Home blood pressure monitoring.

Dr Manish Barman, MD. Membership and Affiliations ESC, European association of cardiovascular prevention and rehabilitation. Acute Cardiovascular Care Association. ESC, Working Group on Hypertension & the Heart. ESC, Working Group on e-Cardiology. American College of Cardiology. American Heart Association.

Corresponding address: Department of cardiology. Al Ahli Hospital, Doha, Qatar. About high blood pressure 

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Why Blood Pressure Matters High blood pressure (hypertension) is one of the most important preventable causes of premature morbidity and mortality in the world. Hypertension is a major risk factor for ischemic and hemorrhagic stroke, myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death. Untreated hypertension is usually associated with a progressive rise in blood pressure. The vascular and renal damage that this may cause can culminate in a treatment-resistant state. When does HBP require emergency medical treatment? High blood pressure often does its damage without creating symptoms, but when blood pressure numbers rise above 180 for the systolic pressure or 110 for the diastolic pressure, you need emergency treatment. When is blood pressure too low? Although it is possible that low blood pressure can alert you to a problem, it is usually only dangerous if it causes notable signs and symptoms.

Understanding the numbers Blood pressure is typically recorded as two numbers, written as a ratio like this; Systolic/diastolic mmhg. It is read as systolic number over diastolic number millimeters of mercury. For example, 120 / 80 mmhg.

Accepted recommendations for healthy blood pressure Blood Pressure

Systolic

Diastolic

Category

mm Hg (upper )

mm Hg (lower )

Normal

Prehypertension High Blood Pressure (Hypertension) Stage 1 High Blood Pressure (Hypertension) Stage 2 Hypertensive Crisis (Emergency care needed)

Less than 120

and

less than 80

120 – 139

or

80 – 89

140 – 159

or

90 – 99

160 or higher

or

100 or higher

Higher than 180

or

Higher than 110

Which number is more important, top (systolic) or bottom (diastolic)? Typically more attention is given to the top number (the systolic blood pressure) as a major risk factor for cardiovascular disease for people over 50 years old. In most people, systolic blood pressure rises steadily with age due to increasing stiffness of large arteries, long-term build-up of plaque, and increased incidence of cardiac and vascular disease.

Individuals whose blood pressure is higher than 140/90 mm Hg (140 systolic or above or 90 diastolic or above) often become patients treated for serious cardiovascular problems.

~77% of patients treated for a first stroke have blood pressure over 140/90

~69% of patients who have a first heart attack have blood pressure over 140/90

~74% of patients with congestive heart failure have blood pressure over 140/90

Your risk increases even more if you have high blood pressure along with other risk factors:        

Age Heredity (including race) Gender (male) Overweight or obesity Smoking High cholesterol Diabetes Physical inactivity

Through risk reduction and treatment of HBP, you can lower your risk for many of these diseases.

Risk factors for developing high blood pressure, also called hypertension: 

Family history Height, hair and eye color runs in families --- so can high blood pressure. If your parents or close blood relatives have had HBP, you are more likely to develop it, too. You might

also pass that risk factor on to your children. That's why it's important for children as well as adults to have regular blood pressure checks. You can’t control heredity, but you can take steps to live a healthy life and lower your other risk factors.

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Advanced age. As we age, we all develop higher risk for high blood pressure and cardiovascular disease. Blood vessels lose flexibility with age which can contribute to increasing pressure throughout the system. Gender-related risk patterns. A higher percentage of men than women have HBP until 45 years of age. From ages 45 to 54 and 55 to 64, the percentages of men and women with HBP are similar. After that, a much higher percentage of women have HBP than men. Lack of physical activity Physical activity is good for your heart and circulatory system. An inactive lifestyle increases the chance of high blood pressure, heart disease, blood vessel disease and stroke. Inactivity also makes it easier to become overweight or obese. Poor diet, especially one that includes too much salt. To care for our bodies, we all need good nutrition from a variety of food sources. A diet that's high in calories, fats and sugars and low in essential nutrients contributes directly to poor health as well as to obesity. In addition, there are some problems that can happen from eating too much salt. Salt keeps excess fluid in the body that can add to the burden on the heart. While too much salt can be dangerous, healthy food choices can actually lower blood pressure.

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Overweight and obesity Being overweight increases your chances of developing high blood pressure. A body mass index between 25 and 30 is considered overweight. A body mass index over 30 is considered obese. Losing as little as 10 to 20 pounds can help lower your blood pressure and your heart disease risk.

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Drinking too much alcohol Heavy and regular use of alcohol can increase blood pressure dramatically. It can also cause heart failure, lead to stroke and produce irregular heartbeats. Too much alcohol can contribute to high triglycerides, cancer and other diseases, obesity, alcoholism, suicide and accidents. If you drink alcohol, do so in moderation.

Possible contributing factors There is some connection between blood pressure and these factors but science has not proven that they actually cause high blood pressure. a. Stress b. Smoking and second-hand smoke c. Sleep Apnea

Secondary hypertension: HBP caused by a pre-existing problem In 5-10 percent of high blood pressure cases, the HBP is caused by a pre-existing problem. This type of HBP is called secondary hypertension because another problem was present first. Factors that may lead to secondary hypertension include: o o o

Kidney abnormality, including a tumor on the adrenal gland, which is located on top of the kidneys A structural abnormality of the aorta (the large blood vessel leaving the heart) that has existed since birth Narrowing of certain arteries.

Home Blood Pressure Monitoring Out-of-office BP, assessed by ambulatory or home BP monitoring, is an important adjunct to office BP measurement. The prediction of CV events is significantly better with out-of-office BP than with office BP. Prognosis is better in white-coat hypertension than in sustained hypertension and appears to be similar to that in true normotension. The incidence of CV events is about two times higher in masked hypertension than in true normotension and similar to the incidence in sustained hypertension [1]. Home BP monitoring has been investigated for use and acceptability in a primary care setting way back in 1999 however it has been much under utilized since then. Patients, doctors, and nurses have found monitoring valuable, and found the instruments easy to use with few problems. It has been, they recommended as the preferred alternative to ambulatory monitoring in primary care [2]. Colman et al have recently reported that Methods of obtaining accurate BP readings in general practice is important for clinicians and having both a regular system of follow up together with HBPM is crucial [3]. Home BP is more closely related to hypertension-induced organ damage than office BP, particularly LVH, and recent meta-analyses of the few prospective studies in the general population, in primary care and in hypertensive patients, indicate that the prediction of CV morbidity and mortality is significantly better with home BP than with office BP. Studies in which both ABPM and HBPM were performed show that home BP is at least as well correlated with organ damage as is the ambulatory BP, and that the prognostic significance of home BP is similar to that of ambulatory BP after adjustment for age and gender [4].

To help control high blood pressure, also called hypertension, research has shown that monitoring blood pressure at home can be helpful in addition to regular monitoring in a healthcare provider's office. Your doctor may recommend that you monitor your blood pressure at home if:   

You have been diagnosed with pre-hypertension (systolic --- top --- number between 120 and 139 mm Hg OR diastolic --- bottom --- number between 80 and 89 mm Hg) You have been diagnosed with hypertension (systolic 140 mm Hg or above OR diastolic 90 mm Hg or above) You have risk factors for high blood pressure.

Recommendation Home monitoring is recommended for all people with high blood pressure to help the healthcare provider determine whether treatments are working. Home monitoring is not a substitute for regular visits to your physician. If you have been prescribed medication to lower your blood pressure, don't stop taking your medication without consulting your doctor, even if your blood pressure readings are in the normal range during home monitoring.

Why is home monitoring important? Charting provides a "time-lapse picture" Your healthcare provider will want an accurate picture of the situation inside your arteries. One measurement taken at the doctor's office is like a snapshot. It tells what your blood pressure is at that moment. Since there are no symptoms for HBP and no way to sense fluctuations in blood pressure, measuring is the only way to get the facts. Readings can vary throughout the day and can be temporarily influenced by factors such as emotions, diet and medication. A record of readings taken over time can provide you and your healthcare provider a clearer picture of your blood pressure. It can be like a time-lapse picture or movie, providing information on what is happening with your blood pressure over time. Charting can help eliminate false readings. Some people experience anxiety when at a doctor's office, which leads to temporarily higher readings. This condition is known as "whitecoat hypertension." At the other extreme, some individuals have normal readings in a professional's office but elevated readings outside the office. This condition is often referred to as "reverse white-coat hypertension" or "masked hypertension.

Such false readings can lead to over-diagnosis or misdiagnosis of HBP. Self-measurement at home is good to reveal whether your blood pressure reading in the doctor's office is correct.

Who should home monitor? Home monitoring may be especially useful for:      

Patients starting HBP treatment to determine its effectiveness Patients requiring closer monitoring than intermittent office visits provide, especially individuals with coronary heart disease, diabetes and/or kidney disease Pregnant women since preeclampsia or pregnancy-induced hypertension can develop rapidly People who have some high readings at the doctor's office, to rule out white-coat hypertension and confirm true HBP Elderly patients, because the white-coat effect increases progressively with age People suspected of having masked hypertension

Who should not home monitor? People with atrial fibrillation or other arrhythmias may not be good candidates for home monitoring. Why? Oscillometric-method monitoring devices recommended for use at home may not be able to give accurate measurements for people with these conditions. If your healthcare professional recommends home monitoring, have your monitor's readings compared to readings taken by the auscultatory method. In this monitoring method, the professional uses a manual blood pressure cuff and stethoscope to listen to the blood pulsing through your brachial artery.

There are eight main ways you can control your blood pressure. They are:       

Eat a better diet, which may include reducing salt Enjoy regular physical activity Maintain a healthy weight Manage stress Avoid tobacco smoke Comply with medication prescriptions If you drink, limit alcohol

Adopting a healthy lifestyle is critical for the prevention of HBP and an indispensable part of managing it. Think of these changes as a "lifestyle prescription" and make every effort to comply with them. Whether you have been diagnosed with high blood pressure, also called hypertension, or are concerned because you have some of the risk factors for the disease, understand this: while there is no cure, high blood pressure is manageable. By adopting a heart-healthy lifestyle, you can:    

Reduce high blood pressure Prevent or delay the development of HBP Enhance the effectiveness of blood pressure medications Lower your risk of heart attack, heart disease, stroke and kidney disease

Here's how to do your part: 

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Be informed. Of all people with high blood pressure, over 20 percent are unaware of their condition. This symptomless disease could leave them with substantial health consequences. Are you one of them? If you don't know, see a healthcare professional to be tested. Do your part to reach your treatment goals Consider these statistics regarding those with known HBP: o 69 percent are under current treatment o 31 percent are not currently under treatment, even though they know their blood pressure is high There is no healthy level of high blood pressure. Don't take life-or-death chances with this disease. Instead, take responsibility! Work with your healthcare professional to determine your treatment goals and map out your best action plan for HBP prevention and management.

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Change your life and reduce your risks Even if your blood pressure is normal (less than 120 mm Hg systolic AND less than 80 mm Hg diastolic) and your goal is prevention only, the lifestyle modifications provide a prescription for healthy living. If your resting blood pressure falls in the pre-hypertension range (systolic - top- number between 120 and 139 mm Hg OR diastolic - bottom - number between 80 and 89 mm Hg), your doctor will recommend lifestyle modifications. Lifestyle modifications are essential. These changes may reduce your blood pressure without the use of prescription medications.

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Take medication if it is prescribed for you. If your blood pressure is 140/90 or higher, your doctor will likely prescribe medication in addition to lifestyle modifications. Follow your healthcare professional's recommendations carefully, even if it means taking medication every day for the rest of your life. High blood pressure is a lifelong disease, and by partnering with your healthcare team, you can successfully reach your treatment goals and enjoy the benefits of better health.

Once your treatment program becomes routine, maintaining a lower blood pressure is easier. Remind yourself that by managing your blood pressure, you are lowering your risk of heart attack, heart failure, stroke, peripheral artery disease and kidney disease. Death rates from these diseases have decreased significantly, thanks in part to earlier and better treatment of HBP. Managing blood pressure is a lifelong commitment; make a pledge to do so starting today for yourself and for those you love. Listen to your doctor, read the sound medical information on this site, and act on the information to live a heart-healthier life.

Latest evidence suggests that as the population above 60 years of age is the fastest growing and hypertension is highly prevalent in this group, accurate blood pressure (BP) measurement in the elderly is a very important and widely applicable subject. As with any other population, an accurate measurement of BP is essential to plan therapy and this remains an important consideration in the elderly as well. There are some unique problems of BP measurement in the elderly, including drug-induced orthostatic hypotension, white-coat hypertension, and advanced atherosclerotic disease with stiff arteries. For clinical use, home blood pressure monitoring (HBPM), office measurement, and ambulatory blood pressure monitoring all play a role in patient management. Because the white-coat effect is common in this group, there is a good case for the use of HBPM, which could also be used to detect orthostatic changes at home. Also, HBPM predicts cardiovascular events better than clinical BP, and is also useful in monitoring treatment [5].

Below are some suggestions regarding the best way to check your blood pressure accurately: 1. Pick a validated machine that gives automatic readings - a nonprofit website, Dableducational.org lists monitors that have been tested according to the standards of the European Society of Hypertension. 2. Arm monitors – meaning, machines with a “cuff,” or sleeve that fits on the upper arm — tend to be more accurate than wrist monitors. 3. Make sure the cuff – the sleeve of the machine that fits around your arm — is the correct size for your arm. The inflatable part of the sleeve should fit around 80 percent of your upper arm. If your arms are large, you may need to buy a large cuff separately. Before using the machine, bring it to your clinic or doctor’s office so that the staff can check its accuracy and make sure you know how to operate it correctly. The American Academy of Family Physicians and British Hypertension Society also post online instructions that can help orient you when you begin using your machine. 4. Basic rules for checking blood pressure (in the clinic as well as at home) include sitting in a chair that supports the back, with both feet in a comfortable position on the ground, for five minutes before taking the measurement. Smoking, exercising and drinking coffee should be avoided for half an hour prior to the reading, since these can make blood pressure levels rise transiently. 5. Check your blood pressure two to three times a week, at times when you are relatively calm. 6. Remember, the goal of checking your blood pressure at home is to keep an overall record

that will help your doctor or nurse decide on what treatment to recommend. 7. Don’t panic if the levels fluctuate. Individual high or low readings have little, if any, significance. 8. Bring your machine back to your doctor’s office every year, so that the staff can make sure it’s still working accurately. 9. Don’t rely on the free blood pressure monitors available at the grocery store or pharmacy, as they aren’t always accurate.

References 1. Essential messages from ESC guidelines. Committee for practice guidelines to improve the quality of clinical practice and patient care in Europe. ESC guidelines. 2. M Aylett, G Marples, and K Jones. Home blood pressure monitoring; its effect on the management of hypertension in general practice. Br J Gen Pract. Sep 1999; 49(446): 725–728. PubMed 3. Colman Siu-Cheung Fung , William Chi-Wai Wong, Carlos King-Ho Wong , Albert Lee ,Cindy Lo Kuen Lam. Home blood pressure monitoring. A trial on the effect of a structured education program. AFP, Workplace Volume 42, No.4, April 2013 Pages 233-237. AFP, RACGP 4. 2013 ESH/ESC Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). ESH and ESC Guidelines. 5. Reddy, Arun, K. Jogendra, Mather R. D. Rosendorff, Clive. Blood pressure measurement in the geriatric population. Blood Pressure Monitoring: April 2014 - Volume 19 - Issue 2 - p 59-63. Doi: 10.1097/MBP.0000000000000021. LWW Journal