June 5, 2013

Monitoring Blood Pressure: The Best Way . . . and My Way

About 67 million Americans -- a third of all adults -- have hypertension, a symptomless disease and major contributor to heart disease, stroke and kidney disease. But the traditional cuff is no longer considered the best way to monitor your blood pressure, according to a recent report in the Washington Post.

The Old Way
We're tracking this silent killer with random readings from a device invented in the 1890s, the report says. A better solution is out there. Will we use it?

Sporadic checks with a cuff monitor in a doctor's office don't detect hypertension very well. About 20 percent of patients who are consistently hypertensive in the doctor's office or the clinic don't have high blood pressure the rest of the day. On the flip side, about 10 percent of patients whose blood pressure readings are normal in the doctor's office actually have hypertension, and their disease goes undetected.

And then there are folks with "resistant hypertension" -- people who can't get their office blood pressure under control even with a fistful of medications. Studies have shown that 30 percent or more of these patients are actually well controlled or even over controlled. They don't need more medications and may even need less.

The Better Way
Home blood pressure monitors are more reliable if readings are taken several times a day. One of the problems with readings in your doctor's office is that the systolic (upper) readings can vary 10-30 points even when taken within a few minutes of each other. Those variations can be particularly evident for people using acetaminophen, antidepressants, decongestants, NSAIDs, caffeine, and even herbal supplements, as I found out with my 5-HTP.

The American Heart Association recommends that people with high blood pressure or suspected high blood pressure routinely monitor their bp.

Home monitors are readily available and easy to use. If you're a subscriber, you can get recommendations from Consumer Reports. Based on their recommendations, I have an arm and a wrist monitor, both made by Omron and available for about $50-60 on Amazon.com.

But home monitors are susceptible to human error and bias. The patient decides when to initiate a check. If he keeps a written record, the patient might leave out the higher readings or round them down a little. I can attest to that tendency.

The Best Way 
The average blood pressure recorded by 24-hour ambulatory monitors is viewed as the most accurate and the best predictor of hypertension risk. These monitors use a cuff outfitted with a microchip to measure and record bp at regular intervals throughout the day. Recent advances have made them more convenient and accurate.

As a result, we've seen what office-based bp readings have missed -- a lot.

In 2011, an analysis published in the British medical journal Lancet showed that ambulatory blood pressure monitoring (ABPM) isn't only more effective than testing at home or in the doctor's office; it also saved money in almost every patient group. Since then, British doctors began using ABPM on nearly all patients suspected of having hypertension. It's been especially effective in lowering costs and improving outcomes for patients over 50.

The study concluded that the cost of making ABPM universal would be far less than the cost of treating patients who would otherwise be erroneously diagnosed.

Unfortunately in America, ABPM is used mainly by hypertension specialists and some cardiology and nephrology practices. The old random cuff monitoring is still used in most doctor's offices. Getting the ABPM equipment and software, and then training staff to use them require more time and money than most primary-care providers are willing to spend.

Medicare pays for ABPM but only if "white-coat hypertension" is suspected. Other insurers are more likely to cover some of the costs, but patients still might have to pay part of  the tab.

My Way
I started monitoring my blood pressure at home about a year ago when my internist and I were searching for a bp med that worked for me without causing symptoms like the chronic cough an earlier med generated. When I learned that my favorite supplement, 5-HTP, could create bp spikes, I began using the home monitor.

I started recording my bp numbers through the day. I've refined this practice, and it's become a useful personal health journal. Here's what it looked like yesterday morning:

Don't bother trying to read my scrawl. My handwriting was always barely legible, but now the Parkinson's micrographia (small, cramped handwriting) makes it indecipherable.

I use a blue pen to record bp in the normal range, which I define as systolic readings from 120-150. (I mentioned before that my bp specialist agrees that readings of 120-140 are good for someone my age, and that even 140-150 is acceptable.)

I enter readings outside that range in red. I also note in red any changes in the medications, and any major changes in my physical or emotional makeup. I've found this journal very helpful.

I just noted tonight that the new pain medication -- Tylenol #3 -- seemed to be causing greatly increased fatigue and a worsening of the balance problems and muscle stiffness associated with Parkinson's. I noted that I would try substituting regular Tylenol for the Tylenol #3.

My home monitor readings certainly convinced me of the danger in prescribing blood pressure meds based on a doctor's office reading. I've had readings of 110 and 160 in the same day! 


acnecans said...

Such devices should preferably be approved by the Food and Drug Administration (FDA) and also meets with the standards laid down by the Association for the Advancement of Medical Instrumentation. Those products which meet the highest standards for accuracy are capable of measuring blood pressure in the brachial artery.

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