Blood pressure

Blood pressure
Medical diagnostics
A sphygmomanometer, a device used for measuring arterial pressure
MeSH D001795
MedlinePlus 007490
LOINC 35094-2

Blood pressure (BP) is the pressure of circulating blood on the walls of blood vessels. Used without further specification, "blood pressure" usually refers to the pressure in large arteries of the systemic circulation. Blood pressure is usually expressed in terms of the systolic pressure (maximum during one heart beat) over diastolic pressure (minimum in between two heart beats) and is measured in millimeters of mercury (mmHg), above the surrounding atmospheric pressure.

Blood pressure is one of the vital signs, along with respiratory rate, heart rate, oxygen saturation, and body temperature. Normal resting blood pressure in an adult is approximately 120 millimetres of mercury (16 kPa) systolic, and 80 millimetres of mercury (11 kPa) diastolic, abbreviated "120/80 mmHg".

Traditionally, blood pressure was measured non-invasively using a mercury-tube sphygmomanometer, or an aneroid gauge, which is still generally considered to be the gold standard of accuracy for auscultatory readings.[1] More recently other semi-automated methods have become common, largely due to concerns about potential mercury toxicity,[2] although cost and ease of use have also influenced this trend.[1] Early automated alternatives to mercury-tube sphygmomanometers were often seriously inaccurate, but validated devices allow for an average difference between two standardized reading methods of 5 mm Hg or less and a standard deviation of less than 8 mm Hg.[1]

Blood pressure is influenced by cardiac output, total peripheral resistance and arterial stiffness and varies depending on situation, emotional state, activity, and relative health/disease states. In the short term, blood pressure is regulated by baroreceptors which act via the brain to influence nervous and endocrine systems.

Blood pressure that is low is called hypotension, and pressure that is consistently high is hypertension. Both have many causes and may be of sudden onset or of long duration. Long-term hypertension is a risk factor for many diseases, including heart disease, stroke and kidney failure. Long-term hypertension is more common than long-term hypotension, which often goes undetected because of infrequent monitoring and the absence of symptoms.

Classification

Systemic arterial pressure

Classification of blood pressure (adults)[3][4][5]
Category systolic, mmHg diastolic, mmHg
Hypotension
< 90
< 60
Normal
90–119[6]

90–129[5]
60–79[6]

60–84[5]
Prehypertension (high normal)
120–129[6]

130–139[5]
60–79[6]

85–89[5]
Stage 1 hypertension
140–159

130–139[6]
90–99

80–89[6]
Stage 2 hypertension
160–179

>140[6]
100–109

>90[6]
Hypertensive urgency
≥ 180
≥ 110
Isolated systolic hypertension
≥ 160[6]
< 90

The risk of cardiovascular disease increases progressively above 115/75 mmHg.[7] In practice blood pressure is considered too low only if noticeable symptoms are present.[4]

Observational studies demonstrate that people who maintain arterial pressures at the low end of these pressure ranges have much better long term cardiovascular health. There is an ongoing medical debate over what is the optimal level of blood pressure to target when using drugs to lower blood pressure with hypertension, particularly in older people.[8]

The table shows the classification of blood pressure adopted by the American Heart Association for adults who are 18 years and older.[3] It assumes the values are a result of averaging resting blood pressure readings measured at two or more visits to the doctor.[9][10]

In November 2017 the American Heart Association announced revised definitions for blood pressure categories that increased the number of people considered to have high blood pressure.[11]

In the UK, clinic blood pressures are usually categorized into three groups; low (90/60 or lower), normal (between 90/60 and 139/89), and high (140/90 or higher).[12][13]

Blood pressure fluctuates from minute to minute and normally shows a circadian rhythm over a 24-hour period, with highest readings in the early morning and evenings and lowest readings at night.[14][15] Loss of the normal fall in blood pressure at night is associated with a greater future risk of cardiovascular disease and there is evidence that night-time blood pressure is a stronger predictor of cardiovascular events than day-time blood pressure.[16] Also, an individual's blood pressure varies with exercise, emotional reactions, sleep, digestion and time of day (circadian rhythm).

Various other factors, such as age and sex, also influence a person's blood pressure. In children, the normal ranges are lower than for adults and depend on height.[17] Reference blood pressure values have been developed for children in different countries, based on the distribution of blood pressure in children of these countries.[18] As adults age, systolic pressure tends to rise and diastolic pressure tends to fall.[19] Consequently, in the elderly, systolic blood pressure often exceeds the normal adult range,[20] this is thought to be due to increased stiffness of the arteries.[21]

Differences between left and right arm blood pressure measurements tend to be small. However, occasionally there is a consistent difference greater than 10 mmHg which may need further investigation, e.g. for obstructive arterial disease.[22][23]

Reference ranges for blood pressure in children[24]
StageApproximate ageSystolicDiastolic
Infants 1 to 12 months75–10050–70
Toddlers and preschoolers 1 to 5 years80–11050–80
School age 6 to 12 years85–12050–80
Adolescents 13 to 18 years95–14060–90

Mean arterial pressure

The mean arterial pressure (MAP) is the average over a cardiac cycle and is determined by the cardiac output (CO, systemic vascular resistance (SVR), and central venous pressure (CVP):[25]

In practice the contribution of CVP (which is small) is generally ignored and so

MAP can be estimated from measurements of the systolic pressure   and the diastolic pressure  [25]

Pulse pressure

Curve of the arterial pressure during one cardiac cycle. The closing of the aortic valve causes the notch in the curve.

The pulse pressure is the difference between the measured systolic and diastolic pressures,[26]

The up and down fluctuation of the arterial pressure results from the pulsatile nature of the cardiac output, i.e. the heartbeat. Pulse pressure is determined by the interaction of the stroke volume of the heart, the compliance (ability to expand) of the arterial system—largely attributable to the aorta and large elastic arteries—and the resistance to flow in the arterial tree. By expanding under pressure, the aorta absorbs some of the force of the blood surge from the heart during a heartbeat. In this way, the pulse pressure is reduced from what it would be if the aorta were not compliant.[26] The loss of arterial compliance that occurs with aging explains the elevated pulse pressures found in elderly patients.

Systemic venous pressure

SiteNormal
pressure range
(in mmHg)[27]
Central venous pressure3–8
Right ventricular pressuresystolic15–30
diastolic3–8
Pulmonary artery pressuresystolic15–30
diastolic4–12
Pulmonary vein/

Pulmonary capillary wedge pressure

 2–15
Left ventricular pressuresystolic100–140
diastolic3–12

Blood pressure generally refers to the arterial pressure in the systemic circulation. However, measurement of pressures in the venous system and the pulmonary vessels plays an important role in intensive care medicine but requires invasive measurement of pressure using a catheter.

Venous pressure is the vascular pressure in a vein or in the atria of the heart. It is much less than arterial pressure, with common values of 5 mmHg in the right atrium and 8 mmHg in the left atrium.

Variants of venous pressure include:

Pulmonary pressure

Normally, the pressure in the pulmonary artery is about 15 mmHg at rest.[31]

Increased blood pressure in the capillaries of the lung causes pulmonary hypertension, leading to interstitial edema if the pressure increases to above 20 mmHg, and to pulmonary edema at pressures above 25 mmHg.[32]

Disorders

Disorders of blood pressure control include high blood pressure, low blood pressure, and blood pressure that shows excessive or maladaptive fluctuation.

High

Overview of main complications of persistent high blood pressure

Arterial hypertension can be an indicator of other problems and may have long-term adverse effects. Sometimes it can be an acute problem, for example hypertensive emergency.

Levels of arterial pressure put mechanical stress on the arterial walls. Higher pressures increase heart workload and progression of unhealthy tissue growth (atheroma) that develops within the walls of arteries. The higher the pressure, the more stress that is present and the more atheroma tend to progress and the heart muscle tends to thicken, enlarge and become weaker over time.

Persistent hypertension is one of the risk factors for strokes, heart attacks, heart failure and arterial aneurysms, and is the leading cause of chronic kidney failure. Even moderate elevation of arterial pressure leads to shortened life expectancy. At severely high pressures, mean arterial pressures 50% or more above average, a person can expect to live no more than a few years unless appropriately treated.[33]

In the past, most attention was paid to diastolic pressure; but nowadays it is recognized that both high systolic pressure and high pulse pressure (the numerical difference between systolic and diastolic pressures) are also risk factors. In some cases, it appears that a decrease in excessive diastolic pressure can actually increase risk, due probably to the increased difference between systolic and diastolic pressures (see the article on pulse pressure). If systolic blood pressure is elevated (>140 mmHg) with a normal diastolic blood pressure (<90 mmHg), it is called "isolated systolic hypertension" and may present a health concern.[34][35]

For those with heart valve regurgitation, a change in its severity may be associated with a change in diastolic pressure. In a study of people with heart valve regurgitation that compared measurements 2 weeks apart for each person, there was an increased severity of aortic and mitral regurgitation when diastolic blood pressure increased, whereas when diastolic blood pressure decreased, there was a decreased severity.[36]

Low

Blood pressure that is too low is known as hypotension. This is a medical concern if it causes signs or symptoms, such as dizziness, fainting, or in extreme cases, shock.[10]

When arterial pressure and blood flow decrease beyond a certain point, the perfusion of the brain becomes critically decreased (i.e., the blood supply is not sufficient), causing lightheadedness, dizziness, weakness or fainting.[37]

Sometimes the arterial pressure drops significantly when a patient stands up from sitting. This is known as orthostatic hypotension (postural hypotension); gravity reduces the rate of blood return from the body veins below the heart back to the heart, thus reducing stroke volume and cardiac output.

When people are healthy, the veins below their heart quickly constrict and the heart rate increases to minimize and compensate for the gravity effect. This is carried out involuntarily by the autonomic nervous system. The system usually requires a few seconds to fully adjust and if the compensations are too slow or inadequate, the individual will suffer reduced blood flow to the brain, dizziness and potential blackout. Increases in G-loading, such as routinely experienced by aerobatic or combat pilots 'pulling Gs', greatly increases this effect. Repositioning the body horizontally largely eliminates the problem.

Other causes of low arterial pressure include:

Shock is a complex condition which leads to critically decreased perfusion. The usual mechanisms are loss of blood volume, pooling of blood within the veins reducing adequate return to the heart and/or low effective heart pumping. Low arterial pressure, especially low pulse pressure, is a sign of shock and contributes to and reflects decreased perfusion.

If there is a significant difference in the pressure from one arm to the other, that may indicate a narrowing (for example, due to aortic coarctation, aortic dissection, thrombosis or embolism) of an artery.

Fluctuating blood pressure

Normal fluctuation in blood pressure is adaptive and necessary. Fluctuations in pressure that are significantly greater than the norm are associated with greater white matter hyperintensity, a finding consistent with reduced local cerebral blood flow[38] and a heightened risk of cerebrovascular disease.[39] Within both high and low blood pressure groups, a greater degree of fluctuation was found to correlate with an increase in cerebrovascular disease compared to those with less variability, suggesting the consideration of the clinical management of blood pressure fluctuations, even among normotensive older adults.[39] Older individuals and those who had received blood pressure medications were more likely to exhibit larger fluctuations in pressure.[39]

Physiology

Systole on the left and diastole on the right

During each heartbeat, blood pressure varies between a maximum (systolic) and a minimum (diastolic) pressure.[40] The blood pressure in the circulation is principally due to the pumping action of the heart.[41] Differences in mean blood pressure are responsible for blood flow from one location to another in the circulation. The rate of mean blood flow depends on both blood pressure and the resistance to flow presented by the blood vessels. Mean blood pressure decreases as the circulating blood moves away from the heart through arteries and capillaries due to viscous losses of energy. Mean blood pressure drops over the whole circulation, although most of the fall occurs along the small arteries and arterioles.[42] Gravity affects blood pressure via hydrostatic forces (e.g., during standing), and valves in veins, breathing, and pumping from contraction of skeletal muscles also influence blood pressure in veins.[41]

Hemodynamics

Most influences on blood pressure can be understood in terms of their effect on cardiac output and resistance (the determinants of mean arterial pressure).[43]

Some factors are:

  • Blood volume: the greater the blood volume, the higher the cardiac output. There is some relationship between dietary salt intake and increased blood volume, potentially resulting in higher arterial pressure, though this varies with the individual and is highly dependent on autonomic nervous system response and the renin–angiotensin system.[44][45][46]
  • Cardiac output: the pumping action of the heart is ultimately responsible for blood pressure. Increases or decreases in cardiac output can result in increases or decreases respectively in blood pressure.[47]
  • Systemic vascular resistance: the higher the resistance to blood flow, the higher the arterial pressure upstream needs to be to maintain flow. In simple terms, resistance is related to vessel radius by the Hagen-Poiseuille's equation (resistance∝1/radius4, so the smaller the radius, the very much higher the resistance). Other physical factors that affect resistance include: vessel length (the longer the vessel, the higher the resistance), blood viscosity (the higher the viscosity, the higher the resistance)[48] and the presence of an arterial stenosis (a narrow stenosis increases resistance to flow, however this increase in resistance rarely if ever increases systemic blood pressure, it decreases downstream flow).[49] Substances called vasoconstrictors can reduce the calibre of blood vessels, thereby increasing blood pressure. Vasodilators (such as nitroglycerin) increase the calibre of blood vessels, thereby decreasing arterial pressure.

In practice, each individual's autonomic nervous system and other systems regulating blood pressure respond to and regulate all these factors so that, although the above issues are important, they rarely act in isolation and the actual arterial pressure response of a given individual can vary widely in the short and long term.

Regulation

The endogenous regulation of arterial pressure is not completely understood, but the following mechanisms of regulating arterial pressure have been well-characterized:

These different mechanisms are not necessarily independent of each other, as indicated by the link between the RAS and aldosterone release. When blood pressure falls many physiological cascades commence in order to return the blood pressure to a more appropriate level.

  1. The blood pressure fall is detected by a decrease in blood flow and thus a decrease in Glomerular filtration rate (GFR).
  2. Decrease in GFR is sensed as a decrease in Na+ levels by the macula densa.
  3. The macula densa causes an increase in Na+ reabsorption, which causes water to follow in via osmosis and leads to an ultimate increase in plasma volume. Further, the macula densa releases adenosine which causes constriction of the afferent arterioles.
  4. At the same time, the juxtaglomerular cells sense the decrease in blood pressure and release renin.
  5. Renin converts angiotensinogen (inactive form) to angiotensin I (active form).
  6. Angiotensin I flows in the bloodstream until it reaches the capillaries of the lungs where angiotensin converting enzyme (ACE) acts on it to convert it into angiotensin II.
  7. Angiotensin II is a vasoconstrictor which will increase bloodflow to the heart and subsequently the preload, ultimately increasing the cardiac output.
  8. Angiotensin II also causes an increase in the release of aldosterone from the adrenal glands.
  9. Aldosterone further increases the Na+ and H2O reabsorption in the distal convoluted tubule of the nephron.

Currently, the RAS is targeted pharmacologically by ACE inhibitors and angiotensin II receptor antagonists, also known as angiotensin receptor blockers (ARBs). The aldosterone system is directly targeted by spironolactone, an aldosterone antagonist. The fluid retention may be targeted by diuretics; the antihypertensive effect of diuretics is due to its effect on blood volume. Generally, the baroreceptor reflex is not targeted in hypertension because if blocked, individuals may suffer from orthostatic hypotension and fainting.

Measurement

Taking blood pressure with a sphygmomanometer

Arterial pressure is most commonly measured via a sphygmomanometer, which uses the height of a column of mercury, or an aneroid gauge, to reflect the blood pressure by auscultation.[51] The most common automated blood pressure measurement technique is based on the so-called "oscillometric" method.[52] Blood pressure values are generally reported in millimetres of mercury (mmHg), though aneroid and electronic devices do not contain mercury.

For each heartbeat, blood pressure varies between systolic and diastolic pressures. Systolic pressure is peak pressure in the arteries, which occurs near the end of the cardiac cycle when the ventricles are contracting. Diastolic pressure is minimum pressure in the arteries, which occurs near the beginning of the cardiac cycle when the ventricles are filled with blood. An example of normal measured values for a resting, healthy adult human is 120 mmHg systolic and 80 mmHg diastolic (written as 120/80 mmHg, and spoken as "one-twenty over eighty").

Systolic and diastolic arterial blood pressures 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, disease, exercise, and momentarily from standing up. Sometimes the variations are large. Hypertension refers to arterial pressure being abnormally high, as opposed to hypotension, when it is abnormally low. Along with body temperature, respiratory rate, and pulse rate, blood pressure is one of the four main vital signs routinely monitored by medical professionals and healthcare providers.[53]

Measuring pressure invasively, by penetrating the arterial wall to take the measurement, is much less common and usually restricted to a hospital setting.

Fetal blood pressure

In pregnancy, it is the fetal heart and not the mother's heart that builds up the fetal blood pressure to drive blood through the fetal circulation. The blood pressure in the fetal aorta is approximately 30 mmHg at 20 weeks of gestation, and increases to approximately 45 mmHg at 40 weeks of gestation.[54]

The average blood pressure for full-term infants:[55]

  • Systolic 65–95 mmHg
  • Diastolic 30–60 mmHg

Blood pressure in other animals

Blood pressure in non-human mammals is similar to human blood pressure. In contrast, heart rate differs markedly, largely depending on the size of the animal (larger animals have slower heart rates).[56] As in humans, blood pressure in animals differs by age, sex, time of day and circumstances:[57][58] measurements made in laboratories or anesthesia may not be repesentative of values under free-living conditions. Rats, mice, dogs and rabbits have been used extensively to study the causes of high blood pressure.[59]

Blood pressure and heart rate of various mammals (modifed from [57])
Species Systolic blood pressure,

mm Hg

Diastolic blood pressure,

mm Hg

 Heart rate,

beats per minute

Calves 140 70 75–146
Cats 155 68 100–259
Dogs 183 51 62–170
Goats 140 90 80–120
Guinea-pigs 140 90 240–300
Mice 120 75 580–680
Pigs 169 55 74–116
Rabbits 118 67 205–306
Rats 153 51 305–500
Rhesus monkeys 160 125 180–210
Sheep 140 80 63–210

Hypertension in cats and dogs

Hypertension in cats and dogs is diagnosed if the blood pressure is greater than 150 mm Hg (systolic) and/or 95 mm Hg (diastolic).[58]

References

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  52. ↑ Forouzanfar, M.; Dajani, H. R.; Groza, V. Z.; Bolic, M.; Rajan, S.; Batkin, I. (2015-01-01). "Oscillometric Blood Pressure Estimation: Past, Present, and Future". IEEE Reviews in Biomedical Engineering. 8: 44–63. doi:10.1109/RBME.2015.2434215. ISSN 1937-3333. PMID 25993705.
  53. ↑ "Vital Signs (Body Temperature, Pulse Rate, Respiration Rate, Blood Pressure)". OHSU Health Information. Oregon Health & Science University. Retrieved 2014-04-16.
  54. ↑ Struijk PC, Mathews VJ, Loupas T, Stewart PA, Clark EB, Steegers EA, Wladimiroff JW (October 2008). "Blood pressure estimation in the human fetal descending aorta". Ultrasound Obstet Gynecol. 32 (5): 673–81. doi:10.1002/uog.6137. PMID 18816497.
  55. ↑ Sharon, S. M. & Emily, S. M. (2006). Foundations of Maternal-Newborn Nursing. (4th ed p. 476). Philadelphia:Elsevier.
  56. ↑ William,, Prothero, John (2015-10-22). The design of mammals : a scaling approach. Cambridge. ISBN 9781107110472. OCLC 907295832.
  57. 1 2 Gross, David R. (2009). Animal models in cardiovascular research (3rd ed.). Dordrecht: Springer. p. 5. ISBN 9780387959627. OCLC 432709394.
  58. 1 2 Brown, S.; Atkins, C.; Bagley, R.; Carr, A.; Cowgill, L.; Davidson, M.; Egner, B.; Elliott, J.; Henik, R. (2007). "Guidelines for the identification, evaluation, and management of systemic hypertension in dogs and cats". Journal of Veterinary Internal Medicine. 21 (3): 542–558. ISSN 0891-6640. PMID 17552466.
  59. ↑ Lerman, Lilach O.; Chade, Alejandro R.; Sica, Vincenzo; Napoli, Claudio (2005). "Animal models of hypertension: An overview". Journal of Laboratory and Clinical Medicine. 146 (3): 160–173. doi:10.1016/j.lab.2005.05.005. ISSN 0022-2143. PMID 16131455.

Further reading

  • Pickering TG, Hall JE, Appel LJ, et al. (2005). Subcommittee of Professional Public Education of the American Heart Association Council on High Blood Pressure Research. "Recommendations for blood pressure measurement in humans and experimental animals: Part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research". Hypertension. 45 (5): 142–61. doi:10.1161/01.HYP.0000150859.47929.8e. PMID 15611362. Retrieved 2009-10-01.
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