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December 02, 2020 02:30pm
For several years now, home blood pressure monitoring devices (HBPMD) have been inexpensive and reliable.
Blood pressure (BP) monitoring seems like such a simple thing. A patient arrives in the clinic, places him or herself in the hot seat, and presents the arm—usually the left one—for the grip of the sphygmomanometer. Today, almost all BP monitoring devices are electronic, and after a brief mechanical whir and a whish as the cuff deflates, the screen displays the patient’s numbers. If BP exceeds that golden number of 130/80, it’s time to talk about interventions. Hypertension and its measurement are not quite that simple, however. It’s time to heighten awareness of how BP fluctuates and the best way to monitor it.
For several years now, home blood pressure monitoring devices (HBPMD) have been inexpensive and reliable. That’s why a number of organizations have recommended that patients who have, or are at risk for hypertension monitor their BP regularly. Patients who are most likely to purchase and use HBPMD are those who have already been diagnosed with hypertension, or who have concerns about cardiovascular disease or stroke in the future. Today, approximately half of hypertensive individuals use HBPMD, and most report the results of monitoring to their primary care providers.
Up, Down, and All Around
BP follows a circadian pattern in most patients. It falls to its lowest levels during sleep (10% to 30% below daytime levels), rises as the patient awakens in the morning, and tends to be higher and more variable during the daytime. It’s the morning surge in BP that is often associated with adverse events (eg, myocardial infarction, stroke, sudden cardiac death).
Retail health care providers might consider recommending HBPMDs for patients who are prehypertensive or who have overt hypertension. One advantage of home BP monitoring is that it gives clinicians a more comprehensive picture of the patient’s circadian rhythms. It also eliminates “whitecoat hypertension” (isolated BP elevations in the primary care provider’s office). Between 10% and 20% of people experience whitecoat hypertension, yet they have BP that falls within normal limits at home.
Conversely, home BP monitoring can identify the presence of “masked hypertension.” Masked hypertension is the presence of a normal BP reading while the patient is in the office, but elevated readings when the patient is at home—the opposite of whitecoat hypertension, sometimes called “reverse whitecoat hypertension” or “whitecoat normal tension.” Certain people are at elevated risk for masked hypertension: patients who have stressful jobs, chronic kidney disease, sleep apnea, diabetes, or left ventricular hypertrophy. People who smoke, are obese, or have family histories of masked hypertension are also at elevated risk. Recent studies indicate its prevalence is approximately 20%, which is higher than previously assumed. This group of patients is of concern because study results have shown that they incur extensive target organ damage. They often experience left ventricular hypertrophy and escalated plaque deposition.
More than one-third of American adults older than age 20 are hypertensive, and 40% of these patients are untreated. Even among patients who do receive treatment, almost two-thirds don’t reach their target BP. Heightened awareness is critical, and retail health providers can catch some of these undiagnosed or undertreated patients and intervene. The following are some guidelines for interventions:
Since 2008, the American Heart Association, the American Society of Hypertension, and the Preventive Cardiovascular Nurses Association have recommended using HPBMD, as have many international guidelines. Their rationale is that home readings correlate closely with target organ damage. The well-respected, independent, nonprofit publicationConsumer Reportsprovides evidence-based product ratings for HBPMD. It’s a good source for retail health providers and patients when faced with the numerous devices in the OTC aisle. Individuals can usually access it via their public libraries.
Purchasing a Machine is Just the First Step
In addition to reviewing the HBPMD’s directions carefully with patients, retail health care providers must provide direction about how often to measure BP.
Counseling Patients about Home BP Monitoring
Location, Location, Location!
Experts recommend either arm or wrist monitors. Arm monitors tend to be most reliable. For some patients, wrist monitors offer convenience and may be preferred in obese patients who have difficulty applying the cuff above the elbow. Retail health providers must remember that wrist monitors are only accurate when the arm is held above the level of the heart; many new wrist monitors ensure appropriate use because they only operate if the patient holds his or her wrist over the heart. In general, experts prefer the arm monitor.
Experts also warn that finger monitors are notoriously inaccurate.
Some patients may not have the financial resources to purchase an HBPMD. For these patients, advise checking with their insurers to see if an HBPMD is covered because plans now do cover them.
If the patient’s plan doesn’t, then recommend that the use the widely available retail automated devices; the likelihood is that your clinic probably has one of these devices right outside your door, and most grocery stores and malls now have conveniently located BP monitoring devices. Note that studies indicate that store monitors tend to record lower systolic BP and higher diastolic BP, but the difference between store monitors and other BP monitoring devices tends to be statistically or clinically insignificant. Many chain drugstores will now email the patient’s results to a cloud storage medical record or a smart phone, which makes tracking easy.
Margolis KL, Asche SE, Bergdall AR, et al. Effect of home blood pressure telemonitoring and pharmacist management on blood pressure control: a cluster randomized clinical trial.JAMA.2013;310(1):46-56. doi: 10.1001/jama.2013.6549.
Pickering TG, Miller NH, Ogedegbe G, et al; American Heart Association.; American Society of Hypertension.; Preventive Cardiovascular Nurses Association. Call to action on use and reimbursement for home blood pressure monitoring: a joint scientific statement from the American Heart Association, American Society of Hypertension, and Preventive Cardiovascular Nurses Association.J Cardiovasc Nurs.2008;23(4):299-323. doi: 10.1161/HYPERTENSIONAHA.107.189011.
Ross KL, Bhasin S, Wilson MP, Stewart SA, Wilson TW. Accuracy of drug store blood pressure monitors: an observational study.Blood Press Monit.2013;18(6):339-41. doi: 10.1097/MBP.0000000000000003.
Schwartz JE, Burg MM, Shimbo D, et al. Clinic blood pressure underestimatesambulatory blood pressure in an untreated employer-based US population: results from the Masked Hypertension Study.Circulation.2016;134(23):1794-1807.