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July 9, 2018

We're 'notoriously bad' at measuring blood pressure. Here's how to do better.

Daily Briefing

    Many physicians skip necessary steps to properly measure their patients' blood pressure, even though accurate readings play a crucial role in identifying and treating patients with high blood pressure, Dylan Collins writes for Vox.

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    Collins notes that accurate blood pressure readings are essential for patients' health. He writes, "[S]tubbornly high blood pressure becomes dangerous because it can cause arteries to burst, get inflamed, or clog, leading to diseases like heart attacks, strokes, and heart failure."

    To get an accurate reading, experts recommend that providers:

    • Ensure there are no clothes on a patient's arm;
    • Hold a patient's arm at the level of his or her heart;
    • Place cuffs on the appropriate location around a patient's arm; and
    • Use a stethoscope to hear a patient's pulse.

    However, Collins writes that health professionals are "notoriously bad" at following the recommended steps, which may result in inaccurate readings. He cites a 2005 study that found physicians overestimate their patients' blood pressure by about 10 mmHg when compared with nurses who are trained to follow those steps.

    Paul Whelton, a professor at Tulane University who chairs the writing committee for the latest U.S. guidelines on blood pressure, said one primary reason physicians might be skipping some steps is because they are "stretched in many directions" and do not have an incentive to precisely measure a patient's blood pressure. He said, "I don't think there is anything malicious about it, but [doctors wrongly] assume, in many instances, they're doing a great job."

    He added, "We wouldn't fly on a plane where the pilot said, 'I'm going to ignore the guidelines I have for safe travel'"—but that's how many health professionals treat blood pressure recommendations.

    New guidelines

    Earlier this year, the American Heart Association (AHA) and the American College of Cardiology (ACC), published new blood pressure guidelines that experts say could help the United States better identify and address hypertension.

    The guidelines note that blood pressure readings can fluctuate significantly based on the time of day, one's level of physical activity immediately preceding a test, and other factors.

    As a result, the new guidelines call on health care providers to measure a patient's blood pressure several times on multiple occasions to get an appropriate average. They also encourage providers and patients to embrace alternative forms of blood pressure measurement, such as automated devices that can be used outside of the doctor's office.

    For blood pressure measurements conducted in a doctor's office, the guidelines detail a nearly 19-step checklist providers should follow when taking a patient's blood pressure, including:

    • Encouraging the patient to avoid caffeine, exercise, and smoking for 30 minutes before the measurement;
    • Directing the patient to use the bathroom before the reading;

      Instructing the patient not to talk during the reading; and

    • Seating the patient upright in a chair with their feet on the floor for five minutes before the measurement

    A lesson learned from Canada

    Experts say the new guidelines take the United States in the direction of Canada—which, Collins writes is now "recognized as the world leader in lowering blood pressure."

    After decades of poor performance on blood pressure management, Canada adopted an approach the relied heavily on alternative forms of measurement, such as automated devices available outside a provider's office.

    Nadia Khan, president of Hypertension Canada, the not-for-profit group that helped craft Canada's guidelines, said, "Out-of-office measures are much better at predicting future cardiovascular events than office blood pressures." She noted that with the new guidelines the United States is "moving closer to the Canadian approach" (Collins, Vox, 7/3).

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