.
Obtain patient’s pulse rate and blood pressure while supine.
Have the patient sit up for ONE minute.

46. Orthostatic Blood Pressure
Assess the need for orthostatics.
Obtain patient’s pulse rate and blood pressure while supine.
Have the patient sit up for ONE minute.
Obtain the patient’s pulse rate and blood pressure while sitting.

47. Orthostatic Blood Pressure
Assess the need for orthostatics.
Obtain patient’s pulse rate and blood pressure while supine.
Have the patient sit up for ONE minute.
Obtain the patient’s pulse rate and blood pressure while sitting.
If positive orthostatic changes occur while sitting, DO NOT continue to standing position.

48. Orthostatic Blood Pressure
Assess the need for orthostatics.
Obtain patient’s pulse rate and blood pressure while supine.
Have the patient sit up for ONE minute.
Obtain the patient’s pulse rate and blood pressure while sitting.
If positive orthostatic changes occur while sitting, DO NOT continue to standing position.
Have patient stand up for ONE minute. Free standing, not leaning.

49. Orthostatic Blood Pressure
Assess the need for orthostatics.
Obtain patient’s pulse rate and blood pressure while supine.
Have the patient sit up for ONE minute.
Obtain the patient’s pulse rate and blood pressure while sitting.
If positive orthostatic changes occur while sitting, DO NOT continue to standing position.
Have patient stand up for ONE minute. Free standing, not leaning.
Obtain patient’s blood pressure and pulse while standing up.

50. Orthostatic Blood Pressure
Assess the need for orthostatics.
Obtain patient’s pulse rate and blood pressure while supine.
Have the patient sit up for ONE minute.
Obtain the patient’s pulse rate and blood pressure while sitting.
If positive orthostatic changes occur while sitting, DO NOT continue to standing position.
Have patient stand up for ONE minute. Free standing, not leaning.
Obtain patient’s blood pressure and pulse while standing up.
Watch for possibility of orthostatic symptoms or syncope.

51. Orthostatics Result
Orthostatics are considered POSITIVE if:

52. Orthostatics Result Orthostatics are considered POSITIVE if:
Patient becomes severely symptomatic

53. Orthostatics Result Orthostatics are considered POSITIVE if:
Patient becomes severely symptomatic
Pulse increases by more than 20 bpm

54. Orthostatics Result Orthostatics are considered POSITIVE if:
Patient becomes severely symptomatic
Pulse increases by more than 20 bpm
Systolic BP falls by more than 20 mmHg

55. Orthostatics Result Orthostatics are considered POSITIVE if:
Patient becomes severely symptomatic
Pulse increases by more than 20 bpm
Systolic BP falls by more than 20 mmHg
Increase in pulse by 10 bpm AND decrease in systolic BP by more than 10 mmHg in a symptomatic patient

57. THANK YOU