Page 15 - GUIAS ESC ESH 2018

ESC/ESH Guidelines 15

according to office BP readings. These various limitations should be
Table 8 Office blood pressure measurement
kept in mind when estimating CV risk in clinical practice.
Patients should be seated comfortably in a quiet environment
Hypertension and CV risk assessment
for 5 min before beginning BP measurements.
a b Three BP measurements should be recorded, 1–2 min apart,
Recommendation Class Level
and additional measurements only if the first two readings differ
CV risk assessment with the SCORE system by >10 mmHg. BP is recorded as the average of the last two BP
is recommended for hypertensive patients readings.
who are not already at high or very high risk
Additional measurements may have to be performed in patients
due to established CVD, renal disease, or I B
with unstable BP values due to arrhythmias, such as in patents
diabetes, a markedly elevated single risk fac-
with AF, in whom manual auscultatory methods should be used
tor (e.g. cholesterol), or hypertensive
LVH. 33,35 as most automated devices have not been validated for BP
measurement in patients with AF. a
CVD = cardiovascular disease; LVH = left ventricular hypertrophy; SCORE = Use a standard bladder cuff (12–13 cm wide and 35 cm long)
Systematic COronary Risk Evaluation.
a for most patients, but have larger and smaller cuffs available for
Class of recommendation.
b larger (arm circumference >32 cm) and thinner arms,
Level of evidence.
respectively.
The cuff should be positioned at the level of the heart, with the
back and arm supported to avoid muscle contraction and iso-
4 Blood pressure measurement metric exercise-dependant increases in BP.
4.1 Conventional office blood pressure When using auscultatory methods, use phase I and V (sudden
measurement reduction/disappearance) Korotkoff sounds to identify SBP and
DBP, respectively.
Auscultatory or oscillometric semiautomatic or automatic sphyg-
momanometers are the preferred method for measuring BP in the Measure BP in both arms at the first visit to detect possible
doctor’s office. These devices should be validated according to stand- between-arm differences. Use the arm with the higher value as
44
ardized conditions and protocols. BP should initially be measured in the reference.
both upper arms, using an appropriate cuff size for the arm circumfer-
Measure BP 1 min and 3 min after standing from a seated posi-
ence. A consistent and significant SBP difference between arms (i.e.
>15 mmHg) is associated with an increased CV risk, 45 most likely tion in all patients at the first measurement to exclude ortho-
static hypotension. Lying and standing BP measurements should
due to atheromatous vascular disease. Where there is a difference in
also be considered in subsequent visits in older people, people
BP between arms, ideally established by simultaneous measurement,
with diabetes, and people with other conditions in which ortho-
the arm with the higher BP values should be used for all subsequent
static hypotension may frequently occur.
measurements.
In older people, people with diabetes, or people with other causes Record heart rate and use pulse palpation to exclude
of orthostatic hypotension, BP should also be measured 1 min and 3 arrhythmia.
min after standing. Orthostatic hypotension is defined as a reduction
in SBP of >_20 mmHg or in DBP of >_10 mmHg within 3 min of stand-
AF = atrial fibrillation; BP = blood pressure; DBP = diastolic blood pressure; SBP
ing, and is associated with an increased risk of mortality and CV = systolic blood pressure.
46
events. Heart rate should also be recorded at the time of BP meas- a Most automatic devices are not validated for BP measurement in patients with
AF and will record the highest individual systolic pressure wave form rather than
urements because resting heart rate is an independent predictor of
an average of several cardiac cycles. This will lead to overestimation of BP.
CV morbid or fatal events, 47 although heart rate is not included in
any CV risk algorithm. Table 8 summarizes the recommended proce-
dure for routine office BP measurement. It is emphasized that office
.
BP is often performed improperly, with inadequate attention to the . . and unobserved, the ‘white-coat effect’ (see section 4.7.1) can be
standardized conditions recommended for a valid measurement of . . . substantially reduced or eliminated. Moreover, the BP values are
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office BP. Improper measurement of office BP can lead to inaccurate . . . lower than those obtained by conventional office BP measurement
classification, overestimation of a patient’s true BP, and unnecessary . . . and are similar to, or even less than, those provided by daytime
treatment. . . . . . ambulatory blood pressure monitoring (ABPM) or home blood pres-
50
4.2 Unattended office blood pressure . . . . . sure monitoring (HBPM). Use of unattended office BP measure-
ment in a recent clinical trial [the Systolic Blood Pressure
measurement . . . Intervention Trial (SPRINT)] generated controversy about its quan-
51
Automated multiple BP readings in the doctor’s office improve the . . . . titative relationship to conventional office BP measurement (which
reproducibility of BP measurement, and if the patient is seated alone . has been the basis for all previous epidemiological and clinical trial

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