Accurate Blood Pressure in the Office

Abstract

high blood pressure (BP) guidelines have placed major emphasis on proper measurement of BP, beginning with preparation of the patient all the way to appropriate data collection in the clinical setting. 1 Although there is nothing new beyond what we were taught in medical school (ensuring 5 minutes of rest, measurement at the level of the heart without talking to the patient and while their arms are supported, reporting the average from ≥2 measurements), this time-consuming process is often neglected in the majority of clinical practices in hospitals and clinics. Indeed, it has been said that BP assessment is the most common and important clinical measurement that is regularly done incorrectly. This sloppy technique may save time, but it is not without clinical consequence. By not allowing adequate time for a patient to rest and acclimate after being hurried into an examination room and following proper procedures, BP values are almost guaranteed to be overestimated. In certain parts of the world with frigid ambient temperatures, allowing patients to acclimate to normal room temperature before BP measurement can be important. If these factors are not taken into consideration , then hypertension control rates may appear worse than expected, and overtreatment may ensue. Furthermore, our bad practices are being propagated to the next generation of medical students who are now beginning to visit clinics as early as their first year of medical school. In a recent survey of 159 medical students, only 1 student passed a test of proper BP measurement technique and correct interpretation of the resulting values in encounters with simulated patients. 2 The majority of the errors emerged from omitting the 5-minute rest, which is predictable in our volume-driven healthcare environment in which a typical provider visit lasts ≤15 to 20 minutes. With the lower target BP goal and threshold for hypertension treatment of 130/80 mm Hg proposed by the new guidelines, measures to ensure accurate measurement of BP are urgently needed to avoid the consequences of overtreat-ment or undertreatment of hypertension. It is interesting to note that efforts are currently focusing on predicting properly measured BP values from the values obtained in the hurried clinical practice setting rather than developing strategies to promote correct measurement techniques in the first place. Some experts believe that BP measurement in SPRINT (Systolic Blood Pressure Intervention Trial) without medical personnel in the room (so-called unattended BP measurement) would yield a BP value 10 to 15 mm Hg lower than that obtained in the typical clinical setting, providing a value comparable to that obtained by 24-hour ambulatory monitoring. Thus, it may well make sense to propose a BP goal of 130 to 135 mm Hg rather than the 120 mm Hg goal in SPRINT, as reflected in the current guidelines.