Review

Authors: Adam P Bress, Timothy S Anderson, John M Flack...

Over the past 3 decades, a substantial body of high-quality evidence has guided the diagnosis and management of elevated blood pressure (BP) in the outpatient setting. In contrast, there is a lack of comparable evidence for guiding the management of elevated BP in the acute care setting, resulting in significant practice variation. Throughout this scientific statement, we use the terms acute care and inpatient to refer to care received in the emergency department and after admission to the hospital. Elevated inpatient BP is common and can manifest either as asymptomatic or with signs of new or worsening target-organ damage, a condition referred to as hypertensive emergency. Hypertensive emergency involves acute target-organ damage and should be treated swiftly, usually with intravenous antihypertensive medications, in a closely monitored setting. However, the risk-benefit ratio of initiating or intensifying antihypertensive medications for asymptomatic elevated inpatient BP is less clear. Despite this ambiguity, clinicians prescribe oral or intravenous antihypertensive medications in approximately one-third of cases of asymptomatic elevated inpatient BP. Recent observational studies have suggested potential harms associated with treating asymptomatic elevated inpatient BP, which brings current practice into question. Despite the ubiquity of elevated inpatient BPs, few position papers, guidelines, or consensus statements have focused on improving BP management in the acute care setting. Therefore, this scientific statement aims to synthesize the available evidence, provide suggestions for best practice based on the available evidence, identify evidence-based gaps in managing elevated inpatient BP (asymptomatic and hypertensive emergency), and highlight areas requiring further research.

Topics: Humans; Hypertension; Antihypertensive Agents; American Heart Association; United States; Blood Pressure; Practice Guidelines as Topic; Blood Pressure Determination

PubMed: 38804130
DOI: 10.1161/HYP.0000000000000238

Review

Authors: S Magder

Measurement of arterial pressure is one of the most basic elements of patient management. Arterial pressure is determined by the volume ejected by the heart into the arteries, the elastance of the walls of the arteries, and the rate at which the blood flows out of the arteries. This review will discuss the three forces that determine the pressure in a vessel: elastic, kinetic, and gravitational energy. Emphasis will be placed on the importance of the distribution of arterial resistances, the elastance of the walls of the large vessels, and critical closing pressures in small arteries and arterioles. Regulation of arterial pressure occurs through changes in cardiac output and changes in vascular resistance, but these two controlled variables can sometimes be in conflict.

Topics: Blood Pressure; Blood Pressure Determination; Cardiac Output; Humans; Monitoring, Physiologic

PubMed: 30305136
DOI: 10.1186/s13054-018-2171-1

Review

Authors: Bernd Saugel, Karim Kouz, Agnes S Meidert...

Arterial blood pressure (BP) is a fundamental cardiovascular variable, is routinely measured in perioperative and intensive care medicine, and has a significant impact on patient management. The clinical reference method for BP monitoring in high-risk surgical patients and critically ill patients is continuous invasive BP measurement using an arterial catheter. A key prerequisite for correct invasive BP monitoring using an arterial catheter is an in-depth understanding of the measurement principle, of BP waveform quality criteria, and of common pitfalls that can falsify BP readings. Here, we describe how to place an arterial catheter, correctly measure BP, and identify and solve common pitfalls. We focus on 5 important steps, namely (1) how to choose the catheter insertion site, (2) how to choose the type of arterial catheter, (3) how to place the arterial catheter, (4) how to level and zero the transducer, and (5) how to check the quality of the BP waveform.

Topics: Arterial Pressure; Blood Pressure Determination; Critical Illness; Guidelines as Topic; Humans; Intensive Care Units; Monitoring, Physiologic; Patient Positioning; Ultrasonography, Interventional; Vascular Access Devices

PubMed: 32331527
DOI: 10.1186/s13054-020-02859-w

Review

Authors: Andrea Grillo, Lucia Salvi, Paolo Coruzzi...

The close relationship between hypertension and dietary sodium intake is widely recognized and supported by several studies. A reduction in dietary sodium not only decreases the blood pressure and the incidence of hypertension, but is also associated with a reduction in morbidity and mortality from cardiovascular diseases. Prolonged modest reduction in salt intake induces a relevant fall in blood pressure in both hypertensive and normotensive individuals, irrespective of sex and ethnic group, with larger falls in systolic blood pressure for larger reductions in dietary salt. The high sodium intake and the increase in blood pressure levels are related to water retention, increase in systemic peripheral resistance, alterations in the endothelial function, changes in the structure and function of large elastic arteries, modification in sympathetic activity, and in the autonomic neuronal modulation of the cardiovascular system. In this review, we have focused on the effects of sodium intake on vascular hemodynamics and their implication in the pathogenesis of hypertension.

Topics: Arterial Pressure; Arteries; Humans; Hypertension; Sodium, Dietary; Sympathetic Nervous System; Vascular Stiffness

PubMed: 31438636
DOI: 10.3390/nu11091970

Authors: Bernd Saugel, Nick Fletcher, Tong J Gan...

Arterial pressure monitoring and management are mainstays of haemodynamic therapy in patients having surgery. This article presents updated consensus statements and recommendations on perioperative arterial pressure management developed during the 11th POQI PeriOperative Quality Initiative (POQI) consensus conference held in London, UK, on June 4-6, 2023, which included a diverse group of international experts. Based on a modified Delphi approach, we recommend keeping intraoperative mean arterial pressure ≥60 mm Hg in at-risk patients. We further recommend increasing mean arterial pressure targets when venous or compartment pressures are elevated and treating hypotension based on presumed underlying causes. When intraoperative hypertension is treated, we recommend doing so carefully to avoid hypotension. Clinicians should consider continuous intraoperative arterial pressure monitoring as it can help reduce the severity and duration of hypotension compared to intermittent arterial pressure monitoring. Postoperative hypotension is often unrecognised and might be more important than intraoperative hypotension because it is often prolonged and untreated. Future research should focus on identifying patient-specific and organ-specific hypotension harm thresholds and optimal treatment strategies for intraoperative hypotension including choice of vasopressors. Research is also needed to guide monitoring and management strategies for recognising, preventing, and treating postoperative hypotension.

Topics: Humans; Arterial Pressure; Blood Pressure Determination; Consensus; Hypotension; Intraoperative Complications; Monitoring, Intraoperative; Perioperative Care; Postoperative Complications

PubMed: 38839472
DOI: 10.1016/j.bja.2024.04.046

Randomized Controlled Trial

Effects of Moderate Combined Resistance- and Aerobic-Exercise for 12 Weeks on Body Composition, Cardiometabolic Risk Factors, Blood Pressure, Arterial Stiffness, and Physical Functions, among Obese Older Men: A Pilot Study.

Authors: Wonil Park, Won-Sang Jung, Kwangseok Hong...

We demonstrated the hypothesis that combined exercise improves body composition, cardiometabolic risk factors, blood pressure (BP), arterial stiffness, and physical functions, in obese older men. Older men ( = 20) were randomly assigned to combined exercise training (EXP; = 10) or control groups (CON; = 10). The combined exercise was comprised of elastic-band resistance training and walking/running on a treadmill and bicycle at 60-70% of maximal heart rate for 3 days/weeks. EXP showed significant decreases in body weight, body mass index, and %body fat ( < 0.05). The exercise program significantly reduced BP, mean arterial pressure, pulse pressure, and brachial-ankle pulse wave velocity. Furthermore, while the plasma levels of low-density lipoprotein cholesterol and epinephrine were significantly reduced in EXP, VO peak and grip strength were significantly enhanced ( < 0.05). In conclusion, it is indicated that 12-week regular combined exercise improves body composition, cardiometabolic risk factors, hemodynamics, and physical performance in obese older men.

Topics: Aged; Ankle Brachial Index; Arterial Pressure; Blood Pressure; Body Composition; Cardiometabolic Risk Factors; Exercise; Humans; Male; Obesity; Pilot Projects; Pulse Wave Analysis; Vascular Stiffness

PubMed: 33022918
DOI: 10.3390/ijerph17197233

Review

Authors: Bernd Saugel, Karim Kouz, Thomas W L Scheeren...

Pulse wave analysis (PWA) allows estimation of cardiac output (CO) based on continuous analysis of the arterial blood pressure (AP) waveform. We describe the physiology of the AP waveform, basic principles of PWA algorithms for CO estimation, and PWA technologies available for clinical practice. The AP waveform is a complex physiological signal that is determined by interplay of left ventricular stroke volume, systemic vascular resistance, and vascular compliance. Numerous PWA algorithms are available to estimate CO, including Windkessel models, long time interval or multi-beat analysis, pulse power analysis, or the pressure recording analytical method. Invasive, minimally-invasive, and noninvasive PWA monitoring systems can be classified according to the method they use to calibrate estimated CO values in externally calibrated systems, internally calibrated systems, and uncalibrated systems.

Topics: Algorithms; Arterial Pressure; Blood Pressure Determination; Cardiac Output; Humans; Monitoring, Physiologic; Pulse Wave Analysis; Reproducibility of Results

PubMed: 33246581
DOI: 10.1016/j.bja.2020.09.049

Authors: Roland Asmar, George Stergiou, Alejandro de la Sierra...

Measuring blood pressure (BP) and investigating arterial hemodynamics are essential in understanding cardiovascular disease and assessing cardiovascular risk. Several methods are used to measure BP in the doctor's office, at home, or over 24 h under ambulatory conditions. Similarly, several noninvasive methods have been introduced for assessing arterial structure and function; these methods differ for the large arteries, the small ones, and the capillaries. Consequently, when studying arterial hemodynamics, the clinician is faced with a multitude of assessment methods whose technical details, advantages, and limitations are sometimes unclear. Moreover, the conditions and procedures for their optimal implementation, and/or the reference normality values for the parameters they yield are not always taken into sufficient consideration. Therefore, a practice guideline summarizing the main methods and their use in clinical practice is needed. This expert group position paper was developed by an international group of scientists after a two-day meeting during which each of the most used methods and techniques for blood pressure measurement and arterial function and structure evaluation were presented and discussed, focusing on their advantages, limitations, indications, normal values, and their pragmatic clinical application.

Topics: Humans; Arteries; Blood Pressure; Blood Pressure Determination; Hemodynamics

PubMed: 38899971
DOI: 10.1097/HJH.0000000000003787

Authors: Manan Pareek, Michael Hecht Olsen

Topics: Blood Pressure; Blood Pressure Determination; Ethanol

PubMed: 29253394
DOI: 10.1016/S2468-2667(17)30009-9

Randomized Controlled Trial

Authors: Kamal Maheshwari, Sandeep Khanna, Gausan Ratna Bajracharya...

BACKGROUND

Intraoperative hypotension is associated with postoperative mortality. Early detection of hypotension by continuous hemodynamic monitoring might prompt timely therapy, thereby reducing intraoperative hypotension. We tested the hypothesis that continuous noninvasive blood pressure monitoring reduces intraoperative hypotension.

METHODS

Patients ≥45 years old with American Society of Anesthesiologists physical status III or IV having moderate-to-high-risk noncardiac surgery with general anesthesia were included. All participating patients had continuous noninvasive hemodynamic monitoring using a finger cuff (ClearSight, Edwards Lifesciences, Irvine, CA) and a standard oscillometric cuff. In half the patients, randomly assigned, clinicians were blinded to the continuous values, whereas the others (unblinded) had access to continuous blood pressure readings. Continuous pressures in both groups were used for analysis. Time-weighted average for mean arterial pressure <65 mm Hg was compared using 2-sample Wilcoxon rank-sum tests and Hodges Lehmann estimation of location shift with corresponding asymptotic 95% CI.

RESULTS

Among 320 randomized patients, 316 were included in the intention-to-treat analysis. With 158 patients in each group, those assigned to continuous blood pressure monitoring had significantly lower time-weighted average mean arterial pressure <65 mm Hg, 0.05 [0.00, 0.22] mm Hg, versus intermittent blood pressure monitoring, 0.11 [0.00, 0.54] mm Hg (P = .039, significance criteria P < .048).

CONCLUSIONS

Continuous noninvasive hemodynamic monitoring nearly halved the amount of intraoperative hypotension. Hypotension reduction with continuous monitoring, while statistically significant, is currently of uncertain clinical importance.

Topics: Aged; Anesthesia, General; Anesthesiology; Arterial Pressure; Blood Pressure; Blood Pressure Determination; Female; Hemodynamics; Humans; Hypotension; Male; Middle Aged; Monitoring, Intraoperative; Monitoring, Physiologic; Oscillometry; Reproducibility of Results; Surgical Procedures, Operative; Treatment Outcome

PubMed: 29916861
DOI: 10.1213/ANE.0000000000003482