The People's Perspective on Medicine

Was Your Blood Pressure Measured Incorrectly?

Cardiologists keep lowering the bar when it comes to hypertension. Normal is now BELOW 120/80. Do you have hypertension? Was your blood pressure measured correctly?
Doctor measuring blood pressure of overweight woman in hospital

Do you have high blood pressure? There’s a 50% chance that you do. That’s because anything above 120/80 is now considered hypertension. But was your blood pressure measured correctly? There’s a strong possibility the answer is no. Perhaps you do not have hypertension after all.

Listening to Blood “Whooshing:”

There was a time when doctors did not diagnose hypertension until a patient’s systolic blood pressure was over 140. Diastolic blood pressure had to be above 90.

In the 1980s the doctor (and it usually was the doctor back then) measured your blood pressure with a sphygmomanometer and a stethoscope. He (and it often was a he) would listen to the sounds over the brachial artery in the crook of your elbow.

The first “whoosh” of blood equals systolic blood pressure and the last “whisper” represents diastolic blood pressure. These “Korotkoff” sounds correspond to the peak pressure at the moment the heart contracts (systole) and pumps blood through arteries and the lowest blood pressure when the heart relaxes (diastole).

Lowering the Bar:

If you had your blood pressure measured 30 years ago and it was 145/95, your chart would probably say you had “mild” or “borderline” hypertension. You might have been told to lose weight, cut back on salt or exercise more.

In 2017 the same reading would be interpreted quite differently. More specifically, you would be diagnosed with stage 2 hypertension. That year the American College of Cardiology and the American Heart Association (AHA) determined that hypertension was anything over 130/80 (Annals of Internal Medicine, March 6, 2018). 

Previous guidelines urged doctors to treat patients whose blood pressure measured 140/90 or higher. The first and higher number is systolic blood pressure: the pressure within the vascular system when the heart is squeezing blood through it. The second number, diastolic blood pressure, is the pressure remaining while the heart relaxes between beats. Under the new criteria, blood pressure at or above 130/80 is defined as high blood pressure. Most people at that measurement will need to take steps to reduce it.

Why the Change In Defining High Blood Pressure?

The lower threshold appears to flow from a study called SPRINT that was published two years ago. It showed clearly that people who were able to lower their systolic blood pressure close to 120 were 25 percent less likely to have a heart attack or a stroke. In absolute terms, the difference did not look enormous: 1.65 percent of those getting systolic blood pressure down near 120 had a cardiovascular complication compared to 2.19 percent of those whose systolic blood pressure was lowered only to 140. Still, when you consider how many millions of us (approximately 103 million) have blood pressure at or above 130/80, a little difference can add up to an awful lot of people. Avoiding a heart attack or stroke will be a huge benefit for them.

Roughly half of all adults in America (over 100 million people) were instantly labeled hypertensive. Even though their American colleagues were lowering the bar, European cardiologists retained the 140/90 cutoff (Circulation Research, March 2019). 

Do You Have High Blood Pressure?

If you live in the U.S., you now have high blood pressure if your readings are greater than 120/80. “Normal” blood pressure is defined as anything less than 120/80. That’s true whether you are 25 or 85. If you can’t get your blood pressure below that cutoff with weight loss, exercise or a low-salt diet, many doctors feel obligated to prescribe medications. It is possible to lower blood pressure without drugs, but it requires diligence and effort: exercise, meditation and a DASH diet with plenty of vegetables and fruits can work.

Measuring Blood Pressure is Challenging:

Since the outcome matters so much, you would think blood pressure measurement would be highly accurate. That turns out to be harder than you might imagine.

Clinics and hospitals are trying to be more efficient. Time is money. To save both time and money doctors and nurses rarely check your blood pressure themselves. That’s because there are automated electronic BP machines. This equipment seems so easy to use that hospitals and doctors’ offices may not spend a lot of time training the technicians who use it.

We have personally observed an astonishing number of mistakes when blood pressure is measured. And we cannot always blame a technician. Even doctors and nurses may make serious errors when taking automated blood pressure readings.

Measuring Blood Pressure Correctly:

We have not made up these recommendations. They come from the American Heart Association (AHA)(Hypertension, May, 2019

  1. You should always empty your bladder prior to blood pressure measurement. If you had to deal with traffic congestion, parking problems or any other stressors, you should be given time to go to the bathroom and then recover your equilibrium.
  2. When it comes time to have your blood pressure taken, you should be given more time to sit quietly (for at least five minutes) in a comfortable chair prior to any measurement. Feet should be flat on the floor and the back must be supported. The temperature in the room should be at least 72 degrees F. Blood pressure should never be measured while the patient sits on an exam table with feet and arms dangling.
  3. Most important, the blood pressure cuff should be the right size for your arm, neither too big nor too small. When was the last time someone actually measured your arm for cuff size? The arm must be supported at heart height.
  4. Equally important, there should be no talking during blood pressure measurement. Even casual conversation can artificially raise blood pressure.
  5. Multiple readings are appropriate with at least a minute between each reading. The AHA recommends three measurements. You should not be told you are hypertensive based on one reading!

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Readers Sound Off About Bad BP Measurements:

Readers frequently complain about faulty blood pressure technique. One woman reported that having her blood pressure measured is like being pinched really hard.

She asks:

“If pain can elevate BP during other procedures, why not if someone is squeezing the daylights out of my arm?”

The answer is yes, pain can raise blood pressure (Journal of Clinical Hypertension, June 10, 2013).  The cuff is likely the wrong size.

Another reader asks:

“I have seen techs, nurses, and doctors place the blood pressure cuff over heavy sweatshirts and take a blood pressure. When I asked about this, they all said it did not matter. Does it?”

Answer: yes. The article in the journal Hypertension that describes the AHA’s recommendations about proper blood pressure techniques states:

“Remove clothing covering the location of cuff placement.”

By the way, take a look at the photo at the top of this article. How many mistakes did you count? Here are some hints:

  1. Is the patient sitting in a comfortable chair?
  2. Is her back supported?
  3. Does the patient have her feet resting on the floor?
  4. Is the patient’s arm supported at heart height?
  5. Is the blood pressure cuff the right size?

How Can You Tell If You Have High Blood Pressure?

Because so many mistakes can be made in a doctor’s office or hospital clinic, we encourage people to measure their own blood pressure at home. Our eGuide to Blood Pressure Treatment provides guidelines and strategies for both measurement and management of hypertension. It is available in the Health eGuide section

You may also want to listen to our podcast: Show 1134: Can you Control Your Blood Pressure Without Drugs?

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    About the Author
    Joe Graedon is a pharmacologist who has dedicated his career to making drug information understandable to consumers. His best-selling book, The People’s Pharmacy, was published in 1976 and led to a syndicated newspaper column, syndicated public radio show and web site. In 2006, Long Island University awarded him an honorary doctorate as “one of the country's leading drug experts for the consumer.” .
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    New guidelines define many more Americans as having high blood pressure. Medications to treat it may have side effects. Can you lower your blood pressure naturally?

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    Citations
    • Carey, R. M., et al, “Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Synopsis of the 2017 American College of Cardiology/American Heart Association Hypertension Guideline,” Annals of Internal Medicine, March 6, 2018, DOI: 10.7326/M17-3203
    • Muntner, P., et al, “Measurement of Blood Pressure in Humans: A Scientific Statement From the American Heart Association” Hypertension, May, 2019, https://doi.org/10.1161/HYP.0000000000000087
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    My family doctor uses the old fashioned way of taking BP, and mine is usually about the same from visit to visit. Others not so much. I had an echo done, and while sitting on the table, feet dangling, the technician put the cuff around my arm, and my arm just hung down. My BP was sky high. She said, “That’s pretty high. Is that what it usually is?”. I said no, and she said she’d check it again after the procedure. She did it the same way again. Also had this done at my dentist and it was the same thing. I don’t think they have been trained at all.

    According to this article, I haven’t had a correct BP measurement in over 20 years (or longer)! I repeatedly tell them to use an extra large cuff (am usually told none is available). So after the cuff pops off my arm, they use my forearm instead of my very large upper arm. How accurate is a forearm reading? Especially after my arm has been squeezed to the point of extremely severe pain? I asked about supporting my arm (told it doesn’t matter, or they never heard of that). I’ve been told I don’t have to remove shirt, jacket, or sweater (I do anyway), They rarely wait 1 minute between multiple readings from the same arm. Doctor rarely takes my BP, even after grossly high readings.

    But it’s not only the “ideal” BP numbers that are being lowered. “Normal” diabetic blood readings keep getting lower and lower too; 20 years ago, they wanted my numbers around 125. Now, they want them below 100 and want me to take multiple diabetic meds, despite horrible side effects, to achieve such numbers, “because the doctor has determined that the [minimal] benefits outweigh the risks.” Really? Shouldn’t the patient make that determination, since they are the ones who will have to live with the side effects?

    I have also been told I could be “fired” as a patient for refusing to “follow the doctor’s prescribed meducations (statins).” Whatever happened to “First, do no harm?” Or did they lower that bar too? Finally, how much influence did Big Pharma have on the new guidelines? How much more money do they make if more people are diagnosed with HBP, or “elevated” blood sugar readings? I no longer trust the medical profession, or the health care industry in this country. It is profit, not patient, driven!

    I agree with the point about the automatic versus the manual taking of blood pressure. For some reason, my readings are often quite a bit higher with the automatic option. Fortunately, the doctor or his assistant usually retakes my blood pressure manually, and the readings are significantly lower.

    So, it is important to request a retake manually if one gets a high reading with the automatic option.

    What about white coat syndrome? I seem to have inherited it from my dad, who had it. I have been getting insane readings at times that are not typical for me at all. Sometimes they are willing to try again before I leave the doctor’s office, and it has gone down. I’m starting to feel I should give up on doctors if I have to be put on BP medicine over these horrible rules. I think they should crack down on doctor’ offices and inspect how each one is taking their patients’ blood pressure!

    My endocrinologist measures my bBP correctly. Cardiology, Dermatology and Primary Care doctors do not. Never high in his office.

    NO ONE including myself, my doctors, or my husband can get an accurate BP reading on me using unautomated, automated or any kind of cuff. I don’t just have “white coat” syndrome. I have “fear of bBP readings” syndrome.

    There is a solution to this—24 hour ambulatory bp monitoring. I’ve had this twice. Similar to a halter monitor, an ambulatory BP monitor is worn constantly for 24 hours and inflates automatically every 30 minutes day and night (including while sleeping). The data is retrieved by (or sent to) the physician so she can see the results. Both times my readings with the monitor were drastically better than readings done manually.

    I live in a city known for outstanding medical care. People come here from all over the world. However, NO ONE, including cardiovascular specialists provided this test. I had to drive an hour to a regular primary care medical doc (with a holistic tendency) who offered this test, pay out of pocket for the test, and stay in a hotel overnight (car rides affected the readings—it was best to be fairly sedentary for the 24 hours). Worth every penny!

    Now ambulatory BP monitoring is available through two companies with a doctor’s order. I understand that in England doctors use this test so they don’t overmedicate their patients. Gee, what a concept: actually getting an accurate measurement before prescribing more medicine! Full disclosure, I am on BP meds but I like knowing I am on the correct and necessary amount.

    Rather than a picture showing the wrong way to take blood pressure, perhaps a photo to show the right way.

    It seems every primary care & specialist I’ve seen has med techs who follow the same procedure: You take off shoes & coat for weight, then pick up shoes, coat, & purse from floor & tramp to exam room, sit down & have BP taken immediately while answering questions about history & meds. My husband sees a different set of docs but has the same experience.

    Because I regularly take my BP at home on a calibrated machine, I’m familiar with the 15 – 20 point systolic “leap” under the circumstances described above. So I refuse measurement until the AHA recommendations are met. My primary care doc has accommodated to this demand, but other doctors express displeasure.

    Perhaps if more of us started requiring observance of the AHA recommendations, fewer folks would be dxd with hypertension.

    I go to an allergist, ENT, gynecologist, rhuematologist, liver doctor, cardiologist, oncologist, dermatologist, and primary care doctor. Only one, my primary care doctor, has taken my blood pressure following the instructions in the article. Some use the manual method, some use the automatic machine, and sometimes over clothing. None of the nurses at any of these doctor’s offices has followed those instructions. I have RA and fibromyalgia with daily pain. Four months ago I was diagnosed with hypertension based on the new guidelines and put on Losartan. I am now wondering how much my RA pain affects my BP reading. I will certainly take the instructions and ask every nurse to take my BP correctly in addition to wearing appropriate clothing.

    A JAMA paper, 2-5-14, “Evidence based guidelines for the management of high blood pressure in adults” gives much higher limits before requiring medication, especially for those over 60.

    My husband is concerned because each arm has a different reading. The left, doctor could not hear at all, although he did it himself 3 times. Finally he could hear it but the right was at 159. My husband was sitting properly and arm was placed correctly. The doctor put him on the table, and there in left arm he could hear a whoosh. off and on.
    I just want people to have both arms checked.

    About the electronic BP machines: after experiencing my 3rd one being *painful, I asked if the reading could possibly be accurate. Seeing as those readings were ridiculously high, I knew they weren’t and wasn’t happy to see them now in my health records along with “Hypertensive”.

    I asked my primary Dr about this, and he said aside from the fact that I have contractures in both arms due to RA, those machines can be way off; and yes, if it’s painful, it will raise your BP. He also said their main purpose is so the nurse can multi-task, saving time and money. It seems that the electronic machines are “set too high”, and I guess that’s why they pump up so much that it feels like your arm might explode. 😱

    When I had cataract surgery the electronic machine was used before I knew it, and the anesthesiologist called “BP high, she’s tacky!” (tachycardia). I then told them it was because I was in pain from RA plus the BP machine. If you’ve had cataract surgery you know there are like 5 people all working on you at once in a very tiny cubicle while you’re being prepared in a prone position. For the second eye, they already had in my chart not to use it, used regular cuff, and my BP was normal.

    My primary said to tell anyone who wants to use it on me that my Dr said I needed to have the regular cuff method used. That’s what I’ve done ever since. A couple of times, the nurse/tech had difficulty using the old-fashioned method.

    One has to wonder just how many of us are mistakenly diagnosed with hypertension as I’ve been? When the regular cuff is used instead of the machine, my BP averages 130/60 unless my RA pain is really bad that day. So far I haven’t been offered any BP meds.

    I have a good, easy-to-use BP monitor at home and have taken readings for several days in a row enough times to know if it’s in normal range. I’d advise anyone with any doubts to buy one and check their BP at home using guidelines above.

    Just a thought, but when does anyone have time throughout the day to sit quietly (and in a particular position), are pain free, have to wait to empty your bladder, have stressful situations, and all the other specifics for getting an accurate reading? Our days are full of many things that raise our blood pressure, so that we can function. I’m not saying high blood pressure is much ado about nothing, but it seems that the prescribed safe numbers are pretty extreme for most people.

    I went to the Annals of Internal Medicine site to see if the article was available. It claims to be “free,” but one must have an ID or register to access the “free” article. I really don’t want to register for one article — personal information is often required. Would it be possible for the People’s Pharmacy to obtain consent from the AIM organization to post the “free” PDF copy of the original article for your readers/subscribers to download. If I am to have a discussion about proper technique with my medical professionals I believe my credibility will be enhanced if I can deliver a copy of the article to them.

    Paul,
    I am not sure what the problem is. Here is a link to the full text which is free:

    https://annals.org/aim/fullarticle/2670318/prevention-detection-evaluation-management-high-blood-pressure-adults-synopsis-2017

    The same is true for the article in the journal Hypertension:

    https://www.ahajournals.org/doi/full/10.1161/HYP.0000000000000087

    Here’s another issue: If the technician checks your pressure with the “old” mercury manometer, they pump it up and let it drop in 1 second! I am certified in an 8-hr class in measuring blood pressure, and the air must be very slowly released in order to obtain an accurate BP.

    I did not see an answer to an important question: Some offices cuff you over your shirt or even thick sweater. I disagree. It should be on your bare skin.

    Bill,

    Perhaps you missed the answer:

    “I have seen techs, nurses, and doctors place the blood pressure cuff over heavy sweatshirts and take a blood pressure. When I asked about this, they all said it did not matter. Does it?”

    Answer: yes. The article in the journal Hypertension that describes the AHA’s recommendations about proper blood pressure techniques states:

    “Remove clothing covering the location of cuff placement.”

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