130/80 is the New 140/90? Hypertension Guideline Update · J Hypertension 2017;71(1):1-167. Measuring Blood Pressure Support the patient’s arm. Position the cuff at midpoint of

130/80 is the New 140/90?

Hypertension Guideline UpdateJennifer L. Rosselli, Pharm.D., BCPS, BCACP

Southern Illinois University Edwardsville School of Pharmacy

SIHF Healthcare

Jennifer Rosselli declares no conflicts of interest, real or

apparent, and no financial interests in any company,

product, or service mentioned in this program, including

grants, employment, gifts, stock holdings and honoraria.

Disclosures and Conflict of Interest

At the conclusion of the program, the pharmacists will be

able to:

1. Identify methods to properly measure blood pressure.

2. Classify blood pressure measurements according to the

2017 ACC/AHA high blood pressure guidelines.

3. Discuss evidence-based treatment plans for managing

hypertension.

Pharmacist Objectives

Which of the following lifestyle modifications can have the

greatest blood pressure lowering effects?

A. Decreased alcohol consumption if excessive

B. Increased physical activity

C. DASH diet (decreased sodium and increased potassium intake)

D. Weight loss of 1 kilogram

Pre-Test Question 1

Which of the following is the correct way for a patient to be

positioned when a health care provider is measuring blood

pressure?

A. Seated upright on an examination table

B. In the supine position on an examination table

C. Seated upright on a bench or backless chair

D. In the supine position on the floor

E. Seated upright in a chair with back support

Pre-Test Question 2

According to the 2017 ACC/AHA high blood pressure guideline,

which of the following is the correct classification of a 3-visit

average blood pressure 136/88 mmHg?

A. Normal blood pressure

B. Pre-hypertension

C. Elevated blood pressure

D. Stage 1 hypertension

E. Stage 2 hypertension

Pre-Test Question 3

Joint National Committee (JNC): Where

Hypertension (HTN) Management Has Been

Classification of Blood Pressure*

Systolic Blood Pressure

(SBP) mmHg

Diastolic Blood Pressure

(DBP) mmHg

JNC 7

< 120 And < 80 Normal blood pressure (BP)

120-129 And < 80Prehypertension

130-139 Or 80-89

> 140 Or > 90 Stage 1 hypertension


> 180 And/or > 120 Hypertensive urgency or

emergency**

* Individuals with SBP and DBP in 2 categories should be designated to the higher BP category

**urgency=no target organ damage (TOD), emergency=acute or progressive TOD

***Classified after an average of > 2 careful readings obtained on > 2 occasions.

JAMA 2003;289(19):2560-72.

BP Goals for Patients with HTN: JNC8

Patient Population BP Goal

General population > 60 years < 150/90 mmHg

General population < 60 years

< 140/90 mmHgDiabetes (DM)

Chronic Kidney Disease (CKD)

JAMA 2014;311(5):507-20.

2017 ACC/AHA High Blood Pressure

Guideline

Classification of Blood Pressure*

SBP mmHg DBP mmHg JNC 7 2017 ACC / AHA***

< 120 And < 80 Normal BP Normal BP

120-129 And < 80Prehypertension

Elevated

130-139 Or 80-89 Stage 1 hypertension

> 140 Or > 90 Stage 1 hypertensionStage 2 hypertension


> 180 And/or > 120 Hypertensive urgency or emergency**

* Individuals with systolic BP and diastolic BP in 2 categories should be designated to the

higher BP category

**urgency=no target organ damage (TOD), emergency=acute or progressive TOD

***Classified after an average of > 2 careful readings obtained on > 2 occasions.

JAMA 2003;289(19):2560-72.

J Hypertension 2017;71(1):1-167.

Measuring Blood Pressure

✓The patient should be sitting with feet on floor and back

supported for > 5 minutes.

✓Patient should avoid caffeine, exercise, or smoking for at

least 30 min. before measurement.

✓Remove all clothing where the cuff will touch the patient.

✓Ensure patient has emptied his/her bladder.

✓Neither the patient nor the observer should talk during the

rest period or during the measurement.


Measuring Blood Pressure

✓ Support the patient’s arm.

✓Position the cuff at midpoint of the sternum.

✓Use a cuff of the correct size for the patient. At first visit,

record BP in both arms. Use arm that gives higher reading for

subsequent readings.

✓ Separate repeated measurements by 1 – 2 minutes.

✓For auscultatory readings, deflate the cuff pressure 2 mmHg

per second when listening for Korotkoff sounds.

*See Table 8 in 2017 ACC/AHA guidelines for all steps and complete checklist


Out-of-office BP Measurements

In-office BP measurements are recognized as being inconsistent with out-of-office measurements

Recommended uses

To identify masked hypertension in patients with persistently elevated BP without HTN diagnosis or if normotensive but has TOD or CVD risk increased

To confirm a HTN diagnosis if BP 130-160/80-100 mmHg

To assist in need for dose adjustments of antihypertensive therapy if BP within 10 mmHg above goal

Ambulatory BP monitoring (ABPM) over 24 hours is preferred method; however, home BP monitoring (HBPM) is usually more practical

See Table 10 of 2017 ACC/AHA guidelines for HBPM guidance &/or AHA website for patient instruction sheetJ Hypertension 2017;71(1):1-167.

Cardiovascular Disease (CVD) Risk

Factors Common to Co-exist with HTN

Modifiable Risk Factors* Relatively Fixed Risk Factors**

• Current cigarette smoking,

secondhand smoking

• Diabetes mellitus

• Dyslipidemia/hypercholesterolemia

• Overweight/obesity

• Physical inactivity/low fitness

• Unhealthy diet

• CKD

• Family history

• Increased age

• Low socioeconomic/educational

status

• Male sex

• Obstructive sleep apnea

• Psychosocial stress

*Factors that can be changed and, if changed, may reduce CVD risk.

**Factors that are difficult to change (CKD, low socioeconomic/educational status,

obstructive sleep apnea), cannot be changed (family history, increased age, male

sex), or, if changed through the use of current intervention techniques, may not

reduce CVD risk (psychosocial stress).J Hypertension 2017;71(1):1-167.

Blood Pressure Management:

2017 ACC/AHA HBP Clinical Practice Guideline

< 120 and

< 80

Healthy Lifestyle Choices

Annual BP Check

120 – 129 and < 80

Healthy Lifestyle Changes

Reassess in

3–6 months

130-139 or 80-89


Initiate BP medications if clinical ASCVD*, or

10-yr ASCVD risk. > 10%**

If 10-yr risk < 10%, reassess in 3-6 mo.

If > 10% risk, f/u monthly


Initiate 2 different classes of

medications

>140 or

> 90

Reassess in

3–6 months

Monthly follow ups until BP controlled


BP Range Treatment and Follow-up

Normal

Elevated

Stage 1

Stage 2

Once BP

goal met,

f/u every

3-6 mo

*BP threshold = > 140/90 when starting BP lowering

medication in secondary stroke management

**Use Pooled Cohort Equations to estimate ASCVD risk

Dashing to Lower Blood Pressure

DASH-style eating plan to decrease Na+ intake and increase K+ intake

Reduce Na+ intake to 2300 mg/day. Start by decreasing by 1000 mg/day. Limit of 1500 mg/day optimal, but often not achievable.

Increase K+ intake to at least 90 mmol (3510 mg)/day

Can reduce BP approx. 11 mmHg

Weight loss if not at ideal body weight

1 kg can decrease BP by 1 mmHg

Increased physical activity

Mixture of activities including aerobic, resistance training, and isometric exercises are beneficial

Can reduce BP up to 8 mmHg

Decrease alcohol consumption if excessive

Can reduce BP up to 4 mmHg

https://www.nhlbi.nih.gov/health-topics/dash-eating-plan


Selecting Medications for HTN: 2017 ACC/AHA

Indication Preferred medication

1st-line for general population including diabetes Thiazide, ACEI, ARB, or CCB

Atrial fibrillation ARB

Black patients with or without diabetes Thiazide or CCB

CKD categories G3-G5 or G1-2 plus albuminuria > 300 mg/g ACEI or ARB if ACEI not tolerated

Heart failure with preserved ejection fraction (HFpEF) Diuretics for volume overload

ACEI or ARB + BB

Stable ischemic heart disease (SIHD) BB, ACEI, or ARB based on compelling

indications

Add CCB to BB if angina + uncontrolled BP

Post-kidney transplant CCB

Pregnancy Methyldopa, nifedipine, or labetalol

Stroke or transient ischemic attack Thiazide, ACEI, ARB, or thiazide + ACEI


ACEI=ace inhibitor, ARB=angiotensin receptor blocker, CCB=calcium channel blocker, BB=beta blocker,

CKD=chronic kidney disease

BP Goals for Patients with HTN: 2017 ACC/AHA

Patient Population BP Goal

No ASCVD and 10-yr risk <10%*

< 130/80 mmHg

10-yr ASCVD risk >10%

Known ASCVD (SIHD, stroke or TIA, history of MI)

Diabetes

Chronic Kidney Disease or Post-kidney

Transplant

Heart Failure Reduced EF (HFrEF)

Heart Failure Preserved EF (HFpEF)

< 130 SBP mmHgAdults > 65 years† living independently in the

community

Lacunar Stroke


*Weak recommendation. Evidence largely supports <140/90 mm Hg goal

† More lenient BP goal may be appropriate for patients with multiple

comorbidities, shorter life expectancy, high fall riskASCVD=atherosclerotic cardiovascular disease, SIHD=stable ischemic heart disease, TIA=transient ischemic

attack, MI=myocardial infarction, SBP=systolic blood pressure

Evidence-based Dosing for Primary

Agents (truncated version)

Medication Initial Daily Dose

(mg)

Target Dose

(mg)

Daily

Administration

Frequency

Thiazide-type diuretics

Chlorthalidone 12.5 12.5 – 25 1

Hydrochlorothiazide 12.5 – 25 25 – 50 1 - 2

Indapamide 1.25 1.25 – 2.5 1

Calcium channel blockers - dihydropyridines

Amlodipine 2.5 10 1

Nifedipine LA 30-60 60-120 1

Calcium channel blockers – non-dihydropyridines

Diltiazem ER 120 – 180 120-480 1

Verapamil SR 160 240-480 1 - 2

JAMA 2014;311(5):507-20.


Evidence-based Dosing for Primary

Agents (truncated version)

Medication Initial Daily

Dose (mg)

Target Dose

(mg)

Daily

Administration

Frequency

ACE-inhibitors

Benazepril 10 20 - 40 1 - 2

Enalapril 5 20 1 - 2

Lisinopril 10 40 1

Ramipril 2.5 2.5 - 10 1 - 2

Angiotensin receptor blockers

Eprosartan 400 600 – 800 1 – 2

Candesartan 4 12 – 32 1

Losartan 50 100 1 – 2

Valsartan 40 – 80 160 – 320 1

Irbesartan 75 300 1JAMA 2014;311(5):507-20.


Resistant Hypertension

Management of Resistant Hypertension

Exclude pseudoresistance

Address contributing

lifestyle factors

Discontinue or minimize

interfering substances

Screen for secondary

causes

Maximize diuretic therapy

(chlorthalidone or indapamide

instead of hydrochlorothiazide)

Add mineralocorticoid receptor

antagonist

Add other agents with different

mechanisms

Use loop diuretics in CKD

When average office BP > 130/80 mmHg in patients adhering to

> 3 antihypertensive agents from different classes at optimal doses,

including a diuretic; or requiring > 4 antihypertensive medications.

Ann Intern Med. 2018;168:351-58.

Key Clinical Trials

SPRINTing to Lower Blood Pressure GoalsSystolic Blood Pressure Intervention Trial (SPRINT)

Population N=9,361

Age > 50 yrs (median age 67.9 yrs), baseline SBP 130-180 mmHg (mean

139.7 mmHg) and increased CV risk

Excluded patients with diabetes or stroke

Intervention Compared treatment to SBP goal < 120 mmHg vs. < 140 mmHg

Any antihypertensive medications could be used

Median follow-up 3.26 years (planned to follow-up for 5 years)

Stopped early due to the 25% reduction in major adverse CV events in

the intensive treatment group

Primary outcome Composite MI, other type of ACS, stroke, acute HF, or death from CV

causes

• 5.2% vs. 6.8%; HR 0.75 (95% CI, 0.64 to 0.89; p < 0.001)

• NNT=62 over 3 years

May see higher incidence of hypotension, syncope, electrolyte abnormality, and acute kidney

injury when pursuing SBP < 120 mmHg.N Engl J Med. 2015;373:2103-16.

SPRINTing to Lower Blood Pressure Target

ACCORDing to Diabetes Status

SPRINT-Eligible Participants of Action to Control Cardiovascular Risk in Diabetes Blood Pressure

(ACCORD-BP) Trial

Population N=1,258

Post-hoc analysis of ACCORD-BP participants in the standard glucose control arm

and had additional CVD risk factors required for SPRINT eligibility.

Intervention Intensive BP control (goal SBP < 120 mmHg) and standard BP control (goal SBP <

140 mmHg)

Primary outcome Composite MI, any revascularization, stroke, heart failure, or death from CV

causes (primary from SPRINT)

• HR 0.79 (95% CI, 0.65 to 0.96; p=0.02)

Composite CVD death, nonfatal MI, and nonfatal stroke (primary from ACCORD-BP)

• HR 0.69 (95% CI, 0.51 to 0.93; p=0.01)

Consider more strict BP goal < 130/80 mmHg in patients with T2DM plus high risk of CV events. BP

goal < 140/90 mmHg reasonable for patients at lower risk of CV events, frail older adult, if risk of

medication-related adverse events is high, and when pill burden or costs are unacceptable.

Diabetes Care. 2017;40:1733-38.

PATHWAY to Managing Resistant HypertensionSpironolactone vs. placebo, bisoprolol, and doxazosin to determine optimal treatment for drug-

resistant hypertension (PATHWAY-2) trial

Population N=335

Age 18-79 years, uncontrolled seated SBP > 140 mmHg, > 135 mmHg with

diabetes and treated x > 3 months with maximally tolerated doses of ACE-I or

ARB, CCB, and a diuretic (except spironolactone)

Intervention Cross-over trial of patients receiving spironolactone 25 mg and 50 mg,

bisoprolol 5 and 10 mg, doxazosin 4 and 8 mg, and placebo each for 12

weeks. Medication doses were doubled after 6 weeks of each cycle.

Median follow-up 12 week, 4 treatment cycles

Primary outcome Difference in averaged home SBP

• Spironolactone vs. placebo: -8.7 mmHg (95% CI, -9.72 to -7.69; p < 0.0001)

• Sprinolactone vs. mean bisoprolol & doxazosin: -4.26 (95% CI, -5.13 to -

3.38; p < 0.0001)

• Spironolactone vs. doxazosin: -4.03 (95% CI, -5.04 to -3.02; p < 0.0001)

• Spironolactone vs. bisoprolol: -4.48 (95% CI, -5.50 to -3.46; p < 0.0001)

Lancet. 2015;386:2059-68.

Administering Antihypertensives at BedtimeAmbulatory Blood Pressure Monitoring for Prediction of Cardiovascular Events (MAPEC) Trial

Population N=2156

Mean age 55.6 ± 13.6 yrs, mean clinic BP 155/87 mmHg, mean 48-h

ambulatory BP 130/78 mmHg, 54-55% non-dippers (sleep-time relative SBP

decline <10%)

Excluded for type 1 DM or CV disease, nephropathy, retinopathy

Intervention Compared administering all antihypertensive agents in the morning vs. at

least 1 medication at bedtime.

BP evaluated via 48 hour ambulatory BP monitor

Median follow-up 5.6 years

Primary outcome Composite of death from all causes, MI, angina pectoris,

revascularization, heart failure, acute arterial occlusion of lower

extremities, aortic aneurysm rupture, thrombotic occlusion of retinal

artery, hemorrhagic stroke, ischemic stroke, and TIA.

• ARR 0.39 (95% CI, 0.29 to 0.51; p < 0.001)

Secondary outcome Major CVD events (CVD deaths, MI, ischemic stroke, hemorrhagic stroke

• ARR 0.33 (95% CI, 0.19 to 0.55; p < 001)Chronobiol Int. 2010;27:1629-51.

Can Self—Monitoring Lower Blood Pressure?Efficacy of self-monitored blood pressure, with or without telemonitoring, for titration of

antihypertensive medication (TASMINH4) – unblinded, parallel, randomized trial

Population N=1173 enrolled, N=1003 (85%) included in analysis

Mean age > 66.9 yrs (SD 9.4), baseline SBP > 145 mmHg (mean BP 153.1/85.5

mmHg, SD 14.0/10.3), > 95% White, taking < 3 antihypertensive agents

Intervention Compared self-monitoring alone (readings mailed to provider), self-

monitoring with telemonitoring (readings sent via email/app to provider),

and usual care

Goal BP was 150/90 mmHg, physicians could adjust medications at any time

Primary outcome Systolic BP at 12 months

• Self-monitoring SBP 137.0 (SD 16.7) mmHg

• Telemonitoring 136.0 (SD 16.1) mmHg

• Usual care 140.4 (SD 16.5) mmHg

• Adjusted mean differences vs usual care: self-monitoring alone –3.5

mmHg (95% CI: –5.8 to –1.2), telemonitoring –4.7 mmHg (–7.0 to –2.4)

Secondary outcome • Cardiovascular events: 12 in self-monitoring, 11 in telemonitoring, 9 in usual care

• No difference in self-reported adherence rates, body weight, waist

circumference, lifestyle factors, or quality of life scores between the groups.Lancet. 2018; 391:949-59.

Questions??

Identify the errors in this health care practitioner’s blood

pressure measurement technique.

Post Test Question #1

According to the 2017 ACC/AHA high blood pressure guideline,

which of the following is the correct classification of a 3-visit

average blood pressure 136/88 mmHg?

A. Normal blood pressure

B. Pre-hypertension

C. Elevated blood pressure

D. Stage 1 hypertension

E. Stage 2 hypertension


You have begun providing a collaborative HTN management

service with one of the physician groups that have an office

in the same medical building where your pharmacy is

located.

Arrangements have been made for you to provide clinical

services. You have received a referral to assess and

determine therapy recommendations for a new patient who

has had high blood pressure readings during the last several

office visits.


Donald is a 63-year-old Black male patient with a 1-year history of type 2 diabetes. Current medications: metformin 1000 mg potwice daily, glipizide ER 10 mg po daily.

He has no known medication allergies or intolerances, and no other known medical problems other than T2DM.

He has no complaints today and says he feels great.

Social history: smokes 1 pack of menthol cigarettes every 2-3 days, drinks 1-2, 24-ounce cans of beer or shares a bottle of liquor with friends every SuperBowl once/year, smokes marijuana once/week.

Labs last week: A1C 6.7, glu 88, BUN 15, SCr 1.03, eGFR 88,

Na 142, K 4.4, Ca 9.8

TC 157, TG 157, HDL 46, LDL-d 68

Post Test Question #3, continued

Please develop a plan for Donald that includes the following:

Classification of blood pressure

Plan for nonpharmacologic therapy

Plan for drug therapy

Goal blood pressure with treatment

Plan for follow-up

Post Test Question #3, continued

Date Body Mass Index (mg/kg2) Blood Pressure (mmHg) Heart Rate

(beats per minute)

Today 30.9 168/82 (1st, right arm)

164/90 (2nd, left arm)

88 (regular)

3 months ago 30.7 164/82 (left arm) 90 (regular)

6 months ago 31.1 160/80 (1st left arm)

152/86 (2nd right arm)

78 (regular)

Blood pressure categories and terminology have changed.

Out-of-office BP measurements are valuable.

Use thiazide-type diuretics, ACEI, ARB, or CCB as first-line agents.

Optimize diuretics and consider spironolactone for resistant hypertension not at goal.

TAKE HOME POINTS

Normal systolic <120 mmHg and diastolic <80 mmHg

Elevated Blood Pressure systolic 120 to 129 mmHg and diastolic <80 mmHg

Stage 1 Hypertension systolic 130 to 139 mmHg or diastolic 80 to 89 mmHg

Stage 2 Hypertension systolic >140 mmHg or diastolic >90 mmHg

Patient instructions and recommendations for home blood pressure monitoring

➢ http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/SymptomsDiagnosisMonitoringofHighBloodPress%20ure/Home-Blood-Pressure-Monitoring_UCM_301874_Article.jsp#.WlPYJVQ-dAa

DASH diet resource

➢ https://www.nhlbi.nih.gov/health-topics/dash-eating-plan

Synopsis of 2017 guideline for high blood pressure in adults

➢ http://www.acc.org/latest-in-cardiology/ten-points-to-remember/2017/11/09/11/41/2017-guideline-for-high-blood-pressure-in-adults

Pooled Cohort Equations to estimate ASCVD risk

➢ http://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/

➢ https://itunes.apple.com/us/app/ascvd-risk-estimator-plus/id808875968?mt=8

➢ https://play.google.com/store/apps/details?id=org.acc.cvrisk&hl=en_US

Resources

http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/SymptomsDiagnosisMonitoringofHighBloodPress ure/Home-Blood-Pressure-Monitoring_UCM_301874_Article.jsp#.WlPYJVQ-dAa

https://www.nhlbi.nih.gov/health-topics/dash-eating-plan

http://www.acc.org/latest-in-cardiology/ten-points-to-remember/2017/11/09/11/41/2017-guideline-for-high-blood-pressure-in-adults

http://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/

https://itunes.apple.com/us/app/ascvd-risk-estimator-plus/id808875968?mt=8

https://play.google.com/store/apps/details?id=org.acc.cvrisk&hl=en_US

Chobanian AV, Bakris GL, Black HR, et al; Joint National Committee on Prevention, Detection, Evaluation, and Treatment of

High Blood Pressure. National Heart, Lung, and Blood Institute. Seventh report of the Joint National Committee on

Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42:1206-52. [PMID: 14656957]

James PA, Oparil S, Carter BL, et al. 2014 Evidence-based guidelines for the management of high blood pressure in adults:

report from the panel members appointed to the eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520.

Whelton PK, Carey RM, Aronow WS, et al. ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideine for the

prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of

Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2017. [PMID: 23929910]

Carey RM, Whelton PK, 2017 ACC/AHA Hypertension Guideline Writing Committee. Prevention, detection, evaluation, and

management of high blood pressure in adults: synopsis of the 2017 American College of Cardiology/American Heart

Association Hypertension Guideline. Ann Intern Med. 2018;168(5):351-358.

Wright JT Jr, Williamson JD, Whelton PK, et al; SPRINT Research Group. A randomized trial of intensive versus standard blood-

pressure control.nN Engl J Med. 2015;373:2103-16. [PMID 26551272] doi:10.1056/NEJMoa1511939.

Buckley LF, Dixon DL, Wohlford GF, Wijesinghe DS, Baker WL, Van Tassess BW. Intensive versus standard blood pressure control

in SPRINT-eligible participants of ACCORD-BP. Diabetes Care. 2017;40:1733-38. doi: 10.2337/dc17-11366.

Williams B, MacDonald TM, Morant S, et al; The British Hypertension Society's PATHWAY Studies Group. Spironolactone versus

placebo, bisoprolol, and doxazosin to determine the optimal treatment for drug-resistant hypertension (PATHWAY-2): a

randomised, double-blind crossover trial.

Hermida RC, Ayala DE, Mojon A, Fernandez JR. Influence of circadian time of hypertension treatment on cardiovascular risk:

results of the MAPEC study. Chronobiol Int. 2010;27(8)1629-51. doi: 10.3109/07420528.2010.510230.

McManus RJ, Mant J, Franssen M, et al. Efficacy of self-monitored blood pressure, with or without telemonitoring, for

titration of antihypertensive medication (TASMINH4): an unmasked randomised controlled trial. Lancet. 2018;391:949-59.

References

Speaker Contact InformationJennifer L. Rosselli, Pharm.D., BCPS, BCACP

[email protected]

130/80 is the New 140/90?

Hypertension Guideline UpdateJennifer L. Rosselli, Pharm.D., BCPS, BCACP

Southern Illinois University Edwardsville School of Pharmacy

SIHF Healthcare

130/80 is the New 140/90? Hypertension Guideline Update · J Hypertension 2017;71(1):1-167. Measuring Blood Pressure Support the patient’s arm. Position the cuff at midpoint of

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