Thirty-minute compared to standardised office blood pressure measurement in general practice

Using 15-Minute Serial Blood Pressures as an Alternative to Measuring a Single Blood Pressure

Thirty-minute office blood pressure (OBP-30) is an alternative to ambulatory blood pressure (BP) measurement, yet is impractical to implement. This study aimed to determine whether unattended BP readings over 15 minutes would result in a similar probability of obtaining a BP of <140/90. Sixty-seven adults self-described as having high BP were analyzed. BP was measured at baseline and every 5 minutes for 15 minutes with the initial reading compared to the average of the last three readings (OBP-15). Compared to baseline, there was a decline in both average systolic (4.2 points) and diastolic (2.8 points) BP. The probability of BP control predicted by multivariate model was 71.6% at baseline and 78.0% using OBP-15 (p=0.011). The increase in BP control from initial to OBP-15 measurement was significant for indigenous or persons of color compared to whites, and men compared to women. OBP-15 is convenient and results in lower BP readings and higher probability of BP control compared to the initial reading.

Implementation of an At-home Blood Pressure Measurement Protocol in a Hypertension Management Clinical Trial During the COVID-19 Pandemic

BACKGROUND

The Dietary Approaches to Stop Hypertension eating plan is an evidence-based treatment of hypertension; however, adherence to the Dietary Approaches to Stop Hypertension is low. To improve adherence to the Dietary Approaches to Stop Hypertension among adults with hypertension, we designed Nourish, a 2-arm, 12-month randomized controlled trial. The COVID-19 pandemic necessitated a change from in-person to remotely delivered visits, requiring substantial protocol modifications to measure blood pressure accurately and safely for secondary outcome data.

PURPOSE

The purpose of this article is to describe the implementation of an at-home blood pressure measurement protocol for the Nourish trial.

CONCLUSION

Our investigator team and study staff developed and implemented a robust and feasible blood pressure measurement protocol to be executed within an at-home format.

CLINICAL IMPLICATIONS

The described blood pressure measurement protocol provides a framework for use in future clinical trials and clinical settings in which a remote visit is preferred or required.

Evaluation of 30-Minute Office Blood Pressure in a Diverse Urban Population

BACKGROUND

Previous studies have shown benefits of 30-minute office blood pressure (OBP-30) but did not report on race and gender. The purpose of this study was to determine if similar effects are seen in a diverse urban population.

METHODS

Patients with diabetes and/or cardiovascular disease (age 18-89) were invited to participate. Blood pressure was measured using standard procedure (SOBP). Patients were left alone in an exam room connected to an automated office blood pressure monitor which obtained BP readings every 5 minutes for 30 minutes. The last 5 measurements were averaged for the OBP-30 measurement. Primary outcomes were BPs measured using SOBP and OBP-30. Multivariate logit methods were used to estimate the average probability of having a BP measured <140/90 mm Hg (BPM <140/90) for the 2 measurement methods. Differences were computed across methods, in total and by sex and race, all other factors held constant.

RESULTS

The adjusted probability of having a BPM <140/90 was 47.1% using SOBP and 66.7% using OBP-30 (P < 0.01). Using SOBP, females had a 26.2 PP lower probability of having a BPM <140/90 (P < 0.001) than males. Relative to white patients, Black patients had a 43.9 PP lower (P < 0.001) and other races a 38.5 PP lower (P < 0.001) probability of having a BPM <140/90 using SOBP. Using OBP-30, these differences narrowed and became statistically insignificant.

CONCLUSIONS

OBP-30 may increase the probability of BPM meeting goals, especially in females and patients who are Black, indigenous, or persons of color.

Development and Psychometric Validation of the Hypertension Beliefs Assessment Tool Among Adult Population in Northwest Ethiopia

BACKGROUND

In Ethiopia, the majority of hypertension cases remain undiagnosed, untreated, and uncontrolled. Beliefs about hypertension and its complications play an important role in hypertension management behaviors. Accurate assessment of individuals' beliefs towards the disease is of paramount importance in the design of hypertension education. This study aimed to develop and validate a hypertension belief assessment tool based on the Health Belief Model for the general population among rural adults in northwest Ethiopia.

METHODS

The study included item construction, face and content validation, factor analysis, and establishment of reliability and validity of the tool. A total of 308 rural adults participated in the study. Inter-item and item-to-total correlations were used to examine the items assessed with the same content on a scale. Principal component analysis with promax rotation was used to extract the factors. Internal consistency reliability was assessed using Cronbach's alpha coefficient. Convergent and discriminant validity were assessed using average variance extraction and maximum shared variance.

RESULTS

The median age of the participants was 41 (IQR: 31-55) years. Of the participants, 175 (56.8%) were female and 287 (93.2%) were farmers. Kaiser-Meyer-Olkin test value of 0.84 and significant Bartlett's test of sphericity (p=0.000) revealed that the data were suitable for exploratory factor analysis. The principal component analysis identified 6 factors, which explained 70.06% of the variation of the hypertension belief. Cronbach's alpha was 0.85 for the entire scale, ranging from 0.74 to 0.92 for the sub-domains. The average variance extracted was above 0.5 for all factors, indicating convergent validity. The maximum shared variance between the two constructs was lower than the average variance extracted from each factor, indicating that discriminating validity had been established.

CONCLUSION

The hypertension belief assessment tool was found to be valid and reliable, which can be used to measure the health beliefs on hypertension for the rural adult population.

The use of automated sequential blood pressure in hypertension clinics compared with office and ambulatory blood pressure measurements

BACKGROUND

Office blood pressure (OBP) measurement is the most common method of blood pressure measurement. However, it is associated with several pitfalls as white coat effect and masked hypertension. Ambulatory blood pressure monitoring (ABPM) is usually used for diagnosis of hypertension and elimination of white coat effect. This study aimed to assess the correlation and degree of agreement of the automated sequential blood pressure (ASqBP) with OBP and ABPM. Patients presented to hypertension clinic were included. Each patient had his blood pressure recorded by three methods: OBP using a digital sphygmomanometer device, unattended ASqBP using sequential BP devices with recording of the readings over 30 min, and ABPM that was performed within 48 h of office visit using portable BP devices with BP recording over 24 h.

RESULTS

We recruited 64 patients (age 50.0 ± 15.0 years and female gender 53.1%). We found a strong positive correlation between ASqBP and OBP readings (r 0.81 for SBP and 0.83 for DBP, p < 0.001). We also found a strong positive correlation between ASqBP and ABPM readings (r 0.74, p < 0.001). The ASqBP readings were lower than OBP (137.0 ± 16.8/86.4 ± 13.8 vs. 142.7 ± 15.5/88.5 ± 12.3) and close to ABPM readings (average 24 h, 134.0 ± 15.4/88.5 ± 12.3, and daytime, 135.8 ± 15.7/82.1 ± 13.7). For SBP readings, there was moderate agreement between ASqBP and AMBP (both average and daytime). For DBP readings, there was fair agreement between ASqBP and AMBP (both average and daytime).

CONCLUSION

ASqBP measurement has good correlation with OBP and ABPM readings. Unattended automated office pressure has moderate degree of agreement with ABPM for the SBP& fair degree of agreement for the DBP. It can be used in the hypertension clinics to eliminate the problems of white coat effect and marked BP variability.

Comparison of multiple blood pressure frequency methods with optimum blood pressure measurement among Iranian individuals

Background:

Proper blood pressure (BP) measurement frequency method is less evaluated to optimize hypertension (HTN) status among different nations due to cultural patience variations. The aim of this study was to compare the first (BP₁), second (BP₂), and the mean of first and second (BP_1,2) and all the three (BP_1,2,3) with the second and third BP measurements in Iranian individuals.

Materials and Methods:

This cross-sectional study was done on 2264 individuals aged 18 years or more living in Isfahan city, Iran. Their BPs were assessed from right arms by the standard tools and methods after 5 min of rest in a quiet room by a trained staff. The mean second and third readings were considered as reference, and the other aforementioned variables were compared with it.

Results:

The mean age of total population was 40.9 ± 16.1 years (males: 52%). Men had significant higher means of systolic BP (SBP) and diastolic BP (DBP) with any measurement frequency methods than women (P < 0.001 and P = 0.009). Considerable clinical significant (≥5 mmHg) ranges were mostly observed in BP₁ compared with BP_2,3. SBP₂ and DBP₂ indices showed insignificant differences compared with reference mean. Moreover, abnormal BP levels (≥140/90 mmHg) were mostly observed in terms of BP₁ measurement with no remarkable variability in BP₂ reading in comparison to the reference.

Conclusion:

Our considerable data suggested that BP₂ could appropriately categorize BP status similar to BP_2,3 and it may be rational for physicians considering this mean and excluding the first BP measurement as a sole criterion for HTN assessment in Iranian adults. Multiple researches are necessary quantifying appropriate frequencies of BP reading.

Sources of inaccuracy in the measurement of adult patients' resting blood pressure in clinical settings: a systematic review

BACKGROUND

To interpret blood pressure (BP) data appropriately, healthcare providers need to be knowledgeable of the factors that can potentially impact the accuracy of BP measurement and contribute to variability between measurements.

METHODS

A systematic review of studies quantifying BP measurement inaccuracy. Medline and CINAHL databases were searched for empirical articles and systematic reviews published up to June 2015. Empirical articles were included if they reported a study that was relevant to the measurement of adult patients' resting BP at the upper arm in a clinical setting (e.g. ward or office); identified a specific source of inaccuracy; and quantified its effect. Reference lists and reviews were searched for additional articles.

RESULTS

A total of 328 empirical studies were included. They investigated 29 potential sources of inaccuracy, categorized as relating to the patient, device, procedure or observer. Significant directional effects were found for 27; however, for some, the effects were inconsistent in direction. Compared with true resting BP, significant effects of individual sources ranged from -23.6 to +33 mmHg SBP and -14 to +23 mmHg DBP.

CONCLUSION

A single BP value outside the expected range should be interpreted with caution and not taken as a definitive indicator of clinical deterioration. Where a measurement is abnormally high or low, further measurements should be taken and averaged. Wherever possible, BP values should be recorded graphically within ranges. This may reduce the impact of sources of inaccuracy and reduce the scope for misinterpretations based on small, likely erroneous or misleading, changes.

Thirty-Minute Office Blood Pressure Monitoring in Primary Care

PURPOSE

Automated office blood pressure monitoring during 30 minutes (OBP30) may reduce overtreatment of patients with white-coat hypertension in primary health care. OBP30 results approximate those of ambulatory blood pressure monitoring, but OBP30 is much more convenient. In this study, we compared OBP30 with routine office blood pressure (OBP) readings for different indications in primary care and evaluated how OBP30 influenced the medication prescribing of family physicians.

METHODS

All consecutive patients who underwent OBP30 for medical reasons over a 6-month period in a single primary health care center in the Netherlands were enrolled. We compared patients' OBP30 results with their last preceding routine OBP reading, and we asked their physicians why they ordered OBP30, how they treated their patients, and how they would have treated their patients without it.

RESULTS

We enrolled 201 patients (mean age 68.6 years, 56.7% women). The mean systolic OBP30 was 22.8 mm Hg lower than the mean systolic OBP (95% CI, 19.8-26.1 mm Hg). The mean diastolic OBP30 was 11.6 mm Hg lower than the mean diastolic OBP (95% CI, 10.2-13.1 mm Hg). Considerable differences between OBP and OBP30 existed in patients with and without suspected white-coat hypertension, and differences were larger in individuals aged 70 years or older. Based on OBP alone, physicians said they would have started or intensified medication therapy in 79.1% of the studied cases (95% CI, 73.6%-84.6%). In fact, with the results of OBP30 available, physicians started or intensified medication therapy in 24.9% of cases (95% CI, 18.9%-30.9%).

CONCLUSIONS

OBP30 yields considerably lower blood pressure readings than OBP in all studied patient groups. OBP30 is a promising technique to reduce overtreatment of white-coat hypertension in primary health care.

Comparison of the average of five readings with averages from fewer readings for automated oscillometric blood pressure measurement in an outpatient clinic

BACKGROUND AND OBJECTIVES

The optimal number of consecutive measurements for obtaining an average blood pressure (BP) reading in clinical practice is yet undefined by research. This study aimed to compare readings obtained from an average of 5 with averages of 2, 3, and 4, sequential measurements.

SUBJECTS AND METHODS

Using an automated oscillometric device (BpTRU), BP measurement was conducted on 410 consenting adults attending a general outpatients clinic. Comparison of an average of 5 readings with averages of 2, 3, and 4 readings involved evaluation of correlations, Bland-Altman analysis, comparison of means and distribution of readings, and determination of the proportion of differences between compared readings which were clinically non-significant.

RESULTS

397 (96.8%) sets of complete BP readings were suitable for analysis. Clinically non-significant differences (≤5 mm Hg) were found between at least 79.3% (n=315) and 96.5% (n=383) of compared systolic and diastolic readings, respectively. Bland-Altman's analysis revealed that the 95% limits of agreement for the differences between compared readings were approximately 2-4, 3-7, and 4-11 mm Hg for 2, 3 and 4 readings' systolic comparisons while those for diastolic comparisons were 2-3, 3-5, and 4-7 mm Hg, respectively. Statistically non-significant differences were observed in all comparisons of the distributions of readings that were classified as <140 mm Hg or ≥140 mm Hg and <90 mm Hg or ≥90 mm Hg for systolic and diastolic readings, respectively. Strong positive correlations were found between 5 average readings and each of 2, 3, and 4 average readings, respectively.

CONCLUSION

An average of 5 readings may be excessive for routine BP measurement using this device at outpatient clinics.