Pressure measurement blood flow

Pressure measurement blood flow

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During blood pressure measurement, when the flow within the arteries of the arm is interrupted, how is blood flow redistributed to the rest of the circulatory system? Is it possible that more blood enters the carotid arteries and therefore causes an increase in blood flow in the brain?

You have a point there, but it probably does not play a big role. First one arm is not such a big branch, and then the carotids contain the main pressure "sensors", so the heart might just beat a bit weaker/slower. Resistance is higher, but demand is less.

Compressions like that can happen all the time, through weight or muscle tension. If it is not both legs at once, this is only a problem for the blocked-off part, after a while.

Blood Pressure and Exercise Lab

To learn about external means to measure blood pressure, observe features of venous circulation, and observe the effects of exercise on blood pressure, heart rate, and electrocardiogram (ECG).

This lab will build on the class material we have covered on blood flow and pressure and cardiac contraction. It will also introduce some ideas we still have to cover on control of the cardiovascular system in response to exercise and the electrocardiogram.

To prepare, please review the notes and text on the vascular system and blood pressure and also read the section in your text (or any other good physiology book) on exercise.

See the web site for a description of this measurement.

Arterial blood pressure is measured by a sphygmomanometer. This consists of:

  1. A rubber bag surrounded by a cuff.
  2. A manometer (usually a mechanical gauge, sometimes electronic, rarely a mercury column).
  3. An inflating bulb to elevate the pressure.
  4. A deflating valve.

Figure 1 below shows how blood pressure is measured. After the cuff is placed snugly over the arm, the radial artery is palpated while the pressure is increased until the pulse can no longer be felt, then 30 mm Hg more. As the pressure is released the artery is palpated until the pulse is felt again. This palpatory method will detect systolic pressure only.

The auscultatory method detects diastolic as well as systolic pressure. The sounds heard when a stethoscope bell (or diaphragm) is applied to the region below the cuff were described by Korotkow in 1905 and are called Korotkow's sounds.

The artery is compressed by pressure and as the pressure is released the first sound heard is a sharp thud which becomes first softer and then louder again. It suddenly becomes muffled and later disappears. Most people register the first sound as Systolic, the muffled sound as the first diastolic and the place where it disappears as the second diastolic. It requires practice to distinguish the first diastolic, so, for our laboratory, we will record only the first sound (systolic) and the disappearance of the sound (second diastolic). These will not be difficult to elicit, and a little practice will enable you to get almost the same reading on a fellow student three times in succession.

    Improper positioning of the extremity. Whether the subject is sitting, standing, or supine, the position of the artery in which the blood pressure is measured must be at the level of the heart. However, it is not necessary that the sphygmomanometer be at the level of the heart.

A defective air release valve or porous rubber tubing connections make it difficult to control the inflation and deflation of the cuff. The aneroid manometer gauge tube should be clean.

If an aneroid manometer is used, its accuracy must be checked regularly against a standard manometer. The needle should indicate zero when the cuff is fully deflated.

The lab is divided into 4 sections, the first 3 of which you should do in parallel in the usual paired groups. For the final section, please form groups of 4-5 as this exercise needs this many people to carry out.

Have the subject relax with both arms resting comfortably at his sides. Wrap the sphygmomanometer cuff about the arm so that it is at heart level. The air bag inside the cuff should overlay the anterior portion of the arm about an inch above the antecubital fossa (the interior angle of elbow). The cuff should be wrapped snugly about the arm.

Palpate the radial pulse with the index and middle fingers near the base of the thumb on the anterior surface of the wrist. While palpating the radial pulse, rapidly inflate the cuff until the blood pressure manometer reads 200 mm Hg pressure. Set the valve on the rubber bulb so that the pressure leaks out slowly (about 5 mm per second). Continue palpating the radial pulse, and watch the manometer while air leaks out of the cuff. Note the pressure at which the pulse reappears.

Record the pressure: mm Hg.
This is Systolic pressure as detected by palpation. Allow the pressure to continue to decrease, noticing the changes in the strength of the radial pulse.

Elevate the pressure in the cuff 20 mm Hg higher than the pressure at which the radial pulse reappeared in A. Apply the stethoscope bell lightly against the skin in the antecubital fossa over the brachial artery. There will be no sounds heard if the cuff pressure is higher than the systolic blood pressure because no blood will flow through the artery beyond the cuff. As the cuff is slowly deflated, blood flow is turbulent beneath the stethoscope. It is this turbulent flow that produces Korotkow's sounds. Laminar flow is silent. Thus when the cuff is deflated completely, no sounds are heard at the antecubital fossa. Deflate the cuff completely and allow the subject to rest for a few minutes. DO NOT REMOVE THE CUFF.

Palpate the radial artery, and elevate the pressure in the cuff to 20 mm Hg Higher than that at which the radial pulse reappeared. Apply the stethoscope to the skin over the brachial artery, and allow pressure to leak slowly from the cuff. Note the pressures:
(1) At which the radial pulse is first felt: mm Hg.
(2) At which the sound is first heard with the stethoscope: mm Hg.

The pressure at which the sound was first heard is recorded as systolic blood pressure. Allow the pressure to continue to fall. The Korotkow's sounds grow more and more intense as the pressure is reduced. Then they suddenly acquire a muffled tone and finally disappear.

The pressure observed at the first muffled tone is the first Diastolic pressure.

The pressure observed when the sound disappears is the second diastolic pressure. Record this pressure as the diastolic pressure for this laboratory. (Note: In practice you should record both diastolic pressures.)

Repeat the blood pressure determination at least three times, or until sufficient proficiency is acquired that agreement within 5 mm Hg is obtained between consecutive readings. Blood pressure is recorded with the systolic pressure reading first,

e.g., 120/80 means Systolic 120 mm Hg Diastolic 80 mm Hg.

Pulse Pressure is the difference between Systolic and Diastolic blood pressure.

How do the measurements from these two methods compare? Which do you think was more accurate and why? Try and explain any differences in results in the Discussion section of lab report.

One can measure the approximate venous pressure by noting how much above the level of the heart an extremity must be so that hydrostatic and venous pressures are equal. At that point, there is barely enough venous pressure to lift blood against the hydrostatic pressure of the elevate limb.

With the subject lying on his/her back, hands placed alongside the body, observe the veins on a relaxed, dependent hand 1 . While the subject is reclining, passively raise and lower the subject's arm and observe for filling and collapsing of the veins of the back of the hand. Measure the distance in millimeters from the position where the veins are just barely collapsed to the level of the heart (in the supine subject approximately midway between the spine and the sternum). This will give the venous pressure in mm of blood.

Venous pressure mm of blood.

The specific gravity of blood is 1.056.
The specific gravity of mercury is 13.6.
Compute the venous pressure in mm Hg:

Mm of blood * mathend000# Sp.Gr. of blood = mm of mercury * mathend000# Sp.Gr. of mercury

Choose a student with prominent arm veins. Apply a fairly tight band around the arm above the elbow. Notice any swellings in the veins. Place a finger on a vein about six inches below the band and, with another finger, press the blood from the vein up towards the heart. This will empty the vein. Remove the second finger.

What do you observe? Please include your response in the lab report.

With the subject lying or sitting, draw the blunt end of a pen with moderate pressure across the skin of the subject's forearm. Wait 2-3 min and observe the effects. Repeat with firmer pressure.

What could be the reason for the flare or redness that you should see?

Note that this is not the brief, immediate discoloration but instead the response that arises a few minutes after the stimulation.

The goal of this part of the lab is to record the response of a test subject to moderate exercise. For this, each team needs 3-4 people organized as follows (see Figure 2): Subject: in comfortable clothes with ECG electrodes applied and blood pressure cuff applied loosely around an upper arm. IMPORTANT: It is critical the subject be willing to work hard. Most underestimate their ability, leading to poor preliminary data. Blood pressure monitor: stationed at the side of the subject with stethoscope and blood pressure manometer and bulb in hand. This person will carry out the BP measurements during the breaks in the exercise. Pulse monitor: stationed on the other side of the subject, this person's job is to measure heart rate from the radial pulse during the breaks in the exercise. ECG/Computer operator: sitting at the bench, this person's task is to make ECG measurements and record all other measurements from the blood pressure and pulse monitors. This person is also responsible for tracking the time and setting the pedal frequency.

Figure 3: System of limb lead ECG showing the heart dipole and how it projects onto each of the three limb potentials.

Form groups of 4-6 for the duration of the lab.

We will use a simplified version of the limb lead recording technique you perfected in the last lab so this should be very familiar to you (see Figure 3). Use only Lead II of that standard Limb Leads.

  1. Identify the following four sites on the torso of the subject and use an alcohol swab to clean the skin beforehand:
    • Right anterior shoulder, just below the clavicle (RA)
    • Left lower ribs, near the mid-axillary line (LL)
    • Right lower ribs, near the mid-axillary line (RL)

  • Right arm, or anterior shoulder, (RA): -, G2 input, blue dot on the connector
  • Left leg, or lower left ribs (LL): +, G1 input, yellow dot
  • Right leg, or lower right ribs (RL): reference, COM, green dot
  • Switch calibrator switch to 100 V mathend000#.
  • Set the LO FREQ. setting to 1 Hz.
  • Set Amplification to 5
  • Set HI FREQ. to 0.1 kHz
  • Press the CAL G1 NEG button This button makes G1 negative with respect to G2 by (in this case) 100 V mathend000#. The oscilloscope should register a downward deflection. The opposite occurs when the button is released.
  • Adjust the ``ADJ. CAL'' screw until the gain is 2000 Note: if ADJ. CAL is all the way to the left the resulting gain is approximately 1700.
  • Make sure to use the same settings for ALL channels.

There are two protocols for these experiments, but before beginning, let the subject warm up and make sure he/she is comfortable on the bike and has selected a comfortable gear and resistance setting to be able to complete 8-10 minutes of pedaling.

  1. Set the Agilent (or Hewlett-Packard) 33120A function generator to the following settings:
    • Function: square wave
    • Amplitude: about 1 VPP (volts peak-to-peak)
    • Duty cycle: 50%
    • DC offset: 0.0
  2. Connect a T-connector from the output of the function generator and connect one side of it to the Channel 2 input of the oscilloscope. use the oscilloscope to monitor the output of the function generator, especially its frequency.
  3. Connect a cable from the other end of the T-connector to the BNC/Banana converted and then to the adapter cable to a 1/8'' female plug for the headphones. Adjust volume with the headphone controls and the amplitude control of the function generator.
  4. Adjust the frequency of the signal generator to a level that the subjects find comfortable. Sample the signal with the oscilloscope and note the period and associated frequency.
  • Carry out measurements during the breaks at the end of each 2-minute interval as quickly as possible! The subject will recover during these breaks and thus reduce accuracy of the study the breaks should be no longer than 30 seconds.
  • Subjects should try and be as still as possible during the breaks and the ECG operator is responsible for measuring during an interval when the signals are as quiet and stable as possible. Observe the signal in the oscilloscope to determine if the signal is quiet and stable.
  • Don't let the lead wires hang free. Someone should hold them.
  • When you examine the resulting signals, select a short interval containing 1-3 beats and scale this to clearly see the characteristics of the signal shape.
  • When displaying the results of the ECG recordings, try and use the same scaling on the axes so that it is possible to compare results between different recordings.
  1. Give the subject a 5-minute recovery period and take resting measurements of BP, pulse, and ECG. Set the metronome to the cadence you worked out beforehand with the subject.
  2. Exercise 2 minutes: Let the subject pedal at the set rate for 2 minutes and then stop and as quickly as possible, measure blood pressure and pulse, and take a sample of the ECG on the computer.
  3. Exercise 4 minutes: Let the subject pedal another 2 minutes and repeat.
  4. Exercise 6 minutes: Let the subject pedal another 2 minutes and repeat.
  5. Exercise 8 minutes: Exercise for another two minutes and then measure again. Stop the exercise at this point but keep subject on bicycle.
  6. Recover 2 minutes: repeat measurements.
  7. Recover 4 minutes: repeat measurements.
  8. Recover 6 minutes: repeat measurements.
  9. Let subject relax and cool down.

The goal for this protocol is to apply a graded stress to the subject and observe the response. For this, have the subject select a gear that he/she can maintain over a cadence range of 60-90 rpm. The subject will spend 2 minutes at each cadence, then stop for measurements, then continue at an increased cadence for 2 minutes, and so on.

Work out beforehand a sequence of cadences and associated periods that will span 60-90 rpm in 4 steps.

  1. Give the subject a 5-minute recovery period and take resting measurements of BP, pulse, and ECG. Set the metronome to produce a cadence rate of approximately 60 bpm.
  2. Exercise 2 minutes: Let the subject pedal at the set rate for 2 minutes and then stop and as quickly as possible, measure blood pressure and pulse, and take a sample of the ECG on the computer. During the measurement, set the new cadence on the metronome.
  3. Exercise 4 minutes: Let the subject pedal another 2 minutes at the new cadence and repeat measurements. Increase the cadence again.
  4. Exercise 6 minutes: Let the subject pedal another 2 minutes at the new cadence and repeat measurements. Increase the cadence again.
  5. Exercise 8 minutes: Let the subject pedal another 2 minutes at the new cadence and repeat measurements. Stop the exercise at this point but keep subject on bicycle.
  6. Recover 2 minutes: repeat measurements.
  7. Recover 4 minutes: repeat measurements.
  8. Recover 6 minutes: repeat measurements.
  9. Let subject relax and cool down.

In a final test protocol, instead of pure recovery, after the subject reaches the peak cadence (and work) rate, step back through the same cadences and have the subject hold each for two minutes. Thus, the protocol consists of two identical series but with one increasing load and the other decreasing load.

  1. Give the subject a 5-minute recovery period and take resting measurements of BP, pulse, and ECG. Set the metronome to produce a cadence rate of approximately 60 bpm.
  2. Exercise 2 minutes: Let the subject pedal at the set rate for 2 minutes and then stop and as quickly as possible, measure blood pressure and pulse, and take a sample of the ECG on the computer. During the measurement, set the new cadence on the metronome.
  3. Exercise 4 minutes: Let the subject pedal another 2 minutes at the new cadence and repeat measurements. Increase the cadence again.
  4. Exercise 6 minutes: Let the subject pedal another 2 minutes at the new cadence and repeat measurements. Increase the cadence again.
  5. Exercise 8 minutes: Let the subject pedal another 2 minutes at the new cadence and repeat measurements. Stop the exercise at this point but keep subject on bicycle.
  6. Reduced Exercise 10 minutes: reduce the cadence to the value at 6 minutes and at the end of 2 minutes, stop and repeat measurements.
  7. Reduced Exercise 12 minutes: reduce the cadence to the value at 4 minutes and at the end of 2 minutes, stop and repeat measurements.
  8. Reduced Exercise 14minutes: reduce the cadence to the value at 2 minutes and at the end of 2 minutes, stop and repeat measurements. Stop the exercise at this point.
  9. Recovery 16 minutes: with subject stopped completely, at the end of 2 minutes, repeat measurements.
  10. Recovery 18 minutes: with stopped completely, at the end of 2 minutes, repeat measurements.
  11. Let subject relax and cool down.

The lab report should contain the following sections: Introduction: a brief overview of the purpose and goals of the lab as you understand them. Methods: a very brief summary of methods do not reproduce material (figures or text) from the lab description. Results: include all relevant data you recorded in all the various parts, with a brief explanation for each, along with any qualitative observations you made ( i.e., responses you observed but for which you did not collect specifics).

From the exercise protocols, view all ECG time signals yourself and then include selected examples of them in the report and include the heart rate for each. Comment on any changes you saw in the morphology of the ECG, especially during or after the exercise sessions. In the first of the ECG tracings, mark the P, QRS, and T waves. Plot blood pressure and pulse rate as a function of time during both exercise sequences. Discussion: Compare and contrast the responses to the two different exercise protocols, both in terms of ECG and BP changes.

Describe briefly the physiological mechanisms of some of the changes you observed. Make sure to answer all the questions marked in bold in the lab description.

Describe any experimental challenges you had to face in the lab and how you dealt with them or how you would plan to deal with them were you to repeat these experiments in the future.

This document was generated using the LaTeX 2HTML translator Version 2002-2-1 (1.71)

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Blood pressure is one of the most commonly measured clinical parameters and blood pressure values are major determinants of therapeutic decisions. However, interpretation of the physiological meaning of blood pressure in an individual patient is not always an easy task. This paper reviews the physical basis and physiological determinants of arterial pressure, and the relationship of arterial pressure to tissue perfusion. Some of the issues have been covered in a previous review on blood pressure [1]. The objective of this paper is to provide guidance when considering therapeutic options but it is not possible to give a definitive algorithm with current knowledge.

Measurement of Blood Pressure

Blood pressure is one of the critical parameters measured on virtually every patient in every healthcare setting. The technique used today was developed more than 100 years ago by a pioneering Russian physician, Dr. Nikolai Korotkoff. Turbulent blood flow through the vessels can be heard as a soft ticking while measuring blood pressure these sounds are known as Korotkoff sounds. The technique of measuring blood pressure requires the use of a sphygmomanometer (a blood pressure cuff attached to a measuring device) and a stethoscope. The technique is as follows:

• The clinician wraps an inflatable cuff tightly around the patient’s arm at about the level of the heart.

• The clinician squeezes a rubber pump to inject air into the cuff, raising pressure around the artery and temporarily cutting off blood flow into the patient’s arm.

• The clinician places the stethoscope on the patient’s antecubital region and, while gradually allowing air within the cuff to escape, listens for the Korotkoff sounds.

Although there are five recognized Korotkoff sounds, only two are normally recorded. Initially, no sounds are heard since there is no blood flow through the vessels, but as air pressure drops, the cuff relaxes, and blood flow returns to the arm. As shown in picture above, the first sound heard through the stethoscope—the first Korotkoff sound—indicates systolic pressure. As more air is released from the cuff, blood is able to flow freely through the brachial artery and all sounds disappear. The point at which the last sound is heard is recorded as the patient’s diastolic pressure.

Differences between auscultatory and oscillometric blood pressure readings

Automated oscillometric machines differ with respect to their algorithms, transducers, inflation and deflation rates, cuff sizes and materials, all of which may affect the estimation of BP. These may result in significant differences in estimations of systolic and diastolic BP compared with auscultatory readings in the same patient. Some machines may be accurate in one subject group but not necessarily in others e.g. in obese or pregnant subjects. Therefore, it is essential that oscillometric machines are validated against auscultatory readings in specified groups of subjects by experienced observers, approval being given to those machines which are deemed sufficiently accurate. The British and Irish Hypertension Society [3] and other organisations assess and publish lists of successfully validated oscillometric machines. A variety of validation protocols have been used but these are being superseded by a new Universal Standard [4].

Despite these considerations, the development of automated oscillometric BP machines has facilitated access to BP measurement without the need for expert training. BP screening and identification and management of hypertension is now more widely available than ever before.

Measurement of Blood Pressure

In this article, we shall study the origin and measurement of blood pressure.

Origin of Blood Pressure:

Due to the contraction of the heart and by the muscles that surround our blood vessels, blood moves through our circulation system since it is under pressure by it. The measure of this force is blood pressure. In the two main arteries, Blood pressure will always be highest, which is just outside the heart, but since the pulmonary circulation is inaccessible, blood pressure is measured in the systemic circulation only, i.e. blood leaving the left ventricle only normally in the upper arm. Blood pressure is measured by an instrument called the Sphygmomanometer.

Normal systolic pressure is about 120 mm Hg for males 110mm Hg for females. Average systolic pressure rises with age so (100 + your age) is a safe maximum. Normal diastolic pressure is about 80 mm Hg for males and 70 mm Hg for females. Blood pressure readings are given as two numbers, the systolic (higher) figure over the diastolic (lower) figure e.g. 120/80 mm Hg.

Hypertension (high blood pressure) is diagnosed when the diastolic pressure is >10mm Hg above the normal the systolic pressure is of less concern.

Measurement of Blood Pressure:

  • Ensure the patient is relaxed and has not taken any exercise for at least 10 minutes. A cuff is inflated around a person’s arm – stopping the flow of blood through the artery.
  • The pressure in the cuff is slowly released whilst listening for the first sounds of blood passing through the artery. This means that the ventricles are pumping with enough force to overcome the pressure exerted by the cuff. This is the systolic pressure.
  • The pressure continues to be released now listening for the disappearance of sound – indicating a steady flow of blood. This is the diastolic pressure when the pressure of the blood is sufficient to keep the arteries open even when the ventricles relax.

Blood Pressure at Different Positions in a Human Body:

Blood pressure in pulmonary arteries is slightly greater than that in capillaries while the blood pressure in pulmonary veins is slightly higher than the veins.


Blood pressure is constantly monitored by the human body and adjusted constantly to meet the needs of the body. This monitoring is performed by baroreceptors. Baroreceptors are special receptors that detect changes in blood pressure. Baroreceptors are found within the walls of blood vessels. The aorta and the carotid sinus contain important baroreceptors which constantly monitor blood pressure fluctuations. These baroreceptors transmit their data to the central nervous system, and more specifically, to the cardio regulatory centre of the medulla oblongata.

Blood Pressure Regulation:

If blood pressure within the aorta or the carotid sinus increases, the walls of these arteries stretch and stimulate increased activity within the baroreceptor. This information is then sent via nerves to the cardio regulatory center within the medulla, which responds by initiating mechanisms that decrease the blood pressure to a normal level.

To lower blood pressure, we first see a decrease of sympathetic input (increase heart rate) and an increase in parasympathetic input (decrease heart rate) to the heart. Therefore, by shutting off the sympathetic stimulation and boosting the parasympathetic stimulation, there is a decrease in the heart rate and stroke volume, which decreases the cardiac output and decreases blood pressure. If the baroreceptors are detecting that blood pressure is too high, the cardio regulatory centre of the medulla will decrease sympathetic input to the blood vessels. This causes vasodilation, which decreases total peripheral resistance and decreases blood pressure.

A decrease in blood pressure causes a decrease in action potentials sent to the cardio regulatory centre of the medulla. Therefore, to raise blood pressure, the body will first cause an increase in sympathetic nerve activity to the SA node, causing it to fire more frequently, which increases the heart rate. The heart muscle is also stimulated to pump with more force, and this increases the stroke volume. When heart rate and stroke volume increase, there is an increase in cardiac output. An increase in cardiac output causes increased blood pressure, restoring blood pressure back to a normal level. This causes an increased sympathetic input to the blood vessels, which stimulates the smooth muscle to contract, causing vasoconstriction, which increases total peripheral resistance and increases blood pressure.

Sources of error in automated oscillometric cuff measurement

The technique of measuring blood pressure using the automatec oscillometric cuff device obviously owes its accuracy to the cuff and the device. Moreover, in any scenario where clinical data is generated by an algorithm, the calculation also becomes a source of error, as whatever coefficients are used to multiply the measured numbers can magnify the error. To summarise, the following factors can become sources of error in the automated oscillometric measurement of blood pressure:

  • Incorrect technique
    • Wrong size cuff for the patient
    • Deflation which is too rapid
    • Inflation which is too great (causing pain and increasing the BP)
    • Patient movement (erratic arm muscle contractions are transmitted to the cuff and mistaken for pulse)
    • Atrial fibrillation (the erratic pulse pressure confuses the oscillometric cuff)
    • Use of coefficients and constants in the calculation of the systolic and diastolic pressure gives rise to inaccuracy
    • The automated measurement device can drift from factory calibration

    Of these, the cuff thing is probably the biggest issue. Bur et al (2003) found that fiddling with the algorithm is probably not going to achieve any appreciable increases in accuracy unless the cuff is well matched to the upper arm circumference.


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    Myers MG, Godwin M, Dawes M, Kiss A, Tobe SW, Grant FC, Kaczorowski J

    Myers MG, Valdivieso M, Kiss A

    Myers MG, Valdivieso M, Kiss A

    Godwin M, Birtwhistle R, Delva D, Lam M, Casson I, MacDonald S, Seguin R

    Myers MG, Valdivieso M, Chessman M, Kiss A

    Andreadis EA, Agaliotis GD, Angelopoulos ET, Tsakanikas AP, Chaveles IA, Mousoulis GP

    Padwal RS, Townsend RR, Trudeau L, Hamilton PG, Gelfer M

    Ringrose JS, Cena J, Ip S, Morales F, Hamilton P, Padwal R

    Myers MG, Oh PI, Reeves RA, Joyner CD

    Campbell NR, McKay DW, Conradson H, Lonn E, Title LM, Anderson T

    Kaczorowski J, Chambers LW, Dolovich L, Paterson JM, Karwalajtys T, Gierman T, Farrell B, McDonough B, Thabane L, Tu K, Zagorski B, Goeree R, Levitt CA, Hogg W, Laryea S, Carter MA, Cross D, Sabaldt RJ

    Myers MG, Kaczorowski J, Paterson JM, Dolovich L, Tu K

    Myers MG, Kaczorowski J, Dolovich L, Tu K, Paterson JM

    Leung AA, Daskalopoulou SS, Dasgupta K, McBrien K, Butalia S, Zarnke KB, Nerenberg K, Harris KC, Nakhla M, Cloutier L, Gelfer M, Lamarre-Cliche M, Milot A, Bolli P, Tremblay G, McLean D, Tran KC, Tobe SW, Ruzicka M, Burns KD, Vallée M, Prasad GVR, Gryn SE, Feldman RD, Selby P, Pipe A, Schiffrin EL, McFarlane PA, Oh P, Hegele RA, Khara M, Wilson TW, Penner SB, Burgess E, Sivapalan P, Herman RJ, Bacon SL, Rabkin SW, Gilbert RE, Campbell TS, Grover S, Honos G, Lindsay P, Hill MD, Coutts SB, Gubitz G, Campbell NRC, Moe GW, Howlett JG, Boulanger JM, Prebtani A, Kline G, Leiter LA, Jones C, Côté AM, Woo V, Kaczorowski J, Trudeau L, Tsuyuki RT, Hiremath S, Drouin D, Lavoie KL, Hamet P, Grégoire JC, Lewanczuk R, Dresser GK, Sharma M, Reid D, Lear SA, Moullec G, Gupta M, Magee LA, Logan AG, Dionne J, Fournier A, Benoit G, Feber J, Poirier L, Padwal RS, Rabi DM

    Kaczorowski J, Myers MG, Gelfer M, Dawes M, Mang EJ, Berg A, Grande CD, Kljujic D

    Mancia G, Parati G, Pomidossi G, Grassi G, Casadei R, Zanchetti A

    Bauer F, Seibert FS, Rohn B, Bauer KAR, Rolshoven E, Babel N, Westhoff TH

    Johnson KC, Whelton PK, Cushman WC, Cutler JA, Evans GW, Snyder JK , Ambrosius WT, Beddhu S, Cheung AK, Fine LJ, Lewis CE, Rahman M, Reboussin DM, Rocco MV, Oparil S, Wright JT

    Stergiou G, Kollias A, Parati G, O’Brien E

    Powers BJ, Olsen MK, Smith VA, Woolson RF, Bosworth HB, Oddone EZ

    Clark CE, Taylor RS, Shore AC, Campbell JL

    Eguchi K, Yacoub M, Jhalani J, Gerin W, Schwartz JE, Pickering TG

    Weinberg I, Gona P, O’Donnell CJ, Jaff MR, Murabito JM

    Clark CE, Taylor RS, Butcher I, Stewart MC, Price J, Fowkes FG, Shore AC, Campbell JL

    Wright JT, Williamson JD, Whelton PK, Snyder JK, Sink KM, Rocco MV, Reboussin DM, Rahman M, Oparil S, Lewis CE, Kimmel PL, Johnson KC, Goff DC, Fine LJ, Cutler JA, Cushman WC, Cheung AK, Ambrosius WT

    Stergiou GS, Baibas NM, Gantzarou AP, Skeva II, Kalkana CB, Roussias LG, Mountokalakis TD

    Freestone S, Silas JH, Ramsay LE

    Sakuma M, Imai Y, Nagai K, Watanabe N, Sakuma H, Minami N, Satoh H, Abe K

    Espinosa R, Spruill TM, Zawadzki MJ, Vandekar L, Garcia-Vera MP, Sanz J, Pickering TG, Linden WL, Gerin W

    Roubsanthisuk W, Wongsurin U, Saravich S, Buranakitjaroen P

    Muntner P, Carey RM, Gidding S, Jones DW, Taler SJ, Wright JT, Whelton PK

    . Ambulatory monitoring of blood pressure: an overview of devices, analyses, and clinical utility.

    Perloff D, Sokolow M, Cowan R

    Shimbo D, Kent ST, Diaz KM, Huang L, Viera AJ, Kilgore M, Oparil S, Muntner P

    Pickering TG, Gerin W, Schwartz JE, Spruill TM, Davidson KW

    . Validation and reliability testing of blood pressure monitors.

    di Rienzo M, Grassi G, Pedotti A, Mancia G

    Parati G, Stergiou G, O’Brien E, Asmar R, Beilin L, Bilo G, Clement D, de la Sierra A, de Leeuw P, Dolan E, Fagard R, Graves J, Head GA, Imai Y, Kario K, Lurbe E, Mallion JM, Mancia G, Mengden T, Myers M, Ogedegbe G, Ohkubo T, Omboni S, Palatini P, Redon J, Ruilope LM, Shennan A, Staessen JA, vanMontfrans G, Verdecchia P, Waeber B, Wang J, Zanchetti A, Zhang Y

    O’Brien E, Parati G, Stergiou G, Asmar R, Beilin L, Bilo G, Clement D, de la Sierra A, de Leeuw P, Dolan E, Fagard R, Graves J, Head GA, Imai Y, Kario K, Lurbe E, Mallion JM, Mancia G, Mengden T, Myers M, Ogedegbe G, Ohkubo T, Omboni S, Palatini P, Redon J, Ruilope LM, Shennan A, Staessen JA, vanMontfrans G, Verdecchia P, Waeber B, Wang J, Zanchetti A, Zhang Y

    de la Sierra A, Redon J, Banegas JR, Segura J, Parati G, Gorostidi M, de la Cruz JJ, Sobrino J, Llisterri JL, Alonso J, Vinyoles E, Pallarés V, Sarría A, Aranda P, Ruilope LM

    Banegas JR, Ruilope LM, de la Sierra A, Vinyoles E, Gorostidi M, de la Cruz JJ, Ruiz-Hurtado G, Segura J, Rodríguez-Artalejo F, Williams B

    Boggia J, Li Y, Thijs L, Hansen TW, Kikuya M, Björklund-Bodegård K, Richart T, Ohkubo T, Kuznetsova T, Torp-Pedersen C, Lind L, Ibsen H, Imai Y, Wang J, Sandoya E, O’Brien E, Staessen JA

    Thomas SJ, Booth JN, Bromfield SG, Seals SR, Spruill TM, Ogedegbe G, Kidambi S, Shimbo D, Calhoun D, Muntner P

    Li Y, Staessen JA, Lu L, Li LH, Wang GL, Wang JG

    Stergiou GS, Malakos JS, Zourbaki AS, Achimastos AD, Mountokalakis TD

    Booth JN, Muntner P, Abdalla M, Diaz KM, Viera AJ, Reynolds K, Schwartz JE, Shimbo D

    Pickering TG, James GD, Boddie C, Harshfield GA, Blank S, Laragh JH

    Franklin SS, Thijs L, Hansen TW, O’Brien E, Staessen JA

    Omboni S, Aristizabal D, De la Sierra A, Dolan E, Head G, Kahan T, Kantola I, Kario K, Kawecka-Jaszcz K, Malan L, Narkiewicz K, Octavio JA, Ohkubo T, Palatini P, Siègelovà J, Silva E, Stergiou G, Zhang Y, Mancia G, Parati G

    Brown MA, Buddle ML, Martin A

    de la Sierra A, Segura J, Banegas JR, Gorostidi M, de la Cruz JJ, Armario P, Oliveras A, Ruilope LM

    Muntner P, Booth JN, Shimbo D, Schwartz JE

    Asayama K, Thijs L, Li Y, Gu YM, Hara A, Liu YP, Zhang Z, Wei FF, Lujambio I, Mena LJ, Boggia J, Hansen TW, Björklund-Bodegård K, Nomura K, Ohkubo T, Jeppesen J, Torp-Pedersen C, Dolan E, Stolarz-Skrzypek K, Malyutina S, Casiglia E, Nikitin Y, Lind L, Luzardo L, Kawecka-Jaszcz K, Sandoya E, Filipovský J, Maestre GE, Wang J, Imai Y, Franklin SS, O’Brien E, Staessen JA

    de la Sierra A, Vinyoles E, Banegas JR, Segura J, Gorostidi M, de la Cruz JJ, Ruilope LM

    Franklin SS, Thijs L, Asayama K, Li Y, Hansen TW, Boggia J, Jacobs L, Zhang Z, Kikuya M, Björklund-Bodegård K, Ohkubo T, Yang WY, Jeppesen J, Dolan E, Kuznetsova T, Stolarz-Skrzypek K, Tikhonoff V, Malyutina S, Casiglia E, Nikitin Y, Lind L, Sandoya E, Kawecka-Jaszcz K, Filipovský J, Imai Y, Wang JG, O’Brien E, Staessen JA

    Fagard RH, Staessen JA, Thijs L, Gasowski J, Bulpitt CJ, Clement D, de Leeuw PW, Dobovisek J, Jääskivi M, Leonetti G, O’Brien E, Palatini P, Parati G, Rodicio JL, Vanhanen H, Webster J

    Mancia G, Bombelli M, Facchetti R, Madotto F, Quarti-Trevano F, Polo Friz H, Grassi G, Sega R

    Piper MA, Evans CV, Burda BU, Margolis KL, O’Connor E, Whitlock EP

    Pickering TG, Davidson K, Gerin W, Schwartz JE

    Wang YC, Shimbo D, Muntner P, Moran AE, Krakoff LR, Schwartz JE

    Booth JN, Diaz KM, Seals SR, Sims M, Ravenell J, Muntner P, Shimbo D

    Shimbo D, Newman JD, Schwartz JE

    Viera AJ, Lin FC, Tuttle LA, Shimbo D, Diaz KM, Olsson E, Stankevitz K, Hinderliter AL

    Schwartz JE, Burg MM, Shimbo D, Broderick JE, Stone AA, Ishikawa J, Sloan R, Yurgel T, Grossman S, Pickering TG

    Franklin SS, Thijs L, Li Y, Hansen TW, Boggia J, Liu Y, Asayama K, Björklund-Bodegård K, Ohkubo T, Jeppesen J, Torp-Pedersen C, Dolan E, Kuznetsova T, Stolarz-Skrzypek K, Tikhonoff V, Malyutina S, Casiglia E, Nikitin Y, Lind L, Sandoya E, Kawecka-Jaszcz K, Filipovsky J, Imai Y, Wang J, Ibsen H, O’Brien E, Staessen JA

    Gorostidi M, Sarafidis PA, de la Sierra A, Segura J, de la Cruz JJ, Banegas JR, Ruilope LM

    Baguet JP, Lévy P, Barone-Rochette G, Tamisier R, Pierre H, Peeters M, Mallion JM, Pépin JL

    Pogue V, Rahman M, Lipkowitz M, Toto R, Miller E, Faulkner M, Rostand S, Hiremath L, Sika M, Kendrick C, Hu B, Greene T, Appel L, Phillips RA

    Sega R, Trocino G, Lanzarotti A, Carugo S, Cesana G, Schiavina R, Valagussa F, Bombelli M, Giannattasio C, Zanchetti A, Mancia G

    Liu JE, Roman MJ, Pini R, Schwartz JE, Pickering TG, Devereux RB

    Pierdomenico SD, Cuccurullo F

    Ohkubo T, Kikuya M, Metoki H, Asayama K, Obara T, Hashimoto J, Totsune K, Hoshi H, Satoh H, Imai Y

    Tomiyama M, Horio T, Yoshii M, Takiuchi S, Kamide K, Nakamura S, Yoshihara F, Nakahama H, Inenaga T, Kawano Y

    Husain A, Lin FC, Tuttle LA, Olsson E, Viera AJ

    Dolan E, Stanton A, Thijs L, Hinedi K, Atkins N, McClory S, Den Hond E, McCormack P, Staessen JA, O’Brien E

    O’Brien E, Sheridan J, O’Malley K

    Roush GC, Fagard RH, Salles GF, Pierdomenico SD, Reboldi G, Verdecchia P, Eguchi K, Kario K, Hoshide S, Polonia J, de la Sierra A, Hermida RC, Dolan E, Zamalloa H

    Hansen TW, Li Y, Boggia J, Thijs L, Richart T, Staessen JA

    Fan HQ, Li Y, Thijs L, Hansen TW, Boggia J, Kikuya M, Björklund-Bodegård K, Richart T, Ohkubo T, Jeppesen J, Torp-Pedersen C, Dolan E, Kuznetsova T, Stolarz-Skrzypek K, Tikhonoff V, Malyutina S, Casiglia E, Nikitin Y, Lind L, Sandoya E, Kawecka-Jaszcz K, Imai Y, Ibsen H, O’Brien E, Wang J, Staessen JA

    Hermida RC, Ayala DE, Mojón A, Fernández JR

    Rahman M, Greene T, Phillips RA, Agodoa LY, Bakris GL, Charleston J, Contreras G, Gabbai F, Hiremath L, Jamerson K, Kendrick C, Kusek JW, Lash JP, Lea J, Miller ER, Rostand S, Toto R, Wang X, Wright JT, Appel LJ

    Portaluppi F, Tiseo R, Smolensky MH, Hermida RC, Ayala DE, Fabbian F

    Muntner P, Lewis CE, Diaz KM, Carson AP, Kim Y, Calhoun D, Yano Y, Viera AJ, Shimbo D

    Fagard RH, Thijs L, Staessen JA, Clement DL, De Buyzere ML, De Bacquer DA

    Tsioufis C, Andrikou I, Thomopoulos C, Syrseloudis D, Stergiou G, Stefanadis C

    Ohkubo T, Hozawa A, Yamaguchi J, Kikuya M, Ohmori K, Michimata M, Matsubara M, Hashimoto J, Hoshi H, Araki T, Tsuji I, Satoh H, Hisamichi S, Imai Y

    Kario K, Pickering TG, Matsuo T, Hoshide S, Schwartz JE, Shimada K

    Muller JE, Stone PH, Turi ZG, Rutherford JD, Czeisler CA, Parker C, Poole WK, Passamani E, Roberts R, Robertson T

    Willich SN, Levy D, Rocco MB, Tofler GH, Stone PH, Muller JE

    Kario K, Pickering TG, Umeda Y, Hoshide S, Hoshide Y, Morinari M, Murata M, Kuroda T, Schwartz JE, Shimada K

    Li Y, Thijs L, Hansen TW, Kikuya M, Boggia J, Richart T, Metoki H, Ohkubo T, Torp-Pedersen C, Kuznetsova T, Stolarz-Skrzypek K, Tikhonoff V, Malyutina S, Casiglia E, Nikitin Y, Sandoya E, Kawecka-Jaszcz K, Ibsen H, Imai Y, Wang J, Staessen JA

    Eguchi K, Hoshide S, Hoshide Y, Ishikawa S, Shimada K, Kario K

    Musso NR, Vergassola C, Barone C, Lotti G

    Hinderliter AL, Routledge FS, Blumenthal JA, Koch G, Hussey MA, Wohlgemuth WK, Sherwood A

    van der Steen MS, Lenders JW, Graafsma SJ, den Arend J, Thien T

    Abdalla M, Goldsmith J, Muntner P, Diaz KM, Reynolds K, Schwartz JE, Shimbo D

    Viera AJ, Lin FC, Tuttle LA, Olsson E, Stankevitz K, Girdler SS, Klein JL, Hinderliter AL

    de la Sierra A, Vinyoles E, Banegas JR, Parati G, de la Cruz JJ, Gorostidi M, Segura J, Ruilope LM

    Weber MA, Schiffrin EL, White WB, Mann S, Lindholm LH, Kenerson JG, Flack JM, Carter BL, Materson BJ, Ram CV, Cohen DL, Cadet JC, Jean-Charles RR, Taler S, Kountz D, Townsend RR, Chalmers J, Ramirez AJ, Bakris GL, Wang J, Schutte AE, Bisognano JD, Touyz RM, Sica D, Harrap SB

    Krause T, Lovibond K, Caulfield M, McCormack T, Williams B

    Dasgupta K, Quinn RR, Zarnke KB, Rabi DM, Ravani P, Daskalopoulou SS, Rabkin SW, Trudeau L, Feldman RD, Cloutier L, Prebtani A, Herman RJ, Bacon SL, Gilbert RE, Ruzicka M, McKay DW, Campbell TS, Grover S, Honos G, Schiffrin EL, Bolli P, Wilson TW, Lindsay P, Hill MD, Coutts SB, Gubitz G, Gelfer M, Vallée M, Prasad GV, Lebel M, McLean D, Arnold JM, Moe GW, Howlett JG, Boulanger JM, Larochelle P, Leiter LA, Jones C, Ogilvie RI, Woo V, Kaczorowski J, Burns KD, Petrella RJ, Hiremath S, Milot A, Stone JA, Drouin D, Lavoie KL, Lamarre-Cliche M, Tremblay G, Hamet P, Fodor G, Carruthers SG, Pylypchuk GB, Burgess E, Lewanczuk R, Dresser GK, Penner SB, Hegele RA, McFarlane PA, Khara M, Pipe A, Oh P, Selby P, Sharma M, Reid DJ, Tobe SW, Padwal RS, Poirier L

    Aronow WS, Fleg JL, Pepine CJ, Artinian NT, Bakris G, Brown AS, Ferdinand KC, Ann Forciea M, Frishman WH, Jaigobin C, Kostis JB, Mancia G, Oparil S, Ortiz E, Reisin E, Rich MW, Schocken DD, Weber MA, Wesley DJ

    Lovibond K, Jowett S, Barton P, Caulfield M, Heneghan C, Hobbs FD, Hodgkinson J, Mant J, Martin U, Williams B, Wonderling D, McManus RJ

    McCormack T, Krause T, O’Flynn N

    Fagard RH, Van Den Broeke C, De Cort P

    Pickering TG, Miller NH, Ogedegbe G, Krakoff LR, Artinian NT, Goff D

    Ward AM, Takahashi O, Stevens R, Heneghan C

    Ohkubo T, Imai Y, Tsuji I, Nagai K, Kato J, Kikuchi N, Nishiyama A, Aihara A, Sekino M, Kikuya M, Ito S, Satoh H, Hisamichi S

    Niiranen TJ, Hänninen MR, Johansson J, Reunanen A, Jula AM

    Stergiou GS, Nasothimiou EG, Destounis A, Poulidakis E, Evagelou I, Tzamouranis D

    Green BB, Cook AJ, Ralston JD, Fishman PA, Catz SL, Carlson J, Carrell D, Tyll L, Larson EB, Thompson RS

    Agarwal R, Bills JE, Hecht TJ, Light RP

    Pawloski PA, Asche SE, Trower NK, Bergdall AR, Dehmer SP, Maciosek MV, Nyboer RA, O’Connor PJ, Sperl-Hillen JM, Green BB, Margolis KL

    Parati G, Stergiou GS, Asmar R, Bilo G, de Leeuw P, Imai Y, Kario K, Lurbe E, Manolis A, Mengden T, O'Brien E, Ohkubo T, Padfield P, Palatini P, Pickering T, Redon J, Revera M, Ruilope LM, Shennan A, Staessen JA, Tisler A, Waeber B, Zanchetti A, Mancia G

    Stergiou GS, Skeva II, Zourbaki AS, Mountokalakis TD

    Stergiou GS, Nasothimiou EG, Kalogeropoulos PG, Pantazis N, Baibas NM

    Parati G, Stergiou GS, Asmar R, Bilo G, de Leeuw P, Imai Y, Kario K, Lurbe E, Manolis A, Mengden T, O’Brien E, Ohkubo T, Padfield P, Palatini P, Pickering TG, Redon J, Revera M, Ruilope LM, Shennan A, Staessen JA, Tisler A, Waeber B, Zanchetti A, Mancia G

    Stergiou GS, Asayama K, Thijs L, Kollias A, Niiranen TJ, Hozawa A, Boggia J, Johansson JK, Ohkubo T, Tsuji I, Jula AM, Imai Y, Staessen JA

    Calvo-Vargas C, Padilla Rios V, Troyo-Sanromán R, Grover-Paez F

    Scisney-Matlock M, Grand A, Steigerwalt SP, Normolle D

    Tucker KL, Sheppard JP, Stevens R, Bosworth HB, Bove A, Bray EP, Earle K, George J, Godwin M, Green BB, Hebert P, Hobbs FDR, Kantola I, Kerry SM, Leiva A, Magid DJ, Mant J, Margolis KL, McKinstry B, McLaughlin MA, Omboni S, Ogedegbe O, Parati G, Qamar N, Tabaei BP, Varis J, Verberk WJ, Wakefield BJ, McManus RJ

    Uhlig K, Patel K, Ip S, Kitsios GD, Balk EM

    Magid DJ, Olson KL, Billups SJ, Wagner NM, Lyons EE, Kroner BA

    Kerby TJ, Asche SE, Maciosek MV, O’Connor PJ, Sperl-Hillen JM, Margolis KL

    Ralston JD, Cook AJ, Anderson ML, Catz SL, Fishman PA, Carlson J, Johnson R, Green BB

    Bosworth HB, Powers BJ, Olsen MK, McCant F, Grubber J, Smith V, Gentry PW, Rose C, Van Houtven C, Wang V, Goldstein MK, Oddone EZ

    McKinstry B, Hanley J, Wild S, Pagliari C, Paterson M, Lewis S, Sheikh A, Krishan A, Stoddart A, Padfield P

    Ogedegbe G, Schoenthaler A

    Fletcher BR, Hartmann-Boyce J, Hinton L, McManus RJ

    Shimbo D, Abdalla M, Falzon L, Townsend RR, Muntner P

    Kronish IM, Kent S, Moise N, Shimbo D, Safford MM, Kynerd RE, O’Beirne R, Sullivan A, Muntner P

    Kent ST, Shimbo D, Huang L, Diaz KM, Viera AJ, Kilgore M, Oparil S, Muntner P

    Viera AJ, Lingley K, Hinderliter AL

    van der Steen MS, Lenders JW, Thien T

    Johnson KA, Partsch DJ, Rippole LL, McVey DM

    Logan AG, Dunai A, McIsaac WJ, Irvine MJ, Tisler A

    Tislér A, Dunai A, Keszei A, Fekete B, Othmane Tel H, Torzsa P, Logan AG

    Cheng C, Studdiford JS, Diamond JJ, Chambers CV

    Staessen J, Bulpitt CJ, Fagard R, Mancia G, O’Brien ET, Thijs L, Vyncke G, Amery A

    Staessen JA, O’Brien ET, Amery AK, Atkins N, Baumgart P, De Cort P, Degaute JP, Dolenc P, De Gaudemaris R, Enström I

    Head GA, Mihailidou AS, Duggan KA, Beilin LJ, Berry N, Brown MA, Bune AJ, Cowley D, Chalmers JP, Howe PR, Hodgson J, Ludbrook J, Mangoni AA, McGrath BP, Nelson MR, Sharman JE, Stowasser M

    Mancia G, Sega R, Bravi C, De Vito G, Valagussa F, Cesana G, Zanchetti A

    Kikuya M, Hansen TW, Thijs L, Björklund-Bodegård K, Kuznetsova T, Ohkubo T, Richart T, Torp-Pedersen C, Lind L, Ibsen H, Imai Y, Staessen JA

    Ohkubo T, Imai Y, Tsuji I, Nagai K, Ito S, Satoh H, Hisamichi S

    Ravenell J, Shimbo D, Booth JN, Sarpong DF, Agyemang C, Beatty Moody DL, Abdalla M, Spruill TM, Shallcross AJ, Bress AP, Muntner P, Ogedegbe G

    Niiranen TJ, Asayama K, Thijs L, Johansson JK, Ohkubo T, Kikuya M, Boggia J, Hozawa A, Sandoya E, Stergiou GS, Tsuji I, Jula AM, Imai Y, Staessen JA

    Staessen JA, Thijs L, Ohkubo T, Kikuya M, Richart T, Boggia J, Adiyaman A, Dechering DG, Kuznetsova T, Thien T, de Leeuw P, Imai Y, O’brien E, Parati G

    Cloutier L, Daskalopoulou SS, Padwal RS, Lamarre-Cliche M, Bolli P, McLean D, Milot A, Tobe SW, Tremblay G, McKay DW, Townsend R, Campbell N, Gelfer M

    Head GA, McGrath BP, Mihailidou AS, Nelson MR, Schlaich MP, Stowasser M, Mangoni AA, Cowley D, Brown MA, Ruta LA, Wilson A

    Gerhard-Herman MD, Gornik HL, Barrett C, Barshes NR, Corriere MA, Drachman DE, Fleisher LA, Fowkes FG, Hamburg NM, Kinlay S, Lookstein R, Misra S, Mureebe L, Olin JW, Patel RA, Regensteiner JG, Schanzer A, Shishehbor MH, Stewart KJ, Treat-Jacobson D, Walsh ME

    van Egmond J, Hasenbos M, Crul JF

    Parati G, Casadei R, Groppelli A, Di Rienzo M, Mancia G

    Altunkan S, Iliman N, Altunkan E

    Casiglia E, Tikhonoff V, Albertini F, Palatini P

    Thomas SS, Nathan V, Zong C, Soundarapandian K, Shi X, Jafari R

    Deutsch C, Krüger R, Saito K, Yamashita S, Sawanoi Y, Beime B, Bramlage P

    Davies JH, Kenkre J, Williams EM

    Harju J, Vehkaoja A, Kumpulainen P, Campadello S, Lindroos V, Yli-Hankala A, Oksala N

    Stergiou GS, Lourida P, Tzamouranis D

    Beulen BW, Bijnens N, Koutsouridis GG, Brands PJ, Rutten MC, van de Vosse FN

    Idzenga T, Reesink KD, van Swelm Y, Hansen HH, Holewijn S, de Korte CL

    Nelson MR, Stepanek J, Cevette M, Covalciuc M, Hurst RT, Tajik AJ

    Fischer MO, Avram R, Cârjaliu I, Massetti M, Gérard JL, Hanouz JL, Fellahi JL

    Kumar N, Khunger M, Gupta A, Garg N

    Cortez NG, Cohen IG, Kesselheim AS

    Bruining N, Caiani E, Chronaki C, Guzik P, van der Velde E

    Woo SH, Choi YY, Kim DJ, Bien F, Kim JJ

    Chandrasekaran V, Dantu R, Jonnada S, Thiyagaraja S, Subbu KP

    Nwankwo T, Yoon SS, Burt V, Gu Q

    Dobson RT, Taylor JG, Henry CJ, Lachaine J, Zello GA, Keegan DL, Forbes DA

    Sabater-Hernández D, Sánchez-Villegas P, Lacampa P, Artiles-Campelo A, Jorge-Rodríguez ME, Faus MJ

    Santschi V, Chiolero A, Burnand B, Colosimo AL, Paradis G

    Santschi V, Chiolero A, Colosimo AL, Platt RW, Taffé P, Burnier M, Burnand B, Paradis G

    Albasri A, O’Sullivan JW, Roberts NW, Prinjha S, McManus RJ, Sheppard JP

    Sendra-Lillo J, Sabater-Hernández D, Sendra-Ortolá Á, Martínez-Martínez F

    Sabater-Hernández D, de la Sierra A, Sánchez-Villegas P, Baena MI, Amariles P, Faus MJ

    Sabater-Hernández D, Sánchez-Villegas P, García-Corpas JP, Amariles P, Sendra-Lillo J, Faus MJ

    Sendra-Lillo J, Sabater-Hernández D, Sendra-Ortolá A, Martínez-Martínez F

    Campbell NR, Niebylski ML, Redburn K, Lisheng L, Nilsson P, Zhang XH, Lackland DT

    Ostchega Y, Hughes JP, Zhang G, Nwankwo T, Chiappa MM

    Alpert BS, Dart RA, Sica DA

    Al Hamarneh YN, Houle SK, Chatterley P, Tsuyuki RT

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    The non-invasive 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, non-invasive methods may yield somewhat lower accuracy and small systematic differences in numerical results. Non-invasive measurement methods are more commonly used for routine examinations and monitoring. New non-invasive and continuous technologies based on the CNAP vascular unloading technique, are making non-invasive measurement of blood pressure and further advanced hemodynamic parameters more applicable in general anesthesia and surgery where periods of hypotension might be missed by intermittent measurements. [4]

    Palpation Edit

    A minimum systolic value can be roughly estimated by palpation, most often used in emergency situations, but should be used with caution. [5] 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. [5]

    A more accurate value of systolic blood pressure can be obtained with a sphygmomanometer and palpating the radial pulse. [6] Methods using constitutive models have been proposed to measure blood pressure from radial artery pulse. [7] 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 Edit

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

    A cuff of the appropriate size [8] is fitted smoothly and also snugly, then inflated manually by repeatedly squeezing a rubber bulb until the artery is completely occluded. It is important that the cuff size is correct: undersized cuffs record too high a pressure oversized cuffs may yield too low a pressure. [9] Usually three or four cuff sizes should be available to allow measurements in arms of different size. [9] Listening with the stethoscope to the brachial artery at the antecubital area of 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). [10] 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. [11]

    Oscillometric Edit

    The oscillometric method was first demonstrated in 1876 and involves the observation of oscillations in the sphygmomanometer cuff pressure [12] which are caused by the oscillations of blood flow, i.e., the pulse. [13] The electronic version of this method is sometimes used in long-term measurements and general practice. The first fully automated oscillometric blood pressure cuff called the Dinamap 825, an acronym for "Device for Indirect Non-invasive Mean Arterial Pressure", was made available in 1976. [14] It was replaced in 1978 by the Dinamap 845 which could also measure systolic and diastolic blood pressure, as well as heart rate. [15]

    The oscillometric method 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. [16] Oscillometric measurement requires less skill than the auscultatory technique and may be suitable for use by untrained staff and for automated patient home monitoring. As for the auscultatory technique it is important that the cuff size is appropriate for the arm. There are some single cuff devices that may be used for arms of differing sizes, although experience with these is limited. [9]

    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. 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.

    Over the deflation period, the recorded pressure waveform forms a signal known as the cuff deflation curve. A bandpass filter is utilized to extract the oscillometric pulses from the cuff deflation curve. Over the deflation period, the extracted oscillometric pulses form a signal known as the oscillometric waveform (OMW). The amplitude of the oscillometric pulses increases to a maximum and then decreases with further deflation. A variety of analysis algorithms can be employed in order to estimate the systolic, diastolic, and mean arterial pressure.

    Oscillometric monitors may produce inaccurate readings in patients with heart and circulation problems, which include arteriosclerosis, arrhythmia, preeclampsia, pulsus alternans, and pulsus paradoxus. [9] [17]

    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.

    Recently, several coefficient-free oscillometric algorithms have developed for estimation of blood pressure. [16] These algorithms do not rely on experimentally obtained coefficients and have been shown to provide more accurate and robust estimation of blood pressure. These algorithms are based on finding the fundamental relationship between the oscillometric waveform and the blood pressure using modeling [18] and learning [19] approaches. Pulse transit time measurements have been also used to improve oscillometric blood pressure estimates. [20]

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

    Continuous noninvasive techniques Edit

    Continuous Noninvasive Arterial Pressure (CNAP) is the method of measuring arterial blood pressure in real-time without any interruptions and without cannulating the human body. CNAP combines the advantages of the following two clinical “gold standards”: it measures blood pressure continuously in real-time like the invasive arterial catheter system and it is noninvasive like the standard upper arm sphygmomanometer. Latest developments in this field show promising results in terms of accuracy, ease of use and clinical acceptance. An advanced hemodynamic monitoring system incorporating the CNAP method is the NICCI technology of the company Pulsion Medical Systems. The system uses photoplethysmography to detect the blood flow in the patient’s fingers and pressure cuffs to create a constant flow. The resulting pressure in the finger sensor corresponds to the real arterial pressure. Based on the vascular unloading technique, the NICCI Technology provides continuous and noninvasive hemodynamic parameters during surgeries. The measurement results are comparable to invasive arterial line measurements in terms of continuity, accuracy and waveform dynamics.

    Pulse wave velocity Edit

    Since the 1990s a novel family of techniques based on the so-called pulse wave velocity (PWV) principle have been developed. These techniques rely on the fact that the velocity at which an arterial pressure pulse travels along the arterial tree depends, among others, on the underlying blood pressure. [21] Accordingly, after a calibration maneuver, these techniques provide indirect estimates of blood pressure by translating PWV values into blood pressure values. [22] The main advantage of these techniques is that it is possible to measure PWV values of a subject continuously (beat-by-beat), without medical supervision, and without the need of continuously inflating brachial cuffs. [23]

    Ambulatory and home monitoring Edit

    Ambulatory blood pressure devices take readings regularly (e.g. every half-hour throughout the day and night). They have been used to exclude measurement problems like white-coat hypertension and provide more reliable estimates of usual blood pressure and cardiovascular risk. Blood pressure readings outside of a clinical setting are usually slightly lower in the majority of people however studies that quantified the risks from hypertension and the benefits of lowering blood pressure have mostly been based on readings in a clinical environment. Use of ambulatory measurements is not widespread but guidelines developed by the UK National Institute for Health and Care Excellence and the British Hypertension Society recommended that 24-hour ambulatory blood pressure monitoring should be used for diagnosis of hypertension. [24] Health economic analysis suggested that this approach would be cost effective compared with repeated clinic measurements. [25] Not all home blood pressure machines are accurate, [26] and "wide range" (one-size fits all) home blood pressure monitoring units do not have adequate evidence to support their use. [27] In addition, health care professionals are recommending that people validate their home devices before relying on the results. [28]

    Home monitoring is a cheap and simple alternative to ambulatory blood pressure monitoring, although it does not usually allow assessment of blood pressure during sleep which may be a disadvantage. [29] [30] Automatic self-contained blood pressure monitors are available at reasonable prices, however measurements may not be accurate in patients with atrial fibrillation or other arrhythmias such as frequent ectopic beats. [29] [30] Home monitoring may be used to improve hypertension management and to monitor the effects of lifestyle changes and medication related to blood pressure. [31] Compared to ambulatory blood pressure measurements, home monitoring has been found to be an effective and lower cost alternative, [29] [32] [33] but ambulatory monitoring is more accurate than both clinic and home monitoring in diagnosing hypertension.

    When measuring blood pressure in the home, 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 arises, 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. The same arm should be used for all measurements. During the reading, the arm that is used should be relaxed and kept at heart level, for example by resting it on a table. [34]

    Since blood pressure varies throughout the day, home measurements should be taken at the same time of day. A Joint Scientific Statement From the American Heart Association, American Society of Hypertension, and Preventive Cardiovascular Nurses Association on home monitoring in 2008 [30] recommended that 2 to 3 readings should be taken in the morning (after awakening, before washing/dressing, taking breakfast/drink or taking medication) and another 2 to 3 readings at night, each day over a period of 1 week. It was also recommended that the readings from the first day should be discarded and that a total of ≥12 readings (i.e. at least two readings per day for the remaining 6 days of the week) should be used for making clinical decisions.

    Observer error Edit

    There are many factors that can play a role in the blood pressure reading by physician, such as hearing problem, auditory perception of the physician. Karimi Hosseini et al evaluated the interobserver differences among specialists without any auditory impairment, and reported 68% of observers recorded systolic blood pressure in a range of 9.4 mmHg, diastolic blood pressure in a range of 20.5 mmHg and mean blood pressure in a range of 16.1mmHg. [35] Neufeld et al reported standard deviations for both systolic and diastolic readings were roughly 3.5 to 5.5 mm Hg. In general standard deviation for the diastolic pressure would be greater because of the difficulty in judging when the sounds disappear. [36]

    White-coat hypertension Edit

    For some patients, blood pressure measurements taken in a doctor's office may not correctly characterize their typical blood pressure. [37] 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. [38] White coat hypertension can also occur because, in a clinical setting, patients are seldom given the opportunity to rest for five minutes before blood pressure readings are taken. 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. [39] In some cases a lower blood pressure reading occurs at the doctor's - this has been termed 'masked hypertension'. [40]

    Alternative settings, such as pharmacies, have been proposed as alternatives to office blood pressure. The threshold for blood pressure from pharmacy readings is 135/85 mmHg, suggesting a reduced white coat effect, similar to daytime ambulatory measurements. [41] [ clarification needed ]

    Arterial blood pressure is most accurately measured invasively through an arterial line. Invasive arterial pressure measurement with intravascular cannulae involves direct measurement of arterial pressure by placing a cannula needle in an artery (usually radial, femoral, dorsalis pedis or brachial). The cannula is inserted either via palpation or with the use of ultrasound guidance. [42]

    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.

    Measuring Pulse

    You should know that your "pulse" refers both to the physical thump created in your arteries by the contraction of your heart muscles and the number of these thumps your heart causes per minute. You have seven pulse points--places where arteries come close to your skin--on your body:

    a. carotid arteries (located on your neck)
    b. radial arteries (on your wrists)
    c. brachial arteries (on your arms)
    d. aortic arch (by your heart)
    e. abdominal aorta (near your stomach)
    f. femoral arteries (on your thighs)
    g. popliteal arteries (near your knees)

    Measure Using Your Radial Artery

    To find your radial artery (the most common point from which people take pulses), hold one hand straight out, elbow bent, palm relaxed and facing up. Raise your thumb slightly skyward, as if holding an apple or a tennis ball, to create a small pocket under your thumb at the top of your wrist where you will place the tips of your index and middle finger. (Don't use your thumb--it's also got a pulse and could cause counting confusion.)

    * Count the beats for 30 seconds and multiply by two. This is your pulse rate:______________

    Measure Using Your Carotid artery

    Neck pulse points are stronger and more accessible. The carotid is located just below your jaw in the groove where your head and neck meet, on either side of your windpipe. Use your index and middle fingertips to feel around in the groove for a pulsation.

    *Measure the pulse rate of two test subjects using either the carotid or brachial artery. What is your pulse rate at the carotid? _________

    Watch the video: Korotkoff Sounds Annotated Video (October 2022).