Bakris: Take time, follow guidelines for accurate BP measurements
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Key takeaways:
- Many providers do not follow guidelines for taking a proper BP measurement.
- Avoiding simple steps can lead to faulty BP readings and misdiagnoses.
ARLINGTON, Texas — An accurate BP measurement is essential to properly diagnose and manage hypertension, yet most providers do not have time to follow the guideline-recommended steps, according to a speaker.
Clinic or office BP measurements are one of the most common medical procedures; however, many providers do not follow a standardized approach or do not use clinically validated devices, leading to faulty BP measurements, George L. Bakris, MD, professor of medicine and director of the American Heart Association-accredited Comprehensive Hypertension Center at the University of Chicago Medicine, said during a presentation at the American Society for Preventive Cardiology Congress on CVD Prevention.
Image: Adobe Stock
An international consensus statement on standardized clinic BP measurement, published in the American Journal of Medicine in May, includes a four-step checklist that highlights how to properly measure BP, Bakris said. Steps include asking a patient to rest in a quiet room with a comfortable temperature for at least 3 to 5 minutes, without talking, before any measurement, followed by using a clinically validated device measuring BP at the brachial artery with a properly fitted cuff. The provider should then conduct at least two BP measurements at least 1 minute apart, with no talking between measurements, and then average and record the BP readings.
“Just like there is not enough time to properly counsel patients, there is not enough time to do this right,” Bakris said during the presentation. “If you go to any random practice and see that this checklist is being followed, I will pay you $100. There is no way this is all happening. You are going to get all kinds of faulty readings. You are going to miss white-coat hypertension. You are going to overdiagnose white-coat hypertension. There are reasons for this checklist, and they need to be taught and followed.”
Steps for standardized BP measurements
For a proper BP reading, a patient must be seated, quietly and with their back supported, for at least 5 minutes, with their arm similarly well supported. Feet should be flat on the floor with legs uncrossed. The BP cuff should be applied to the bare upper arm, approximately 2 cm to 3 cm above the elbow crease.
The provider should take three BP readings, each 1 minute apart, Bakris said.
“Throw the first reading away, and then average the other two,” Bakris said. “That is your BP. That is how I teach patients to take it at home, in the morning, before they take their medicine. Most of these drugs we give them last 24 hours. The highest BP of the day is going to be first thing in the morning, when they wake up. It is important to have this concept in mind. Educate the patient so they give you reliable readings when they check at home.”
The guidelines also stress that properly sized cuffs be used for BP measurement, Bakris said. A small adult cuff size is recommended for an arm circumference of 22 cm to 26 cm; adult size for a circumference of 27 cm to 34 cm; large adult size for 35 cm to 44 cm and adult thigh size for a circumference of 45 cm to 54 cm.
“Many people do not pay attention to the cuff size, the machine is inflating and the cuff is unraveling as they speak,” Bakris said. “If you think that is an accurate BP, you’re hallucinating.”
Bakris recommended providers keep a tape measure in the room to measure a patient’s arm at the center of the biceps.
“That is the centimeter-size cuff you need for that person,” Bakris said. “Otherwise, if it is too big, you will get a falsely low reading; if it is too tight, you will get a falsely high reading.”
Home, ambulatory BP monitoring guidance
Guidelines recommend out-of-office BP measurements to confirm a diagnosis of hypertension and for titration of BP-lowering medication, in conjunction with telehealth counseling or clinical interventions, Bakris said. Several sites recommend validated BP monitors and it is important that patients taking home BP follow the guidance of these sources, Bakris said.
“There are machines that I have seen that are 15 years old that provide accurate BPs,” Bakris said. “There are also machines that I have seen that are 8 months old that do not measure an accurate BP. You need sources to give you guidance on which device to use.”
There are reasons to use ambulatory BP monitoring, such as ruling out so-called white-coat hypertension, determining the existence of masked hypertension and assessing BP therapy in people with resistant hypertension and in people with sleep disorders, Bakris said.
“If you are really serious about BP management, then you really need to measure it correctly, at least once, to see what is really going on,” Bakris said. “Then, teach the patient to measure BP correctly at home, because they usually do have the time.”
Reference:
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Bakris G. Session 7: The most prevalent CV risk factor of all – Contemporary and future approaches to hypertension. Presented at: American Society for Preventive Cardiology Congress on CVD Prevention; July 21-23, 2023; Arlington, Texas.
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