(strictly speaking: vascular pressure) refers to the force exerted by circulating blood on the walls of blood vessels, and constitutes one of the principal vital signs. The pressure of the circulating blood decreases as blood moves through arteries, arterioles, capillaries, and veins; the term blood pressure generally refers to arterial pressure, i.e., the pressure in the larger arteries, arteries being the blood vessels which take blood away from the heart. Arterial pressure is most commonly measured via a sphygmomanometer, which uses the height of a column of mercury to reflect the circulating pressure (see Non-invasive measurement). Although many modern vascular pressure devices no longer use mercury, vascular pressure values are still universally reported in millimetres of mercury (mmHg).

The systolic arterial pressure is defined as the peak pressure in the arteries, which occurs near the beginning of the cardiac cycle; the diastolic arterial pressure is the lowest pressure (at the resting phase of the cardiac cycle). The average pressure throughout the cardiac cycle is reported as mean arterial pressure; the pulse pressure reflects the difference between the maximum and minimum pressures measured.

Typical values for a resting, healthy adult human are approximately 120 mmHg (16 kPa) systolic and 80 mmHg (11 kPa) diastolic (written as 120/80 mmHg, and spoken as “one twenty over eighty”) with large individual variations. These measures of arterial pressure are not static, but undergo natural variations from one heartbeat to another and throughout the day (in a circadian rhythm); they also change in response to stress, nutritional factors, drugs, or disease. Hypertension refers to arterial pressure being abnormally high, as opposed to hypotension, when it is abnormally low. Along with body temperature, blood pressure measurements are the most commonly measured physiological parameters.

Arterial pressures can be measured invasively (by penetrating the skin and measuring inside the blood vessels) or non-invasively. The former is usually restricted to a hospital setting.

Non-invasive measurement

The non-invasive auscultatory (from the Latin for listening) and oscillometric measurements are simpler and quicker than invasive measurements, require less expertise in fitting, have virtually no complications, and are less unpleasant and painful for the patient. However, non-invasive measures may yield somewhat lower accuracy and small systematic differences in numerical results. Non-invasive measurement methods are more commonly used for routine examinations and monitoring.

The auscultatory method uses a stethoscope and a sphygmomanometer. This comprises an inflatable (Riva-Rocci) cuff placed around the upper arm at roughly the same vertical height as the heart, attached to a mercury or aneroid manometer. The mercury manometer, considered to be the gold standard for arterial pressure measurement, measures the height of a column of mercury, giving an absolute result without need for calibration, and consequently not subject to the errors and drift of calibration which affect other methods. The use of mercury manometers is often required in clinical trials and for the clinical measurement of hypertension in high risk patients, including pregnant women.

A cuff of appropriate size is fitted and inflated manually by repeatedly squeezing a rubber bulb until the artery is completely occluded. Listening with the stethoscope to the brachial artery at the elbow, the examiner slowly releases the pressure in the cuff. When blood just starts to flow in the artery, the turbulent flow creates a “whooshing” or pounding (first Korotkoff sound). The pressure at which this sound is first heard is the systolic blood pressure. The cuff pressure is further released until no sound can be heard (fifth Korotkoff sound), at the diastolic arterial pressure. Sometimes, the pressure is palpated (felt by hand) to get an estimate before auscultation.

Oscillometric methods

Oscillometric methods are sometimes used in the long-term measurement and sometimes in general practice. The equipment is functionally similar to that of the auscultatory method, but with an electronic pressure sensor (transducer) fitted in to detect blood flow, instead of using the stethoscope and the expert’s ear. In practice, the pressure sensor is a calibrated electronic device with a numerical readout of blood pressure. To maintain accuracy, calibration must be checked periodically, unlike the inherently accurate mercury manometer. In most cases the cuff is inflated and released by an electrically operated pump and valve, which may be fitted on the wrist (elevated to heart height), although the upper arm is preferred. They vary widely in accuracy, and should be checked at specified intervals and if necessary recalibrated.

Oscillometric measurement requires less skill than the auscultatory technique, and may be suitable for use by untrained staff and for automated patient home monitoring.

The cuff is inflated to a pressure initially in excess of the systolic arterial pressure, and then reduces to below diastolic pressure over a period of about 30 seconds. When blood flow is nil (cuff pressure exceeding systolic pressure) or unimpeded (cuff pressure below diastolic pressure), cuff pressure will be essentially constant. It is essential that the cuff size is correct: undersized cuffs may yield too high a pressure, whereas oversized cuffs yields too low a pressure. When blood flow is present, but restricted, the cuff pressure, which is monitored by the pressure sensor, will vary periodically in synchrony with the cyclic expansion and contraction of the brachial artery, i.e., it will oscillate. The values of systolic and diastolic pressure are computed, not actually measured from the raw data, using an algorithm; the computed results are displayed.

Oscillometric monitors may produce inaccurate readings in patients with heart and circulation problems, that include arterial sclerosis, arrhythmia, preeclampsia, pulsus alternans, and pulsus paradoxus.

In practice the different methods do not give identical results; an algorithm and experimentally obtained coefficients are used to adjust the oscillometric results to give readings which match the auscultatory as well as possible. Some equipment uses computer-aided analysis of the instantaneous arterial pressure waveform to determine the systolic, mean, and diastolic points. Since many oscillometric devices have not been validated, caution must be given as most are not suitable in clinical and acute care settings.

The term NIBP, for Non-Invasive Blood Pressure, is often used to describe oscillometric monitoring equipment.

Invasive measurement

Arterial blood pressure (BP) is most accurately measured invasively through an arterial line. Invasive arterial pressure measurement with intravascular cannulae involves direct measurement of arterial pressure by placing a cannula needle in an artery (usually radial, femoral, dorsalis pedis or brachial). This is usually done by an anesthesiologist or surgeon in a hospital.

The cannula must be connected to a sterile, fluid-filled system, which is connected to an electronic pressure transducer. The advantage of this system is that pressure is constantly monitored beat-by-beat, and a waveform (a graph of pressure against time) can be displayed. This invasive technique is regularly employed in human and veterinary intensive care medicine, anesthesiology, and for research purposes.

Cannulation for invasive vascular pressure monitoring is infrequently associated with complications such as thrombosis, infection, and bleeding. Patients with invasive arterial monitoring require very close supervision, as there is a danger of severe bleeding if the line becomes disconnected. It is generally reserved for patients where rapid variations in arterial pressure are anticipated.

Invasive vascular pressure monitors are pressure monitoring systems designed to acquire pressure information for display and processing. There are a variety of invasive vascular pressure monitors for trauma, critical care, and operating room applications. These include single pressure, dual pressure, and multi-parameter (i.e. pressure / temperature). The monitors can be used for measurement and follow-up of arterial, central venous, pulmonary arterial, left atrial, right atrial, femoral arterial, umbilical venous, umbilical arterial, and intracranial pressures.

Vascular pressure parameters are derived in the monitor’s microcomputer system. Usually, systolic, diastolic, and mean pressures are displayed simultaneously for pulsatile waveforms (i.e. arterial and pulmonary arterial). Some monitors also calculate and display CPP (cerebral perfusion pressure). Normally, a zero key on the front of the monitor makes pressure zeroing extremely fast and easy. Alarm limits may be set to assist the medical professional responsible for observing the patient. High and low alarms may be set on displayed temperature parameters.

Home monitoring

Up to 25% of patients diagnosed with hypertension do not suffer from it, but rather from white coat hypertension (elevated arterial pressure specifically during medical exams, probably as a result of anxiety). Thus, well-performed, accurate home arterial pressure monitoring can prevent unnecessary anxiety, as well as costly and potentially dangerous therapy in many millions of people worldwide. Home arterial pressure monitoring provides a measurement of a person’s arterial pressure at different times and in different environments, such as at home and at work, throughout the day. Home arterial pressure monitoring may assist in the diagnosis of high or low arterial pressure. It may also be used to monitor the effects of medication or lifestyle changes taken to lower or regulate arterial pressure levels.

Automatic self-contained blood pressure monitors are available at reasonable prices, some of which are capable of Korotov’s measurement in addition to oscillometric methods, enabling irregular heartbeat patients to accurately measure their blood pressure at home, which was not possible using the traditional devices.

The 2003 US Joint National Committee recommends the use of self monitoring of arterial pressure, before considering the more expensive ambulatory monitoring of arterial pressure, to improve hypertension management. Both the Joint National Committee and the 2003 guidelines from the European Society of Hypertension and the European Society of Cardiology suggest that self monitoring might also be used as an alternative to ambulatory monitoring for the diagnosis of white coat hypertension.

A study published in the May 2006 American Journal of Hypertension compared home and ambulatory blood pressure monitoring methods in the adjustment of antihypertensive treatment. The study showed home arterial pressure monitoring is as accurate as a 24 hour ambulatory monitoring in determining arterial pressure levels. Researchers at the University of Turku, Finland studied 98 patients with untreated hypertension. They compared patients using a home arterial pressure device and those wearing a 24hr ambulatory monitor. Researcher Dr. Niiranen said that, “home blood pressure measurement can be used effectively for guiding anti-hypertensive treatment”. Dr. Stergiou added that home tracking of arterial pressure, “is more convenient and also less costly than ambulatory blood pressure monitoring”.

A clinical study published in the May 2007 edition of The American Journal of Hypertension compared the accuracy of 3 different methods of taking arterial pressure in indicating cardiovascular health. The study aim was to assess the accuracy of home blood pressure monitoring (HBP), 24hr ambulatory blood pressure monitoring (ABP) and arterial pressure readings taken in a doctor’s office (OBP). The arterial pressure tests were compared to the left-ventricular mass index (LVMI). The LVMI was calculated from an echocardiogram of the heart and indicates cardiovascular organ damage, an indicator of arterial pressure. Researchers at The Columbia University Medical Center, New York found that home arterial pressure monitoring, over a 10 week period was a significant independent predictor of LVMI even after adjusting for age, sex and BMI (body mass index). They found that home monitoring over time is a better indicator of cardiovascular health than ambulatory readings or readings taken at the doctors’ office. The value of home monitoring increases over time with a number of measurements taken.

The June 2007 AMNews; Newspaper for America’s Physicians released a study which showed arterial pressure readings taken in a doctors office are often unreliable. The American Medical Association newspaper quoted Prof Norman Kaplan from the University of Texas Southwestern Medical Center who said, “Of all the procedures done in a doctor’s office, measurement of blood pressure is usually the least well performed but has the most important implications for the care of the patient.” The paper explained that arterial pressure readings taken in a Doctors office can be falsely raised or lowered. This can be due to the presence of a Doctor or clinician which results in the patient experiencing white coat hypertension.

The American Heart Association website states, “You may have what’s called ‘white coat hypertension’; that means your blood pressure goes up when you’re at the doctor’s office. Monitoring at home will help you measure your true blood pressure and can provide your doctor with a log of blood pressure measurements over time. This is helpful in diagnosing and preventing potential health problems.”

Those using home arterial pressure monitoring devices are increasingly also making use of arterial pressure charting software. These charting methods provide print outs for the patients physician and reminders on how often to check arterial pressure.

Accuracy of Home Monitoring

The National Heart, Lung and Blood Institute has issued to the guidelines for taking blood pressure using home monitoring devices. Obtaining an accurate reading requires that the patient should not drink coffee, smoke cigarettes, or engage in strenuous exercise for 30 minutes before taking the reading. For 5 minutes before the test, the patient should be sitting upright in a chair with his or her feet flat on the floor and without any limbs crossed. The arm should be relaxed and kept at heart level during the reading. The blood pressure cuff should always be against bare skin, as readings taken over a shirt sleeve are less accurate. A full bladder may have a small effect on blood pressure readings, so if the urge to urinate exists, the patient should be encouraged to go before the reading.