University of Zagreb

Faculty of Electrical Engineering

and Computing

Biomedical Instrumentation
Blood pressure measurement

prof.dr.sc. Ratko Magjarević

October 2018
 Blood pressure
• Blood pressure is the lateral pressure on the
blood vessel wall surface
• The difference in blood pressure (pressure
gradient) between the aorta and vena is a
result of heart beating, which is the main
activator of blood in the cardiovascular
system
• During heart muscle relaxation, pressure still
exists in the veins as a result of vein blood
charge and contraction of smooth muscle in
the vessel wall.
 Blood pressure
• Blood pressure is influenced by:
• cardiac output,
• total peripheral resistance and
• arterial stiffness.
BP varies depending on:
• situation,
• emotional state,
• activity, and
• relative health/disease states.
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 Arterial stiffness
• Blood pressure is influenced by:
• cardiac output,
• total peripheral resistance and
• arterial stiffness.
BP varies depending on:
• situation,
• emotional state,
• activity, and
• relative health/disease states.
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 Cardiac output

Cardiac output (CO) is a term used in cardiac physiology that describes the
volume of blood being pumped by the heart, in particular by the left or right
ventricle, per unit time. Cardiac output is the product of the heart rate (HR), or the
number of heart beats per minute (bpm), and the stroke volume (SV), which is the
volume of blood pumped from the ventricle per beat; thus
CO = HR × SV. 5
Values for cardiac output are usually denoted as L/min.
 Blood vessels pressure and
flow
• The character of blood pressure and flow
in arteries is pulsating
• Flow in veins and capillaries is
– mostly static,
– pressure is significantly lower than in arteries,
– difficult to palpate pulse
Relations of significant values in different parts
of the circulatory system

Mean arterial pressure,

blood flow velocity, vessel
cross-sectional area and the
blood volume in the veins
of sistematic blood
circulation
AO - aorta,
VA - great arteries,
MA - small arteries,
ART - arterioles,
DROP - capillaries,
VEN - venules,
MV - small veins,
VV - large veins,
VK – vena cava
• Mean arterial blood pressure approximately
corresponds to aorta medium pressure. In arterioles
there is a signicifant pressure drop and pulse
attenuation
• Blood flow velocity in any part of the circulatory system
is inversely proportional to the cross sectional area of
all vessels in that segment
• Mean flow velocity in capillaries is approx. thousand
times lower than in the aorta, because the total cross-
sectional area of capillaries is approx. thousand times
greater than the cross sectional area of the aorta
• Since the flow velocity is not the same throughout the
vessel cross section, mean velocity is considered
• Blood flow velocity gradually increases on the way
toward the right atrium.
• Venous system volume capacity is significantly larger
(about 65% of the total volume of blood is in the veins)
 https://www.youtube.com/watch?reload=9&v=nKjxwyl8uKM
http://www.fed.cuhk.edu.hk/~johnson/teaching/transport/animations/HyperHeart.swf
Cardiac cycle
 Arterial blood pressure
p [mmHg] 130 Systolic pressure
120
110 Medium
100 arterial Pulse pressure
90 pressure
80
70 Diastolic pressure
60
50
40
30
20
10
t [s]
0
0 1 t1 2 t2 3 4

• Typical pressures:
– systolic (maximum)
– diastolic (minimum)
– mean arterial pressure psr
– pulse pressure
 Characteristic values of arterial
pressure
• Pressure changes rhythmicaly between the maximum
and minimum values depending on the heart action.
The highest stage is the systolic ejection of blood from
the heart (maximum or systolic pressure) and the
lowest is diastolic end (minimum or diastolic pressure).
• Mean arterial pressure is defined as mean waveform
arterial pressure
• Mean arterial pressure is not equal to the arithmetic
mean of systolic and diastolic pressure. It is slightly
closer to diastolic values
• Pulse pressure is the difference between systolic and
diastolic pressure
 Blood pressure measuring units
• Blood pressure is measured in millimeters of
mercury, mm Hg
• mmHg is not SI units, but is allowed for
expressing blood pressure
• 1 kPa = 7.5 mmHg
kPa mmHg mbar cmH2O PSI
kPa 1,000 7,5006 10,000 10,1973 0,14504
mmHg * 0,13332 1,000 1,3332 1,3595 1,9377 10-2
mbar 0,100 0,75006 1,000 1,01973 0,01450
cmH2O ** 0,09806 0,7355 0,9806 1,000 1,4223 10-2
PSI *** 6,8948 51,715 68,948 68,948 1,000

• Units in the line are converted into units in a column by multiplying by a

factor in the table. * at 0 °C, ** at 4 °C *** PSI - pounds per square
inch.
 Normal blood pressure
• Normal blood pressure is 120/80 mmHg
mm[Hg] Systolic Diastolic
pressure pressure
Normal < 140 < 90
Borderline hypertension 140 - 160 90 – 95
Hypertension > 160 > 95
Isolated sistolic > 160 < 90
hypertension

• Hypertension - Blood pressure high

• Hypotension - Blood pressure low
Blood pressure measurement
• Each vessel has its own blood pressure
value
• Blood pressure depends on where it is
measured
• Each heart beat results in different blood
pressure
• Primarily to measure arterial pressure and
its two values: systolic pressure and
diastolic pressure
Blood pressure measurement
• Invasive methods (direct)
– Retracting the catheter into a blood vessel
– Intravascular or external pressure sensor (into the vein)
Advantages:
– The most accurate method
– Gives a total pressure waveform
Disadvantages:
– Invasiveness, the possibility of infection, the possibility of
embolism
– Application in hospital conditions
– External blood pressure sensor - it is necessary to mind
the resonant frequency
Blood pressure measurement
• Non invasive (indirect) methods
– Pressure is measured indirectly, usually using
cufflinks
– Do not measure the pressure in the blood
vessel
Lower accuracy comparing to direct methods
Korotkov Method (Riva-Rocci
auscultatory method)
 Korotkov method
• Cuff wrapped around the upper arm
• Put the stethoscope in the cubital fossa , distal to the cuff
• Pump inflate the cuff above the expected systolic pressure
• The pressure in the cuff overcomes the brachial artery
pressure
• Open the valve and empty the cuff 3-5 mmHg per beat
• When the cuff pressure drops to a value of systolic blood
pressure , Korotkovljev noise (phase I) hearable in the
stethoscope
• The pressure in the cuff at that point is the systolic pressure
• Further cuff discharge changes the intensity and character of
the Korotkov noise
• When the noise is silenced and lost (Phase IV) , the cuff
pressure corresponding to diastolic pressure
 Korotkov method
• Korotkov noise is due to turbulence of blood flowing through
partly open artery

• Accuracy comparison of auscultatory methods to invasive

methods:
– Systolic pressure error : -2 mmHg
– Diastolic pressure error : +4 to +10 mmHg
• Error due to hydrostatic pressure
– None if the place of measurement is on the same level as heart
• Accuracy can be affected by the width of cufflinks
• Standard width of an average population is 12 cm
• If upper arm has a large volume, the cuff must be broader
 Korotkov method
• Kortkov method can be automatized in
terms of cuff inflation and drain,
microphone recording of Korotkov noise
instead of a stethoscope, and automatic
recognition of noise
• Disadvantage of such automated methods
is in microphone recording of other
ambient sounds which makes it difficult to
identify the Korotkov noise
 Oscillometric method

• Cuff pressure with superimposed Korotkoff sounds, which appear between

systolic and diastolic pressures. Bottom: the oscillometric method detects
when the amplified cuff pressure pulsations exceed about 30% of maximal
pulsations.
 Oscillometric method
• Oscillometric method is based on pressure fluctuations that occur
due to arterial pulsation in the pressure cuff during inflation or
discharge
• Cuff is inflated above the expectation values of systolic pressure and
begins to discharge
• During the discharge waveform of pressure cuff is recorded
• The pressure in the cuff has a caused slow drop-down discharge
component and a superimposed small component of the pressure
oscillations in the cuff
• These oscillations exist above sistolic pressure and below diastolic
pressure
• Oscillation amplitude changes, grows, reaches its maximum and
then decreases
• Oscillations maximum correspondes to the moment when the
pressure in the cuff is equal to mean arterial pressure
• Systolic and diastolic blood pressure are determined indirectly by
oscillometric method, based on the mean arterial pressure and
empirically determined ratios
 Oscillometric method
• Systolic ratio:
ksyst = Asyst / Amax (typ 0.5)

• Diastolic ratio:
kdiast = Adiast / Amax (typ 0.4-0.7)

• Systolic pressure is measured as the mean pressure in the

cuff, which is higher than the mean arterial pressure and has
amplitude fluctuations Asyst and maximum amplitude Amax
ratio (systolic ratio) equal to a defined value ksyst.
• Diastolic pressure is defined as the mean pressure in the cuff,
which is lower than the mean arterial pressure and has
amplitude fluctuations Adiast and maximum amplitude Amax
ratio (diastolic ratio) equal to a defined value kdiast

• Method error : 5-10 mmHg

Sphygmomanometer
• Upper Arm Blood
Pressure Meter
• Digital meters employ oscillometric
measurements and electronic
calculations rather than
auscultation.
• They may use manual or automatic
inflation, but both types are
electronic, easy to operate without
training, and can be used in noisy
environments.
• They measure systolic and diastolic
pressures by oscillometric
detection, employing either
deformable membranes that are
measured using differential
capacitance, or differential
piezoresistance
Continuous blood pressure measurement
using pulse transit time (PTT)
• PTT is defined as the time it takes the
pulse wave to travel between two
arterial sites within the same cardiac
cycle. This time is related to the
propagation velocity of the pulse wave.
• functional relation between arterial wall
stiffness, pulse wave velocity and BP
• used for absolute BP measurement when
combined with calibration
• BP monitoring during sleep
Determination of PTT
including the pre-ejection From: A. Hennig, A. Patzak, Continuous blood pressure
period. ECG measurement using pulse transit time, Somnologie -
electrocardiogram, PCG Schlafforschung und Schlafmedizin 2013, 1-7
phonocardiogram, PPG
photoplethysmogram
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 Literature
• John G. Webster: Medical Instrumentation,
Chapter 7, Blood Pressure and Sound
• (A. Šantić, “Biomedicinska elektronika”,
poglavlje 7.1 “Mjerenje krvnog tlaka invazivnim
metodama” i 7.2 “Neinvazivne metode mjerenja
krvnog tlaka”)

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