The Skeptical Cardiologist’s 2019 Guide to Self-Monitoring Hypertension (High Blood Pressure)

Because uncontrolled high blood pressure (hypertension) is a well documented risk factor for stroke, heart attack and heart failure I discuss it a lot on this site and with my patients.

I just updated my page on hypertension which summarizes my thoughts and recommendations on home BP self-monitoring along with the latest on the optimal BP goal.

What To Monitor and How To Measure

I primarily makes decisions on blood pressure treatment these days based on patient self-monitoring. I discuss this in detail in a post entitled  (Why I Encourage Self-Monitoring Of Blood Pressure In My Patients With High Blood Pressure.)

I have found self-monitoring of patient’s BP to substantially enhance patient engagement in the process. Self-monitoring patients are more empowered to understand the lifestyle factors which influence their BP and make positive changes.

Blood pressures are amazingly dynamic and as patient’s gain understanding of what influences their BP they are going to be able to take control of it.

If high readings are obtained in the office I instruct patients to use an automatic BP cuff at home and make a measurement when they first get up and again 12 hours later. After two weeks they report the values to me (preferably through the electronic patient portal or by Kardia Pro.)

I discuss in detail the recommended technique for BP measurementin my 2018 post entitled  “Optimal Home Blood Pressure Monitoring: Must The Legs Be Uncrossed and The Feet Flat?

The 2018 ACC/AHA guidelines on hypertension  specify in detail how to optimally make home BP measurements as follows:

• Remain still:

• Avoid smoking, caffeinated beverages, or exercise within 30 min before BP measurements.

• Ensure ≥5 min of quiet rest before BP measurements.

• Sit with back straight and supported (on a straight-backed dining chair, for example, rather than a sofa).

• Sit with feet flat on the floor and legs uncrossed.

• Keep arm supported on a flat surface (such as a table), with the upper arm at heart level.

• Bottom of the cuff should be placed directly above the antecubital fossa (bend of the elbow).

• Take at least 2 readings 1 min apart in morning before taking medications and in evening before supper. Optimally, measure and record BP daily. Ideally, obtain weekly BP readings beginning 2 weeks after a change in the treatment regimen and during the week before a clinic visit.

• Record all readings accurately:

• Monitors with built-in memory should be brought to all clinic appointments.

And, spoiler alert, it does matter if you cross or uncross your legs.

What Should The BP Goal Be?

For many patients with hypertension, SPRINT trial data published in 2015 suggest that a systolic blood pressure target of <120 mm Hg (intensive therapy) is preferable to a target of <140 mm Hg.

The SPRINT trial found that cardiovascular events like stroke and heart attack and death from these cardiovascular causes was lower by 25% in those patients treated intensively.  Overall death was lower by 27%

Read my post on SPRINT here and have a discussion with your physician about whether these more stringent BP goals are right for you. Keep in mind that the technique used in SPRINT likely gives us lower BP than home self-monitoring.

I discuss recent European and American BP guidelines which came to different BP goals after SPRINT in a post entitled “Becoming Enlightened About More Stringent Blood Pressure Goals: Sapere Aude”.

“As a 64 year old who has emerged from his nonage with hypertension, I have carefully examined the latest American hypertension guidelines especially in light of the SPRINT study and elected to add a third anti-hypertensive agent to get my average BP below 130/80. It’s worked for me with minimal  side effects but I carefully monitor my BP.

If I notice any symptoms (light-headed, fatigued) suggesting hypotension associated with systolic BP <120 mm Hg I tweak my medical regimen to allow a higher BP.

Like all of my patients I would prefer to be on less medications, not more but when it comes to enlightenment about the effects of hypertension, it is now clear that lower is better for most of us in our sixties down to at least 130/80*

Home Blood Pressure Monitoring Devices

You can get a good validated automatic BP monitor at Walgreens or CVS for around 35-40$.

But if you want to spend a little more you can get  BP devices which have added features such as style, portability, BlueTooth communication with smartphone apps and perhaps most importantly connection through the cloud with your physician.

My favorite BP cuff used to be the QardioArm (QardioArm: Stylish, Accurate and Portable. Is It the iPhone of Home Blood Pressure Monitors?)

I still love the QardioArm but lately I’ve been recommending the Omron Evolv for my patients who need monitoring as their recordings can be connected with me through Omron/Alivecor’s smartphone app:

The Omron Evolv One-Piece Blood Pressure Monitor: Accurate, Quick And Connected

For my patients using Omron Bluetooth BP monitors plus Alivecor’s Kardia Mobile ECG and the KardiaPro cloud connection I can view their rhythm and blood pressure at any time and analyze summary data via my patient dashboard as below.Finally, be aware that scam methods of BP measurement are being promoted to the public.

I wrote about one such  smartphone app called “Instant blood pressure”

Sphygmomanometrically Yours,

-ACP

10 thoughts on “The Skeptical Cardiologist’s 2019 Guide to Self-Monitoring Hypertension (High Blood Pressure)”

  1. I wrote this in 2008: I believe it is still correct. Debate all u want

    “The Journal of Clinical Hypertension

    Re: “Call To Action on Use and Reimbursement for Home Blood Pressure Monitoring: Executive Summary”
    H. Robert Silverstein MD
    First published: 04 November 2008
    https://doi.org/10.1111/j.1751-7176.2008.00033_1.x

    To the Editor:

    The injunction contained in “Call To Action on Use and Reimbursement for Home Blood Pressure Monitoring: Executive Summary”1 against wrist BP monitors is arbitrary, prejudicial, lacking in clinical experience, and nonsense. Currently, there are so many people with large arms that, rather than larger cuffs, wrist monitors work uniformly well; moreover, wrist monitors fit just fine, are more convenient, are easily portable, and can be verified as accurate. The method that I use is as follows: apply the blood pressure (BP) cuff and record the BP (arm or wrist). BP is immediately measured again using my (lifetime‐certified) upper arm BP cuff. This is repeated twice in quick succession. The patient’s BP cuff and mine are used on the same arm, since there may be an important difference in readings between the two arms.

    If the two cuffs measure identical readings or provide readings that are minimally different, the patient is informed of what to add or subtract from the systolic and/or diastolic values. Pickering and colleagues1 merely and inadequately state that the BP cuff is to be verified, with no specific method discussed.

    This article’s recommended method for BP recording has nothing to do with the realities of life. It is ideal to see what the BP is at any time and under any circumstance, as well in the “9 times zones”: before and after each meal, in between meals, and at bedtime. These can be measured over 3 or 4 days, giving the physician a comprehensive picture of daytime and evening BP levels. This is more likely to be accomplished with the smaller and more portable wrist cuff. Sitting calmly in a near‐meditative state resembles no part of conscious life I am aware of. If the patient smokes, drinks, or exercises, I want to know what their BP numbers are(!). There is no reason to assume that these wrist monitors become inaccurate over time, and if such occurs, the discrepancy is usually obvious and readily identifiable.
    Reference

    Volume10, Issue11 November 2008 Pages 885-885

    1. I have both an Omron wrist monitor and the Omron Evol cuff. I also compared to the manual method of osculation. They all give results that over ia 6 weeks period using daily measures show no statistically significant difference. For this reason, I have been using only the wrist monitor. You just rap it around this wrist and go. The reliability is as good as the osculation with + or – .03 percent deviation over time which comforts to the international hypertension measurement standards.

      1. Erwin and HRS,
        thanks for raising this topic. I studied wave reflection and arterial dynamics extensively when I was at Ohio State University attempting to get noninvasive measures of arterial impedance from Doppler and peripheral tonometry and I remember very distinctly that the further you travel out from the central aorta (to the fingers or the toes) the higher the systolic pressure. The mean BP stays the same but due to arterial wave reflection the systolic is higher and the diastolic lower the further you measure peripherally.
        I did a quick search to see if there is anything new in this area and this reference confirms higher systolics at the radial than the brachial artery…https://www.ahajournals.org/doi/10.1161/HYPERTENSIONAHA.119.12674
        It would be great if the radial could be substituted and perhaps in some individuals it can as this paper suggests but one would have to verify extensively as Mr. Witt appears to have done. Perhaps you can send me your data and I’ll write a full post on this fascinating topic.

        1. That’s interesting, I figured there was some correlation to distal monitoring and less accurate BPs but I didn’t know it correlated to a higher systolic. I occasionally measure my BP in both arms, is there any physiological or anatomical differences between arterial arm systems that would produce slightly different readings? I wondered since the left subclavian directly splits off the ascending aorta vs the brachiocephalic artery that has a thicker trunk off the AA but splits to RCCA and RSA, if that mattered. Also the heart being slightly to the left side of the body if that resulted in any difference in brachial arm pressures?

  2. I love reading your posts and I love that you question everything. You remind me of my 5 year old self. Thank you for posting.

  3. Thank you for the great article on self-monitoring BP. I have a request/suggestion. Most non-medical people, including myself, have really only a vague idea of the location of their heart. So the instruction to have the upper arm at heart level is meaningless, but at the same time, I assume it is important. Unless I raise my arm, I assume it is “at heart level”. I diagram would help.

    1. Bob,
      Great comment. I’ve actually been thinking a lot about the position of the upper arm during BP measurement. I’ve made some observations on myself and found a great paper that I’ll post about hopefully in the next few weeks.

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