Saturday, August 09, 2008

How to take a blood pressure reading

Blood pressure reading does not seem to be done correctly in any medical clinic. And yet, the single most important thing physicians do in their medical life is take an accurate blood pressure measurement.
--Clarence Grim, MD, Medical College of Wisconsin

Well this is Grim news indeed for those of us who've been at this for decades. Per Grim(1), a proper blood pressure assessment is nuanced and time-consuming, an unwelcome proclamation in a world where appointment time in your average PCP's office (that would be mine) is limited and largely unreimbursed.

So here's the scoop. Ms. Patient needs to be sitting in a chair, back supported, feet flat on ground for 5 minutes before the exam, her arm on a table such that the center of the BP cuff, which needs to be the proper size relative to the circumference of her arm, is at heart level. Then, get this!, I'm to take readings in both arms (do I have to let her rest between measurements for another five?), and I can't chat as I measure. That's my downfall, I'm usually grilling her about her day, her job, her kids, her opinion of the Rockies (watch that pressure soar), when what I really need to do is just shut up and pump the cuff.

Research suggests that our worst failing as BP measuring health professionals is that rest thing, we don't let the patient rest. Here's what Joseph Izzo, MD, hypertension researcher extraordinaire has to say about that: "The problem is that physicians cannot afford financially to take the time to properly measure blood pressure--they aren't compensated."

And I would add that none of my patients spend their day at rest, so oughtn't we be measuring their pressures in real world, on-the-go conditions, when time constraints and tonight's preseason performance by the Broncos is driving their hearts and their minds?
Mitka, M. Many Physician Practices Fall Short on Accurate Blood Pressure Measurement. JAMA, June 25, 2008-Vol 299, No. 24.


Beverly said...

I agree with you. I usually am sitting with my arm at the level of my heart, but it certainly isn't at a resting rate...sometimes they have to find a big cuff, because, well, my arms are a bit on the heavy side.

But as you say, how many of us are generally resting? Not so much.

Laura in L.A. said...

This drives me crazy! When I am at home, I follow the directions that came with my Omron monitor, and I sit quietly for 10 minutes before taking a reading. (I even special-ordered the larger cuff to increase accuracy!) My BP is always normal or below.

But at the doctor's office, I'm nervous enough as it is, and the nurses tend to take my BP first thing-- right after they weigh me! My BP then is usually high-normal then.

Glad it's not just me that has this problem!

Laura :):)

kenju said...

That doesn't seem plausible at all. What about people who have to take their BP 3-4 times a day?

Mauigirl said...

That is a very good point that I've wondered myself. If one's blood pressure is skyrocketing every time one rushes from one place to another, or gets annoyed about something at work, surely that is a better real-world measure of one's blood pressure.

I always wondered why people discount "white coat hypertension" by saying "Oh, it just happens because he or she is in the doctor's office, they should measure it at home." But to me, if the stress of going to the doctor makes their BP go up, then so do a lot of other stressors in their lives and to me that should be a concern for that person.

Reality Man said...

Don't get me started on BP. It often follows immediately after being weighed with your shoes on--and is frequently followed by no comment even if it is borderline--which it often is for those of us with white coat syndrome.

Dreaming again said...

Before I really *DID* have hypertention (even at home, in various situations) ..the only place I EVER had it ... was in my GI's office.

There .. it would be SKY high. He would get really upset that my doctor wasn't treating my hypertention. My blood pressure in his office was inevitably ..very high. Not just slightly elevated, but very high. Finally, he called my doctor to ask her if he could start me on something for my high blood pressure and she said "my goodness no! She has low blood pressure!"
(I tried to tell him that!)

He came back in, and said "What's the deal?"

I told him ... I come to you ...and you want to stick camera's where they don't belong ... I'm terrified of you!

(incidently ..had to see him 2 weeks ago ..and yep ... EGD scheduled for September. Just can't win with this guy and he wonders why my B/P soars)

Anonymous said...

And maybe, "Why don't you get your front office to quit annoying the patient so his/her BP goes up/"

Femail doc said...

All of you make the great point that is also known (but not mentioned by me in this particular post), and that is that BPs taken by patients at home are an accurate reflection of average blood pressure. My frustration on that count is that many people don't check their BPs out of my office ("I feel good so my BP must be good") so we are left working solely with in-office values to gauge BP control. Best of all are BP readings taken by a 24 hr. ambulatory monitor; expensive, bothersome, but best of all.

White coat hypertension has been shown to confer intermediate risk on those who display it, somewhere between uniformly perfect BP (even when your GI specialist is going to stick a tube somewhere!) and consistently high BP.

Oh dear, Anon, I felt that. I am sorry that my front office is annoying you. They sometimes take policy and run with it, trampling our patients/customers in their zeal to enforce the rules. Let me know if there is something I should know about in particular.

Wendy said...

Ah well now, that's what you have an "office nurse" for (if you're lucky!)

dada said...

As one on BP medication, I'm proud to say my record readings always occur in the doctor's office. (Where the rules for proper BP readings are not strictly adhered to.) However, the vast majority of time such readings are very good at home. (Maybe I should just lock myself in the house?)

But reading this thread (and no offense intended for anyone here) for some unknown reason, I found myself humming songs from Pink Floyd's album, the "Dark Side of the Moon."

rob said...

a useful discussion Doc. I have been studying this recently. Having been a pharmacist for nearly 30yrs i qualified this spring as a prescriber. I am specialising in hypertension and CVD risk assessment. The recommendations you say about 5minutes rest before taking BP i do follow, and the trying to get a patient to be calm & not talking as i take it. These and many other recommendations are on the British Hypertension Soc website, and referred to by the excellent NPCi website and the UK MHRA - Medicines regulatoary agency. I'll try & get links later. As for using home measurements as some posters have commented- all the research on treating hypertension has been on 'office' BP, so we usually have to add a little say 8-10mmhg to the home reading.
all best Rob in wales UK