Measurement of Blood Pressure: Issues and Challenges Sadhana Bhagwat, NPO WCO India - PowerPoint Presentation

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Measurement of Blood Pressure: Issues and Challenges Sadhana Bhagwat, NPO WCO India13 December 2018 1

Silent killer Most hypertensive people have no symptoms Under-diagnosis Under-treatment 2

Hypertension Prevalence, Awareness, Treatment Millions 78m 12m 230m 300m China: Age 35-75. Liu J, Lancet. 2017 Dec 9;390(10112):2549-2558

Most with Hypertension in India Are Not Aware and Hence Not treated Roy A et al. BMJ Open. 2017;7:e015639 . Data for Delhi National Capital Region weighted and applied nationally. <11% 218M 74M 60M 24M Barely 1 in 10 of the 218 million adults with hypertension in India have it under control

WHO Guidance on Hypertension Best buys, Global action plan CVD, risk factors -STEP survey -WHS plus FDC , Blood Pressure Device, Self care Risk stratification Technical package -Screen

Diagnosis Confirmation of hypertension: after two visits ideally 1 to 4 weeks apart Systolic blood pressure on both days is ≥140 mmHg and/or Diastolic blood pressure on both days is ≥90 mmHgPatients with SBP ≥160 mmHg or DBP ≥100 mmHg may be indicated for immediate treatment based on one assessment 6

Essential technology (device and lab) Challenges at PHC at low resource settings - Affordable technology blood pressure measuring devices for low resource settings, WHO 2005

8 Prolonged Treatment Diagnosis and treatment of hypertension Detection Diagnosis confirmation

Challenges in Diagnosis 9 Three sources of error in the measurement of blood pressure (AHA) Observer bias Faulty equipment Failure to standardize the technique of measurement Diagnosis confirmation

10 Three sources of error in the measurement of blood pressure (AHA) Observer bias Faulty equipment Failure to standardize the technique of measurement

Raise the pressure to 30mm above pulse palpation Lower at 2mm/sec (faster rate: lower SBP and higher DBP ) Terminal digit preference: rounding off to the zero : over estimation Common errors…. *Office blood pressure measurement practices among community health providers ( medical and paramedical) in northern district of India; Bishav Mohan a,*, Naved Aslam a, Upma Ralhan b, Sarit Sharma et al, India Heart Journal 6 6 ( 2 0 1 4 ) 4 0 1 -4 0 7

12 Three sources of error in the measurement of blood pressure (AHA) Observer bias Faulty equipment Failure to standardize the technique of measurement

The best equipment???? Calibration interval Common errors….*

14 Three sources of error in the measurement of blood pressure (AHA) Observer bias Faulty equipment Failure to standardize the technique of measurement

Supporting the arm: lower SBP/DBP by 11 and 12mm as compared to unsupported armRight cuff sizes: if small (obese people) SBP can rise by 8mm Resting the patient : food, cold weather, stress, activity, coffee, tobacco Auscultation: 1st appearance of sound: systolicComplete disappearance of sound: diastolicCommon errors….

Common errors…. Minimum two readings Sitting is better than supine: 3mm SBP raised and 3mm DBP lowered in supine Centre of the bladder: Heart level: Increases if above, decreases if below that 16

17 WHO Guidance

Objectives of the workshop Present the available guidelines and preliminary progress on guidance updating Solicit practical country-level inputs from representatives on the most suitable devices for different levels of health care Purchasing and maintaining blood pressure devices at different levels of health care provision18

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