What doctors are saying about measuring blood pressure accurately

AMA Wire
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When Wisconsin family medicine physician Kim Hardy, MD, saw this blood pressure chart the AMA posted on Twitter, she knew it was something that could help her practice obtain more accurate blood pressure measurements. She shared her success story, which inspired other physicians to weigh in on how they ensure accurate blood pressure measurement in their practices.

Using the chart helped Dr. Hardy immediately improve a patient’s blood pressure measurement, preventing her from having to readjust the patient’s medication. Here's what other physicians had to say:

CHAIMTN: A diary of multiple recordings, AM & PM, for month prior to visit may be best measure for adjusting Rx.

lissr: Surprised size of cuff not mentioned...very big deal in some circles—different widths can make very disparate readings!

lonestar32: Another common contributor to elevated readings: The patient is running late, rushes from parking lot, checks in and BP is read immediately before returning to baseline. This happened to me, with a hillside parking compounding the problem. With very well-controlled mild essential hypertension, I was getting systolic readings of 135-140. When I made a point of coming 10 minutes early and sitting in the waiting room before checking in, I got the below -110 readings I was getting at home, avoided the risk of "dealing with" the elevated reading inappropriately.

james blaine: I have practiced medicine for 40 years, half of that in emergency trauma and the last half in family practice. Diagnosing and treating hypertension has always seemed mystical to me. As an emergency physician, almost all of my patients had elevated blood pressures. As a family physician, the regulation seemed unscientific at best.

A few years ago, I read an article in the Hypertension Journal that made a great deal of sense: home blood pressure monitoring (HBPM). The patient is instructed in the proper method of taking his/her BP and asked to take the measurement twice in the morning (a few minutes apart) and twice in the evening for a week. The patient then returns the list, and we average it.

A significant percentage of the patients are normotensive at home and turn out to have office hypertension; the others are treated with diet, salt restriction and aerobic exercise, and then, if needed, medication. Their treatment efficacy is also monitored by HBPM. We have preprinted HBPM monitor sheets for the patients, and loan them an automatic BP machine if they do not have one. If they are diagnosed as hypertensive, they are requested to purchase their own.

Since initiating this protocol, hypertension diagnosis and treatment is no longer mystical to me, and my patients seem to assume better ownership of their BP management.

Read more comments at AMA Wire®.

Several physicians touched on what is known as “white coat” hypertension, pointing to home blood pressure monitoring as a way to ensure more accurate readings. Physician practices in Illinois and Maryland are addressing this issue and others as part of the AMA’s Improving Health Outcomes initiative, which seeks to apply principles of safe design in the ambulatory setting to improve outcomes around high blood pressure.

Practices participating in the program are investigating resources in their communities that could help patients get home blood pressure devices or direct patients to local programs that could take blood pressure measurements and provide feedback to physicians.

Other participating practices are employing automated blood pressure devices, which help gain accurate measurements outside of the medical office setting.

Join the discussion:  Share what methods you’ve found successful in improving outcomes around hypertension in your practice in a comment below on AMA Wire,and on Facebook.

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Comments

All of the comments are helpful. Do remember the diurnal variation of blood pressure, rising on waking and peaking about 10 AM and gradually tapering through the evening, dropping with sleep and minimizing about 3 AM. So don't simply 'average' home readings taken at different times of day without considering time of day. Encourage loud people to cool their 'attitude' as temper kills!
Blood pressure access is more precise among space crew and can be compared with people at earth,thus normal value ranges for 120-80 mmhg.
Something I've found that make a dramatic difference in my blood pressure is taking it manually vs the automatic machines. After a lifetime of healthy, low readings, I was considering medication after consistently systolic readings of 150+ for a year. A nurse realized that I always seemed in pain during the readings and suggested doing it manually. Systolic Pressure reads a 120 sone this way. Later found we could also get the more accurate reading by using the pediatric setting on machines.
Measuring BP in the position of function, that is, standing, should be the standard. Chairs were used only by royalty until modern times. Yet all studies of BP are done in the seated position. We get away with this in the young and relatively healthy, but in my geriatric practice, seated BPs are worthless. Orthostatic hypotension from meds or autonomic neuropathy is so common. And the elderly do not sense it as dizziness. They may complain of weakness or dyspnea. We need a new paradigm for BP measurement.
They are missing the most important ones!!! OMG!!!
On a recent visit to my cardiologist, I started rolling up my sleeve for the nurse to check my BP - he said roll it back down, I'll check it through your shirtsleeve. My med school mentors 50+ years ago said that a stethoscope always needs to go on bare skin, whether chest, heart, or elsewhere. Maybe we need to digress a bit.
I was taught the 140/90 was set at the Framingham clinics by Harvard based on life expectancy. The clinic environment accounted for "white coat", weather, "my dog died", etc. I was taught the 120/80 "average / goal was set by the actuarial department of an insurance company in the 1950's using the Phys. Ed. Dept. at Univ. Chicago using healthy men ages 18 to 25. Individually, I think my best measurement of a patient's BP is with a stethoscope and a mercury sphygmomanometer; but we no longer keep mercury around. I checked the National Library of Medicine, and the Omron brand of automatic machines are being validated as accurate. I hope this helps.
My own systolic BP drops 9% with 3 minutes of simply calming my thoughts.
Agreed. It would be wiser to average out the readings relative to time only rather than daily meaning an avg. reading based at readings taken roughly at 3 pm every day for a week/month.
Blood pressure should be taken in both arms. Also when a patient is led into an office they should be allowed to sit for 5 minutes prior to taking the BP.

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