PMT Scribe Academy

Blood Pressure

Blood pressure (BP) is the measurement of the force exerted by the heart, against resistance created by the arteries—this pressure helps to keep blood flowing through the body.

High Blood Pressure, or hypertension, is when the force of blood against the arterial walls is greater than it should be; eventually, long-term force against the artery walls increases a person's risk for health problems, including heart attack and stroke. According to the Center for Disease Control (CDC), high blood pressure is a common and potentially dangerous condition. About 75 million people in the U.S.—or 1 of 3 U.S. adults—have high blood pressure. The terrifying fact is that only about half of people with high blood pressure have the condition under control.

Low Blood Pressure, or hypertension, is when the force of blood pushing against the walls of the arteries is lower than it should be. Low blood pressure is only a concern if a person experiences signs or symptoms or is associated with a serious medical condition, such as heart disease.

Difference Between Blood Pressure and Pulse

Many people think blood pressure and pulse—also called heart rate—go hand-in-hand. After all, these two vital signs are often measured at the same time at the doctor’s office. Vital signs are clinical measurements that indicate the state of a person’s bodily functions, specifically, BP, pulse rate, temperature, and respiratory rate.

But each of these vital signs measures distinctly different components of the heart. As mentioned, the blood pressure is the force of flowing blood against the arteries, while the pulse, is the number of times the heart beats per minute (bpm).

The BP and pulse often rise and fall simultaneously; however, if the heart rate increases this doesn't mean the blood pressure increase or vice versa. For example, when faced with fear the hormone epinephrine, also known as adrenaline, is released into the circulatory system causing the blood pressure and pulse rate to rise.

How Does the Body Maintain Blood Pressure?

The body’s nervous system helps regulate internal processes by using sensors in the walls of arteries that sense blood pressure and send signals to the vessels, the heart, and the kidneys—causing them to raise or lower blood pressure.

The aorta and carotid arteries have important stretch sensors called baroreceptors. These are the most sensitive receptors of the circulatory system, which allows for immediate correction of abnormal arterial pressure.

Understanding Blood Pressure Readings

A BP reading is determined by both the amount of blood the heart pumps and the amount of resistance to blood flow in the arteries. Constricted arteries will cause an increase in resistance to the blood flow; therefore, the more narrow the arteries, the higher a person's blood pressure.

How is Blood Pressure Measured?

Blood pressure is an easy measurement that is done at a doctor’s office, at home, or at a pharmacy. Often, home readings and measurements at the pharmacy are taken with a mechanical blood pressure monitor.
Some doctors may prefer to take a manual blood pressure (BP) with a sphygmomanometer. This technique is known as the auscultatory method.

Basic steps for taking a manual blood pressure are as follows:

  1. The blood pressure cuff wraps snugly around the arm, on the biceps, just above the antecubital fossa, the shallow depression located on the anterior aspect of the arm.
  2. Correct cuff size is crucial for an accurate reading. Note, the cuff bladder should cover 80 percent of the person’s arm circumference.
  3. Light pressure is used to place the bell of the stethoscope over the brachial artery.
  4. The valve on the sphygmomanometer bulb is closed, as to not let air out of the cuff during inflation.
  5. The cuff is inflated to above the maximal or estimated systolic pressure.
  6. As the cuff pressure is slowly released clear tapping sounds are heard through the stethoscope—the appearance and disappearance of these sounds are noted on the manometer, or the gauge that measures the blood pressure in millimeters of mercury (mmHg).

Two numbers are heard and measured when taking a blood pressure:

  1. Systolic is the first (top number)—it is noted upon the appearance of the thumping or tapping sound, which is the pressure in the arteries when the heart beats. Systolic pressure is clinically more significant than diastolic when it comes to determining the risk of cardiovascular disease.
  2. Diastolic is the second (bottom number)—it is derived from the disappearance of the sound heard as the thumping fades out, which is the silence in between the beats—the heart at rest.
  3. The tapping sounds heard with the stethoscope when taking a blood pressure are universally known as Korotkoff sounds, or K-Sounds. However, the exact physical basis for the mechanism producing these sounds is poorly understood.

Classification of blood pressure sounds are as follows:

  • Phase-1 (K-1): the appearance of clear tapping sounds; the first clear sound is the systolic pressure.
  • Phase-2 (K-2): softening and elongation of the sound; characterized by a swishing sound.
  • Phase-3 (K-3): the sharpening of the sound; crisp and loud, similar to K-1.
  • Phase-4 (K-4): soft muffling sound; as the blood flow become less turbulent with the release of the air in the cuff.
  • Phase-5 (K-5): the sounds disappear completely since the blood flow through the artery has returned to normal; the last audible sound is the diastolic pressure

Over the years K-4 and K-5 have both been used as the diastolic blood pressure. The Journal of the American Society of Hypertension (2015), explains there is some evidence that the muffling in K-4 may be a more accurate end-point than K-5 in children, pregnancy, and exercise.

Some people may not have a distinct fifth sound—the muffling sound of K-4 is heard all the way to 0 mmHg; for these people, K-4 is noted as the diastolic pressure.

Some practitioners often take note of all three numbers 120/86/72 (K-1/K-4/K-5).

Blood pressure guidelines exist, but what is optimal, or healthy, varies from person to person—keep this in mind when reviewing the table 1.

Table 1. Blood Pressure Guidelines.

Blood Pressure Category Systolic (upper #) Diastolic (lower #)
Hypotension <90 <60
Optimal ⥶120 ⥶80
Prehypertension (Normal) 120 - 139 80 - 89
Hypertension (Stage 1) 140 - 159 90 - 99
Hypertension (Stage 2) 160⥸ 100⥸

A person's age and health condition determine their particular "optimal" blood pressure reading.

The Eighth Joint National Committee (JNC 8) released target blood pressure recommendations (Table 2).

Table 2. Target Blood Pressure.

Age and Health Condition Target
30 – 59 140/90
⥸60 150/90
People with diabetes or people with non-diabetic chronic kidney disease 140/90

Blood pressure doesn’t stay the same throughout the day—it decreases during sleep and increases upon awakening. Blood pressure also increases during activity, anxiety, and excitement.

High Blood Pressure

Development and Risk Factors

The exact cause of hypertension is not known; however, several conditions and factors may have a role in the development, including:

  • Smoking
  • Being overweight or obese
  • Lack of physical activity

  • High sodium (salt) in the diet
  • More than 1-2 alcoholic drinks a day
  • Older age
  • Stress
  • Race
  • Genetics and family history
  • Chronic kidney disease
  • Adrenal and thyroid disorders
  • Sleep apnea
  • Low Potassium or vitamin D

Clinical Manifestations

Many people with hypertension have zero signs or symptoms, even when the blood pressure measurement reaches high levels. Often, prolonged hypertension is called the “silent killer.” A few people with high blood pressure may have shortness of breath, headaches, facial flushing, or nosebleeds. These clinical manifestations are not distinctive or inclusive and usually don’t occur until the blood pressure has reached a life-threatening stage.

Types of High Blood Pressure

Primary or Essential Hypertension

High BP that develops over several years as a person ages.

Secondary High Blood Pressure

Type of BP that develops from an abnormality in the arteries that supply blood to the kidneys.

Additional Types of Hypertension

  • Isolated Systolic – systolic rises above 140 and diastolic stays near normal or below 90 mmHg.
  • Malignant (discussed in untreated complications) – occurs in about 1 percent of people and is more common in young adults, women who have toxemia from pregnancy, and black men of African descent.

  • Resistant – diagnosed when the person is prescribed three different types of antihypertensive medications and the blood pressure remains high; it is resistant to treatment. It occurs in 20 to 30 percent of people with hypertension.

Low Blood Pressure

Development and Risk Factors

Development of hypotension most commonly occurs in two different scenarios.

  1. When a person stands up quickly from lying down gravitational force pulls the person’s blood, however briefly, to the lower extremities.
  2. After a person has been standing for a long time.

In a functional or healthy nervous system and circulatory system the body is extremely sensitive and responsive to changes. Therefore, the body rapidly adjusts to ensure enough blood and oxygen are available to the brain and other essential organs. With most forms of hypotension, the body can’t bring the blood pressure back to normal or can’t do it quick enough. Some people have a normally low blood pressure—all the time—and they have no symptoms. In other people, certain conditions cause an abnormally low blood pressure; resulting in less blood and oxygen to the body’s organs.

  • Occurs in all ages (older adults at increased risk)
  • Hardened or sclerotic arteries
  • Medication
  • Dehydration or hypovolemia
  • Prolonged immobility

  • Pregnancy
  • Medical condition(s)
  • Autonomic dysfunction
  • Malfunction of baroreceptor response

Clinical Manifestations

Many of the signs and symptoms are related to the cause of hypotension and not the effects of hypotension.

  • Dizziness
  • Lightheadedness
  • Blurry vision
  • Headache
  • Confusion
  • Fatigue
  • Shortness of breath
  • Irregular heartbeat

Types of Low Blood Pressure

Orthostatic hypotension, neurally mediated hypotension (NMH), postprandial hypotension, and severe hypotension (discussed in untreated complications) are three types of hypotension.

Orthostatic Hypotension

Orthostatic hypotension, often called postural hypotension, is a type of low blood pressure that happens when a person stands up from a sitting or lying position; symptoms usually only last a few seconds or for some people may be a few minutes. Once the blood pressure and blood flow adjust, the symptoms subside.

Neurally Mediated Hypotension

With NMH, blood pressure lowers after a person has been standing for a long time. Also, this type of low blood pressure can occur if a person has an unpleasant, scary, or upsetting experience that raises the individual’s blood pressure. Once high blood pressure is detected, the body’s nervous system is stimulated to lower the blood pressure; in some cases, this response malfunctions and a person will have dilation in the veins of the lower extremity with a rapid drop in blood pressure resulting in syncope, or fainting.

Postprandial Hypotension

Postprandial hypotension is a rare condition that is characterized by a fall in blood pressure occurring 15 to 90 minutes after meals, or postprandial. The digestive system requires a sizable amount of blood for digestion after a meal—the heart rate increases and blood vessels in other parts of the body, such as the extremities, constrict to help sustain blood pressure. In postprandial hypotension, blood flows to the intestine, but the heart rate does not increase sufficiently, and blood vessels do not constrict adequately to retain a stable blood pressure; consequently, blood pressure drops. It happens in a small percentage of older people, but virtually never takes place in younger individuals. A person with high blood pressure or a disorder affecting the autonomic nervous system is at an increased risk for postprandial hypotension.

When to Take Blood Pressure

Blood pressure is customarily taken during a routine doctor’s appointment. The following table is a replication of the 2015 U.S. Preventative Services Task Force (USPSTF) clinical guidelines for blood pressure screening (Table 3).

Table 3. USPSTF Screening for High Blood Pressure in Adults: Clinical Summary.

Factors Suggestions and Advice
Population Adults aged ≥18 y without known hypertension
Recommendation Screen for high blood pressure; obtain measurements outside of the clinical setting for diagnostic confirmation.
Risk Assessment Persons at increased risk for high blood pressure are those who have high-normal blood pressure (130–139/85–89 mmHg), those who are overweight or obese, and African Americans.
Screening Tests Office measurement of blood pressure is done with a manual or automated sphygmomanometer. Proper protocol is to use the mean of 2 measurements taken while the patient is seated, allow for ≥5 min between entry into the office and blood pressure measurement, use an appropriately sized arm cuff, and place the patient’s arm at the level of the right atrium. Multiple measurements over time have better positive predictive value than a single measurement.Ambulatory and home blood pressure monitoring can be used to confirm a diagnosis of hypertension after initial screening.
Screening Interval Adults aged ≥40 y and persons at increased risk for high blood pressure should be screened annually. Adults aged 18 to 39 y with normal blood pressure (<130/85 mmHg) who do not have other risk factors should be rescreened every 3 to 5 y.
Treatment and Interventions For non-black people, initial treatment consists of a calcium-channel blocker, angiotensin-receptor blocker, angiotensin-converting enzyme inhibitor, or a thiazide diuretic. For black people, initial treatment is a calcium-channel blocker or a thiazide diuretic. Initial or add-on treatments for people with chronic kidney disease consists of either an angiotensin-receptor blocker or an angiotensin-converting enzyme inhibitor, but not both.

High blood pressure in children is a growing health concern that is often overlooked. Children 3 years and older will ordinarily have a blood pressure check during their yearly check-up. Normal blood pressure readings for children and adolescents are based on sex, age, and height—prehypertension is defined as a blood pressure in at least the 90th percentile, but less than the 95th percentile, for sex, age, and height, or a measurement of 120/80 mmHg or higher.

The National Institute of Health provides details of blood pressure levels based on age and height percentiles of boys and girls in this table. Under JNC 8, in all cases, target blood pressure levels should be reached within 30 days of starting any treatment.

Lifestyle and Home Remedies

Lifestyle changes are an enormous part of managing proper blood pressure levels, whether the person has hypertension or hypotension.

Healthy Lifestyle Habits

  • Eating Healthy
    • Limiting sodium, or salt
    • Heart-healthy whole-foods—fibrous vegetables, legumes, fruit, and protein
    • Fish high in omega-3 fatty acids are recommended twice aweek
    • Avoiding sugary food and beverages
    • Limiting alcohol intake
  • Being physically active
  • Maintaining a healthy weight
  • Managing stress
  • Taking medications as prescribed

Untreated Blood Pressure Complications

Hypertension is more likely to cause complications than hypotension, both, however, need to be taken seriously.

High Blood Pressure Crisis

Excessive pressure on the arteries, if left uncontrolled, can lead to:

  • Heart attack – blockage of blood flow to the heart muscle.
  • Heart failure – heart doesn’t pump blood as well as it should.
  • Stroke – damage to the brain from interruption of blood supply.
  • Aneurysm – blood vessels that weaken and bulge.
  • Weak and narrow blood vessels in kidneys.
  • Thickened, narrow, or torn blood vessels in eyes.
  • Memory issues and difficulty understanding.

Hypertensive Urgency

A hypertensive urgency is defined as a severe increase in blood pressure marked by systolic greater than 220 mmHg or diastolic greater than 120 with no evidence of organ damage.

Hypertensive Emergency

A hypertensive emergency occurs when hypertension results in organ damage. Systems most affected include the central nervous system, the cardiovascular system, and the renal system.

  • Accelerated hypertension is a recent increase of blood pressure over baseline and is associated with organ damage, but without papilledema, swelling of the optic disc.
  • Malignant hypertension is hypertension with the presence of papilledema.

Low Blood Pressure Crisis

If blood pressure is sufficiently low, syncope and seizures can occur.

Severe Hypotension Linked to Shock

To healthcare providers the word shock implies a collapse of the cardiovascular system from a possibility of several reasons. Shock related to hypotension occurs when not enough oxygenated blood is flowing to the body’s major organs, including the brain. Signs and symptoms of shock vary, depending on the cause. Typical characteristics include:

  • Diaphoretic – skin becomes cold and sweaty
  • Pallor – skin is pale or gray
  • Slowed capillary refill – pressed skin returns to normal color more slowly than usual
  • Weak and rapid pulse
  • Rapid respirations

Vasodilatory Shock

In vasodilatory shock, blood vessels suddenly relax causing an extreme drop in blood pressure. A person will feel warm and have flushed skin at first, then they become diaphoretic and weak. As shock worsens, the person cannot sit up without passing out, and if not treated, the person will lose consciousness. As with any medical emergency, a person needs treatment right away. If a person has signs or symptoms of a hypotensive or hypertensive urgency or emergency, call 911.

References

How Common is High Blood Pressure: https://www.cdc.gov/bloodpressure/

High Blood Pressure Educational Materials for Patients: https://www.cdc.gov/bloodpressure/materials_for_patients.htm

Types of Hypertension: https://www.nhlbi.nih.gov/health/health-topics/topics/hbp

Measuring Blood Pressure: https://www.cdc.gov/bloodpressure/measure.htm

The origin of Korotkoff sounds and the accuracy of auscultatory blood pressure measurements: https://www.sciencedirect.com/science/article/pii/S1933171115007068

Hypertensionin 2017—What is the Right Target?: https://jamanetwork.com/journals/jama/article-abstract/2600610?resultClick=1

What is Hypotension: https://www.nhlbi.nih.gov/health/health-topics/topics/hyp

What Are the Signs and Symptoms of Hypotension?: https://www.nhlbi.nih.gov/health/health-topics/topics/hyp/signs

Types of Hypotension: https://www.nhlbi.nih.gov/health/health-topics/topics/hyp/types

The Vasovagal Response: https://www.ncbi.nlm.nih.gov/pubmed/1661644

Postprandial Hypotension: https://www.uptodate.com/contents/treatment-of-orthostatic-and-postprandial-hypotension

Screening for High Blood Pressure in Adults: U.S. Preventive Services Task Force Recommendation Statement:https://www.uspreventiveservicestaskforce.org/Home/GetFile/1/374/Screening%20for%20High%20BP%20Final%20RS_Print%20Version_11.20.15/pdf

High Blood Pressure in Children and Adolescents: https://www.aafp.org/afp/2012/0401/p693.html

Blood Pressure Levels for Boys and Girls by Age and Height Percentile: https://www.nhlbi.nih.gov/files/docs/guidelines/child_tbl.pdf

Children 3 years and older will ordinarily have a blood pressure check during their yearly check-up.

Normal blood pressure readings for children and adolescents are based on sex, age, and height—prehypertension is defined as a blood pressure in at least the 90th percentile, but less than the 95th percentile, for sex, age, and height, or a measurement of 120/80 mmHg or higher. ​
The National Institute of Health provides details of blood pressure levels based on age and height percentiles of boys and girls in this table.

Under JNC 8, in all cases, target blood pressure levels should be reached within 30 days of starting any treatment.

Lifestyle and Home Remedies

Lifestyle changes are an enormous part of managing proper blood pressure levels, whether the person has hypertension or hypotension.

Healthy Lifestyle Habits

  • Eating Healthy
    • Limiting sodium, or salt
    • Heart-healthy whole-foods—fibrous vegetables, legumes, fruit, and protein
    • Fish high in omega-3 fatty acids are recommended twice aweek
    • Avoiding sugary food and beverages
    • Limiting alcohol intake
  • Being physically active
  • Maintaining a healthy weight
  • Managing stress
  • Taking medications as prescribed

Untreated Blood Pressure Complications

Hypertension is more likely to cause complications than hypotension, both, however, need to be taken seriously.

High Blood Pressure Crisis

Excessive pressure on the arteries, if left uncontrolled, can lead to:

● Heart attack – blockage of blood flow to the heart muscle.

● Heart failure – heart doesn't pump blood as well as it should.

● Stroke – damage to the brain from interruption of blood supply.

● Aneurysm – blood vessels that weaken and bulge.

● Weak and narrow blood vessels in kidneys.

● Thickened, narrow, or torn blood vessels in eyes.

● Memory issues and difficulty understanding.

Hypertensive Urgency

A hypertensive urgency is defined as a severe increase in blood pressure marked by systolic greater than 220mmHg or diastolic greater than 120 with no evidence of organ damage.

Hypertensive Emergency

A hypertensive emergency occurs when hypertension results in organ damage. Systems most affected include the central nervous system, the cardiovascular system, and the renal system.

  • Accelerated hypertension is a recent increase of blood pressure over baseline and is associated with organ damage, but without papilledema, swelling of the optic disc.
  • Malignant hypertension is hypertension with the presence of papilledema.

Low Blood Pressure Crisis

If blood pressure is sufficiently low, syncope and seizures can occur.

Severe Hypotension Linked to Shock

To healthcare providers the word shock implies a collapse of the cardiovascular system from a possibility of several reasons. Shock related to hypotension occurs when not enough oxygenated blood is flowing to the body's major organs, including the brain.

Signs and symptoms of shock vary, depending on the cause. Typical characteristics include:

  • Diaphoretic – skin becomes cold and sweaty
  • Pallor – skin is pale or gray
  • Slowed capillary refill – pressed skin returns to normal color more slowly than usual
  • Weak and rapid pulse
  • Rapid respirations

Vasodilatory Shock

In vasodilatory shock, blood vessels suddenly relax causing an extreme drop in blood pressure. A person will feel warm and have flushed skin at first, then they become diaphoretic and weak. As shock worsens, the person cannot sit up without passing out, and if not treated, the person will lose consciousness. As with any medical emergency, a person needs treatment right away. If a person has signs or symptoms of a hypotensive or hypertensive urgency or emergency, call 911.

References

How Common is High Blood Pressure: https://www.cdc.gov/bloodpressure/

High Blood Pressure Educational Materials for Patients: https://www.cdc.gov/bloodpressure/materials_for_patients.htm

Types of Hypertension: https://www.nhlbi.nih.gov/health/health-topics/topics/hbp

Measuring Blood Pressure: https://www.cdc.gov/bloodpressure/measure.htm

The origin of Korotkoff sounds and the accuracy of auscultatory blood pressure measurements: https://www.sciencedirect.com/science/article/pii/S1933171115007068

Hypertensionin 2017—What is the Right Target?: https://jamanetwork.com/journals/jama/article-abstract/2600610?resultClick=1

What is Hypotension: https://www.nhlbi.nih.gov/health/health-topics/topics/hyp

What Are the Signs and Symptoms of Hypotension?: https://www.nhlbi.nih.gov/health/health-topics/topics/hyp/signs

Types of Hypotension: https://www.nhlbi.nih.gov/health/health-topics/topics/hyp/types

The Vasovagal Response: https://www.ncbi.nlm.nih.gov/pubmed/1661644

Postprandial Hypotension: https://www.uptodate.com/contents/treatment-of-orthostatic-and-postprandial-hypotension

Screening for High Blood Pressure in Adults: U.S. Preventive Services Task Force Recommendation Statement:https://www.uspreventiveservicestaskforce.org/Home/GetFile/1/374/Screening%20for%20High%20BP%20Final%20RS_Print%20Version_11.20.15/pdf

High Blood Pressure in Children and Adolescents: https://www.aafp.org/afp/2012/0401/p693.html

Blood Pressure Levels for Boys and Girls by Age and Height Percentile: https://www.nhlbi.nih.gov/files/docs/guidelines/child_tbl.pdf

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