I can’t vouch for the Keyto chocolate shake or the basil pesto that they are now including with Black Friday sales but I love the Keyto.
By the way, it wasn’t clear to me when I first got the Keyto device what kind of diet Keyto promotes. They favor a plant-based keto (with fish) diet which they consider “heart healthy.” More on this down the line.
The skeptical cardiologist primarily makes decisions on blood pressure treatment these days based on patient self-monitoring. 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.
Although I’ve been recommending self-monitoring to my patients for decades it is only recently that guidelines have endorsed the approach and good scientific studies verified its superiority. I was pleased when the 2017 ACC/AHA guidelines for High Blood Pressure made home self-monitoring of BP a IA recommendation.
And last year a very good study, the TASMNH4 was published which demonstrated the superiority of self-monitoring compared to usual care.
TASMINH4 was a parallel randomised controlled trial done in 142 general practices in the UK, and included hypertensive patients older than 35 years, with blood pressure higher than 140/90 mm Hg, who were willing to self-monitor their blood pressure. Patients were randomly assigned (1:1:1) to self-monitoring blood pressure (self-montoring group), to self-monitoring blood pressure with telemonitoring (telemonitoring group), or to usual care (clinic blood pressure; usual care group).
The home BP goal was 135/85 mm Hg, 5 mm Hg lower than the office BP goal. At one year both home self-monitoring groups had significantly lower systolic blood pressure than the usual care group.
This trial was not powered to detect cardiovascular outcomes, but the differences between the interventions and control in systolic blood pressure would be expected to result in around a 20% reduction in stroke risk and 10% reduction in coronary heart disease risk. Although not significantly different from each other at 12 months, blood pressure in the group using telemonitoring for medication titration became lower more quickly (at 6 months) than those self-monitoring alone, an effect which is likely to further reduce cardiovascular events and might improve longer term control.
Advantages of Home Self-Monitored Blood Pressure-Limitations of Office BPs
Every patient I see in my office gets a BP check. This is typically done by one of the office assistants who is “rooming” the patient using the classic method with , listening with stethoscope for Korotkov sounds. If the BP seems unexpectedly high or low I will recheck it myself.
Often the BP we record is significantly higher than what the patient has been getting at home or at other physician offices.
There are multiple factors that could be raising the office BP: mental stress from driving to the doctor or being hurried or physical stress from walking from the parking lot.
In addition, I feel that multiple assessments of out of office BP over the course of the day and different days are more likely representative of the BP that we are consistently exposed to rather than one reading in the doctor’s office.
Accuracy and technique in the doctor’s office is also an issue.
Interestingly, we have assumed that manual office BP measurement is superior to automatic but this recent paper found the opposite:
Automated office blood pressure readings, only when recorded properly with the patient sitting alone in a quiet place, are more accurate than office BP readings in routine clinical practice and are similar to awake ambulatory BP readings, with mean AOBP being devoid of any white coat effect.
A patient left a comment to that paper which is quite insightful:
I had a high blood pressure event several years ago. Since then I have monitored my BP at home, sitting with both feet flat on the floor, not eating or drinking, not speaking or moving around, on a chair with a back, and without clothes on the arm being used for the measure. My BP remains normal.
I have never had my BP taken correctly in a doctor’s office. They will do it while I am speaking with the doctor, sitting on an exam table with my legs swinging, with the monitor band over my heavy winter sweater, right after I have sat down. They do not ensure that my arm is supported or at the right height. If I recommend that I take off my sweater, or move to a chair with a back, they tell me that is not needed. I have decided to refuse such measurements. How can they possibly be monitoring my health this way?
This patient’s observations are not unique and I suspect the majority of office BPs have most if not all of the limitations she describes.
Self Monitoring Improves Patient Engagement In BP Control
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.
I take my BP almost daily and adjust my BP medications based on the readings. After prolonged work or exercise in heat, for example, BPs will decline to a point where I’m light headed or fatigued. Less BP med at this time is indicated. Conversely, if I’ve been overly stressed BPs increase and upward titration of medication is warranted.
With some of my most engaged and enlightened patients we perform similar titrations depending on their circumstances. Sometimes patients perform these titrations on their own and tell me about them at the next office visit.
What’s The Best Way To Communicate Home BPs?
Many of my patients provide me with a hand-written record of their BPs over two weeks. Some mail them to me, others bring them in to the office. We scan these into the EMR. I look at these and make an estimate of the average systolic blood pressure, the variation over time and the variation during the day. It’s not feasible for me or my staff to enter the numbers or precisely obtain an average.
Some patients send us the numbers through the internet-based patient portal into the EMR. This is preferable as I can view these and respond quickly and directly back to the patient with recommendations.
More and more patients are utilizing their smart phones to record and aggregate their health data and will bring them in for me to look at during an office visit. I’ve described one stylish and slick BP cuff, the QardioArm which has neither tubes nor wires and works through a smartphone app. Omron , also has multiple cuffs which communicate via BlueTooth to store data in a smartphone app.
Ideally, we would have a way for me to view those digitally recorded BPs with nicely calculated averages online and within the EMR. Unfortunately, such connectivity is not routinely available.
However, for my patients who are already monitoring their heart rhythms with a Kardia mobile ECG and are connected with me online through KardiaPro Remote I can view their BP recordings online.
I’ll discuss in detail in a subsequent post the Omron Evolv home automatic BP cuff (my current favorite) which is wireless and tubeless and connects seamlessly to KardiaPro allowing me to view both BP and heart rhythm (and weight) recordings in my patients
To me, this empowerment of patients to record, monitor and respond to their own physiologic parameters is the future of medicine.
From the 2017 ACC/AHA BP guidelines
and the proper technique for office BP measurement
The skeptical cardiologist frequently has his hypertensive patients check their BPs at home and report the values to him.
An easy, accurate and efficient way to record BPs at home, and transmit to the doctor, is my Holy Grail for management of hypertension; QardioArm offers to improve on this process compared to more conventional home BP cuffs.
I recently bought a QardioArm for my father and tested one myself over the last month, and herein are my findings. I compared it closely to my prior “go to” BP device, the Omron 10 (which I recommended as a Christmas gift here).
The QardioArm looks like and is packaged like an Apple product. The box containing the device is esthetically pleasing, and can serve as an excellent storage and transportation mechanism. The case closes magnetically and has a pocket, within which resides the manual.
Upon removing the QardioArm, one is struck by how compact, sleek and cool it looks. This is not your father’s BP cuff. There are no wires or tubes coming off it, and the cuff wraps around a red (white, blue or gold) plastic rectangular cuboid.
The cuff/cuboid is small enough to easily fit in a purse or satchel, facilitating portability.
Ease of Use
Once you understand how the device works it is a breeze to use. However, if you are inclined, like me, to skip reading the instruction manual, you run the risk of being incredibly frustrated.
First, you must download the free Qardio App to your smartphone, create a user login, register and create your personal account. If you don’t have a smartphone or tablet or don’t use the internet, this cuff if not for you. For me, this was a simple, quick process.
After setting up the Qardio App, you pair the QardioArm with the App. This requires the QardioArm be on and Blue Tooth be enabled on your smartphone.
You might think that turning on the QardioArm, and knowing it is on,
would be an incredibly easy and obvious process: it is not (unless you pay close attention to the instructions). If you read reviews of Qardioarm on Consumer Reports or Amazon, you will encounter many very unhappy users. This is primarily because some folks could not get it to turn on.
Here are my detailed instructions for turning it on:
There is a small magnet inside the cuff.
The device turns itself on when you unwrap the cuff and it turns off when you wrap the cuff back up. (I am not good at wrapping things up properly and ran into issues initially because of this). When you wrap the cuff up properly you can feel the magnet locking into place and thus turning the device off.
When the device is on there is no light to indicate it is on. A green light flashes on the side when it turns on, but then goes out. Many user reviews indicate frustration with this and often they end up trying to change the batteries, believing that the device is dead. I went through this same thought process initially.
The device turns off “after a few minutes” if not used. You won’t know if it is on or off. If it doesn’t respond when you trigger it from the App, you must carefully rewrap the cuff and then unwrap it. If you don’t trigger the device properly with the magnet, it won’t wake up.
Now that you know how to turn the device on and have paired it with your Cardio App, put the cuff over your upper arm with the cuboid over the inner aspect of your arm,
hit the big green START button and sit back while the cuff is magically inflated and an oscillometric measurement of your blood pressure performed.
The blood pressure is displayed on the app instantaneously along with pulse. If the device detects irregularity of the pulse (a possible but not reliable sign of atrial fibrillation or other abnormal heart rhythms), it display an “irregular heart beat” warning.
You can have the QardioArm take 3 BPs, a variable amount of time apart, and average the readings.
BP and pulse data can be viewed in tabular or graphic formats and can be synched with the Apple Health App:
I found the QardioArm BP measurements to be very accurate. My medical assistant, Jenny, recorded our patient’s BPs using the “gold-standard” manual technique, and with QardioArm (consecutively and in the same arm), and there was excellent agreement. In one man with a very large arm, she could not record a BP (QardioArm’s cuff fits the arm of most people, and is appropriate for use by adults with an upper arm size between 22 and 37 cm (8.7 and 14.6 inches). If your upper arm is larger than that, this device is not for you. In one patient who was in atrial fibrillation, the device properly recorded an “irregular heart beat.”
From the Qardio website:
QardioArm is a highly accurate blood pressure monitor and has undergone independent, formal clinical validation according to ANSI/AAMI/ISO 81060-1:2007, ANSI/AAMI/ISO 81060-2:2009, ANSI/AAMI/IEC 80601-2-30:2009, as well as British Standard EN 1060-4:2004.
QardioArm is a regulated medical device: FDA cleared, European CE marked and Canadian CE marked.
It measures blood pressure with a resolution of 1 mmHg and pulse with 1 beat/min.
The accuracy is +/- 3 mmHg or 2% of readout value for blood pressure, and +/- 5% of readout value for pulse.
Comparison To Omron 10
I spent time evaluating the accuracy of QardioArm because a few online reviewers suggest that it is highly inaccurate for them and Consumer Reports gives it a “poor” rating for accuracy.
I compared it to the Omron 10 (Consumer Reports highest-rated BP device), and found close agreement between the two.
I took my own BP with the QardioArm on the left arm and the Omron 10 on the right arm. Multiple simultaneous measurements showed less than 3 mmHg difference in systolic blood pressure between the two.
Unlike Consumer Reports, I found QardioArm superior to the Omron 10 in several areas:
QardioArm is faster. It took 30 seconds to complete a BP measurement, compared to 50 seconds for the Omron 10.
BPs are immediately available on my iPhone with QardioArm, whereas a separate Bluetooth synching process is required for the Omron App. This process never works well for me, as the Omron fails to transmit measurements reliably.
It is amazingly easy to transmit BPs via email to your doctor (or friends if so inclined).
I found the QardioArm website to be very informative and helpful. The manual that comes with the device is very complete and you should definitely read it before using the device. I did not need telephone or email support services, so I can’t comment on those.
Overall Rating and a Caveat
Despite an initial frustration with QardioArm, I ended up really liking this device a lot. This sounds a little silly but the QardioArm improved the esthetic experience of home BP monitoring for me. Because it is compact, sleek and attractive, patients may be more likely to utilize it on a regular basis. In particular, I see it as something that you would be much more inclined to take with you for BP monitoring at work or on vacation.
I will be recommending this to my tech-savvy, style-conscious patients who require home BP monitoring. Previously, this type of patient would bring in their smartphone and show me the accumulated data from their BP readings. With a QardioArm, they can easily email my office the data and we can have it scanned into their record.
My final caveat: the QardioArm I gave my father for his 91st birthday does not work on his arm. It works without a problem on the arms of his friends and relatives. I have no idea why, but fortunately QardioArm honored their 30 day 100% money-back no questions asked guarantee. I’ve asked him to give me his nonagenarian perspective on the QardioArm experience so I can share it in a future post.