In my state, dentists and hygienists are required to check blood pressure, although we have no substantive guidelines of what we are to do besides record it. I find it to be quite silly, since most patients have elevated BP coming to the dentist. And if we try to have a conversation about an elevated reading, patients become quite irritated which in turn doesn’t help the BP.
The measurement of blood pressure has always been an area of great focus for me. After years of checking blood pressure in the office and recognizing that the nurse got one value, I got a different reading made me realize that there is a lot of variability in the results we get. Yet we place a LOT of value in these numbers and we either treat or don't treat. So they are important. After further digging and research, this is what I've gleaned and how I manage blood pressures in my practice.
The method and the procedure by which we actually check blood pressure is supremely important! What any clinic should focus on (and patients doing their own home BP monitoring) - try to follow the recommended method/procedure as best you can. This will give us the most accurate data. Using an AUTOMATIC CUFF (not a hand held or wall mounted) is recommended. For home blood pressures, finding a basic automatic cuff that has been validated.
You should be in a room by yourself; not talking; legs not crossed. Wait 5 minutes before the check.
Doing some home checks gives more data points to supplement what your doctor gets in the office. (again, follow accurate procedure when checking)
The other thing that really frustrated me re: blood pressure was managing HTN becomes a great parameter to focus on per Quality Metrics. Our big health care system set a policy that the last blood pressure a patient had in the record by the end of the year was the one that would count for measuring the doctor's quality of care! This is such an arbitrary number since this is a highly variable reading. I could only see the negative effects: doctors pushed to randomly call patients back into clinic to get another BP reading to "make sure" their number met the metric. I would not doubt it drove some physicians to just write in a number that fit. It would push other doctors to start medications when they otherwise wouldn't. Just a great example of the very real negative effects the silly "quality metric" "pay for performance" and proving our "value" is not only a waste of time but potential leading to suboptimal care.
Robert, thanks for your comment. I would not bet against the black swan; "all" is too much, so that I would say "most". It wouldn't be fair to take your money. The prevalence of hypertension in centenarians varies from 19% to 60%. Cohorts of centenarians are not common, but they support the view that BP increases late in their lives. Please take a look at Figure 2 in the first reference I mentioned earlier. It is not possible to paste it here, apparently.
As a radiologist I see imaging biomarkers that could reliably prognosticate hypertensive complications, such as prominent arterial ectasia on angiographic studies and brain microhemorrhages and white matter hyperintensities on MRI. It seems as though lack of such permanent structural changes could mitigate against major patient anxiety about transient BP elevations.
If I'm having trouble deciding if we truly have "white coat HTN", I do look for signs of end organ effects. At times I've gotten an Echo to look for LVH. Certainly any brain changes would encourage more aggressive control of blood pressures!
Question: Reperfusion injury is considered a risk of rapidly lowering blood pressure. How does this differ fron the following:
1) Exercise where BP goes very high, and may rapidly decline upon resting.
2) Emotional BP which goes up and down quick.
Why aren't people injured by those rapid BP drops? I would guess some elderly people with chronic high BP or small vessel disease could be harmed by such day to day events?
The specific situations you describe are normal physiologic responses and the body is so good at managing these changing situations. The risk of rapid lowering of blood pressure really occurs when we are lowering blood pressure artificially with medications - then we override the body's own mechanisms and can definitely cause harm.
The body's finely tuned mechanisms to modulate blood pressure can be affected by age and certain medical conditions. Elderly people are at risk for "autonomic dysfunction" when the mechanism to manage and control blood pressure and heart rate response are no longer well-coordinated. They become at risk for falls/passing out and often have bothersome symptoms of dizziness. They are more sensitive to the effects of blood pressure medicines. Parkinson't disease and POTS are other situations people have these problems.
My sister-in-law in her late 70s, following the long illness of her husband and his death was having these horribly high blood pressure spikes in the middle of the night, systolic over 200. Ambulances were called, She was seen by multiple physicians including internal medicine who could not identify a way to treat it without tanking her blood pressure during the day. Being only a nurse 😉. I held my tongue for a while, and then I asked her why she was checking her blood pressure in the middle of the night. Did she have a pounding headache that woke her up or some other symptom that could be attributed to blood pressure? No she said, I wake up, feeling panicked and anxious, and then I check my blood pressure…
Well, perhaps you are checking your blood pressure in the middle of a panic attack, which would obviously be high….
“Huh”-she said… I think I’ll stop doing that and perhaps do some journaling about my grief and see if the panic attacks go away…and they did… and her BP is lovely.
More data is not necessarily helpful and I would whole heartedly agree we that we need to understand why and when we treat - with great confidence because the new era of personal health monitoring is throwing a whole lot of data points at us and creating anxiety and feedback loops and eroding the confidence of patients in their caregivers… we need to be solid in our assessments and listen well so that our patients may listen to us.
My sister-in-law in her late 70s, following the long illness of her husband and his death was having these horribly high blood pressure spikes in the middle of the night, systolic over 200. Ambulances were called, She was seen by multiple physicians including internal medicine who could not identify a way to treat it without tanking her blood pressure during the day. Being only a nurse 😉. I held my tongue for a while, and then I asked her why she was checking her blood pressure in the middle of the night. Did she have a pounding headache that woke her up or some other symptom that could be attributed to blood pressure? No she said, I wake up, feeling panicked and anxious, and then I check my blood pressure…
Well, perhaps you are checking your blood pressure in the middle of a panic attack, which would obviously be high….
Thank goodness for a sensible post re high BP! We treat thousands because of statistical risk and a huge proportion of them would never have a problem from their raised BP but they do suffer from their medication.
Great post. I still get calls from CCU about SBP 180 and asymptomatic.
This OP could be added to a large series of clinicians treating ourselves to make us feel better, whilst achieving nothing for our pts (except maybe causing side effects).
Excellent article. The same sensible reasoning should be applied to surrogate markers such as A1C and lipid levels. The figures commonly quoted for risk of stroke, heart attack, etc. are almost always relative risk and are of no practical significance despite achievement of "statistical significance" on observational data of dubious accuracy.
Another BP issue is operator variability: the same patient often has disparate numbers when measured by different examiners: often by 10-20 mm. Hard to know what to make of studies that tout 5-10 mm of BP reduction as beneficial??
Hello all, as a new subscriber, I'm unsure how I'll be identified; it may be Danni, my middle name, but I prefer F Fuchs. I appreciate Dr. Joshua's comment, but I would like to address this issue from a different perspective. High blood pressure is the major risk factor (contributing to more than 50% of attributable risk for CHD, stroke, valve diseases, AFib, HFpEF, dementias, CKD, etc.). Vascular aging is not inevitable, and all centenarians had blood pressure below 110 mmHg throughout their lives. I am sharing these ideas, acting as a scientific advocate. If the editors are interested, I can expand on this here, but the ideas are published in two manuscripts I wrote with Paul Whelton (the first link) and with Whelton, S. Fuchs, and O. Berwanger (the second link). The manuscripts are open for view: https://doi.org/10.1161/HYPERTENSIONAHA.119.14240; https://doi.org/10.1161/HYPERTENSIONAHA.124.21361
Your piece is spot-on! Having served a retirement community for >30 years, and literally seen >100K senior citizens (conservative estimate), your post so resonates with my clinical experience. I have spent hours and hours taking my time explaining to the generally frightened and worried seniors the subtleties of BP treatment and, more so, BP management. It's difficult to do in a high-acuity, busy ER. It takes so much time. It'd be much faster to just give a pill to lower the BP and superficially treat the patient's concern, then go on to the next patient. But, I can't help myself and start explaining and educating. Oh, and when they start off by saying, "I always know when my BP is high..." OMG, here I go with my lecture on hypertension...
Very interesting. 30 years ago when I was 55 I got into a blood pressure study because I was told I had high blood pressure( u of Texas). Interestingly, I had difficulty getting in because they had trouble getting a systolic over 130 because of the 5 min silence protocol. When I was being interviewed by the PI he was measuring 190 because I was challenging his study design.
In the end 24 hour ambulatory was 127/80. On the stress test I did 17 mets and had 250/ 90.
At 84 I take moderate to low dose of amlodipine and losartan. I adjust lower depending on how many time I fall descending a mountain ( in luck, gifted with strong bones). So I perfectly fit your patient with labile BP and I hope you ar correct in your analysis .
In my state, dentists and hygienists are required to check blood pressure, although we have no substantive guidelines of what we are to do besides record it. I find it to be quite silly, since most patients have elevated BP coming to the dentist. And if we try to have a conversation about an elevated reading, patients become quite irritated which in turn doesn’t help the BP.
Appreciate this article!
The measurement of blood pressure has always been an area of great focus for me. After years of checking blood pressure in the office and recognizing that the nurse got one value, I got a different reading made me realize that there is a lot of variability in the results we get. Yet we place a LOT of value in these numbers and we either treat or don't treat. So they are important. After further digging and research, this is what I've gleaned and how I manage blood pressures in my practice.
The method and the procedure by which we actually check blood pressure is supremely important! What any clinic should focus on (and patients doing their own home BP monitoring) - try to follow the recommended method/procedure as best you can. This will give us the most accurate data. Using an AUTOMATIC CUFF (not a hand held or wall mounted) is recommended. For home blood pressures, finding a basic automatic cuff that has been validated.
You should be in a room by yourself; not talking; legs not crossed. Wait 5 minutes before the check.
Doing some home checks gives more data points to supplement what your doctor gets in the office. (again, follow accurate procedure when checking)
The other thing that really frustrated me re: blood pressure was managing HTN becomes a great parameter to focus on per Quality Metrics. Our big health care system set a policy that the last blood pressure a patient had in the record by the end of the year was the one that would count for measuring the doctor's quality of care! This is such an arbitrary number since this is a highly variable reading. I could only see the negative effects: doctors pushed to randomly call patients back into clinic to get another BP reading to "make sure" their number met the metric. I would not doubt it drove some physicians to just write in a number that fit. It would push other doctors to start medications when they otherwise wouldn't. Just a great example of the very real negative effects the silly "quality metric" "pay for performance" and proving our "value" is not only a waste of time but potential leading to suboptimal care.
Robert, thanks for your comment. I would not bet against the black swan; "all" is too much, so that I would say "most". It wouldn't be fair to take your money. The prevalence of hypertension in centenarians varies from 19% to 60%. Cohorts of centenarians are not common, but they support the view that BP increases late in their lives. Please take a look at Figure 2 in the first reference I mentioned earlier. It is not possible to paste it here, apparently.
As a radiologist I see imaging biomarkers that could reliably prognosticate hypertensive complications, such as prominent arterial ectasia on angiographic studies and brain microhemorrhages and white matter hyperintensities on MRI. It seems as though lack of such permanent structural changes could mitigate against major patient anxiety about transient BP elevations.
If I'm having trouble deciding if we truly have "white coat HTN", I do look for signs of end organ effects. At times I've gotten an Echo to look for LVH. Certainly any brain changes would encourage more aggressive control of blood pressures!
Question: Reperfusion injury is considered a risk of rapidly lowering blood pressure. How does this differ fron the following:
1) Exercise where BP goes very high, and may rapidly decline upon resting.
2) Emotional BP which goes up and down quick.
Why aren't people injured by those rapid BP drops? I would guess some elderly people with chronic high BP or small vessel disease could be harmed by such day to day events?
The specific situations you describe are normal physiologic responses and the body is so good at managing these changing situations. The risk of rapid lowering of blood pressure really occurs when we are lowering blood pressure artificially with medications - then we override the body's own mechanisms and can definitely cause harm.
The body's finely tuned mechanisms to modulate blood pressure can be affected by age and certain medical conditions. Elderly people are at risk for "autonomic dysfunction" when the mechanism to manage and control blood pressure and heart rate response are no longer well-coordinated. They become at risk for falls/passing out and often have bothersome symptoms of dizziness. They are more sensitive to the effects of blood pressure medicines. Parkinson't disease and POTS are other situations people have these problems.
My sister-in-law in her late 70s, following the long illness of her husband and his death was having these horribly high blood pressure spikes in the middle of the night, systolic over 200. Ambulances were called, She was seen by multiple physicians including internal medicine who could not identify a way to treat it without tanking her blood pressure during the day. Being only a nurse 😉. I held my tongue for a while, and then I asked her why she was checking her blood pressure in the middle of the night. Did she have a pounding headache that woke her up or some other symptom that could be attributed to blood pressure? No she said, I wake up, feeling panicked and anxious, and then I check my blood pressure…
Well, perhaps you are checking your blood pressure in the middle of a panic attack, which would obviously be high….
“Huh”-she said… I think I’ll stop doing that and perhaps do some journaling about my grief and see if the panic attacks go away…and they did… and her BP is lovely.
More data is not necessarily helpful and I would whole heartedly agree we that we need to understand why and when we treat - with great confidence because the new era of personal health monitoring is throwing a whole lot of data points at us and creating anxiety and feedback loops and eroding the confidence of patients in their caregivers… we need to be solid in our assessments and listen well so that our patients may listen to us.
Great example! I agree with your assessment and conclusions.
My sister-in-law in her late 70s, following the long illness of her husband and his death was having these horribly high blood pressure spikes in the middle of the night, systolic over 200. Ambulances were called, She was seen by multiple physicians including internal medicine who could not identify a way to treat it without tanking her blood pressure during the day. Being only a nurse 😉. I held my tongue for a while, and then I asked her why she was checking her blood pressure in the middle of the night. Did she have a pounding headache that woke her up or some other symptom that could be attributed to blood pressure? No she said, I wake up, feeling panicked and anxious, and then I check my blood pressure…
Well, perhaps you are checking your blood pressure in the middle of a panic attack, which would obviously be high….
Thank goodness for a sensible post re high BP! We treat thousands because of statistical risk and a huge proportion of them would never have a problem from their raised BP but they do suffer from their medication.
Great post. I still get calls from CCU about SBP 180 and asymptomatic.
This OP could be added to a large series of clinicians treating ourselves to make us feel better, whilst achieving nothing for our pts (except maybe causing side effects).
Excellent article. The same sensible reasoning should be applied to surrogate markers such as A1C and lipid levels. The figures commonly quoted for risk of stroke, heart attack, etc. are almost always relative risk and are of no practical significance despite achievement of "statistical significance" on observational data of dubious accuracy.
Bravo. this is what I teach our students and nurses and agree that the pills are reached for too often and too quickly.
Another BP issue is operator variability: the same patient often has disparate numbers when measured by different examiners: often by 10-20 mm. Hard to know what to make of studies that tout 5-10 mm of BP reduction as beneficial??
Hello all, as a new subscriber, I'm unsure how I'll be identified; it may be Danni, my middle name, but I prefer F Fuchs. I appreciate Dr. Joshua's comment, but I would like to address this issue from a different perspective. High blood pressure is the major risk factor (contributing to more than 50% of attributable risk for CHD, stroke, valve diseases, AFib, HFpEF, dementias, CKD, etc.). Vascular aging is not inevitable, and all centenarians had blood pressure below 110 mmHg throughout their lives. I am sharing these ideas, acting as a scientific advocate. If the editors are interested, I can expand on this here, but the ideas are published in two manuscripts I wrote with Paul Whelton (the first link) and with Whelton, S. Fuchs, and O. Berwanger (the second link). The manuscripts are open for view: https://doi.org/10.1161/HYPERTENSIONAHA.119.14240; https://doi.org/10.1161/HYPERTENSIONAHA.124.21361
"all centenarians had blood pressure below 110 mmHg throughout their lives"
If there was a way to prove or disprove that, I'd be willing to bet you money on that.
Your piece is spot-on! Having served a retirement community for >30 years, and literally seen >100K senior citizens (conservative estimate), your post so resonates with my clinical experience. I have spent hours and hours taking my time explaining to the generally frightened and worried seniors the subtleties of BP treatment and, more so, BP management. It's difficult to do in a high-acuity, busy ER. It takes so much time. It'd be much faster to just give a pill to lower the BP and superficially treat the patient's concern, then go on to the next patient. But, I can't help myself and start explaining and educating. Oh, and when they start off by saying, "I always know when my BP is high..." OMG, here I go with my lecture on hypertension...
Agree spot-on. Every ER in America has this scenario.
Amen, more data is always the answer when a patient calls in with asymptomatic elevation of BP. Well written!
Very interesting. 30 years ago when I was 55 I got into a blood pressure study because I was told I had high blood pressure( u of Texas). Interestingly, I had difficulty getting in because they had trouble getting a systolic over 130 because of the 5 min silence protocol. When I was being interviewed by the PI he was measuring 190 because I was challenging his study design.
In the end 24 hour ambulatory was 127/80. On the stress test I did 17 mets and had 250/ 90.
At 84 I take moderate to low dose of amlodipine and losartan. I adjust lower depending on how many time I fall descending a mountain ( in luck, gifted with strong bones). So I perfectly fit your patient with labile BP and I hope you ar correct in your analysis .