Rules for measuring hell algorithm. Correct blood pressure measurement. Rules for measuring blood pressure

Measurement blood pressure(sphygmomanometry)– the main method for diagnosing arterial hypertension.

Blood pressure can spontaneously vary widely over the course of a day, a week, or months.

Hypertension is diagnosed based on repeated blood pressure measurements. If blood pressure is slightly elevated, then repeated measurements should be continued over several months in order to determine the “usual, habitual” blood pressure as accurately as possible. On the other hand, if there is a significant increase in blood pressure, end-organ damage or high cardiovascular risk, then repeated blood pressure measurements are carried out over several weeks or days. As a rule, the diagnosis of arterial hypertension can be established on the basis of double blood pressure measurements at at least, 2 or 3 visits, although especially severe cases it can be diagnosed already at the first visit.

• Conditions for measuring blood pressure (BP)
  • The measurement should be carried out in a quiet, comfortable environment at room temperature.
  • 30-60 minutes before the measurement, it is necessary to avoid smoking, taking tonic drinks, caffeine, alcohol, as well as physical activity.
  • Blood pressure is measured after the patient has rested for more than 5 minutes. If the procedure was preceded by significant physical or emotional stress, the rest period should be increased to 15-30 minutes.
  • Blood pressure is measured in different time day.
  • Your feet should be on the floor, and your arms should be extended and rest freely at heart level.

Blood pressure measurement.

• Method of measuring blood pressure (BP)
  • Blood pressure is determined at the brachial artery with the patient lying on his back or sitting in a comfortable position.
  • The cuff is placed on the shoulder at the level of the heart, its lower edge 2 cm above the elbow.
  • The cuff should be sized to cover 2/3 of the biceps. The cuff bladder is considered long enough if it surrounds more than 80% of the arm and the width of the bladder is at least 40% of the arm circumference. Therefore, if blood pressure is measured in an obese patient, a larger cuff should be used.
  • After putting on the cuff, it is pressurized to values ​​above the expected systolic pressure.
  • Then the pressure is gradually reduced (at a rate of 2 mmHg/sec), and using a phonendoscope, heart sounds are heard over the brachial artery of the same arm.
  • Do not apply too much pressure to the artery with the membrane of the phonendoscope.
  • The pressure at which the first heart sound will be heard is systolic blood pressure.
  • The pressure at which heart sounds can no longer be heard is called diastolic blood pressure.
  • The same principles are used when measuring blood pressure in the forearm (tones are heard on the radial artery) and thigh (tones are heard on the popliteal artery).
  • Blood pressure is measured three times, with an interval of 1–3 minutes, on both arms.
  • If the first two blood pressure measurements differ from each other by no more than 5 mmHg. Art., measurements should be stopped and the average value of these values ​​is taken as the blood pressure level.
  • If there is a difference of more than 5 mm Hg. Art., a third measurement is carried out, which is compared with the second, and then (if necessary) a fourth measurement is performed.
  • If the tones are very weak, you should raise your hand and perform several squeezing movements with the hand, then the measurement is repeated.
  • In patients over 65 years of age, in the presence of diabetes mellitus, and in those receiving antihypertensive therapy, blood pressure should also be measured after 2 minutes of standing.
  • Patients with vascular pathology(for example, with atherosclerosis of the arteries of the lower extremities), determination of blood pressure in both upper and lower limbs. For this purpose, blood pressure is measured not only at the brachial, but also at femoral arteries with the patient in the prone position (the artery can be heard in the popliteal fossa).
  • Sphygmomanometers containing mercury are more accurate; automatic blood pressure machines are less accurate in most cases.
  • Mechanical devices must be calibrated periodically.

• Most common mistakes leading to incorrect blood pressure measurements
  • Incorrect position of the patient's hand.
  • Using a cuff that does not fit the shoulder circumference if your arms are full (the rubber inflated part of the cuff must cover at least 80% of the arm circumference).
  • Short time for the patient to adapt to the conditions of the doctor’s office.
  • High rate of pressure reduction in the cuff.
  • Lack of control of blood pressure asymmetry.

• Patient self-monitoring of blood pressure

  The most important information is provided to the doctor by the patient’s self-monitoring of blood pressure in outpatient setting.

  Self-control allows you to:

  • Learn more about the decreases (rises) in blood pressure at the end of the antihypertensive dosing interval.
  • Increase patient adherence to treatment.
  • Obtain an average value over several days, which, according to research, has greater reproducibility and prognostic value compared to “office” blood pressure.

  The mode and duration of self-monitoring and the type of device used are selected individually.

  It should be noted that few existing wrist-based blood pressure devices have been adequately validated.

  The patient must be informed that normal values blood pressure measured in different conditions, are somewhat different from each other.

  Target "normal" blood pressure numbers.

  Measurement conditions	Systolic blood pressure	Diastolic blood pressure
  Office or clinical	140	90
  Average daily	125-135	80
  Daytime	130-135	85
  Night	120	70
  Homemade	130-135	85

To measure blood pressure, a tonometer (sphygmomanometer) device is used, which consists of:

1. cuffs;
2. pump;
3. pressure gauge.

Tonometers are spring and electronic. To measure blood pressure using a spring tonometer, a stethoscope is required. Electronic tonometers are semi-automatic and automatic. In semi-automatic ones, air is pumped into the cuff manually, in automatic ones - with a compressor built into the pressure gauge. Electronic tonometers determine not only blood pressure, but also heart rate (pulse).

Rules and methods for measuring blood pressure:

1. Blood pressure should be measured:
   • on the brachial artery of the left arm (tonometers that measure blood pressure at the wrist, even if all the rules are followed, give a large error);

   no earlier than 5-10 minutes after being in a sitting position;

   • no earlier than 1 hour after sleep, eating, coffee, smoking a cigarette, drinking alcoholic drink, physical activity, acceptance hot bath, shower, visiting the steam room, spending time on the beach in the open sun.
2. The room where the pressure is measured should not be cold, hot or stuffy.
3. The tonometer should be at heart level.
4. You should not talk while measuring blood pressure. You need to sit on a chair relaxed, leaning your back against the back of the chair, left hand relaxed, placed on the table near the tonometer, you should not cross your legs.
5. Before measuring pressure, it is necessary to determine by palpation (with your fingers) the point of maximum pulsation of the brachial artery (usually this point is located above the ulnar fossa along inner surface shoulder). In this place, when measuring pressure, a stethophonendoscope (if the measurement is performed using a spring tonometer) or a cuff sensor (if the measurement is performed using an electronic tonometer) should be placed. The cuff sensor is placed near the rubber tube coming out of the cuff.
6. The cuff is fixed on the shoulder part of the arm above the ulnar fossa using Velcro. When measuring blood pressure using a spring tonometer, the lower edge of the cuff should be placed above the location of the stethophonendoscope (the place (point) of maximum pulsation of the brachial artery). The width of the cuff should be such that it covers approximately 2/3 of the length of the arm from elbow to shoulder.
7. In spring tonometers and semi-automatic electronic tonometers, a pump in the form of a rubber bulb pumps air into the cuff at a speed of 2 mm. rt. Art. per second, focusing on the pressure gauge dial until the reading on the pressure gauge scale is 180-200 mm. rt. Art.. In electronic tonometers, air is pumped into the cuff by pressing a button located on the pressure gauge by a compressor located in the pressure gauge. The cuff inflates and compresses the brachial artery. Further, the air from the cuff in electronic pressure gauges is automatically released and the measurement result is visible on the screen of the pressure gauge. After this, the remaining air from the cuff is released using a valve located near the rubber bulb. In spring tonometers, air is released from the cuff using a valve located near a rubber bulb. In this case, the appearance of heart sounds (Korotkoff sounds) in the form of pulsating taps is listened to using a stethoscope. At the same time, you need to look at the pressure gauge scale. The pressure gauge reading corresponding to the appearance of Korotkoff sounds will indicate the value of systolic blood pressure. The pressure gauge reading corresponding to the cessation of audibility of Korotkoff sounds will indicate the value of diastolic blood pressure.
   Note: When the pressure in the cuff is greater than systolic, blood does not flow into the brachial artery. When air leaves the cuff, the pressure in the cuff decreases and at a certain stage, pulsating blood begins to flow into the brachial artery. Turbulence and turbulence occur in the artery, creating a characteristic sound - pulsating Korotkoff sounds, which are heard using a stethophonendoscope. These sounds continue to be heard as long as the cuff continues to compress the brachial artery and prevents the free flow of blood through the brachial artery while turbulent movement of blood continues in this section of the artery. Once the pressure in the cuff is reduced enough to no longer impede the free flow of blood through the brachial artery, Korotkoff sounds are no longer audible (blood flow through the artery becomes laminar (uniform)).

Measuring Blood Pressure - Important diagnostic method examinations. Measuring blood pressure is considered by doctors as the main pre-medical procedure, which, if necessary, it is important to be able to carry out independently at home.

Pressure measuring apparatus

For these purposes, a special device for measuring pressure, called a tonometer, is used. It consists of the following elements:

• Sphygmomanometer;
• Pressure gauge.

The main parts of the sphygmomanometer are a rubber cuff for clamping the artery and a balloon (pump) for pumping air. Pressure gauges are spring and mercury.

Typically, tonometers using a stethophonendoscope (stethoscope, phonendoscope) are used to measure blood pressure. The measurement is made using the Korotkoff auditory method.

Basic rules for measuring blood pressure

Blood pressure must be measured following the following rules:

1. The room should be warm;

2. The patient should sit or lie comfortably on his back. Before measuring blood pressure, a person should rest for 10 to 15 minutes. It should be noted that in a supine position, the pressure is usually 5–10 mm lower than when measured in a sitting position;

3. Directly while measuring blood pressure, the patient must remain calm: do not talk or look at the pressure measuring device itself;

4. The patient's arm should be completely bare, with the palm facing upward and placed comfortably at the level of the heart. The raised sleeve of clothing should not put pressure on the veins. The patient's muscles should be completely relaxed;

5. Carefully remove the remaining air from the cuff of the pressure measuring device;

6. Place the cuff tightly on the arm, without tightening it too much. The lower edge of the cuff should be located 2–3 cm above the bend at the elbow. The cuff is then tightened or secured with Velcro;

7. A stethoscope is applied to the inner dimple on the elbow, firmly, but without pressure. It is best if it has two ears and rubber (polyvinyl chloride) tubes;

8. In complete silence, using a cylinder of a pressure measuring device, gradually pump air into the cuff, while the pressure in it is recorded by a pressure gauge;

9. Air is pumped until the sounds or noises stop ulnar artery tones, after which the pressure in the cuff is slightly increased by about 30 mm;

10. Now the air injection is stopped. Slowly opens a small tap near the cylinder. The air begins to gradually escape;

11. The height of the mercury column is fixed (value upper pressure), at which a clear noise is heard for the first time. It is at this point that the air pressure in the blood pressure machine decreases compared to the pressure in the artery, allowing a wave of blood to enter the vessel. Thanks to this, the tone is caused (the sound resembles a loud pulsation, a heartbeat). This value of upper pressure, the first indicator, is an indicator of maximum (systolic) pressure;

12. As the air pressure in the cuff further decreases, unclear noises appear, and then tones are heard again. These tones gradually intensify, then become clearer and more sonorous, but then suddenly weaken and stop completely. The disappearance of tones (heartbeat sounds) indicates the minimum (diastolic) pressure;

13. An additional indicator identified when using pressure measurement methods is the value of the pulse pressure amplitude or pulse pressure. This indicator is calculated by subtracting the minimum value (diastolic pressure) from the maximum value (systolic pressure). Pulse pressure is an important criterion for assessing the condition of cardio-vascular system person;

14. Indicators obtained using pressure measurement methods are written in the form of a fraction separated by a slash. The upper number indicates the systolic pressure, the lower number indicates the diastolic pressure.

Features of pressure measurement

When measuring blood pressure several times in a row, you need to pay attention to some features of the body. Thus, the values ​​of indicators during subsequent measurements, as a rule, turn out to be somewhat lower than during the first measurement. Exceeding the indicators during the first measurement may be caused by the following reasons:

• Some mental agitation;
• Mechanical irritation of the nervous network of blood vessels.

In this regard, it is recommended to repeat the blood pressure measurement without removing the cuff from the arm after the first measurement. Thus, using pressure measurement methods several times, the average results are recorded.

The pressure in the right and left hands is often different. Its size may differ by 10 - 20 mm. Therefore, doctors recommend using methods for measuring pressure on both hands, and recording average values. Blood pressure is measured sequentially on the right and left arms, several times, and the resulting values ​​are then used to calculate the arithmetic average. To do this, the values ​​of each indicator (separately upper pressure and separately lower) are added and divided by the number of times the measurement was made.

If a person has unstable blood pressure, measurements should be taken regularly. Thus, it is possible to grasp the connection between changes in its level due to the influence various factors(sleep, overwork, food, work, rest). All this must be taken into account when applying pressure measurement methods.

Normal values, when using any method of measuring pressure, are pressure readings at the level of 100/60 - 140/90 mm RT. Art.

Possible mistakes

It must be borne in mind that sometimes between the upper and lower pressure the intensity of the tones can weaken, at times significantly. And then this moment can be mistakenly taken for too high pressure. If you continue to release air from the apparatus for measuring pressure, the volume of the tones increases, and they stop at the level of the real lower (diastolic) pressure. If the pressure in the cuff is not raised enough, you can easily make a mistake in the value of systolic pressure. So, in order to avoid mistakes, you need to use pressure measurement methods correctly: raise the pressure level in the cuff high enough to “press”, but when releasing air, you need to continue listening to the tones until the pressure completely drops to zero.

Another mistake is possible. If you press firmly on the brachial artery with a phonendoscope, in some people the tones can be heard down to zero. Therefore, you should not press the head of the phonendoscope directly on the artery, and the value of the lower, diastolic pressure should be recorded according to sharp decline intensity of tones.

Methods for measuring blood pressure: Blood pressure is measured by a doctor or nurse on an outpatient basis or in a hospital (clinical blood pressure). In addition, blood pressure can also be recorded by the patient himself or relatives at home - self-monitoring of blood pressure (SBP). Daily blood pressure monitoring is carried out by health workers on an outpatient basis or in a hospital setting. Clinical measurement of blood pressure has the greatest evidence base to justify the classification of blood pressure levels, risk prediction, and assessment of the effectiveness of therapy.

Accuracy of blood pressure measurement and, accordingly, guarantee correct diagnosis AG,

Determinations of its severity depend on compliance with the rules for its measurement.

To measure blood pressure, the following conditions are important:

Patient position: sitting in a comfortable position; the hand is on the table and is at heart level; The cuff is placed on the shoulder, its lower edge 2 cm above the elbow.

Conditions for measuring blood pressure

Avoid drinking coffee and strong tea for 1 hour before the test;

Avoid taking sympathomimetics, including nasal and eye drops;

Blood pressure is measured at rest after a 5-minute rest; if the procedure for measuring blood pressure was preceded by significant physical or emotional stress, the rest period should be extended to 15-30 minutes.

Equipment:

The size of the cuff must correspond to the size of the arm: the rubber inflated part of the cuff must cover at least 80% of the shoulder circumference; for adults, a cuff 12-13 cm wide and 30-35 cm long is used ( the average size); but it is necessary to have a large and small cuff available for fat and thin arms, respectively;

The mercury column or tonometer needle must be at zero before starting the measurement.

Measurement ratio:

To assess blood pressure levels in each arm, at least two measurements should be taken with an interval of at least a minute; with the difference? 5 mmHg make one additional measurement; the final (recorded) value is taken to be the average of the last two measurements;

To diagnose hypertension in slight increase Blood pressure re-measurement (2-3 times) is carried out after several months;

In case of a pronounced increase in blood pressure and the presence of POM, a high and very high risk of cardiovascular events, repeated blood pressure measurements are carried out after several days.

Measuring technique

Quickly inflate the cuff to a pressure level of 20 mmHg.

Exceeding SBP (by disappearance of pulse);

Blood pressure is measured with an accuracy of 2 mm Hg;

Reduce cuff pressure at a rate of approximately 2 mmHg. per second;

The pressure level at which 1 tone appears corresponds to SBP (1st phase of Korotkoff sounds);

The pressure level at which sounds disappear (phase 5 of Korotkoff sounds) corresponds to DBP; in children, adolescents and young people immediately after physical activity, in pregnant women and in some cases pathological conditions in adults, when it is impossible to determine the 5th phase, one should try to determine the 4th phase of Korotkoff sounds, which is characterized by a significant weakening of the tones;

If the tones are very weak, then you should raise your hand and perform several squeezing movements with the hand, then repeat the measurement, but do not strongly compress the artery with the phonedoscope membrane;

At initial examination The patient's blood pressure should be measured in both arms; further measurements are carried out on the arm where the blood pressure is higher;

In patients over 65 years of age, with diabetes and in those receiving antihypertensive therapy, blood pressure should also be measured after 2 minutes of standing;

It is also advisable to measure blood pressure in the legs, especially in patients under 30 years of age; the measurement is carried out using a wide cuff (the same as for obese people); The phonendoscope is located in the popliteal fossa; to identify occlusive lesions of the arteries and assess the ankle-brachial index, systolic blood pressure is measured using a cuff located on the ankle and/or ultrasound;

The heart rate is calculated from the radial pulse (at least 30 seconds) after the second blood pressure measurement in a sitting position.

Measuring blood pressure at home. Home blood pressure readings can be a valuable addition to clinical blood pressure in diagnosing hypertension and monitoring the effectiveness of treatment, but require the use of different standards. It is generally accepted that a blood pressure value of 140/90 mm Hg, measured at a doctor’s appointment, corresponds to a blood pressure of approximately 130-135/85 mm Hg. when measuring a house. The optimal blood pressure value for self-monitoring is 130/80 mm Hg. For self-monitoring of blood pressure, traditional tonometers with dial gauges can be used, but in last years preference is given to automatic and semi-automatic devices for home use who have passed strict clinical trials to confirm the accuracy of measurements.

Caution should be used when interpreting results obtained from most currently available devices that measure BP at the wrist; It is also necessary to keep in mind that devices that measure blood pressure in the arteries of the fingers are characterized by low accuracy of the blood pressure data obtained.

Blood pressure values ​​obtained with SCAD make it possible to obtain Additional information about the forecast of MTR. It is indicated for suspected isolated clinical arterial hypertension(ICAH) and isolated ambulatory arterial hypertension (IAAH), if long-term blood pressure control is necessary against the background drug treatment, with hypertension resistant to treatment. SCAD can be used in the diagnosis and treatment of hypertension in pregnant women, in patients with diabetes mellitus, in elderly people.

SCAD has the following advantages:

Provides additional information about the effectiveness of antihypertensive therapy;

Improves patient adherence to treatment;

The measurement is carried out under the control of the patient, therefore, in contrast to ABPM, with regard to the data obtained on the level of blood pressure, there are fewer doubts about the reliability of the device and the conditions for measuring blood pressure;

The measurement causes anxiety for the patient;

The patient is inclined to use the results obtained to independently adjust therapy.

At the same time, it must be taken into account that SCAD cannot provide information on blood pressure levels during “everyday” daytime activity, especially in the working part of the population, and on blood pressure at night.

24-hour blood pressure monitoring

Clinical blood pressure is the main method for determining blood pressure and risk stratification, but 24-hour blood pressure monitoring has a number of specific advantages:

Provides information about blood pressure during “everyday” daytime activity and at night;

Allows you to clarify the prognosis of cardiovascular complications;

More closely related to changes in target organs initially and their observed dynamics during treatment;

It more accurately assesses the antihypertensive effect of therapy, as it reduces the “white coat” and placebo effects.

ABPM provides important information about the state of the mechanisms cardiovascular regulation, in particular, makes it possible to determine the daily rhythm of blood pressure, nocturnal hypotension and hypertension, the dynamics of blood pressure over time and the uniformity of the antihypertensive effect of drugs.

Situations in which performing ABPM is most appropriate:

Increased lability of blood pressure during repeated measurements, visits or according to self-monitoring data;

High values ​​of clinical blood pressure in patients with a small number of risk factors and the absence of changes in target organs characteristic of hypertension;

Normal values ​​of clinical blood pressure in patients with a large number risk factors and/or the presence of changes in target organs characteristic of hypertension;

Large differences in blood pressure values ​​at the reception and according to self-monitoring data;

Resistance to antihypertensive therapy;

Episodes of hypotension, especially in elderly patients and patients with diabetes mellitus;

Hypertension in pregnant women and suspected preeclampsia.

For ABPM, only devices that have successfully passed strict clinical tests according to international protocols to confirm the accuracy of measurements can be recommended. When interpreting ABPM data, the main attention should be paid to the average blood pressure values ​​for the day, night and day (and their ratios). The remaining indicators are of undoubted interest, but require further accumulation of evidence.

Isolated clinical hypertension

In some people, when measuring blood pressure medical personnel the recorded blood pressure values ​​correspond to hypertension, while the ABPM or blood pressure measured at home remain within normal values, i.e. there is “white coat” hypertension, or, more preferably, “isolated clinical hypertension”. ICAH is detected in approximately 15% of individuals in the general population. These individuals have a lower risk of cardiovascular complications than patients with hypertension. However, compared to normotensive people, this category of people more often experiences organ and metabolic changes. Often enough

ICAG eventually transforms into conventional hypertension. It is difficult to predict the possibility of detecting hypertension in each specific case, but more often ICAH is observed in grade 1 hypertension in women, in the elderly, in non-smokers, with recent detection of hypertension and with a small number of blood pressure measurements in outpatient and clinical settings.

Diagnosis of ICAH is carried out on the basis of data from SCAD and ABPM. Wherein

Elevated clinical blood pressure is observed with repeated measurements (at least three times), while ABPM (average blood pressure over 7 days of measurement) and ABPM are within normal limits (Table 1). Diagnosis of ICAH based on ABPM and ABPM data may not coincide, and this is especially often observed in working patients. In these cases, it is necessary to focus on ABPM data. Establishing this diagnosis requires a study to clarify the presence of risk factors and target organ damage. In all patients with ICAG it is necessary to use non-drug methods treatment of hypertension. In the presence of high and very high risk SSO is recommended to start antihypertensive therapy.

Isolated ambulatory hypertension

The opposite phenomenon for ICAG is “isolated ambulatory hypertension” or “masked” hypertension, when when measuring blood pressure in medical institution Normal blood pressure values ​​are detected, but the results of ABPM and/or ABPM indicate the presence of hypertension. Information about IAAH is still very limited, but it is known that it is detected in approximately 12-15% of individuals in the general population. In these patients, compared with normotensives, risk factors and POM are more often detected, and the risk of cardiovascular complications is almost the same as in patients with hypertension.

Central AD

In the arterial bed, complex hemodynamic phenomena are observed, leading to the appearance of so-called “reflected” pulse waves mainly from resistive vessels, and their summation with the main (direct) pulse wave that occurs when blood is ejected from the heart. The summation of direct and reflected waves in the systole phase leads to the formation of the phenomenon of “augmentation” (strengthening) of SBP. The sum of direct and reflected waves differs in different vessels, as a result, blood pressure (primarily SBP) differs in different main vessels, and does not coincide with that measured on the shoulder. Thus, it is a well-known fact that normally SBP in the lower extremities exceeds SBP measured in the shoulder by 5-20%. The greatest prognostic value is blood pressure in the ascending or central part of the aorta or “central” blood pressure. In recent years, special techniques have appeared (for example, radial applanation tonometry or carotid artery), which make it possible to calculate central blood pressure based on the quantitative sphygmogram and blood pressure measured on the shoulder. Early studies have shown that this estimated aortic central pressure may be more valuable in assessing the effectiveness of therapy and is likely to identify an additional group of patients with "pseudohypertension" who have normal central pressure but elevated brachial BP from - due to an abnormally high sum of direct and reflected pressure waves in the upper extremities.

A certain contribution to the increase in blood pressure in the brachial artery relative to blood pressure in the aorta is made by an increase in the rigidity of its wall, which means the need to create greater compression in the cuff. These facts certainly need to be taken into account, but the evidence base regarding the advantages of calculated central pressure over traditional BP measured at the upper arm requires further full-scale studies.