Controversy surrounds whether to define resting diastolic blood pressure (DBP) as the onset of the fourth or fifth Korotkoff phase (K4, sound muffling, or K5, sound disappearance) in children and adolescents. Although undetectable in some children (due to sounds continuing to zero cuff pressure), K5 is currently recommended for consistency with adult practice and because K4 can be difficult to discern or undetectable. However, to our knowledge, no studies have specifically assessed the reliability of measuring DBP with K4 and K5 in children and adolescents under exercise conditions. We therefore measured DBP before and immediately after a Bruce protocol stress test in 90 children and adolescents aged 12.3 ± 3.5 years (mean ± SD) in a cardiology clinic setting. When detected, K4 and K5 were 63.5 ± 9.2 and 60.2 ± 12.6 mmHg, respectively, at rest and 59.2 ± 14.6 mmHg (p = 0.028 vs rest) and 52.9 ± 18.3 mmHg (p < 0.001), respectively, immediately post-exercise. K4 and K5 were not detected in 41% and 4% of participants at rest or in 29% and 37% post-exercise, respectively, while K5 resulted in unrealistic DBP values (<30 mmHg) in an additional 11%. Better exercise performance was associated with a more frequent absence of K5 post-exercise, and after excluding participants performing at <10th percentile for age, post-exercise K4 was absent in 23%, and plausible K5 values were not obtained in 59% (p < 0.001). Although neither K4 nor K5 alone were reliable measures of DBP immediately post-exercise, a novel hybrid approach using K4, if detected, or K5, if not, produced reasonable DBP measurements in 97% of participants.
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This work was supported by a grant from the National Health and Medical Research Council of Australia (APP1128516). JPM is supported by a co-funded R.D. Wright Career Development Fellowship from the National Health and Medical Research Council of Australia (APP1143510) and Future Leader Fellowship from the National Heart Foundation of Australia (101866). The Heart Research Group is supported by the Victorian Government’s Operational Infrastructure Support Program, RCH 1000 and Big W.
Conflict of interest
JPM is a consultant for the Brain Protection Company, Tournicare, Masimo Corporation and Baxter Healthcare; none of these consultancies have any relation to the present work. All other authors declare no competing interests.
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Glenning, J.P., Lam, K., Clarke, M.M. et al. Assessment of diastolic blood pressure with the auscultatory method in children and adolescents under exercise conditions. Hypertens Res (2021). https://doi.org/10.1038/s41440-021-00657-7
- Blood pressure measurement
- Diastolic blood pressure
- Exercise stress test
- Korotkoff sounds