Preventing Strokes One

At a Time
Blood Pressure Assessment
and Stroke
2009

Blood Pressure & Stroke

LEARNING OBJECTIVES

Upon completion, participants will be able to:

Practice according to the Canadian Best Practice
Recommendations for Stroke Care as they relate
to blood pressure
Discuss the impact of hypertension on stroke
risk
Use proper technique when taking a blood
pressure
Monitor and interpret blood pressure reading
according to Canadian Hypertension Education
Program recommendations
Teach patient the why & how of proper blood
pressure measurement

Blood Pressure & Stroke

Outline

Hypertension Overview
Blood Pressure Targets
Blood Pressure Measurement
Office
Home
Ambulatory Blood Pressure Monitor

Content from the following slides is derived

from the Canadian Hypertension
Education Program Recommendations,
2009
www.hypertension.ca/blood pressurec

Blood Pressure
Canadian Best Practice Recommendations for Stroke Care, 2008

2.2a Blood Pressure Assessment

All persons at risk for stroke should have their blood

pressure measured at each healthcare encounter
but no less than once annually.
Proper standardized techniques, as described by
the Canadian Hypertension Education Program,
should be followed for blood pressure measurement
Patients found to have elevated blood pressure
should undergo thorough assessment for the
diagnosis of hypertension following the current
guidelines of the Canadian Hypertension Education
Program.
Patients with hypertension or at risk for hypertension
should be advised on lifestyle modifications.

CMAJ 2008;179(12 Suppl):E1-E93.

Blood Pressure
Canadian Best Practice Recommendations for Stroke Care, 2008

2.2b Blood Pressure Management

The Canadian Stroke Strategy recommends target blood

pressure levels as defined by CHEP guidelines for
prevention of first stroke, recurrent stroke and other
vascular events.
For prevention of first stroke in the general population the
systolic blood pressure treatment goal is a pressure level of
less than 140 mm Hg
The diastolic blood pressure treatment goal is a pressure
level of less than 90 mm Hg
Blood pressure lowering treatment is recommended for
patients who have had a stroke or transient ischemic attack
to a target of less than 140/90 mm Hg
In patients who have had a stroke, treatment with an
angiotensin-converting enzyme (ACE) inhibitor and diuretic
is preferred

CMAJ 2008;179(12 Suppl):E1-E93.

2.2b Contd

Blood pressure lowering treatment is recommended for the

prevention of first or recurrent stroke in patients with diabetes to
attain systolic blood pressures of less than 130 mm Hg and diastolic
blood pressures of lower than 80 mm Hg
Blood pressure lowering treatment is recommended for the
prevention of first or recurrent stroke in patients with non diabetic
chronic kidney disease to attain systolic blood pressures of less than
130 mm Hg and diastolic blood pressures of lower than 80 mm Hg
RCTs have not defined the optimal time to initiate BP lowering
therapy after stroke or TIA. It is recommended that blood pressure
lowering treatment be initiated (or modified) before discharge from
hospital.
For recommendations on specific agents and sequence of agents
refer to the current CHEP guidelines www.hypertension.ca/chep

Modifiable Risks for Developing

Hypertension
Obesity
Poor dietary habits
High sodium intake
Sedentary lifestyle
High alcohol consumption

2009 Canadian Hypertension Education Program Recommendations

Challenges to Hypertension
Management: Public Perceptions
80% of people were unaware of the
association between hypertension
and CVD
63% believed that hypertension was
not a serious condition
38% of people thought they could
control high blood pressure without
Can J Cardiol 2005;21:589the help93 of a health professional

2009 Canadian Hypertension Education Program Recommendations

Question
What is the office blood pressure target
for a patient with diabetes and/or
renal disease?
a. < 140/90
b. < 135/85
c. < 160/100
d. < 130/80
e. < 120/80

Blood Pressure Targets for the

Treatment of Hypertension
Condition

Target

Isolated systolic hypertension

<140 mmHg

Systolic/Diastolic Hypertension
Systolic blood pressure
Diastolic blood pressure

<140 mmHg
<90 mmHg

Diabetes or Chronic Kidney

Disease
Systolic
Diastolic

2009 Canadian Hypertension Education Program Recommendations

<130 mmHg
<80 mmHg

Question

By how many mmHg do you need to

lower blood pressure in order to
decrease CV risk?
a. 2 mmHg
b. 5 mmHg
c. 10 mmHg
d. 15 mmHg
e. 20 mmHg

Question
At what blood pressure does the risk for
cardiovascular disease and stroke
start to increase?
a. > 140/90
b. > 130/80
c. > 110/75
d. < 150/95
e. < 120/85

Blood Pressure Measurement

Office (OBPM)
Home (HBPM)
Ambulatory Blood Pressure
Monitoring (ABPM)

2009 Canadian Hypertension Education Program Recommendations

Resting Blood Pressure Measurement

Doing it Right!

Recommendations

Question
How long should a patient rest prior to
taking a resting blood pressure
measurement?
a. 1 minute
b. 2 minutes
c. 5 minutes
d. 10 minutes
e. No rest is required

Types of Readings
Casual blood pressure - a measurement
taken without the required 5 minute rest
period
Resting blood pressure - the seated resting
blood pressure is used to determine and
monitor treatment decisions
Standing blood pressure - is used to test
for postural hypotension, which may
modify treatment if present

2009 Canadian Hypertension Education Program Recommendations

Observer
Positioned comfortably to obtain
measurement
Manometer at eye level
Well maintained stethoscope
Clean earpieces

2009 Canadian Hypertension Education Program Recommendations

Patient Preparation

No caffeine for 30 60 minutes

No smoking for 30 minutes
No exercise for 30 minutes
Bladder/Bowel comfortable
Quiet/temperate, relaxed environment, no
talking
Bare arm with no constrictive clothing
Patient should stay silent prior and during the
procedure
No acute anxiety, stress or pain

2009 Canadian Hypertension Education Program Recommendations

Posture
Calmly seated for 5
minutes
Back well supported
Arm relaxed & supported
at heart level
Legs uncrossed, feet flat
on the floor

2009 Canadian Hypertension Education Program Recommendations

Recommended Equipment for

Measuring Blood Pressure
Mercury manometer
calibrated aneroid

Recently

Validated automated device

2009 Canadian Hypertension Education Program

Recommendations

BpTRU
Product Overview

Automated, non invasive monitor that

measures blood pressure and pulse in patients
using upper arm cuff
Device automatically inflates and deflates the
cuff
Uses oscillometric technique
Has 2 operational modes
Manual mode to take one blood pressure
measurement
Automatic mode takes 6 measurements,
discards the first, and displays the average
of the next 5 readings.

2009 Canadian Hypertension Education Program Recommendations

Cuff Size
Measure arm circumference midpoint
b/w shoulder and elbow
Bladder must encircle at least 80% of
arm circumference
Lower edge of cuff placed 2-3 cm above
elbow crease
Bladder centered over the brachial artery
Tell patient their cuff size

2009 Canadian Hypertension Education Program

Recommendations

Cuff Position & Dimensions

(no standardization between manufacturers)

Locate the brachial pulse and centre the

cuff bladder over it
Position cuff at heart level.
Circumference of Adult
Arm

Size of Bladder (cm)

18-26 cm

9x18 (Child)

> 26-33 cm

12x23 (Regular
Adult)

> 33-41 cm

15X33 (Large)

> 41 cm

18x36 (Extra Large)

2009 Canadian Hypertension Education Program

Recommendations

Office Technique

On initial visit, blood pressure should be

taken in both arms and subsequently it
should be measured in the arm with the
highest reading. Inform the patient
Duplicate, resting readings, 1 2 minutes
apart, should be taken at each visit
If readings vary by > 5mmHg, the readings
should be repeated until 2 consecutive
readings are comparable
Standing blood pressure @ 1 & 3 minutes

2009 Canadian Hypertension Education Program Recommendations

Palpation

Determine systolic blood pressure by

palpation to decrease pain and exclude
possibility of systolic auscultatory gap
1. Palpate the radial pulse
2. Inflate quickly to 60 mmHg and then by
increments of 10mmHg until the pulse disappears
= estimated palpated systolic pressure
3. Slowly deflate at a rate of 2 mmHg/second until
the pulse reappears to confirm your palpated
systolic pressure
4. Add 30 mmHg to this number to determine you
Maximum Inflation Level (MIL)

2009 Canadian Hypertension Education Program Recommendations

Korotkoff Sounds and Auscultatory

Gap
Korotkoff sounds

200
180

No sound
Clear sound

Phase 1

Muffling

Phase 2

140

No sound

Auscultatory
gap

120

Clear sound

Phase 3

Muffled sound

Phase 4

No sound

Phase 5

160

100
80
60
40
20
0
mm Hg

2009 Canadian Hypertension Education Program Recommendations

Systolic blood pressure

Auscultation
1.
2.
3.

4.

5.
6.

Palpate, then place stethoscope over brachial artery

Inflate cuff pressure to the MIL
Deflate cuff pressure by 2 mmHg per second
Appearance of 2 regular tapping sounds
Korotkoff phase I = systolic pressure
Continue to decrease pressure by 2 mmHg per second
Disappearance of sound
Korotkoff phase V = diastolic pressure
If DBP>90 mmHg listen for an additional 30mmHg to
rule out Diastolic auscultatory gap
Record measurement

2009 Canadian Hypertension Education Program Recommendations

The Concept of White Coat vs

Masked Hypertension
Home or ABPM SBP mmHg

140

Masked
Hypertension

From Pickering et al, Hypertension 2002

True
Hypertensive

135

135
True
Normotensive

White Coat
Hypertension

140
Office SBP mmHg
2009 Canadian Hypertension Education Program Recommendations

The Prognosis of Masked

hypertension
Prevalence of masked hypertension is approximately 10% in the
general population (prevalence is higher in diabetic patients).
J Hypertension 2007;25:2193-98

2009 Canadian Hypertension Education Program Recommendations

Question
What is the target home blood pressure
for a patient without Diabetes
Mellitus or Chronic Kidney Disease?
a. < 120/80
b. < 125/75
c. < 130/80
d. < 135/85
e. < 140/90

OBPM HBPM, ABPM Equivalence

A clinic blood pressure of 140/90 mmHg has a
similar risk of a:
Description

Blood Pressure mmHg

Home pressure average

135 / 85

Daytime average ABP

135 / 85

24-hour average ABP

130 / 80

2009 Canadian Hypertension Education Program Recommendations

Important Role for Home Blood

Pressure Measurement

Measuring blood pressure at home has a

stronger association with CV prognosis than
office based readings
Home measurement can help to:
confirm the diagnosis of hypertension
improve blood pressure control
reduce the need for medications
improve medication adherence in non adherent
patients
help to identify white coat and masked
hypertension

2009 Canadian Hypertension Education Program Recommendations

Home Measurement of Blood

Pressure:
Use Validated Blood Pressure
Measurement Devices
This logo* on the
packaging ensures that
this type of device and
model meets the
international standards
for accurate blood
pressure measurement

* Endorsed by the Canadian Hypertension Society

2009 Canadian Hypertension Education Program Recommendations

Home measurement of blood

pressure

A poster and instruction

sheets can be ordered at
the Heart and Stroke
Foundation offices or online at:
http://hypertension.ca/bpc/
wpcontent/uploads/2008/03/bil
ingualposterorderform.pdf

2009 Canadian Hypertension Education Program Recommendations

Patient Instructions

Use a validated monitor

Correct cuff size
Accurate resting technique
Patient technique should be reviewed
regularly
Duplicate measurements 1-2 min. apart
7 days after any Rx change or before a
doctors appointment
AM (before Rx) & PM (2 hrs. after dinner)

2009 Canadian Hypertension Education Program Recommendations

Ambulatory Blood Pressure

Monitor (ABPM)
Shows blood pressure pattern over a 24
hour period
Measures blood pressure through
oscillometric technology which depends
on the pulsatility in the brachial artery
Arm must stay motionless during
inflation and deflation
Less accurate at extremes of systolic
and diastolic blood pressure

2009 Canadian Hypertension Education Program Recommendations

36

Diurnal Pattern/Circadian
Rhythm
Abnormalities in pattern are
associated with increased CV events
Dipping is good

Circadian rhythm of blood pressure is a

>10% fall in blood pressure during sleep

A non-dipping pattern is associated

with an increase risk of MI, stroke,
dementia as blood pressure remains
elevated during sleep

2009 Canadian Hypertension Education Program Recommendations

Benefits 24 hour ABPM

Provides large number of blood pressure readings

outside clinic setting
Helps determine the dynamic changes of blood
pressure throughout 24 hour period
Enables physician to adjust treatment
appropriately to prevent target organ complications
Rules out White Coat hypertension
Used to aid in diagnosis of Masked Hypertension
Identifies Dippers vs. Non-dippers

2009 Canadian Hypertension Education Program Recommendations

Take Home Message

To take accurate blood pressure readings you must
ensure:
1. Proper cuff size
2. Validated monitor
3. Accurate resting technique
Both in the doctors office and at home!
2009 Canadian Hypertension Education Program Recommendations

Blood Pressure

www.heartandstroke.ca/BP
To monitor home blood pressure and encourage
self management of lifestyle

www.hypertension.ca CHEP, 2009 Resources

Health Professional Resources:
o Diagnosis of hypertension
o Assessment
o Treatment
o Blood pressure measurement

Patient Resources: www.hypertension.ca/bpc

How to take a proper blood pressure
o Home blood pressure monitors
o Patient education
o

2009 Canadian Hypertension Education Program Recommendations

Canadian Best Practice Recommendations for Stroke Care, updated 2008

www.canadianstrokestrategy.ca