For most of my career as a cardiologist, I’ve failed to take patients’ blood pressure readings in the most accurate way, and so have most healthcare providers.
Measuring blood pressure is usually the first thing that we do in an office visit. But now that researchers are examining the process more closely, we are learning that these readings are often inaccurate—as much as 60% of the time—and can significantly undermine treatment decisions.
Almost half of American adults—over 100 million people—have high blood pressure, putting them at increased risk for heart attack, heart failure, stroke and many other health problems. Although hypertension is almost always treatable with lifestyle changes and medication, less than half of people with high blood pressure have it under control. It remains the leading cause of preventable death, yet around 90% of cases could be controlled on medications that cost less than $20 a month.
Measuring a person’s blood pressure is more complicated than you may think. Unexpected high readings are typically attributed to so-called white-coat hypertension: when a patient's feeling of anxiety in a medical environment results in elevated blood pressure. However, blood pressures are not always falsely elevated; some patients get lower numbers in the clinic than at home, a phenomenon called masked hypertension.
Target:BP is an evidence-based program that has two goals—obtaining accurate blood pressure readings and improving blood pressure control among patients—and we are hoping to use the results as an example to spread across the health system.
We are currently in phase one of Target:BP’s three-part strategy: measure, act, and partner. In order to more accurately measure blood pressure, we’ve implemented an evidence-based process in our clinic. The most impactful step in improving the process is having the patient sit in a quiet room unattended for five minutes before taking their blood pressure. Patients should sit in a chair with back support, their arms should be supported at heart level, and their feet should be flat on the floor. Clinicians should use an automated cuff, rather than a manual one, and make sure the cuff isn’t wrapped around the patient’s clothes. Additionally, patients should have an empty bladder and not be talking or looking at their cell phones while waiting.
So far, we have gotten tremendous results: we’ve observed that on average, patients have a 15% to 20% drop in systolic blood pressure between the initial reading taken immediately and the reading after a 5-minute rest period.
This has huge implications for how we treat our patients. It increases our confidence that the blood pressure reading obtained is accurate and minimizes the potential to overtreat blood pressure that is actually normal outside of the clinic.
The gold standard for monitoring blood pressure is to measure it outside of the clinic with a 24-hour ambulatory blood pressure monitor. Alternatively, patients can monitor their blood pressure at home and log their measurements with instruction on the appropriate protocol. The next step of the Target:BP program at Banner is to take action: to develop an algorithm for evidence-based treatment and guidelines for providers to agree on and follow. Then, we’ll initiate the third phase: partner. This engages patients as partners in adhering to their treatment plans, through reinforcing home measurements and tracking control rates. Ideally, we’ll use a combination of telemedicine and in-person appointments to help patients keep themselves on track.
Empowering patients to engage in their blood pressure readings is key to successful hypertension management. My colleague Lori-Ann Peterson, a cardiovascular nurse practitioner at Banner – University Medicine Heart Institute who is highly involved in the program, tells her patients, “If there is quality control for laboratory blood work, why would you not want the same quality control for your blood pressure readings?” We take pride in educating our patients to not only know the proper process for getting an accurate blood pressure reading but also to know their own blood pressure numbers, so they can be active partners in their healthcare.
Our hope is that after applying these three phases, 90% or more of our patients will have their blood pressure under control. Taking these steps to improve measurement, treatment, and patient adherence may seem simple, but implementing systemwide change that alters conventional practice can be challenging. I encourage all providers to embrace this challenge and implement the Target:BP program within your practices to improve blood pressure readings and ensure that all patients get the best possible care.
R. Todd Hurst, MD, FACC, FASE, is a board-certified cardiologist, director of the Center for Cardiovascular Health at Banner – University Medicine Heart Institute, and associate professor of medicine at the University of Arizona College of Medicine.