Tag Archives: self-monitoring blood pressure

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

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

When it comes to self-monitoring of blood pressure the best device (assuming equivalent accuracy) is the one that patients are most likely to use.

The Omron Evolv has become that device for the skeptical cardiologist as it combines a unique one-piece design with built in read-out with a quicker, more comfortable  yet highly accurate BP measurement technique.

My previous favorite BP device, the QardioArm remains a close second.

Evolv Form and Function

The Evolv is sleek and stylish in appearance and has no external tubes, wires or connectors. It runs on 4 AAA batteries.

 

 

The  cuff is pre-formed and is incredibly easy to self-administer to the upper arm. Measurement is simple. Press the start button and it immediately starts inflating the cuff.

The results are displayed on an LCD screen on the cuff.

The Omron uses an oscillometric technique to measure the blood pressure as it is inflating. This “inflationary” technique has been shown to be as accurate as measuring during deflation but is much quicker. A study using the recently developed “Universal Standard Protocol” for evaluating the accuracy of BP devices showed that the Omron Evolv was highly accurate compared to gold standard sphygmomanometry.

Omron has come up with some slick marketing terms for the inflationary and pre-formed wrap aspects:

  • Intellisense Technology – Inflates the cuff to the ideal level for each use.
  • Intelli Wrap Cuff – For an easy and accurate reading

With the inflationary technique the cuff knows when to stop inflating, (hence “intellisense”) therefore, there is less tendency to go to higher pressures compared to the deflationary technique and less potential for discomfort from those higher pressures.

Evolv Communication-Sharing Results

The Evolv communicates via Bluetooth with the Omron Wellness (or Connect) smartphone app. Your BP  and heart rate measurements are easily transferred to this app and can be viewed over time.

My blood pressure and heart rate measurements over the last week.

If  one clicks on the little export icon at the upper right had corner of this summary screen you can “export CSV” which creates a file of BP measurements over a defined period that can then be emailed to yourself, your curious friends, or your doctor.

Another option is to export the summary report but this is a premium feature and requires payment.

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Monitoring Heart Rhythm and Blood Pressure-The Omron/Kardia Pro Connection

I’ve discussed in detail how management of my afib patients who have the Kardia mobile ECG device and connect to me via the internet using KardiaPro Remote has tremendously advanced their care.

AliveCor has partnered with Omron and the Omron Connect (or Wellness) app is essentially the Kardia app which my patients utilize to record their ECG recordings and share them with me.

With this app, therefore, patients who have the connection subscription service can utilize the Omron app to share both their ECG and BP recordings with me online. This is really quite an amazing development.

Below are recordings from one of my patients that I took from the patient screen which I view online.

The data can be viewed in various formats including this one which gives a good idea of daytime variation in BP as well as percentage recordings in goal range.

 

For me, this ability to rapidly view patient’s blood pressures over time in meaningful ways greatly facilitates management. If we could find a way to seamlessly import these data directly into our EMR it would an even bigger step forward.

Speaking To Your BP Cuff

I don’t use Alexa but Omron highlights how the Evolv works with Alexa:

 

 

Somehow, this doesn’t seem helpful to me but I tried asking Siri (with both my Apple Watch and iPhone) if she could give me info on my blood pressure and she failed miserably

 

 

 

 

 

 

 

Evolv-The Future of BP Management?

To summarize why I am so enthusiastic about this BP cuff

  • Portability and compactness. One piece design without tubes or wires.
  • Rigorously proven accuracy
  • Esthetically pleasing
  • Quicker and more comfortable than “deflationary” cuffs
  • Read-out on cuff-no separate unit or smartphone required
  • Communicates well with highly functional app for organizing or reporting BP measurements over time
  • Coordination of ECG measurements from Kardia and BP measurements on app through KardiaPro facilitates physician management of patient’s cardiovascular conditions.

Oscillometrically Yours,

-ACP

N.B. In the course of researching the Omron Evolv I looked at multiple home BP monitor review websites online. Almost without exception these were worthless.  I suspect many of these device review sites are funded by companies making the products. Others just aggregate information from company websites and regurgitate it without analysis. Websites with apparent consumer reviews are also suspect as I have found unscrupulous vendors are manipulating the whole review process.

Fortunately, your trusty skeptical cardiologist remains unsullied by any financial connections to corporate America. Or corporate Japan for that matter  (It appears Omron has its headquarters in Kyoto, Japan). However, Omron, if you are listening perhaps you can send me for my review one of your new Complete combined BP and EKG monitoring devices!

 

 

 

 

And one final detail. I checked just now and you can purchase the Evolv at Amazon for $69. Bundles that connect you to your doctor through the cloud and get you an Evolv plus or minus the Kardia ECG device at a reduced price are available through both the Kardia and Omron websites and apps.

 

Why I Encourage Self-Monitoring Of Blood Pressure In My Patients With High Blood Pressure

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.

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

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

I described why I switched to home BPs in a post about the landmark  SPRINT trial in 2015:

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.

Sphygmomanometrically Yours,

-ACP

From the 2017 ACC/AHA BP guidelines

and the proper technique for office BP measurement