More Evidence That Hypertension Treatment Decisions Shouldn鈥檛 Depend Solely on In-Office Blood Pressure Readings

JAMA Diagnostic Test Interpretation

Ambulatory Blood Pressure Monitoring

Tamar S.聽Polonsky,聽MD, MSCI; George L.聽Bakris,聽MD, MA

JAMA
JAMA Patient Page

Monitoring Your Blood Pressure

Sarah聽Melville,聽CRA; James Brian聽Byrd,聽MD, MS

JAMA
Original Investigation

Association of Office and Ambulatory Blood Pressure With Mortality and CV Outcomes

Wen-Yi聽Yang,聽MD, PhD; Jesus D.聽Melgarejo,聽MD; Lutgarde聽Thijs,聽MSc; Zhen-Yu聽Zhang,聽MD, PhD; Jos茅聽Boggia,聽MD, PhD; Fang-Fei聽Wei,聽MD, PhD; Tine W.聽Hansen,聽MD, PhD; Kei聽Asayama,聽MD, PhD; Takayoshi聽Ohkubo,聽MD, PhD; J酶rgen聽Jeppesen,聽MD, PhD; Eamon聽Dolan,聽MD, PhD; Katarzyna聽Stolarz-Skrzypek,聽MD, PhD; Sofia聽Malyutina,聽MD, PhD; Edoardo聽Casiglia,聽MD, PhD; Lars聽Lind,聽MD, PhD; Jan聽Filipovsk媒,聽MD, PhD; Gladys E.聽Maestre,聽MD, PhD; Yan聽Li,聽MD, PhD; Ji-Guang聽Wang,聽MD, PhD; Yutaka聽Imai,聽MD, PhD; Kalina聽Kawecka-Jaszcz,聽MD, PhD; Edgardo聽Sandoya,聽MD, PhD; Krzysztof聽Narkiewicz,聽MD, PhD; Eoin聽O鈥橞rien,聽MD, PhD; Peter聽Verhamme,聽MD, PhD; Jan A.聽Staessen,聽MD, PhD; for The International Database on Ambulatory Blood Pressure in Relation to Cardiovascular Outcomes (IDACO) Investigators

JAMA
US Preventive Services Task Force

USPSTF Recommendation: Screening for Hypertension in Adults

US Preventive Services Task Force; Alex H.聽Krist,聽MD, MPH; Karina W.聽Davidson,聽PhD, MASc; Carol M.聽Mangione,聽MD, MSPH; Michael聽Cabana,聽MD, MA, MPH; Aaron B.聽Caughey,聽MD, PhD; Esa M.聽Davis,聽MD, MPH; Katrina E.聽Donahue,聽MD, MPH; Chyke A.聽Doubeni,聽MD, MPH; Martha聽Kubik,聽PhD, RN; Li聽Li,聽MD, PhD, MPH; Gbenga聽Ogedegbe,聽MD, MPH; Lori聽Pbert,聽PhD; Michael聽Silverstein,聽MD, MPH; James聽Stevermer,聽MD, MSPH; Chien-Wen聽Tseng,聽MD, MPH, MSEE; John B.聽Wong,聽MD

JAMA
Original Investigation

Concordance Between Blood Pressure in SPRINT and in Routine Clinical Practice

Paul E.聽Drawz,聽MD, MHS, MS; Anil聽Agarwal,聽MD; Jamie P.聽Dwyer,聽MD; Edward聽Horwitz,聽MD; James聽Lash,聽MD; Kristin聽Lenoir,聽MPH; Andrew聽McWilliams,聽MD, MPH; Suzanne聽Oparil,聽MD; Frederic聽Rahbari-Oskoui,聽MD; Mahboob聽Rahman,聽MD, MS; Mark A.聽Parkulo,聽MD; Priscilla聽Pemu,聽MBBS; Dominic S.聽Raj,聽MD; Michael聽Rocco,聽MD; Sandeep聽Soman,聽MD; George聽Thomas,聽MD; Delphine S.聽Tuot,聽MDCM, MAS; Paul K.聽Whelton,聽MD, MSc; Nicholas M.聽Pajewski,聽PhD

JAMA Internal Medicine
Research Letter

Prevalence and Frequency of Self-measured Blood Pressure Monitoring in US Adults

Mellanie V.聽Springer,聽MD, MS; Preeti聽Malani,聽MD, MSJ; Erica聽Solway,聽PhD, MSW, MPH; Matthias聽Kirch,聽MS; Dianne C.聽Singer,聽MPH; Jeffrey T.聽Kullgren,聽MD, MS, MPH; Deborah A.聽Levine,聽MD, MPH

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Research has shown that blood pressure readings taken in a physician鈥檚 office can fluctuate from visit to visit, depending on variations in timing and cuffs used, biological changes, and context:

Clinical trials such as the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) visit-to-visit variability (VVV) with an increased risk of cardiovascular disease and death. But the extent and implications of VVV in the real world wasn鈥檛 known.

A recent retrospective cohort of more than half a million adults with more than 7.7 million systolic blood pressure measurements looked for answers.

Its findings 鈥渢hrow into question the way that we鈥檝e been managing blood pressure,鈥� senior author Harlan Krumholz, MD, SM, a cardiologist who directs the Center for Outcomes Research and Evaluation at Yale University, said in an interview. 鈥淭here鈥檚 tension between the articles people see in journals and the real-world experience physicians and patients have.鈥�

6 Comments for this article

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April 27, 2023

Patient Perspective: I Dread Office BP Readings

Elsa Weber | Patient

There are many reasons that office blood pressures (BPs) are so unreliable.

Here is my BP experience in the doctor's office:

The back office person comes and gets you and walks you back to a station set up in the hallway. First you are weighed fully clothed, then he/she sits you in chair and proceeds to take your BP. They put the cuff on over your clothes and then raise your arm to a wire basket that holds the monitor and tell you to hold the basket. They turn the machine on, and while it takes the reading, they interview you with all the typical questions asked during each visit. All this, the raised arm, the continued questions and answers and the public nature of the process, not to mention the arm raised higher than your heart, ends up in a BP much higher than I ever have at home.

What bothers me the most is the offer of medication based on one reading. It bothers me because my home monitoring shows normal numbers for a woman my age. I have no symptom of high blood pressure. And they seem to ignore the home readings I bring to the office each time I go. This has been going on for years and not once has there been any follow up, only the offer to start medication. I lost the primary care provider (PCP) I had gone to for 10 years three years ago. I have changed PCPs three time since then, only to find the same routine. To me, it all seem like a bizarre medical version of an assembly line.

CONFLICT OF INTEREST: None Reported

April 29, 2023

Office Measurement of Blood Pressure

Tim Burge, MB;Chb, MSc, FRCS (Plast) | Burns Unit, Salisbury District Hospital, Salisbury, UK

In 1983 I was a 24 year old doctor in the British Army. My first job was as a single handed Regimental Medical Officer with an infantry battalion in Hong Kong. As well as the soldiers, I was responsible for their accompanying families. This was a total practice of about 2,500 patients, almost all of whom were young and who would generally be deemed fit and well.

Despite the demographics, high blood pressure readings were occasionally identified.

I was reluctant to treat these, so when they occurred I invited the patients to attend for repeat measurements.
These were done every day, for a week, in the much more relaxed, and social, environment of the family clinic that was run by my much more experienced nurse.

In almost every case the subsequent readings gradually fell.

Management decisions were made on the basis of the lowest, rather than the highest, reading.

At first sight this appeared labour-intensive but I believe that the small initial investment was more than repaid by not having to further investigate, label, and treat 'hypertensive' patients.

CONFLICT OF INTEREST: None Reported

April 28, 2023

Office BP Monitoring

Charles Hubbert, MD | Private Practice

It may be that the public should be educated through social media about hypertension and thus obtain BP monitoring outside the doctor's office, because the majority of BP determinations in a physician's office are not correct. Too much false-positive hypertension is being generated from office visits. I doubt that there is much hope to change this presently, since a visit that has been designated to last 5 minutes will hardly accommodate proper BP monitoring. I hadn't fully realized until recently, with the surge in emphasis on proper measurement, that years ago my wife was diagnosed with hypertension based on one faulty office BP taking; thankfully she questioned the diagnosis and stopped her prescribed medication after getting proper measurements elsewhere. Most of the time office assistants have had no training in proper BP measurement, but maybe artificial intelligence will solve this problem for the future? I am eternally grateful for my basic medical education in learning how to take BPs properly. And a proper BP-taking event can be a psychotherapeutic encounter, as long as there is only "laying on of hands" and not too much talking (possibly billable as such?)

CONFLICT OF INTEREST: None Reported

April 30, 2023

Ignores Reality

Stephen Kirk, MD | Private Practice

Publications in JAMA routinely criticize physicians for not following a standard protocol in measuring blood pressure, but ignore the very same in patients measuring their own blood pressures.

Few patients (none) in my experience know the recommendations for measuring blood pressure.

Furthermore, the digital cuffs used at home are never calibrated over time. Patients often use wrist blood pressure monitors, which are not recommended by any literature I know of.

I measure every blood pressure myself, never over a sleeve, more than once, and often get lower than what patients measure at home.

JAMA is doing a disservice by ignoring the "reality" of clinical medicine practiced on the general population and basing recommendations on a studies that represent a fraction of the population over relatively short periods of time.

CONFLICT OF INTEREST: None Reported

May 1, 2023

Pediatric Hypertension

Peppino Peppino, MD, Adj Prof of Ped Card | Post Graduate Medical School of Cardiology Univeristy of Palermo Italy

In response to increased global prevalence and underdiagnosis of hypertension in children, the simplified 2017 AAP pediatric hypertension guidelines aimed to improve diagnosis and management of the condition (1). I would like to stress, apart from Dr. Messerli's observation in this article that 鈥渓ousy blood pressure measurements are just not very useful鈥� (2), the importance of choice of appropriate cuff size, because聽 inappropriate size is the most common cause of hypertension in children (3).The take-home message is to confirm the importance of blood pressure measurement with the proper bladder width-to-length ratio 1:2 calculated for very young people's arms (4).

References

1. Flynn JT, Kaelber DC, Baker-Smith CM, et al; Subcommittee on Screening and Management of High Blood Pressure in Children. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. doi:10.1542/peds.2017-1904

2. Rubin R. More Evidence That Hypertension Treatment Decisions Shouldn鈥檛 Depend Solely on In-Office Blood Pressure Readings. JAMA. Published online April 26, 2023. doi:10.1001/jama.2023.5538

3. Pier Paolo Bassareo, Giuseppe Calcaterra, Jolanda Sabatino, et al., on behalf of the Working group on congenital heart disease, cardiovascular prevention in paediatric age of the Italian Society of Cardiology (SIC). Primary and secondary paediatric hypertension. J Cardiovasc Med 2023, April 24 (suppl 1):e77鈥揺85

4. Falkner B, Chair; Gidding SS, Vice Chair;Baker-Smith MC, et al., on behalf of the American Heart Association Council on Hypertension; Council on Lifelong Congenital Heart Disease and Heart Health in the Young; Council on Kidney in CardiovascularDisease; Council on Lifestyle and Cardiometabolic Health; and Council on Cardiovascular and Stroke Nursing. Hypertension. 2023; 80:00鈥�00. DOI: 10.1161/HYP.0000000000000228

CONFLICT OF INTEREST: None Reported

May 4, 2023

They Do Multiple BP Readings in the Office? Really?

Brett Gaspers | Patient

I've been doing home blood pressure monitoring for years. In all the times I've gone in for routine office visits, I cannot recall a single time where the assistant measured my BP more than once. There seems to be a wide gulf between recommended clinical practice and what actually takes place in the office.

My home BP monitor is set to take three readings. I also take my home monitor with me so I can compare the reading vs. what the assistant just measured (addressing Dr. Kirk's comment on calibration).

CONFLICT OF INTEREST: None Reported

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