Arterial blood pressure

Arterial blood pressure

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  King George’s MedicalUniversity KGMU Institute Of Paramedical Sciences Lucknow Topic:- Arterial Blood Pressure Presented By Drx Prashant Kumar O.T.Tech. KGMU 18-06-2021 1 pk776331@gmail.com
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  ARTERIAL BLOOD PRESSURE Definition: Arterial blood pressure can be defined as the lateral pressure exerted by the moving blood on the walls of the arteries. 18-06-2021 2 pk776331@gmail.com
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  Systolic B.P (S.B.P) Definedas the maximum B.P in the arteries Attainable during systole. Normal 120 + 20 mm Hg. This is mainly contributed by 1. Force of contraction 2. Blood volume 3. Cardiac output 18-06-2021 3 pk776331@gmail.com
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  DIASTOLIC B.P (D.B.P) Def---as the minimum pressure that is obtained at the end of the ventricular diastole. Normal range 60 -90 mm Hg. 1. It represents a constant load on the arterial walls with little or no fluctuation at all. 2. It is an index to the peripheral resistance and decides the filling of the Coronary system. 18-06-2021 4 pk776331@gmail.com
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  Pulse Pressure (P.P) Denotesthe difference between systolic and diastolic pressure. PP= SBP - DBP = 40 mm Hg 18-06-2021 5 pk776331@gmail.com
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  MEAN ARTERIAL PRESSURE MeanBP = Diastolic BP + 1/3 Pulse Pressure Mean BP = (Systolic BP + 2 x Diastolic BP)/3 Normal = 80-90 mm Hg. 18-06-2021 6 pk776331@gmail.com
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  18-06-2021 7 pk776331@gmail.com
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  Physiological Variation InBlood Pressure A) Age B) Build C) Climate D) Diurnal Variation E) Exercise F) Fever G) Gestation H) high Altitude I) Infusion/ Intake J) Pain K) Posture L) Sleep 18-06-2021 8 pk776331@gmail.com
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  Hypertension is definedas systolic blood pressure (SBP) of 140 mmHg or greater, diastolic blood pressure (DBP) of 90 mmHg or greater, or taking antihypertensive medication. 18-06-2021 9 pk776331@gmail.com
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  Blood Pressure Classification Normal<120 and <80 Prehypertension 120–139 or 80–89 Stage 1 Hypertension 140–159 or 90–99 Stage 2 Hypertension >160 or >100 BP Classification SBP mmHg DBP mmHg 18-06-2021 10 pk776331@gmail.com
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  Incidence in India •25% of urban population and 10 % of rural population suffer from hypertension • 70% of all hypertensive patients are stage I hypertension • 12% of all hypertensive suffer from isolated systolic hypertension 18-06-2021 11 pk776331@gmail.com
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  Who are atrisk ? 18-06-2021 12 pk776331@gmail.com
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  Hypertension: Predisposing factors • AdvancingAge • Sex (men and postmenopausal women) • Family history of cardiovascular disease • Sedentary life style & psycho-social stress • Smoking ,High cholesterol diet, Low fruit consumption • Obesity & wt. gain • Co-existing disorders such as diabetes, and hyperlipidaemia • High intake of alcohol 18-06-2021 13 pk776331@gmail.com
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  Types of hypertension •Primary/Essential hypertension – 95% – No underlying cause • Secondary hypertension – Underlying cause 18-06-2021 14 pk776331@gmail.com
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  Aetiology of Systemic Hypertension SecondaryHTN (05%) A. Renal (80%) • AGN • CGN, • CPN, • Polycyst. K.D • Renal Artery stenosis B. Endocrine • Adrenal • Primary aldosteronism • Cushing’s syndrome • Pheochromocytoma • Acromegaly • Exogenous hormone • Oral contraceptive • Glucocorticoids • Hypothyroidism & • Hyperparathyroidism Continue… 18-06-2021 15 pk776331@gmail.com
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  Additional types • IsolatedSystolic HTN • Isolated Diastolic HTN • Resistant HTN • White coat HTN • Masked HTN • Accelerated HTN 18-06-2021 16 pk776331@gmail.com
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  Diseases Attributable to Hypertension HYPERTENSION Gangreneof the Lower Extremities Heart Failure Left Ventricular Hypertrophy Myocardial Infarction Coronary Heart Disease Aortic Aneurym Blindness Chronic Kidney Failure Stroke Preeclampsia/ Eclampsia Cerebral Hemorrhage Hypertensive encephalopathy Adapted from Dustan HP et al. Arch Intern Med. 1996; 156: 1926-1935 18-06-2021 17 pk776331@gmail.com
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  Target Organ Damage Heart • Left ventricular hypertrophy • Angina or myocardial infarction • Heart failure  Brain • ischemic Stroke or transient ischemic attack •Intracerebral hemorrhage  Chronic kidney disease  Peripheral arterial disease  Retinopathy 18-06-2021 18 pk776331@gmail.com
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  RECORDING OF B.P Directmethod Indirect method METHODS Indirect Methods 1. Palpatory method 2. Auscultatory method 18-06-2021 19 pk776331@gmail.com
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  Principle Involved InRecording Blood Pressure 18-06-2021 20 pk776331@gmail.com
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  Measurement Device Aneroid sphygmomanometer Simple mercury sphygmomanometer Automatedbp device 18-06-2021 21 pk776331@gmail.com
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  Which machine? • Allmanometers should be recalibrated and serviced annually • Mercury Manometer is gold standard, but banned due to toxicity. • Aneroid machines (not recommended) should be serviced more often as they deteriorate rapidly 18-06-2021 22 pk776331@gmail.com
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  18-06-2021 23 pk776331@gmail.com
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  Cuff sizes 18-06-2021 24 pk776331@gmail.com
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  Cuff sizes Type SizeSuitability Adult 12cm X 23cm for smaller arms Alternative cuff 12cm X 36cm will cover 95% arms Large adult 15cm X 36cm Often too wide for ‘fat’ arms
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  Which arm? • 6%of hypertensives can have as much as a 10 mmHg difference between arms • If BP higher in one arm than the other, this arm must be used from then on • Document this in records so that everyone uses the same arm. 18-06-2021 26 pk776331@gmail.com
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  Technique • Patient seatedand relaxed, not talking, legs uncrossed • Tight arm clothing removed • Correct cuff size • Arm supported with cuff horizontal with heart • Inform patient of discomfort and that several measurements will be taken • Mercury manometer on firm and level surface at eye level • Locate brachial or radial pulse. 18-06-2021 27 pk776331@gmail.com
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  Technique – cont’d •Place stethoscope gently over brachial artery • Inflate mercury rapidly, 30 mmHg above occlusion of pulse • Deflate very slowly, 2 mmHg per second • Record first of regular sounds (systolic BP) • Record diastolic as disappearance of sound • Record measurements to the nearest 2 mmHg • Repeat twice more and average last two. 18-06-2021 28 pk776331@gmail.com
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  Tapping sound 1 SBP 110mm Hg Banging sound 3 Muffling sound 4 DBP- 95 mm Hg 85 mm Hg Recording of arterial BP by auscultatory method Korotkoff sounds 120 mm Hg Murmurish 2 80 mm Hg No sound 5 Auscultatory Method This method was introduced by a Russian physician Korotkoff 18-06-2021 29 pk776331@gmail.com
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  Stethoscope • Good quality •Short tubing • Well fitting ear pieces (cleaned regularly) • Place gently over the brachial artery • Avoid touching the cuff and tubing. 18-06-2021 30 pk776331@gmail.com
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  Posture • Routine -seated • Standing in patients with symptoms or diabetic (diabetic nephropathy) and the elderly • Supine position unnecessary, inconvenient and cuff position often below the heart. 18-06-2021 31 pk776331@gmail.com
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  Patient • Consent istaken as read when patient rolls up sleeve • Explain the procedure, that it may be a little uncomfortable and that several readings will be taken • Seated, relaxed for at least 5-10 min, not speaking • No smoking, tobacco, tea or coffee for last 1 hour • Tight arm clothing removed • Arm and back supported (not hyper extended) with cuff level with the heart. 18-06-2021 32 pk776331@gmail.com
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  ‘White coat’ hypertension •phenomenon in which patients show elevated blood pressure in a hospital or clinic, while BP is normal in other settings like home. • Maybe from anxiety • 10-20% of subjects labelled ‘hypertensive’ may have ‘white coat’ effect. 18-06-2021 33 pk776331@gmail.com
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  Masked Hypertension • Oppositeof white coat hypertension • BP is normal in clinic or office while elevated at home. 18-06-2021 34 pk776331@gmail.com
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  Ambulatory Blood PressureMeasurement (ABPM)- Indications • Borderline hypertension • White coat hypertension • Masked hypertension • Isolated systolic hypertension • Nocturnal blood pressure • Resistant hypertension • Hypotensive symptoms. 18-06-2021 35 pk776331@gmail.com
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  ABPM • Ambulatory BloodPressure Monitoring (ABPM) is when blood pressure is measured as patients move around, living normal daily life. • It is measured for up to 24 hours. • A small digital blood pressure monitor is attached to a belt around waist and connected to a cuff around upper arm. • Can be expensive • Requires patient co-operation in order to obtain as many readings as possible. 18-06-2021 36 pk776331@gmail.com
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  ABPM 18-06-2021 37 pk776331@gmail.com
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  ABPM • Normal activityto be maintained, except when measurements are being made • Subject’s arm to be still during measurement • Subject’s usual activities to be carried out • Working days not compared to recreational days • For clinical use recordings are usually programmed for every 30 minutes during the day and hourly at night • Subject required to keep a diary of activities and symptoms. 18-06-2021 38 pk776331@gmail.com
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  How to treat? 18-06-2021 39 pk776331@gmail.com
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  Treatment Overview Goals oftherapy Lifestyle modification Pharmacologic treatment  Algorithm for treatment of hypertension Follow up and monitoring 18-06-2021 40 pk776331@gmail.com
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  Goals of Therapy ReduceCardiac and renal morbidity and mortality. Treat to BP <140/90 mmHg or BP <130/80 mmHg in patients with diabetes or chronic kidney disease. 18-06-2021 41 pk776331@gmail.com
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  Life style modifications •Lose weight, if overweight • Increase physical activity • Reduce salt intake • Stop smoking • Limit intake of foods rich in fats and cholesterol • increase consumption of fruits and vegetables • Limit alcohol intake 18-06-2021 42 pk776331@gmail.com
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  Antihypertensive Drugs Continue…. AT1 receptor ARB 18-06-202143 pk776331@gmail.com
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  Diuretics Example: Hydrochlorothiazide • Actby decreasing blood volume and cardiac output • Decrease peripheral resistance during chronic therapy • Drugs of choice in elderly hypertensives Side effects- • Hypokalaemia • Hyponatraemia • Hyperlipidaemia • Hyperuricaemia (hence contraindicated in gout) • Hyperglycaemia (hence not safe in diabetes) • Not safe in renal and hepatic insufficiency 18-06-2021 44 pk776331@gmail.com
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  Beta blockers Example: Atenolol,Metoprolol, nebivolol, • Block b1 receptors on the heart • Block b2 receptors on kidney and inhibit release of renin • Decrease rate and force of contraction and thus reduce cardiac output • Drugs of choice in patients with co-existent coronary heart disease Side effects- • lethargy, impotency, bradycardia • Not safe in patients with co-existing asthma and diabetes • Have an adverse effect on the lipid profile 18-06-2021 45 pk776331@gmail.com
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  Calcium channel blockers Example:Amlodipine • Block entry of calcium through calcium channels • Cause vasodilation and reduce peripheral resistance • Drugs of choice in elderly hypertensives and those with co-existing asthma • Neutral effect on glucose and lipid levels Side effects Flushing, headache, Pedal edema 18-06-2021 46 pk776331@gmail.com
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  ACE inhibitors Example: Ramipril,Lisinopril, Enalapril • Inhibit ACE and formation of angiotensin II and block its effects • Drugs of choice in co-existent diabetes mellitus, Heart failure Side effects- dry cough, hypotension, angioedema 18-06-2021 47 pk776331@gmail.com
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  Angiotensin II receptorblockers Example: Losartan • Block the angiotensin II receptor and inhibit effects of angiotensin II • Drugs of choice in patients with co-existing diabetes mellitus Side effects- safer than ACEI, hypotension, 18-06-2021 48 pk776331@gmail.com
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  Alpha blockers Example: prazosin •Block a-1 receptors and cause vasodilation • Reduce peripheral resistance and venous return • Exert beneficial effects on lipids and insulin sensitivity • Drugs of choice in patients with co-existing BPH Side effects- Postural hypotension, 18-06-2021 49 pk776331@gmail.com
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  Resistant Hypertension • definedas blood pressure that remains above goal despite concurrent use of three antihypertensive agents of different classes, one of which should be a diuretic • Patients whose blood pressure is controlled with four or more medications are also considered to have resistant hypertension 18-06-2021 50 pk776331@gmail.com
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  Causes of Resistant Hypertension Improper BP measurement  Excess sodium intake  Inadequate diuretic therapy  Medication • Inadequate doses • Drug actions and interactions (e.g., (NSAIDs), illicit drugs, sympathomimetics, OCP) • Over-the-counter drugs and some herbal supplements  Excess alcohol intake  Identifiable causes of HTN 18-06-2021 51 pk776331@gmail.com
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  Hypotension  Defined inadults as a systolic pressure below 90 mm Hg Rarely treated unless associated with symptoms 18-06-2021 52 pk776331@gmail.com
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  Causes of Hypotension 1.Hemorrhage 2. Dehydration 3. Vomiting 4. Diarrhea 5. Excessive sweating 6.Adissons disease 7.Hypothyroidism 18-06-2021 53 pk776331@gmail.com
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  Postural hypotension • PosturalHypertension: is a fall in blood pressure that occurs when changing position from lying to sitting or from sitting to standing (fall of 20/10mmHg) (Postural=change in position Hypotension=fall in blood pressure to a low level) • A fall in blood pressure leads to a reduced blood supply to organs and muscles; this can cause a variety of symptoms e.g. - – Feeling dizzy – Changes in vision such as blurring – Feeling vague or muddled • Some diabetic patients may suffer the symptoms of postural hypotension 18-06-2021 54 pk776331@gmail.com
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  Treatment of Hypotension •Treat the cause • Blood transfusion • I.V. Fluids • Vasoconstrictors/Inotropic drugs 18-06-2021 55 pk776331@gmail.com
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  Hypertensive Crisis • BP> 180 systolic/ 120 diastolic • May be life threatening • Require rapid correction of BP otherwise target organ damage occurs 18-06-2021 56 pk776331@gmail.com
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  • Hypertensive Urgency: –defined as a diastolic blood pressure of 110 mm Hg or greater without the acute signs of end-organ damage. – Requires lowering of BP over days • Hypertensive emergency: – The presence of acute and rapidly evolving end-organ damage with an elevated diastolic blood pressure, usually greater than 120 mm Hg – Requires lowering of BP over hours 18-06-2021 57 pk776331@gmail.com
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  • Requires IVantihypertensive drugs – Nitroglycerine’ – Nitroprusside – Labetelol – Fenoldopam – Clavidipine – Esmolol 18-06-2021 58 pk776331@gmail.com