Blood pressure measurement often gets deprioritized as a mundane step in clinic office visits that is little more than an afterthought. In direct opposition to this common false heuristic, an international working group, comprised of many of the world's top clinical hypertension researchers, recently published a consensus statement and call to action to improve the quality of office blood pressure measurement worldwide (1). The authors cited dozens of randomized trials that supported that lowering blood pressure reduces the risk of major cardiovascular events (2), all of which relied on standardized (i.e., systematically performed, high-quality) office blood pressure measurements. Data collected by Drawz et al. (3) revealed that routine office blood pressure measurements yielded systolic blood pressure readings as much as 45 mm Hg above and 30 mm Hg below research study measurements among participants of the Systolic Blood Pressure Intervention Trial (SPRINT). Accordingly, the majority of routine office blood pressure measurements fail to address key steps. These missteps in measurement can easily result in pronounced over- and undertreatment of hypertension.
The consensus statement (1) stresses the importance of working toward standardized office blood pressure measurements as standard of care for the diagnosis and management of hypertension. Standardized office blood pressure measurements require several factors to be in place (Table 1), including appropriate facility, equipment, personnel, patient preparation, and measurement technique. These conditions can be very challenging to achieve in a typical clinical setting. Nonetheless, the authors emphasize the importance of being as pragmatic as possible in implementing these key steps and in avoiding dogmatic assertions about aspects of blood pressure measurement that are not evidence based. Although the U.S. Preventive Services Task Force (4) and several other guidelines recommend out-of-office blood pressure monitoring for the diagnosis of hypertension to overcome many of the limitations of routine office blood pressure measurements, the authors of the consensus statement argue that home and ambulatory blood pressure goals are not yet supported by randomized trial evidence (5) and that standardized office blood pressure measurements remain paramount. The authors acknowledge that there are several barriers to obtaining standardized office blood pressure measurements, most notably, a lack of sufficient time during a typical clinic visit. They argue that these barriers can be readily overcome if health care institutions and payers begin to prioritize accurate blood pressure assessment and point to large-scale success stories that benefited from such support (6, 7).
Necessary conditions to obtain standardized blood pressure measurements
Many clinicians may argue that standardized office blood pressure measurements are far from pragmatic. Nonetheless, growing evidence supports that we do a poor job of measuring blood pressure and may unwittingly be causing harm (3, 8). We owe it to our patients to do better.
Footnotes
References
- 1.↑
Cheung AK, et al. International consensus on standardized clinic blood pressure measurement—a call to action. Am J Med 2023; 136:438–445.e1. doi: 10.1016/j.amjmed.2022.12.015
- 2.↑
Blood Pressure Lowering Treatment Trialists’ Collaboration. Pharmacological blood pressure lowering for primary and secondary prevention of cardiovascular disease across different levels of blood pressure: An individual participant-level data meta-analysis. Lancet 2021; 397:1625–1636. doi: 10.1016/S0140-6736(21)00590-0
- 3.↑
Drawz PE, et al. Concordance between blood pressure in the Systolic Blood Pressure Intervention Trial and in routine clinical practice. JAMA Intern Med 2020; 180:1655–1663. doi: 10.1001/jamainternmed.2020.5028
- 4.↑
Siu AL; U.S. Preventive Services Task Force. Screening for high blood pressure in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2015; 163:778–786. doi: 10.7326/M15-2223
- 5.↑
Parati G, et al. Masked-Uncontrolled Hypertension Management Based on Office BP or on Ambulatory Blood Pressure Measurement (MASTER) study: A randomised controlled trial protocol. BMJ Open 2018; 8:e021038. doi: 10.1136/bmjopen-2017-021038
- 6.↑
Egan BM, et al. Improving hypertension control in primary care with the measure accurately, act rapidly, and partner with patients protocol. Hypertension 2018; 72:1320–1327. doi: 10.1161/HYPERTENSIONAHA.118.11558
- 7.↑
Jaffe MG, Young JD. The Kaiser Permanente Northern California story: Improving hypertension control from 44% to 90% in 13 years (2000 to 2013). J Clin Hypertens (Greenwich) 2016; 18:260–261. doi: 10.1111/jch.12803
- 8.↑
Sakhuja S, et al. Potential impact of systematic and random errors in blood pressure measurement on the prevalence of high office blood pressure in the United States. J Clin Hypertens (Greenwich) 2022; 24:263–270. doi: 10.1111/jch.14418
- 9.
Picone DS, et al. How to find and use validated blood pressure measuring devices. J Hum Hypertens 2023; 37:108–114. https://www.nature.com/articles/s41371-022-00718-5
