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Manual and Oscillometric Blood Pressure in tPA-Treated Acute Ischemic Stroke: What Constitutes Agreement?
Mary A Grove1, Mani Paliwal1, Anne Shearin2
1Hackensack Meridian Health Edison NJ.
Insights
Noninvasive blood pressure (NIBP) devices show poor agreement with manual measurements in patients receiving alteplase. Systolic blood pressure (SBP) derived from NIBP is particularly inaccurate, challenging current thrombolysis guidelines.
Area of Science:
- Biomedical Engineering
- Clinical Medicine
- Cardiovascular Research
Background:
- Noninvasive blood pressure (NIBP) devices algorithmically derive systolic (SBP) and diastolic (DBP) blood pressure from mean arterial pressure (MAP).
- SBP is the least accurate NIBP measurement, yet it is critical for managing blood pressure (BP) in patients undergoing thrombolysis.
- This study investigates the agreement between manual and NIBP measurements in patients treated with alteplase.
Purpose of the Study:
- To determine the agreement between SBP, DBP, and MAP measured manually versus by NIBP.
- To assess the clinical implications of NIBP inaccuracies in patients receiving alteplase therapy.
Main Methods:
- A multisite prospective observational study involving 95 patients treated with alteplase.
- Comparison of 475 paired manual and NIBP BP measurements using Bland-Altman analyses and Lin concordance correlation coefficient.
- Manual BP measurements were taken by two investigators using dual stethoscopes.
Main Results:
- Significant discrepancies were found between NIBP and manual BP measurements across SBP, DBP, and MAP.
- Lin's concordance correlation coefficients were 0.8 for SBP, 0.69 for DBP, and 0.7 for MAP.
- NIBP measures failed to meet guideline recommendations for BP measurement agreement.
Conclusions:
- NIBP devices yield significantly different BP readings compared to manual auscultation.
- The reliance of NIBP on MAP, rather than direct SBP/DBP measurement, necessitates defining safe MAP thresholds for alteplase therapy.
- Clinical practice using automatic BP measurement in alteplase-treated patients requires careful consideration of device-specific limitations.
Background:
Automatic noninvasive oscillometric blood pressure (NIBP) devices measure mean arterial pressure (MAP); systolic and diastolic blood pressure (SBP, DBP) are algorithmically derived from MAP. The most invalid NIBP measure is SBP, yet stroke practitioners use it to manage blood pressure (BP) in accordance with thrombolysis guidelines. We determined agreement between SBP, DBP, and MAP measured manually and by NIBP in patients treated with alteplase.
Methods:
A multisite prospective observational study of NIBP and manual BP agreement was conducted in patients treated with alteplase immediately after bolus and infusion initiation using methods established in guidelines for the assessment of device agreement. Dual auscultatory stethoscopes were used by 2 investigators to ensure agreement with each manual BP variable and MAP was calculated using the standard formula for manual BP measures. Data were analyzed using Bland-Altman analyses and Lin concordance correlation coefficient.
Results:
A total of 7 hospitals participated, collecting 5 sets of manual/NIBP BPs in 95 patients treated with alteplase (475 paired measures). Range in limits of agreement were SBP: -28.91 to 21.41 mmHg with Lin's concordance correlation coefficient 0.8; DBP: -21.0 to 19.0 mmHg with Lin's concordance correlation coefficient 0.69; and MAP: -27.5 to 16.5 mmHg with Lin's concordance correlation coefficient 0.7. There was no difference in device agreement by BP device manufacturer brand. Differences in SBP, DBP, and MAP between NIBP and manual sphygmomanometry failed to reach guideline recommendations requiring 80% of measures to fall within a 5 mmHg difference and 95% of measures to fall within a 10 mmHg difference.
Conclusion:
NIBP devices produce significantly different BP measures then manual sphygmomanometry auscultated BP. Because NIBP devices rely on the MAP and do not directly measure SBP and DBP, definition of what constitutes safe MAP boundaries in patients treated with alteplase should be determined when automatic BP measurement is used in clinical practice.
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