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Dr. Pervaiz Iqbal
Home blood pressure monitoring is used to improve blood pressure management in patients with suspected white coat hypertension, suspected white coat effect in a known hypertensive, masked hypertension or resistant hypertension. It is patient friendly, simple and effective provided evidence is collected over at least 4 to 7 days twice daily, using a validated monitor. Review here its indications, recording and interpretation to promote optimal use. This article is the first in a series devoted to this topic.
Office blood pressure measurement is the traditional tool for screening, diagnosis and management of patients with suspected disorders of blood pressure regulation - namely hypertension, hypotension or a combination of the two. Office blood pressure is limited though, in that only a small number of measurements can be taken in an environment in which the patient doesn't feel completely at ease. This fact may contribute to suspected white coat hypertension, suspected white coat effect in a known hypertensive, masked hypertension or resistant hypertension. Home blood pressure monitoring (HBPM) on the other hand, allows a patient to take as many measurements needed over a number of days in their own comfortable and relaxed environment - home.
Studies have shown that HBPM relative to office blood pressure leads to an improvement in blood pressure control rates (1) and is a better prognostic indicator (2-6). It provides physicians and patients alike with a more detailed assessment of response to the lifestyle modifications and changes in drug treatment. Patients can actively participate in their own management by being given first hand opportunity to observe the impact of lifestyle changes and drug treatment.Home blood pressure monitoring is used to gain more information to make diagnosis of hypertension, white coat hypertension or masked hypertension, adjust treatment upwards to improve overall control or reduce treatment if patient develops hypotensive symptoms.Nevertheless, self-measurement at home can lead to panic or anxiety. It may also lead to self-modification of the treatment regimen. Home blood pressure monitoring should be discouraged in such cases. Out of office blood pressure monitoring refers to both 24 hour ambulatory blood pressure monitoring and home blood pressure monitoring. Unless a patient is equipped with the latest home devices that can take night recordings, home blood pressure monitoring does not provide information about the night time blood pressure levels, presence or absence of nocturnal dip and morning surge, as compared to ambulatory blood pressure monitoring, which does.
Here presented are the conditions that can help ensure that data entry and averaging be well conducted. To ensure that blood pressure measurements are valid, individuals undergoing home blood pressure monitoring need to be fully instructed, educated and trained with the following information regarding how to conduct their home readings. Here are the education and training instructions for subject undertaking of home BP:
Data entry: Registration of the data, if done by hand, should be made using a monitoring sheet that will provide the documentation on (Table 2) to attest that the recording have been entered twice in the morning and the same number of times in the evening at an interval of 1-2 minutes for 4-7 days.
It is recommended to use a fully automated oscillometric upper arm device. The British hypertension society and Irish patient education websites provide a list of the validated devices - they start at 50 euros. Information via telemetry to a designated hypertension unit is possible in some models.Wrist devices should be used in patients who cannot apply cuff easily such as in obesity, in case of conical arm shape or in elderly patients with a compromised dexterity. With wrist monitors, the arm should be kept at the heart level - some of the wrist monitors come equipped with a heart position sensor to make this position easy to set and sustain. Most manufacturers will service and calibrate their own machines but this is costly and certainly when it comes to the less expensive devices it may be cheaper to buy a newer one instead. The details of service centres can be found in the instruction manual that comes with the devices.
Hypertension is an important and treatable cardiovascular risk factor and home blood pressure monitoring provides detailed information in a more comfortable environment for the patient. The procedure is easy to learn and follow and with blood pressure monitors becoming more affordable, home blood pressure monitoring has established itself as an important tool in the management of hypertension. Fig 1: Home blood pressure monitoring sheet. To download or print the document, open form in new window here.
1 - Role of home blood pressure monitoring in overcoming therapeutic inertia and improving hypertension control: a systematic review and meta-analysis. Agarwal R1, Bills JE, Hecht TJ, Light RP. Hypertension. 2011 Jan; 57(1):29-38.2 - Home-measured blood pressure is a stronger predictor of cardiovascular risk than office blood pressure: the Finn-Home study. Niiranen TJ, Hänninen MR, Johansson J, Reunanen A, Jula AM Hypertension. 2010 Jun; 55(6):1346-513 - Home versus ambulatory and office blood pressure in predicting target organ damage in hypertension: a systematic review and meta-analysis . Bliziotis IA, Destounis A, Stergiou GS. J Hypertens. 2012 Jul; 30(7):1289-99 4 - Prognostic significance of home blood pressure control on renal and cardiovascular outcomes in elderly patients with chronic kidney disease. Okada T, Nakao T, Matsumoto H, Nagaoka Y, Tomaru R, Iwasawa H, Wada T. Hypertens Res. 2009 Dec; 32(12):1123-95 - Home measurement of blood pressure and cardiovascular disease: systematic review and meta-analysis of prospective studies. Ward AM, Takahashi O, Stevens R, Heneghan C. Hypertens.2012 Mar; 30(3):449-566-European Society of Hypertension Practice Guidelines for home blood pressure monitoring G Parati, G S Stergiou, R Asmar, G Bilo, P de Leeuw, Y Imai, K Kario, E Lurbe, A Manolis, T Mengden, E O'Brien, T Ohkubo, P Padfield, P Palatini, T G Pickering, J Redon, M Revera, L M Ruilope, A Shennan, J A Staessen1, A Tisler, B Waeber, A Zanchetti and G Mancia on behalf of ESH Working Group on Blood Pressure Monitoring. Journal of Human Hypertension (2010) 24, 779–785, June 20107 - 2013 ESH/ESC guidelines for the management of arterial hypertension. Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A et al. The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J. 2013 Jul;34(28):2159-219
Dr Pervaiz Iqbal MBBS. FRCPI, FRCP (Lond)Consultant Physician and Hypertension SpecialistChesterfield Royal Hospital NHSFTCalow, Chesterfield S44 5BL UKAuthor sent information and disclosure:Dr Pervaiz Iqbal MBBS, FRCPI, FRCP, MBA, is Consultant Physician and Hypertension Specialist based at Chesterfield Royal Hospital NHS FT Chesterfield, UK. He has over 20 year experience of looking after patient with hypertension and has a number of hypertension related publications in peer-reviewed journals. He is a member of Blood Pressure Measurement Committee of British Hypertension Society and member of the European and International Societies of Hypertension.The author is a member of Blood Pressure Measurement Committee of British Hypertension Society. The committee is a premier international body on validation of blood pressure monitors for ambulatory monitoring, Home blood pressure monitoring as well as for routine clinical use. The author does not receive any remuneration for the work involved.