control hypertension, home monitoring, microbiome boost your blood pressure, lower your blood pressure

Have you ever had a nurse or doctor measure blood pressure? Of course you have. It’s almost impossible to avoid having your BP tested these days. The trouble is that more often than not it is measured incorrectly. It is not unusual for allied health personnel (not physicians or nurses) to check your blood pressure. We have seen first hand that 1) they may not support the arm at heart level 2) the arm cuff could be the wrong size 3) they may not wait for you to calm down 4) a chair with proper back support and leg height is not always available and 5) they may ask you questions during the reading. Such mistakes can lead to inaccurate BP measurements.

The Good Old Days?

In the early 20th century, doctors and nurses made quite a ritual out of measuring blood pressure. There was a glass tube containing mercury, a blood pressure cuff and tubing to connect them. In addition, the health care professional had to wear a stethoscope to listen to the blood passing through the brachial artery in the elbow.

The process was complicated and required good hearing to detect the on-off “Korotkoff” sounds. Most health professionals did not think this procedure could ever be mastered by patients at home.

Digital Blood Pressure Machines:

When digital blood pressure monitors became available, many physicians were skeptical about the benefits of such instruments. A review of the machines found in drugstores concluded (Blood Pressure Monitoring, Dec. 2013):

“On average, drug store monitors recorded lower systolic blood pressures and higher diastolic blood pressures than a validated monitor, but the difference was neither statistically nor clinically significant. Single reading comparisons showed a much broader range. In three participants, drug store monitors did reflect the average home blood pressure.”

That’s not to say all the electronic devices are accurate. And the skill of the user will impact the readings. That said, Consumer Reports has been evaluating BP home equipment for many years. Their current recommendations include:

  • Omron 10 Series BP786N
  • Rite Aid Deluxe Automatic BP3AR1-4DRITE
  • Omron Evolv BP7000 (a wireless device with no hoses or wires)
  • A&D Medical UA767F

Can Patients Learn to Measure Blood Pressure?

Many health professionals doubted the value of having patients measure their own blood pressure. There was a sense that this procedure was too complicated for people to master.

A new study in The Lancet puts those concerns to rest (March 10, 2018).  British researchers recruited physicians from 142 general practices in the UK. Patients with poorly controlled hypertension (blood pressure readings over 140/90) were randomized to one of three groups.

What They Did:

Nearly 400 participants monitored their blood pressure at home using an Omron M10-IT electronic device (the self-monitoring group). They were asked to measure their blood pressure two times in the morning and twice each evening for the first week of every month. They were asked to record the readings and send them to their general practitioners for oversight.

A comparable number of volunteers recorded their blood pressure at home in a similar manner but sent the information to their doctors via text message and a web-based data entry system (telemonitoring group).

The “usual care” group had their blood pressure readings measured exclusively in the doctor’s office. The study lasted a full year. All participants were also monitored by research nurses who measured the volunteers’ blood pressure at each follow-up appointment. Blood pressure medications were adjusted based on the measurements from all three groups.

The Envelope Please!

The investigators found that self-monitoring, with or without telemonitoring, produced significantly better blood pressure control than clinic-monitored readings. The authors recommend self-monitoring for all patients who wish to use it.

An editorial in the same issue of The Lancet noted that if self-monitoring were sustained:

“such reductions in blood pressure could be expected to reduce stroke risk by 20 percent and coronary heart disease risk by 10 percent.” The physicians who wrote this editorial titled their article:

“Hypertension: time for doctors to switch the driver’s seat?”

They ask even more controversial questions:

“Should not the driver’s seat be co-chaired by health literate patients and dedicated professionals from allied fields? Could it be a valuable option to empower patients whenever possible, introducing them to self-titration and self-initiation of antihypertensive drug therapy?”

Blood Pressure Varies Enormously!

We have always been fascinated to read articles about the accuracy of home blood pressure monitoring. Many health professionals get excited if the electronic machines are not absolutely perfectly validated. Relying upon one or two readings in a doctor’s office does not reflect day-to-day blood pressure any more than reading a page from the middle of a book will reveal the full story.

Blood pressure varies enormously hour to hour, day to day or even month to month. A huge study published in the American Journal of Hypertension (online, Dec. 23, 2017) included data on over 56,000 individuals from 185 countries. Nearly 17 million BP measurements were analyzed.

Here is what they discovered:

“Novel findings from our study of serial, self-monitored BPs is that BPV [blood pressure variability] is higher during weekdays and winter season, supporting that environmental factors such as job stress and the outside environment influence BPV.”

They found that Monday readings were highest whereas Saturday and Sunday were lowest. Morning BP readings (7:00-10:00 am) were higher than afternoons. The authors conclude:

“Home BP measurements rather than office BP are recommended for the optimal assessment of BP changes. Home BP measurement, which is reliable, reproducible, and free from white-coat effect and observer dilution bias, is associated with target organ damage and offers better prognostic value than office BP measurement. Recently, home BPV measured over 7 consecutive days showed an association with future cardiovascular events.”

People’s Pharmacy Perspective:

We have come a long way from the old-fashioned approach to measuring and treating hypertension. Technology may also enable patients to be more active participants in the treatment of diabetes, irregular heart rhythms and blood thinning regimens. The expanding self-care movement should lead to shared decision making between patients and health professionals.

To learn more about the proper way to measure blood pressure, along with the Dos and Don’ts of managing blood pressure, we offer our Guide to Blood Pressure Treatment.

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  1. Nita
    NC
    Reply

    I think the concerns about the drs. office are well founded. As an ED nurse, I’ve seen so many errors in BPs taken by staff. And during my tenure as a PACU (recovery room) nurse, I’ve had patients on medication coming out of the OR with the electronic BP cuff on backwards or sideways. A lot of times when I positioned the cuff properly, the BP was normal without the IV medications!

  2. Gary
    Vero Beach FL
    Reply

    I am concerned about the use of wrist BP monitors. While more convenient for the office staff,
    I always have higher than normal readings with them.

  3. Marilyn
    Silver Spring, Md.
    Reply

    I have tiny, skinny arms and my CVS home BP monitor has: half of the part that goes around your arm is ‘pre-formed’ meaning it’s for a bigger arm and I can never get it tight enough. Which model will go around a very small arm. I tried the child’s cuff and that was impossible to get on correctly by myself which I have to do since I take my own BP.

  4. Mary
    FL
    Reply

    As an old retired RN I become very annoyed and they become angry when I say a ” thigh size cuff will not accurately register ” on my 11 in arm.

  5. Marti A.
    Reply

    My doctor wants my Bp about 120/65, my friend who goes to the VA says her doc is okay with 140/70. None of the doctors seems to account for the fact that we are all different and normal for one person is a problem for another.

  6. Judith
    Reply

    When I go to my PCP for a physical,and he takes may BP, he puts my arm down. When I say to him that this is not correct, the hand has to be at the heart level, his answer : ” its ok,its ok”. And he continues to take the BP. Is he right? NO !!!

  7. Pepi
    Harrison, OH
    Reply

    I would have like to see in your article the best time of day to measure your blood pressure. Also is it better to lay down or to seat down? I ask because this is a debate my husband and I have often.

    • Terry Graedon
      Reply

      We recommend measuring blood pressure at various times of day. It changes. Take it sitting down, as described in the article, arm supported, feet on the floor. Taking it lying down will give you a lower reading than is true.

  8. Ken
    Silverton, OR
    Reply

    I, like many of the commenters above, have never had my blood pressure taken properly at the doctor’s office. It makes me wonder how many people are needlessly put on blood pressure medications…

  9. Bob
    South Carolina
    Reply

    Years ago I purchased a top of the line Omron BP monitor. I followed the directions on how to use the monitor. However, from the very beginning I notice a wide variation of values when taking consecutive readings. The second reading would be 10 to 15 points below the first reading (systolic). The third reading would be slightly higher than the second and the fourth was lower than the second. Many times the variation between the first and fourth reading was as much as 20 to 25 points. Talked to Omron about this many, many times and they suggested that I return the unit. They checked and by their standards said it was working properly and within +/- 1 point of being accurate. Years passed and I decided to buy a newer model thinking technology changed. Got the same type of number variations. So right now I don’t use the monitor and the readings I get from the doctor’s office can be all over the place. As low as 106/68 to 145/82, both taken in the morning.

    A leading cardiologist on a radio program said you should never use the first reading as it is false. So it is totally confusing. I’m now considering an old fashion manual unit.

    • Sally
      WA
      Reply

      I purchased a monitor last year. Don’t remember the brand but I picked-up at Costco. This monitor was set-up to do a single reading or three readings in about five minutes. The instruction manual suggested using the three readings, which the monitor would average, for the most accurate reading.

  10. Don
    ON
    Reply

    I agree with home monitoring and taking the historical results to a Dr however. I read the review on the Omron Series 10 and it is a great machine but, the cellphone app, which I agree with, is too invasive. It wants access to your files, pictures, location, camera, contacts and on and on. I sent and email to Omron and they say these can be turned off, not fully I found. The easiest way would be for them to not demand so much data.

    Thanks

  11. Jim
    metro Raleigh, NC
    Reply

    Always empty your bladder before BP is taken because it will make a difference. Don’t talk, look away, and visualize a cute or peaceful scene like a puppy with a butterfly on its nose. A long walk an hour or two before the appointment can also help with relaxation. All these add up to a more accurate BP measurement.

  12. laura b.
    Reply

    I know that my bp is fine, but when I go to Dr. office maybe once/year, their automatic cuff squeezes my arm so tightly that it makes me alarmed. When the nurse has uses the stethoscope/cuff, bp measures normal. But, I don’t recall ever having my arm at the same level as my heart in Dr. office.

  13. Margie
    SEA
    Reply

    They slap on an automated blood pressure machine that squeezes my arm so hard that it hurts. It’s bad enough that it causes bruising! Of course this causes my BP to be incredibly high. They laugh when I tell them that the machine is the cause of my high BP. What can I do? They insist on torturing me in this manner.

    • Carol
      Reply

      Margie, I’d go online and find info on the proper size cuff for the circumference of your arm, to make sure, first of all, that they are using the correct cuff on you. If they use a cuff that is too small for your arm, that will give them a reading that is incorrect. I find that very few healthcare workers know this. The other thing I’d do is, once you know the correct size, get a cuff that you can use at home. Then you’ll know what your true blood pressure is and be able to compare it with what you get. If you have the right size cuff and take your blood pressure at home and still get a high reading, it means that you have high blood pressure, whether it hurts or not. These two steps will help you find out what the real story is.

    • Sally
      WA
      Reply

      I know it is a hassle but it sounds to me like it is time to find a new office. If you want to give them another chance tell them to find another way to measure your blood pressure. If they say they don’t have another way take a picture of your bruise. Show them the picture at your next appointment. If they still can’t make any accommodations for you it is time to find a new doctor’s office.

  14. Jean
    Ohio
    Reply

    I blindly took 4 BP meds on Dr.’s advice: losartan/hctz, amlodipine, and atenolol, for 15-20 years. After kidney’s indicated a decline (eGFR 46) Dr. cut losartan in half. Two blood test later eGFR up to 53. I then took it upon myself, w/Dr. approval, to cut amlodipine in half — two months later eGFR 57. In November 2017 I weaned off atenolol over a three week period with three additional weeks of periodic rapid heart rate — but a March 2018 blood test showed eGFR at 61!!! Normal!!!! My home monitored BP is much much lower than in the office — usually around 112/60. Even if this is off slightly no way it would match the office reading of 140/90.

    • ray
      Reply

      i was on 4 diff heart meds after heart attack.every office visit i was told everything fine. one by one i cut the dose in half. same results,everything looks fine.3 months latter i told my dr i had been cutting my med in half still getting a good reading. rarely but it will get above normal and the dr told me which of the 4 to take a full dose to bring it down. i was told not take bp reading right after meal,anything with caffine,certain meds will raise it,and rest 15 min before taking bp

  15. Steve
    Maryland
    Reply

    Thank you very much for this article. I have been measuring my BP at home for 5 years. I keep the readings on a spread sheet. I’m 65 years old and take 10 mg of lisniopril- it was 20 mgs. During a recent visit to my primary care doctor my blood pressure was once again measured incorrectly- it always is and my readings are always higher than at home.

    When my doctor visited with me for 5 minutes he pulled up my chart on his iPad and told me that we needed to do more about my BP as it was borderline the last 3 visits. I shared with him my concern about the conflict between his data and mine. Remember, I have been measuring mine for 5 years to include all seasons, time of day and every other influence. He pointed to his iPad and said here are the numbers, they don’t lie. I said yes but I think mine carry more importance as there is more data and a broader sample. He stood firm on his information and had no interest in what I had to say. The conversation ended.

    I am now carefully considering signing up for concierge medicine. When I first entered his practice many years ago I told him I am actively involved in my care. If exercise and diet help I do it. If herbs or supplements help I take them and finally if no other option exists other than a pharmaceutical I take it. So, I ask questions and make my own decisions about the path I will follow. I don’t think he appreciates my level of knowledge and involvement. I don’t think it’s just him. Our medical care systems is weighted toward what I call “check box medicine” and drugs. Check box means you show up, they go through a number of preprogrammed steps and out the door you go with a drug or follow-up appointment. We can thank insurance companies, lawyers, bureaucrats and many others. AND in my book nothing will change unless we the people learn to be the most important part of our care.

  16. Susan
    Dallas, TX
    Reply

    The nurses at my PCP’s office always take a blood pressure reading OVER the sleeve – doesn’t matter if you have on a thin shirt or a heavy sweater – which from what I understand about taking a correct reading is the wrong way to do it. They also take it as soon as you get to the exam room – no time at all to relax. Add white coat syndrome into the mix and – surprise! – it’s always higher than what I get at home.

    • Sally
      Reply

      A couple thoughts, you could insist on having your arm bare when you have the blood pressure taken. You could also wear short sleeves and push whatever you need to out of the way.

  17. Charles L.
    Portland, OR
    Reply

    On a lark, I bought the $11 made-in-China Wrist BP monitor at Harbor Freight. It gives consistent reading compared to my $100 Omron at home. At the doctor’s office, it is consistent with the nurse’s reading using stethoscope and cuff.

  18. Lida
    Reply

    I agree with David
    There hasn’t been one doctor or nurse who has taken blood pressure properly.
    I am now in the sad position of getting “white coat” syndrome when I take my own at home . Due to all the high readings in the doctors’ offices I am so anxious before taking my own and need to sit still and take at least three readings spaced 5 minutes apart before it goes down. Even then it is still not as low as It needs to be. I think I have been thoroughly traumatized.

    • Nancy
      Portland, OR
      Reply

      In response to Lida, I thought I was the only one with this problem!

      • ED
        RALEIGH
        Reply

        That makes three of us (Lida and Nancy). I have given myself “white coat” hypertension from being anxious when taking my pressure at home because of white coat hypertension at the doctor’s office. I really have to concentrate on relaxing when taking readings and dread taking them.

        Also like Bob in South Carolina, I got an Omron BP786, and it is not unusual for consecutive readings to vary 10-15 points systolic/5-10 diastolic. Similarly, I talked to Omron about this several times, and they suggested that I return the unit. They checked and said it was working properly. Got another BP786N (essentially the same model) and got the same variations.

    • ray
      Reply

      you dont get your 15 min rest before the nurse rush you in.also i was told not recheck my bp like back to back,but wait 15 min before you recheck it.if your first reading is high your bp will probably go up from anxiety.

    • Mary
      Washington
      Reply

      I also experience this same “white coat hypertension” at home due to past stress of doctor’s office staff taking my bp incorrectly and producing elevated readings (resulting in prescribed meds that caused awful side effects). If I do have a high initial reading at home, I can always reduce it to safe levels after one or two attempts. I’m no longer on any meds. I use an Omron 10 BP786N

      I visualize a familiar, calm outdoor scene, focus on my back in contact with the chair, and breathe deeply for several minutes (a technique I learned from a cardiologist’s blog). This morning my bp was 114/65.

  19. jane
    Reply

    I consider personal blood pressure monitoring to be essential for those like myself who suffer white coat syndrome. We can get absurd readings in clinical settings, while getting reasonable readings ourselves. Doctors then try to put us on multiple blood pressure medications ‘just in case’ ignoring serious side effects (such as dizziness). What we were consulting the doctor about in the first place can often end up being ignored!

  20. David McE.
    Iowa
    Reply

    I don’t think I’ve ever had my blood pressure taken correctly by a physician in my entire life, I monitor it myself.

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