Standardized Blood Pressure Measurement Approach Importance and Clinical

Standardized Blood Pressure Measurement: Approach, Importance and Clinical Relevance Presented by Department of Epidemiology Department of Medicine Center for Continuing Education Release Date: November 1, 2018 Expiration Date: March 31, 2021 Estimated time to complete the activity: 25 minutes

NOTES Ø Reference Materials may be found by clicking on the “BP Measurement, ” and “Presentation Slides” buttons below the recording. Ø Complete CME and CEU Information may be found by clicking on the “CE Credit Handout” button below the recording. Ø Technical requirements may be found by clicking on the “Viewing Requirements” link below the recording. Ø Evaluation, Post-test, and Credit Claiming instructions and link will be available following participation in the session. Ø If you have other questions, please contact Tulane University CCE at cme@tulane. edu or 504 -988 -5466. This session was originally recorded between May and October 2018.

GRANT SUPPORT IMPACTS is supported by a grant from the National Heart, Lung, and Blood Institute of the National Institutes of Health under Award Number R 01 HL 133790. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

TULANE UNIVERSITY CENTER FOR CONTINUING EDUCATION DISCLOSURE POLICY • This activity has been planned and implemented in accordance with the ACCME® and IACET Accreditation Requirements to ensure balance, independence, objectivity, and scientific rigor. • All individuals responsible for content, regardless of role(s), are required to document financial relationships or the absence of relationships with commercial interests, and all potential conflicts of interest must be resolved prior to the activity. • Disclosure of off-label, experimental or investigational use of drugs or devices must also be made known to the audience.

DISCLOSURES Listed below is information disclosed by those participating in the activity as presenters, moderators, and in other roles. Any real or apparent conflicts of interest related to the content of their participation or presentations have been resolved. Last Name Bouyelas Brooks Chen Epperson He First Name Lindsey Kenya Jing Melinda Jiang Role in the Activity Committee Member Facilitator Co-activity Director, Tulane CCE; Planning Committee Department Chair Epidemiology Kleinpeter Myra Chair, Tulane CCE Advisory Committee Krane N. Kevin Krousel-Wood Lambuth Tonette Kailin Lind Caroline Peacock Erin Refvem Sarah Schmidt Sliwinski Pamala Roblynn Vice Dean of Academic Affairs, Tulane University School of Medicine Activity Director, Speaker Committee Member Educational Evaluation & Research Specialist, Tulane CCE Committee Member Program Coordinator - Education & Evaluation, Tulane CCE Assistant Director, Tulane CCE Department Administrator, Tulane CCE Whelton Paul Speaker Disclosure Nothing to disclose Nothing to disclose Grant: Amgen, Glaxo Smith Kline, Astra Zeneca; Speakers Bureau: Gilead Sciences, Fresenius Medical Care, OPKO; Stock: BD, Abbvie, P&G; Board Member: Orleans Parish Medical Society, New Orleans East Hospital Nothing to disclose Nothing to disclose Chair, Writing committee, ACC/AHA Task Force on Clinical Practice Guidelines; Chair, SPRINT, ALLHAT, TOHP, and TONE trials

Standardized Blood Pressure Measurement Approach, Importance, and Clinical Relevance Implementation of Multifaceted Patient. Centered Treatment Strategies for Intensive Blood Pressure Control (IMPACTS)

Objectives • Recognize the importance of standardized BP measurement • Identify the benefits of automated versus manual BP measurement • Apply the steps for standardized BP measurement −Equipment −Setting −Participant preparation and position −Timing and recording of measurements • Demonstrate proper use of standardized BP methods

Importance of Standardized Blood Pressure Measurement • • • Correctly categorize level of blood pressure Correctly diagnose hypertension Ascertain blood pressure-related cardiovascular disease risk Guide management of high blood pressure Target resources to appropriate patients − Medications − Home blood pressure monitoring − Health coaching/counseling 2017 ACC/AHA Hypertension Guideline

Benefits of Automated Versus Manual Blood Pressure Measurement Automated Oscillometric Blood Pressure (AOBP) Measurement Manual Office Blood Pressure (MOBP) Measurement

Benefits of Automated (AOBP) Over Manual Office (MOBP) Blood Pressure Measurement • • • AOBP is recommended by the 2017 ACC/AHA Hypertension Guidelines AOBP, awake ambulatory BP, and home BP measurements have the same threshold for diagnosing hypertension Oscillometric devices automatically obtain and average three or more readings, which meets need for multiple consecutive measurements AOBP measurements decrease white coat response (occurs in about 10 -25% of patients) Validated automated devices are readily available and widely used There are no toxicological issues with mercury

Approach to Accurate Blood Pressure Measurement • Equipment ─ whether aneroid, mercury, or electronic ─ should be validated and regularly inspected and calibrated • Provider/Staff ─ should be trained and regularly retrained in the standardized technique; provide certification • Patient ─ must be properly prepared and positioned • Setting ─ quiet room, chair with back support and arm support • Standardized Method ─ valid and reliable

Required Equipment • Professional Digital Blood Pressure Monitor • BP cuff (four sizes) − Small − Medium − Large − Extra large / thigh • Metric tape • Black pen (non permanent)

Key Features of Study Device • Validated • Remains in calibration for up to 100, 000 measurements • Does not have memory, so important to record measurements immediately • Powers off after 5 minutes, if in battery mode only

Cuff Size Determination • Measure upper arm circumference: usually for the right arm (left arm may be used if circumstance prohibits use of the right arm) • Ensure participant’s arm is bare • Have the participant stand, holding forearm horizontal (parallel) to the floor • Measure arm length from the acromion (bony protuberance at the shoulder) to the olecranon (tip of the elbow), using a metric tape • Mark the midpoint on the dorsal surface of the arm

Cuff Size Determination (Continued) • Have participant relax arm along side of the body • Draw the metric tape snugly around the arm at the midpoint mark and measure the arm circumference Note: Keep the tape horizontal. Tape should not indent the skin • Use the “cuff size” table for determining cuff size − Attach copy of the table to the sphygmomanometer for easy reference • Record cuff size • Use the same cuff size for all follow up visits, unless significant weight change has occurred between visits Note: If the arm circumference is > 50 cm, the automated devices cannot be used for BP and patient will not be enrolled in IMPACTS

Cuff Size Table Arm circumference <22 cm (7 to 9") Size of cuff Small ≥ 22 to <32 cm (9 to 13") Medium ≥ 32 to <42 cm (13 to 17") Large ≥ 42 to ≤ 50 cm (17 to 20”) Extra large

Properly Prepare the Patient • Have the patient relax, sitting in a chair (feet on floor, back supported) for >5 minutes. • The patient should avoid caffeine, exercise, alcohol, and smoking for at least 30 minutes before measurement. • Ensure patient has emptied his/her bladder. • Remove all clothing covering the location of cuff placement.

Patient Posture 1. Patients should be seated quietly in a chair (rather than on an exam table) • Talking or active listening can add 8 to 15 mm. Hg to BP 2. Patient back and feet should be supported • 1 3 2 Unsupported back and feet adds 6 mm Hg to BP 3. Patient’s arm should be supported at the level of the heart, and palm of the hand should be turned upward • Unsupported arm, adds 10 to 12 mm. Hg to BP 4. Patient legs should not be crossed • Crossed legs add 2 to 8 mm. Hg to BP 4

BP Cuff Placement • Locate the brachial pulse • Center the BP cuff bladder over the brachial pulse • Position the middle of the cuff on the patient’s upper arm (at the level of the right atrium (the midpoint of the sternum) • Cuff bladder should encircle 80% of the arm • The lower end of the BP cuff should be about 2 to 3 centimeters (e. g. 2 finger widths) above the antecubital fossa • Cuff should fit snugly and allow 1 finger between arm and cuff Antecubital BP cuff fossa bladder

Timing and Recording • Patient should rest alone for at least 5 minutes before measurement. − Provider/staff should leave the room during this 5 minute rest period − Provider/staff would tell patient “I would like you to rest for 5 minutes before I begin taking your blood pressure. I will leave the room. When I return, I will not speak to you but will immediately begin to take your blood pressures. Do you have any questions? ” − Provider/staff leaves the room • After the 5 minute rest − Provider/staff returns to the room for BP measurement − Patient and provider/staff remain silent until after BP measurement is complete

Timing and Recording continued • Program the BP monitor to − take 3 readings at 1 minute intervals − display the average • Push the START button on the machine and wait for the output • Record measurements for systolic and diastolic BP and pulse readings for − each of the 3 readings − average of the 3 readings • Provide patient their BP numbers and the BP goal for their treatment

Standing Blood Pressure Measurement • Obtain immediately after seated measurements as clinically indicated (such as symptomatic orthostatic hypotension) • Change mode selector on the device to take single measurement • Ask or gesture for participant to stand • Patient should be standing with arm slightly bent and supported at heart level • As soon as the patient stands, press the START button and allow for one minute to countdown • After reading is complete, ask patient: “Did you experience any dizziness or lightheaded feelings when standing for this exam? ” • Record measurements and patient response to question • Turn off device

Troubleshooting List of error codes can be found in the manual. Most common errors include: − Inflation error: check that cuff and tubing are secured, cuff is wrapped correctly, check bladder for leaks − Pulse rate error: check for patient movement or possible arrhythmia

Troubleshooting: Atrial Fibrillation • The presence of atrial fibrillation may cause the unit to error and restart the measurement • If the unit has difficulty with the readings − restart the measurements usingle mode − do three readings and − manually average • If there is still a problem the manual technique should be utilized

Demonstration of Standardized BP Measurement • IMPACTS staff will demonstrate technique by video • We encourage FQHC providers and staff to practice the technique • IMPACTS staff will certify FQHC providers and staff on blood pressure measurement technique

Summary • Standardized blood pressure measurement improves correct classification of BP and facilitates BP management • Automated BP measurement is valid and reliable • Appropriate equipment, setting, patient preparation and position, and timing of measurements are necessary to ensure standardized BP measurement • Training on the proper use of standardized BP methods can increase competency and confidence in BP measurement

Thank you!

Evaluation, Post-test & Claiming Credit Ø Thank you for participating in the Standardized Blood Pressure Measurement: Approach, Importance and Clinical Relevance educational activity recorded between May and October 2018 and presented by the Tulane University Center for Continuing Education, Department of Epidemiology, and Department of Medicine. Ø In the upper right corner of your screen, please click on the “Click HERE for the Survey” button to evaluate the content, complete the post-test, and claim credit. This enduring material requires successful completion of a post-test prior to claiming credit with a minimum performance level of 75% (6 of 8 questions). Ø Your feedback is important! Please complete the evaluation regardless of your desire to claim AMA PRA Category 1 Credit™ or CEUs. Evaluations are downloaded as aggregate data to maintain anonymity of your responses. Questions? Please contact Tulane University Center for Continuing Education 504 -988 -5466 cme@tulane. edu