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US Public Health Service. Office of Disease Prevention and Health Promotion. Clinician's Handbook of Preventive Services. 2nd edition. Washington (DC): Department of Health and Human Services (US); 1999.

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

Cover of Clinician's Handbook of Preventive Services

Clinician's Handbook of Preventive Services. 2nd edition.

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28Blood Pressure

Approximately 50 million Americans have blood pressure elevations that warrant monitoring or drug therapy. These persons are at increased risk for coronary artery disease, peripheral vascular disease, stroke, renal disease, and retinopathy. Treatment of hypertension is very effective. Use of antihypertensive therapy has contributed to a 59% reduction in age-adjusted stroke mortality and a 50% reduction in mortality from coronary artery disease since 1972. The benefits of antihypertensive therapy are greatest for persons with the most markedly elevated blood pressure; however, even patients with stage 1, or mild hypertension, benefit from treatment. Recent research has demonstrated the importance of treating "isolated" systolic hypertension, especially in older adults.

Recommendations of Major Authorities

  • American Academy of Family Physicians --
  • Blood pressure should be measured periodically in all patients over 21 years of age.
  • American College of Obstetrics and Gynecology --
  • Blood pressure should be measured as part of periodic evaluation visits, which should occur yearly or as appropriate.
  • American College of Physicians --
  • Blood pressure should be measured in adults every 1 to 2 years. Normotensive patients should have blood pressure measurements at least yearly if any of the following pertains: (1) diastolic blood pressure between 85 and 89 mm Hg; (2) African-American heritage; (3) moderate or extreme obesity; (4) a first-degree relative with hypertension; (5) a personal history of hypertension.
  • Canadian Task Force on the Periodic Health Examination --
  • Case-finding (screening patients seen for any reason) should be considered in all persons aged 21 to 84 years; individual clinical judgement should be exercised in all other cases except pregnant women (for whom blood pressure should be measured as part of prenatal care).
  • National High Blood Pressure Education Program (NHBPEP) of the National Heart, Lung, and Blood Institute --
  • Blood pressure measurements should be performed on adults at least every 2 years and at each patient visit if possible. Patients with diastolic blood pressures of 85 to 89 mm Hg should have their blood pressure rechecked within 1 year. See Tables 28.1 and 28.2 for classification of blood pressure and recommendations for follow-up.
Table 28.1. Classification of Blood Pressure for Adults Aged 18 Years and Older *.

Table

Table 28.1. Classification of Blood Pressure for Adults Aged 18 Years and Older *.

Table 28.2. Recommendations for Follow-Up Based on Initial Set of Blood Pressure Measurements for Adults Aged 18 and Over.

Table

Table 28.2. Recommendations for Follow-Up Based on Initial Set of Blood Pressure Measurements for Adults Aged 18 and Over.

  • US Preventive Services Task Force --
  • Adults should have blood pressure measured periodically, with the optimal interval left to clinical discretion.

Basics of Blood Pressure Screening

1.

Instruct patients not to use tobacco or caffeine for 30 minutes before the measurement is performed.

2.

Seat the patient in a quiet environment, free from temperature extremes, for at least 5 minutes before the measurement is performed.

3.

Perform the measurement with a mercury sphygmomanometer, if available. An aneroid manometer may be used if it is periodically calibrated according to manufacturer's recommendations. A validated electronic device meeting the requirements of the American National Standard for Electronic or Automated Sphygmomanometers set forth by the Association for the Advancement of Medical Instruments may also be used.

4.

Position the manometer at eye level, if possible, to assure accuracy in reading the measurement.

5.

Use an appropriately sized cuff. The bladder of the cuff should encircle 80% to 100% of the arm. The cuff width should be 40% of the circumference of the upper arm. Use of narrow cuffs leads to falsely elevated readings. Use of wide cuffs may falsely lower the reading.

6.

The patient's arm should be bare; avoid constricting the upper arm with a rolled shirt sleeve. Support the arm horizontally so the cuff is positioned at heart level (the fourth intercostal space).

7.

Apply the stethoscope lightly to the antecubital fossa. Excess pressure results in falsely low diastolic blood pressure readings.

8.

Rapidly increase cuff pressure to about 30 mm Hg beyond the point at which the radial pulse is no longer palpable. Decrease pressure at a rate of no more than 2 to 3 mm Hg per second.

9.

In adults, the measured systolic blood pressure (SBP) and the diastolic blood pressure (DBP) readings are the pressures corresponding to the first of two consecutive sounds and the disappearance of sound (not muffling), respectively. Confirm the disappearance of sound by continuing to listen while decreasing pressure 10 to 20 mm Hg below the last sound heard.

10.

Use the average of at least two readings unless the first two differ by more than 5 mm Hg, in which case obtain additional readings. To permit blood to be released from arm veins, allow an interval of 1 to 2 minutes before repeating pressure measurements in the same arm.

11.

Measure blood pressure in both arms initially; at subsequent visits, remeasure using the arm with the higher initial pressures.

12.

Confirming the diagnosis of hypertension requires high blood pressure readings during at least two subsequent visits (unless SBP is 210 mm Hg or higher, DBP is 120 mm Hg or higher, or both). See Table 28.2 for recommendations for follow-up from the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure.

13.

Because blood pressure readings obtained in a medical setting may not be typical of a patient's usual blood pressure, monitoring at home or work by the patient, family, or friends may be valuable. Measurement devices must be calibrated initially and rechecked at least yearly. Instruct the person taking the blood pressure in proper technique, and recheck the technique periodically.

14.

Lifestyle modifications can help prevent development of hypertension and should be the initial treatment modality for the first 3 to 4 months for patients with stage 1 (mild) hypertension. See Table 28.3 for a list of basic lifestyle modifications for controlling blood pressure.

Table 28.3. Life-style Modifications for Hypertension Control.

Table

Table 28.3. Life-style Modifications for Hypertension Control.

Patient Resources

  • High Blood Pressure: Treat it for Life; Check Your Healthy Heart IQ; High Blood Pressure and What You Can Do About It; Six Good Reasons to Control Your High Blood Pressure; Eat Right to Lower Your Blood Pressure. To order these and other materials, in both English and Spanish, contact the National Heart, Lung, and Blood Institute Information Center. PO Box 30105, Bethesda, MD 20824-0105; (301)251-1222. Internet address: http://www.nhlbi.nih.gov/nhlbi/nhlbi.htm.

Provider Resources

  • The Fifth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. To order this report in either English or Spanish, contact the National Heart, Lung, and Blood Institute Information Center, PO Box 30105, Bethesda, MD 20824-0105; (301)251-1222. Internet address: http://www.nhlbi.nih.gov/nhlbi/nhlbi.htm.

Selected References

  1. American Academy of Family Physicians. Summary of Policy Recommendations for Periodic Health Examination. Kansas City, Mo: American Academy of Family Physicians; 1997.
  2. American College of Obstetricians and Gynecologists. Guidelines for Women's Care. Washington, DC: American College of Obstetricians and Gynecologists; 1996.
  3. American College of Physicians. Guidelines. In: Eddy DM, ed. Common Screening Tests. Philadelphia, Pa: American College of Physicians; 1991:396-397.
  4. American College of Physicians. Automated ambulatory blood pressure and self-measured blood pressure monitoring devices: their role in the diagnosis and management of hypertension (position paper) Ann Intern Med. . 1993; 118:889–892. [PubMed: 8480963]
  5. Appel LJ, Stason WB. Ambulatory blood pressure monitoring and blood pressure self-measurement in the diagnosis and management of hypertension. Ann Intern Med. . 1993; 118:867–882. [PubMed: 8093115]
  6. Canadian Task Force on the Periodic Health Examination. Hypertension in the elderly: case-finding and treatment to prevent vascular disease. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 79.
  7. Canadian Task Force on the Periodic Health Examination. Screening for hypertension in young and middle-aged adults. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 53.
  8. Frohlich ED, Grim C, Labarthe DR, et al. Recommendations for human blood pressure determination by sphygmomanometers: report of a special task force appointed by the Steering Committee, American Heart Association. Hypertension. 1988;11:209A-222A.
  9. Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. The fifth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med. . 1993; 153:154–188. [PubMed: 8422206]
  10. Littenberg B. A practice guideline revisited: screening for hypertension. Ann Intern Med . 1995; 122:937–939. [PubMed: 7755230]
  11. National High Blood Pressure Education Program (NHBPEP) Working Group. Report on ambulatory blood pressure monitoring. Arch Intern Med. . 1990; 150:2270–2280. [PubMed: 2122825]
  12. Systolic Hypertension in the Elderly Program (SHEP) Cooperative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. JAMA. . 1991; 265:3255–3264. [PubMed: 2046107]
  13. US Preventive Services Task Force. Screening for hypertension.In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap 3.
  14. Webster J, Newnham D, Petrie JC, Lovell HG. Influence of arm position on measurement of blood pressure. Br Med J. . 1984; 288:1574–157. [PMC free article: PMC1441228] [PubMed: 6426648]
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