American College of Sports Medicine. (2008). Resting and Exercise Blood Pressure and Heart
Rate. In: ACSM's health-related physical fitness assessment manual (2nd ed.). New York:
Lippincott, Williams and Wilkins.
•
Related Readings
− Perloff, D., Grim, C., Flack, J., Frohlich, E.D., Hill, M., McDonald, M., &
Morgenstern, B.Z. (1993). Human blood pressure determination by
sphygmomanometry. Circulation. 88(5 Pt 1), 2460-2470.
− Jones, D.W., Appel, L.J., Sheps, S.G., Roccella, E.J., & Lenfant, C. (2003).
Measuring blood pressure accurately: New and persistent challenges. Journal of the
American Medical Association. 289(8), 1027-1030. [e-Reserve]
•
Blood pressure (BP), force against the arteries walls created by the heart as it
pumps blood
− expressed in millimeters of Mercury (mmHg)
•
Systolic blood pressure (SBP), maximum pressure in the arteries when the
ventricles contract during a heartbeat
− SBP thought to represent overall functioning of the left ventricle
− important indicator of CV function during exercise
•
Diastolic Blood Pressure (DBP), minimum pressure in the arteries when the
ventricles relax
− DBP occurs late in ventricular diastole
− reflects the peripheral resistance in the arterial vessels to blood flow
•
Hypertension, high BP, resting BP, or both SBP and/or DBP, chronically
elevated above desired level
− normal, pre-hypertensive, Stage 1 hypertension, Stage 2 hypertension
•
Hypotension, low BP
− symptoms include lightheadedness, dizziness, fainting
•
Heart rate (HR), # of times heart contracts per unit of time
− expressed as beats per minute (bpm)
− no standards for exercise HR, but HR response to standard workload important variable and
the foundation for CV endurance tests
•
Resting HR (RHR), indicator of CV endurance
− -tends to lower in aerobically fit individuals
− used in Karvonen’s formula
•
Heart rate reserve (HRR), difference between measured or predicted MHR
and RHR
• Cardiovascular (CV) system transports blood to the body with the
heart serving as the pulsatile pump
− adult heart approx. size of a fist, weighs 250-350g
− four chambers
9 two superior chambers atria
9 two inferior chambers ventricles
• CV hemodynamics, overall function of CV system (cardiac function)
− BP and HR, variables responsible for CV hemodynamics
9 combination of BP and HR is known as the rate pressure product (RPP)
− cardiac output (Q) used to express overall CV hemodynamics
9 Q = stroke volume (SV) x HR
• SV, volume pumped per beat
9 Calculate Q: HR 70 bpm, SV 70 ml = Q = 4900 ml/minute
Circulatory system
http://www.youtube.com/watch?v=D3ZDJgFDdk0
Blood Flow Though the Heart
http://www.youtube.com/watch?v=H04d3rJCLCE&feature=related
• BP measurement integral component of assessment
− used in risk stratification
• Importance of BP to health and disease cannot be overemphasized
− Hypertension termed ‘silent killer’ people with hypertension often do not recognise
condition, typically has no symptoms
9 SBP ≥140 mm Hg; DBP of ≥90 mm Hg or on at least two occasions
− High BP modifiable risk factors for CV disease
9 Nonpharmacological intervention provides effective means to lower BP, useful method
for both prevention and treatment of high BP (Burt et al. Arch Intern Med. 153, 154-183, 1993)
− White Coat Syndrome in the measurement of BP
9 Refers to elevation of BP due to effect of being in clinical setting
9 Have client in a relaxed state is important in resting BP measurement
Mean systolic and diastolic blood pressures by age and race/ethnicity
for men and women, US population 18 years of age and older
Burt et al. Hypertension. 25, 305-313, 1995.
• Tendency for SBP to rise progressively in both men and women throughout adult
life, men had a slightly higher average level of DBP than women
NIH Publication No. 04-5230, 2003.
NIH Classifications of Blood Pressure for Adults
Blood Pressure
Classification
Systolic BP
(mm Hg)
Diastolic BP
(mm Hg)
Normal
<120
and < 80
Prehypertension
120-139
or 80-89
Stage 1 hypertension
140-159
or 90-99
Stage 2 hypertension
≥ 160
or ≥ 100
National High Blood Pressure Education Program. The Seventh Report of the Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High Blood Pressure. National Heart, Lung, and Blood Institute, National Institute
of Health, NIH Publication No. 04-5230, Bethesda, MD. 2003
www.nhlbi.nih.gov/guidelines/hypertension/
Algorithm for Treatment of Hypertension
Lifestyle Modifications
Not at Goal Blood Pressure (<140/90 mmHg)
(<130/80 mmHg for those with diabetes or chronic kidney disease)
Initial Drug Choices
Without Compelling
Indications
With Compelling
Indications
Stage 1 Hypertension
Stage 2 Hypertension
(SBP 140–159 or DBP 90–99 mmHg)
Thiazide-type diuretics for most.
May consider ACEI, ARB, BB, CCB,
or combination.
(SBP >160 or DBP >100 mmHg)
2-drug combination for most (usually
thiazide-type diuretic and
ACEI, or ARB, or BB, or CCB)
Drug(s) for the compelling
indications
Other antihypertensive drugs
(diuretics, ACEI, ARB, BB, CCB)
as needed.
Not at Goal
Blood Pressure
Optimize dosages or add additional drugs
until goal blood pressure is achieved.
Consider consultation with hypertension specialist.
NIH Publication No. 04-5230, 2003.
•
Common method is brachial artery auscultation
− listening to the sounds of Korotkoff on arterial walls
− reported accuracy of indirect auscultation is within 10% of direct measures
Theory of Auscultation
•
Korotkoff sounds heard through stethoscope during BP measurement come
from the turbulence of blood in the artery
− blood moving from an area of high pressure to area of lower pressure
•
Pressure inside BP cuff occludes brachial artery blood flow
− pressure in artery equals the pressure inside the BP cuff, first sound = SBP
− artery is fully opened, Korotkoff sounds disappear, pressure inside cuff = DBP
A. BP, taken with stethoscope
B. Sphygmomanometer, inflatable cuff
C. Connected by rubber tubes to
monometer, measures pressure in
millimeters of mercury
D. Rubber bulb regulates air during
measurements
E. BP, force of blood against walls of
arteries and veins created by the heart
F. BP cuff fits over brachial artery
G. Common carotid artery, upper circle
H. Radial artery, lower circle for HR
Korotkoff Sounds
•
Phase 1. First, initial sound or the onset of sound. Sounds like: clear, repetitive
tapping. This sound approximates SBP
− maximum pressure that occurs near the end of the stroke output or systole of LV
− SBP reflects the force of contraction of the left ventricle
•
Phase 2. Sounds like: soft tapping or murmur.
− described as having a swishing component
− typically 10 to 15 mmHg after onset of sound or below the phase 1 sounds
•
Phase 3. Sounds like: loud tapping sound; high in pitch/intensity
− sounds are crisper and louder than the phase two sounds
•
Phase 4. Sounds like: muffling, ↓ in sound intensity
− Often considered as true DBP
•
Phase 5. Sounds like: complete disappearance of sound
− Known as clinical DBP
Three major phases of Korotkoff sounds
120 mmHg
Phase 1
SBP
Sharp tapping
sound
Phase 4
DBP
Muffling
sound
Phase 5
Clinical DBP
Silence
First sound
90 mmHg
Substantial decrease in
sound intensity
80 mmHg
Disappearance of sound due to
laminar flow – non-turbulent
• Sphygmomanometer: consists of manometer and BP cuff
− sphygmo- refers to the occlusion of the artery by a cuff
− manometer is device used to measure pressure
• Cuff consists of a rubber bladder and two tubes;
− one to the manometer
− one to a hand bulb with a valve that is used for inflation
• Three common BP cuff sizes
− pediatric cuff for small arm sizes (13 to 20 cm)
− normal adult cuff arm sizes between (24 and 32 cm)
− large adult cuff for larger arm sizes (32 to 42 cm)
1. Position BP cuff on the upper arm over you client's brachial artery with the
cuff at heart level and secure
− Client's arm should be slightly flexed at elbow
2. Firmly place the bell of stethoscope over the artery in the antecubital fossa
3. Inflate BP cuff up to 150 to 180 mmHg, for a resting BP
4. Deflate the pressure slowly; 2 to 3 mmHg per heartbeat
− or 2 to 5 mmHg /sec
5. Record measures of SBP and DBP in even numbers
6. Deflate the cuff rapidly to zero after DBP is obtained
7. Wait one full minute before redoing the BP measurement
• BP response to ex often-used as criterion for test termination
− SBP marker of left ventricular function during exercise, SBP should rise
during aerobic ex (graded or steady-state, constant load ex)
− DBP remain the same as at rest or slightly decline
• An abnormal exercise SBP response may
predict future resting hypertension
− individuals with large ↑ in SBP during GXT more
likely to develop hypertension
• BP should be taken every 3min during XT
− tape cuff to the arm with adhesive surgical tape
− pump cuff up higher than for a resting BP; 180 to
200 mmHg starting point
− as ex intensity ↑ SBP rises, may need to pump cuff
up higher; > 220 mmHg may be necessary
Abbreviations: XT = exercise testing; GXT = graded exercise test
Neiman (2006). Exercise Testing and Prescription - A Health-related approach (6th ed.). New Boston: McGraw Hill.
Pattern of SBP and DBP during graded exercise testing
During exertion, DPB remains similar to resting DPB reading,
whereas SPB rises linearly with the increase in workload
• Mean arterial pressure (MAP), mean BP in the arterial system
− MAP represents integration, or combination, of both SBP and DBP
Formula for Mean Arterial Pressure
MAP = DBP + (0.33 [SBP – DBP])
• Calculate the following;
− SBP 150 mmHg and DBP 80 mmHg
Blacher et al. Arch Intern Med 160(8), 1085-1089, 2000.
• Pulse pressure (PP), difference between SBP and DBP
− PP is the change in BP seen during a contraction of the heart
− PP provides an approximation of SV
− high PP important risk factor for heart disease
Formula for Pulse Pressure
PP = SBP – DBP
• Calculate the following;
− SBP 140 mmHg and DBP 84 mmHg
ACSM HRPFAM. p40, 2008.
• Rate pressure product (RPP), or double product (DP), reflects
myocardial (heart) oxygen demand or consumption (mVO2)
− oxygen demand of heart related to workload of heart
− RPP is the product of HR and SBP
− useful in exercise testing and training clients with cardiovascular disease
Formula for Rate Pressure Product
RPP = (HR ⋅ SBP) ⋅ 10–2
• Calculate the following;
− HR 120 bpm and BP 150/90 mmHg during submax XT
Note: 10–2 = 0.01
• Heart rate (HR) can be measured by several techniques;
−
−
−
−
Palpation of pulse at an anatomical site
Auscultation using a stethoscope
Electric HR monitor/watches
Electrocardiography
• Palpation or auscultation;
− measure number of beats in 15s or 30s, multiply to
convert to 1-min value (bpm)
− 30s count more accurate, less prone to error
• Calculating target HR (THR)
− Karvonen formula
− factors in RHR to calculate THR
1.
2.
3.
4.
• Ex HR in clinic best determined by electrocardiography (ECG)
− Use a heart rate ruler
− Count the number of large squares between R waves and divide into 300
9 2 large blocks between R waves, HR formula 300/2 = 150 bpm
− Count the number of millimeters between four R waves and divide into 6,000
9 40 mm separate for R waves, HR formula 6000/40 = 150 bpm
Normal response to GXT in healthy subjects
Fletcher et al. Circulation 104: 1694-1740, 2001.
• Measurement of HR and BP, both at rest and during exercise, is
central in AEP assessment
• BP skill is especially important to client's overall heart health
− BP used in risk stratification
− Blood Pressure Calculations
9 Mean arterial pressure
9 Pulse pressure
9 Rate of pressure product
• HR measurement and calculation important in ExRx
− HR measured from the ECG strip several ways
− Karvonen formula
1. What are NIH Classifications of blood pressure for adults?
2. What is White Coat Syndrome ?
3. What is cardiac output (Q) used to express?
4. How is Q calculated?
5. Blood pressure calculations
•
MAP, PP, RPP
6. Calculate THR zones at 60% & 80% using Karvonen formula