Blood pressure should be measured with a well-calibrated sphygmomanometer. The bladder width within the cuff should encircle at least 80% of the arm circumference. Readings should be taken after the patient has been resting comfortably, back supported in the sitting or supine position, for at least 5 minutes and at least 30 minutes after smoking or coffee ingestion. A video demonstrating the correct technique can be found at http://www.abdn.ac.uk/medical/bhs/tutorial/tutorial.htm. Automated office blood pressure readings, made with office-based devices that permit multiple automated measurements after a pre-programmed rest period, produce data that are independent of digit preference bias (tendency to favor numbers that end with zero or five) and the “white coat” phenomenon (where blood pressure is elevated in the clinic but normal at home). Blood pressure measurements taken outside the office environment, either by intermittent self-monitoring (home blood pressure) or with an automated device programmed to take measurements at regular intervals (ambulatory blood pressure) are more powerful predictors of outcomes and are advocated in clinical guidelines. Home measurements are also helpful in differentiating white coat hypertension from hypertension that is resistant to treatment, and in diagnosis of “masked hypertension” (where blood pressure is normal in the clinic but elevated at home). The cardiovascular risk associated with masked hypertension is similar to that observed in sustained hypertension.
A single elevated blood pressure reading is not sufficient to establish the diagnosis of hypertension. The major exceptions to this rule are hypertensive presentations with unequivocal evidence of life-threatening end-organ damage, as seen in hypertensive emergency, or in hypertensive urgency where blood pressure is greater than 220/125 mm Hg but life-threatening end-organ damage is absent. In less severe cases, the diagnosis of hypertension depends on a series of measurements of blood pressure, since readings can vary and tend to regress toward the mean with time. Patients whose initial blood pressure is in the hypertensive range exhibit the greatest fall toward the normal range between the first and second encounters. However, the concern for diagnostic precision needs to be balanced by an appreciation of the importance of establishing the diagnosis of hypertension as quickly as possible, since a 3-month delay in treatment of hypertension in high-risk patients is associated with a twofold increase in cardiovascular morbidity and mortality. Based on epidemiological data, the conventional 140/90 mm Hg threshold for the diagnosis of hypertension has been revised. The 2017 guidelines from the American College of Cardiology and American Heart Association (ACC/AHA) suggest that, for conventional office-based measurement, normal be defined as less than 120/80 mm Hg, elevated as 120–129/less than 80 mm Hg, stage 1 as 130–139/80–89 mm Hg and stage 2 as greater than or equal to 140/90 mm Hg. As exemplified by Hypertension Canada’s 2017 guidelines (Figure 11–1), automated and home blood pressure measurements have assumed greater prominence in the diagnostic algorithms published by many national hypertension workgroups. Equivalent blood pressure for these different modes of measurement are described in Table 11–1.
According to these recommendations, if AOBP measurements are not available, blood pressures recorded manually in the office may be substituted if taken as the mean of the last two readings of three consecutive readings. Note that the blood pressure threshold for diagnosing hypertension is higher if recorded manually in these guidelines. If home blood pressure monitoring is unavailable, office measurements recorded over three to five separate visits can be substituted. (Reproduced, with permission, from Leung AA et al; Hypertension Canada. Hypertension Canada’s 2017 guidelines for diagnosis, risk assessment, prevention, and treatment of hypertension in adults. Can J Cardiol. 2017 May;33(5):557–76. Erratum in: Can J Cardiol. 2017 Dec;33(12):1733–4. Copyright © 2017 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)
Table 11–1.Corresponding blood pressure values across a range of blood pressure measurement methods. ||Download (.pdf) Table 11–1. Corresponding blood pressure values across a range of blood pressure measurement methods.
|Manual Measurement in Clinic1 ||Home Blood Pressure Measurement ||Ambulatory Blood Pressure Measurement (Daytime) ||Ambulatory Blood Pressure Measurement (Nighttime) ||Ambulatory Blood Pressure Measurement (24-Hour) |
|120/80 mm Hg ||120/80 mm Hg ||120/80 mm Hg ||100/65 mm Hg ||115/75 mm Hg |
|130/80 mm Hg ||130/80 mm Hg ||130/80 mm Hg ||110/65 mm Hg ||125/75 mm Hg |
|140/90 mm Hg ||135/85 mm Hg ||135/85 mm Hg ||120/70 mm Hg ||130/80 mm Hg |
|160/100 mm Hg ||145/90 mm Hg ||145/90 mm Hg ||140/85 mm Hg ||145/90 mm Hg |
Ambulatory blood pressure readings are normally lowest at night and the loss of this nocturnal dip is a dominant predictor of cardiovascular risk, particularly risk of thrombotic stroke. An accentuation of the normal morning increase in blood pressure is associated with increased likelihood of cerebral hemorrhage. Furthermore, variability of systolic blood pressure predicts cardiovascular events independently of mean systolic blood pressure.
It is important to recognize that the diagnosis of hypertension does not automatically entail drug treatment; this decision depends on the clinical setting, as discussed below.
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