Blood Pressure

General

Blood pressure (BP) is the pressure exerted by circulating blood upon the walls of blood vessels, and is one of the principal vital signs. When used without further specification, "blood pressure" usually refers to the arterial pressure of the systemic circulation. During each heartbeat, blood pressure varies between a maximum (systolic) and a minimum (diastolic) pressure. The blood pressure in the circulation is principally due to the pumping action of the heart. Differences in mean blood pressure are responsible for blood flow from one location to another in the circulation. The rate of mean blood flow depends on the resistance to flow presented by the blood vessels. Mean blood pressure decreases as the circulating blood moves away from the heart through arteries, capillaries and veins due to viscous losses of energy. Mean blood pressure drops over the whole circulation, although most of the fall occurs along the small arteries and arterioles. Gravity affects blood pressure via hydrostatic forces (e.g., during standing) and valves in veins, breathing, and pumping from contraction of skeletal muscles also influence blood pressure in veins.

The measurement blood pressure without further specification usually refers to the systemic arterial pressure measured at a person's upper arm and is a measure of the pressure in the brachial artery, major artery in the upper arm. A person’s blood pressure is usually expressed in terms of the systolic pressure over diastolic pressure and is measured in millimetres of mercury (mmHg), for example 140/90.

Systemic arterial blood pressure

Classification

                          Classification of blood pressure for adults

                       according to the American Heart Association

Category	systolic, mmHg	diastolic, mmHg
Hypotension	< 90	< 60
Desirable	90–119	60–79
Prehypertension	120–139	or 80–89
Stage 1 Hypertension	140–159	or 90–99
Stage 2 Hypertension	160–179	or 100–109
Hypertensive Crisis	≥ 180	or ≥ 110

The information above shows the classification of blood pressure adopted by the American Heart Association for adults who are 18 years and older. It assumes the values are a result of averaging blood pressure readings measured at two or more visits to the doctor.

In the UK, blood pressures are usually categorized into three groups: low (90/60 or lower), high (140/90 or higher), and normal (values above 90/60 and below 130/80).

Normal

While average values for arterial pressure could be computed for any given population, there is often a large variation from person to person; arterial pressure also varies in individuals from moment to moment. Additionally, the average of any given population may have a questionable correlation with its general health; thus the relevance of such average values is equally questionable. However, in a study of 100 human subjects with no known history of hypertension, an average blood pressure of 112/64 mmHg was found,which are currently classified as desirable or "normal" values. Normal values fluctuate through the 24-hour cycle, with highest readings in the afternoons and lowest readings at night.

Various factors, such as age and gender influence average values, influence a person's average blood pressure and variations. In children, the normal ranges are lower than for adults and depend on height. As adults age, systolic pressure tends to rise and diastolic tends to fall. In the elderly, blood pressure tends to be above the normal adult range,largely because of reduced flexibility of the arteries. Also, an individual's blood pressure varies with exercise, emotional reactions, sleep, digestion and time of day.

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 mmHg which may need further investigation, e.g. for obstructive arterial disease.

The risk of cardiovascular disease increases progressively above 115/75 mmHg. 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.

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 morbidity and mortality.

Average blood pressure in (mmHg):

1 year	6–9 years	adults
95/65	100/65	110/65 – 140/90

Physiology

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, obesity, and so-forth.

Some physical factors are:

• Rate of pumping. In the circulatory system, this rate is called heart rate, the rate at which blood (the fluid) is pumped by the heart. The volume of blood flow from the heart is called the cardiac output which is the heart rate (the rate of contraction) multiplied by the stroke volume (the amount of blood pumped out from the heart with each contraction). The higher the heart rate, the higher the mean arterial pressure, assuming no reduction in stroke volume or central venous return.
• Volume of fluid or blood volume, the amount of blood that is present in the body. The more blood present in the body, the higher the rate of blood return to the heart and the resulting cardiac output. There is some relationship between dietary salt intake and increased blood volume, potentially resulting in higher arterial pressure, though this varies with the individual and is highly dependent on autonomic nervous system response and the renin-angiotensin system.
• 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 build up of fatty deposits on the arterial walls. Substances called vasoconstrictors can reduce the size of blood vessels, thereby increasing blood pressure. Vasodilators (such as nitroglycerin) increase the size of blood vessels, thereby decreasing arterial pressure. Resistance, and its relation to volumetric flow rate (Q) and pressure difference between the two ends of a vessel are described by 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 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 = cardiac output X 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.

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), 

MAP can be approximately determined from measurements of the systolic pressure   and the diastolic pressure   while there is a normal resting heart rate,

Pulse pressure

Curve of the arterial pressure during one cardiac cycle

The up and down fluctuation of the arterial pressure results from the pulsatile nature of the cardiac output, i.e. the heartbeat. The pulse pressure is determined by the interaction of the stroke volume of the heart, compliance (ability to expand) of the aorta, 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 wasn't compliant. The loss of arterial compliance that occurs with aging explains the elevated pulse pressures found in elderly patients.

The pulse pressure can be simply calculated from the difference of the measured systolic and diastolic pressures,

Arm–leg gradient

The arm–leg (blood pressure) gradient is the difference between the blood pressure measured in the arms and that measured in the legs. It is normally less than 10 mmHg, but may be increased in e.g. coarctation of the aorta.

Vascular resistance

The larger arteries, including all large enough to see without magnification, are conduits with low vascular resistance (assuming no advanced atherosclerotic changes) with high flow rates that generate only small drops in pressure. The smaller arteries and arterioles have higher resistance, and confer the main drop in blood pressure along the circulatory system.

Vascular pressure wave

Modern physiology developed the concept of the vascular pressure wave (VPW). This wave is created by the heart during the systole and originates in the ascending aorta. Much faster than the stream of blood itself, it is then transported through the vessel walls to the peripheral arteries. There the pressure wave can be palpated as the peripheral pulse. As the wave is reflected at the peripheral veins, it runs back in a centripetal fashion. When the reflected wave meets the next outbound pressure wave, the pressure inside the vessel rises higher than the pressure in the aorta. This concept explains why the arterial pressure inside the peripheral arteries of the legs and arms is higher than the arterial pressure in the aorta, and in turn for the higher pressures seen at the ankle compared to the arm with normal ankle brachial pressure index values.

Regulation

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

• Baroreceptor reflex: Baroreceptors in the high pressure receptor zones (mainly in the aortic arch and carotid sinus) detect changes in arterial pressure. These baroreceptors send signals ultimately to the medulla of the brain stem, specifically to the Rostral ventrolateral medulla (RVLM). The medulla, by way of the autonomic nervous system, adjusts the mean arterial pressure by altering both the force and speed of the heart's contractions, as well as the total peripheral resistance. The most important arterial baroreceptors are located in the left and right carotid sinuses and in the aortic arch.
• Renin-angiotensin system (RAS): This system is generally known for its long-term adjustment of arterial pressure. This system allows the kidney to compensate for loss in blood volume or drops in arterial pressure by activating an endogenous vasoconstrictor known as angiotensin II.
• Aldosterone release: This steroid hormone is released from the adrenal cortex in response to angiotensin II or high serum potassium levels. Aldosterone stimulates sodium retention and potassium excretion by the kidneys. Since sodium is the main ion that determines the amount of fluid in the blood vessels by osmosis, aldosterone will increase fluid retention, and indirectly, arterial pressure.
• Baroreceptors in low pressure receptor zones (mainly in the venae cavae and the pulmonary veins, and in the atria) result in feedback by regulating the secretion of antidiuretic hormone (ADH/Vasopressin), renin and aldosterone. The resultant increase in blood volume results an increased cardiac output by the Frank–Starling law of the heart, in turn increasing arterial blood pressure.

These different mechanisms are not necessarily independent of each other, as indicated by the link between the RAS and aldosterone release. 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

Arterial pressure is most commonly measured via a sphygmomanometer, which historically used the height of a column of mercury to reflect the circulating pressure. Blood pressure values are generally reported in millimetres of mercury(mmHg), though aneroid and electronic devices do not use 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 mmHg systolic and 80 mmHg diastolic (written as 120/80 mmHg, and spoken [in the US and UK] 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.

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 palpation, most often used in emergency situations, but should be used with caution. It has been estimated that, using 50% percentiles, carotid, femoral and radial pulses are present in patients with a systolic blood pressure > 70 mmHg, carotid and femoral pulses alone in patients with systolic blood pressure of > 50 mmHg, and only a carotid pulse in patients with a systolic blood pressure of > 40 mmHg.

A more accurate value of systolic blood pressure can be obtained with a sphygmomanometer and palpating the radial pulse. 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

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 trialsand for the clinical measurement of hypertension in high-risk patients, such as pregnant women.

A cuff of appropriate size is fitted smoothly and snugly, then inflated manually by repeatedly squeezing a rubber bulb until the artery is completely occluded. Listening with the stethoscope to the brachial artery at the elbow, the examiner slowly releases the pressure in the cuff. When blood just starts to flow in the artery, the turbulent flow creates a "whooshing" or pounding (first 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.

Oscillometric

The oscillometric method was first demonstrated in 1876 and involves the observation of oscillations in the sphygmomanometer cuff pressure which are caused by the oscillations of blood flow, i.e., the pulse. The electronic version of this method is sometimes used in long-term measurements and general practice. It uses a sphygmomanometer cuff, like the auscultatory method, but with an electronic pressure sensor (transducer) 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. The values of systolic and diastolic pressure are computed, not actually measured from the raw data, using an algorithm; the computed results are displayed.

Oscillometric monitors may produce inaccurate readings in patients with heart and circulation problems, which include arterial sclerosis, arrhythmia, preeclampsia, pulsus alternans, and pulsus paradoxus.

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.

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

White-coat hypertension

For some patients, blood pressure measurements taken in a doctor's office may not correctly characterize their typical blood pressure. In up to 25% of patients, the office measurement is higher than their typical blood pressure. This type of error is called white-coat hypertension (WCH) and can result from anxiety related to an examination by a health care professional. The misdiagnosis of hypertension for these patients can result in needless and possibly harmful medication. WCH can be reduced (but not eliminated) with automated blood pressure measurements over 15 to 20 minutes in a quiet part of the office or clinic.

Debate continues regarding the significance of this effect. Some reactive patients will react to many other stimuli throughout their daily lives and require treatment. In some cases a lower blood pressure reading occurs at the doctor's office.

Home monitoring

Ambulatory blood pressure devices that take readings every half hour throughout the day and night have been used for identifying and mitigating measurement problems like white-coat hypertension. Except for sleep, home monitoring could be used for these purposes instead of ambulatory blood pressure monitoring. Home monitoring may be used to improve hypertension management and to monitor the effects of lifestyle changes and medication related to blood pressure. Compared to ambulatory blood pressure measurements, home monitoring has been found to be an effective and lower cost alternative, but ambulatory monitoring is more accurate than both clinic and home monitoring in diagnosing hypertension. Ambulatory monitoring is recommended for most patients before the start of antihypertensive drugs.

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 exists, 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.

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.

Invasive

Arterial blood pressure (BP) is most accurately measured invasively through an arterial line. Invasive arterial pressure measurement with intravascular cannulaeinvolves direct measurement of arterial pressure by placing a cannula needle in an artery (usually radial, femoral, dorsalis pedis or 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 intensive care medicine, anesthesiology, and for research purposes.

Cannulation for invasive vascular pressure monitoring is infrequently associated with complications such as thrombosis, infection, and 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.

Reference

http://en.wikipedia.org/wiki/Blood_pressure