ESH guidelines
AHA guidelines
Measurement procedure and schedule:
Measurement procedure and schedule:
Seven-day home measurements (minimum of 3 days). At initial assessment, when assessing treatment effects, and in the long-term follow-up before each clinic/office visit. Take two readings morning (before drug intake if treated) and two readings evening (before eating). Readings should be 1–2 min apart. Long-term follow-up: less frequent measurements (for example, once or twice per week) could be regularly performed aimed at reinforcing compliance, although isolated readings should never be used for diagnostic purposes. Overuse of the method and self-modification of treatment should be avoided.
Take multiple readings. Each time you measure, take two or three readings one minute apart and record all the results. Measure at the same time daily. It is important to take the readings at the same time each day, such as morning and evening, or as your healthcare professional recommends.
Accurately record all your results. Keep a record of all of your readings, including the date and time taken. Share your blood pressure records with your healthcare team. Some monitors have built-in memory to store your readings; if yours does, take it with you to your appointments. Some monitors may also allow you to upload your readings to a secure web site.
Healthcare professionals should also be aware of any national or local guidelines to follow, as well, as even the smallest deviations in protocol could result in differences in the resulting measurement levels.
6.1 Monitoring Schedule
Most guidelines suggest that for the initial evaluation of blood pressure levels, including for the diagnosis of hypertension, as well as for the assessment of the effects of antihypertensive treatment including changes in drug or dose, HBPM should be performed daily during at least 3 days before the appointment at the clinic (Parati et al. 2010; Pickering et al. 2005b). Duplicate measurements should be obtained in the morning before drug intake, and in the evening before eating. Measurements of the first monitoring day are usually higher and unstable and are excluded. Well-treated hypertensive patients may also perform regular home BP measurements as a long-term follow-up, e.g. once per week, with the additional aim to reinforce their treatment compliance levels, but the diagnostic value of such long-term measurements is not well-established (Parati et al. 2010).
6.2 Measurement Recommendations
Common to all guidelines, it is recommended that the cuff should be wrapped around the arm with its inflatable bladder centered on the arm with the lower edge of the cuff approximately 2–3 cm above the bend of the elbow. The bladder should always be positioned at the heart level. Also, the measurement should be performed in a quiet room and the patient should remain seated comfortably, not moving during measurements, with the arm resting on a table or other support. Also, the patient should not talk during measurements, and refrain from talking in the minutes before the measurement is taken if feasible.
Please note the subtle differences between ESH and AHA guidelines, where AHA requires the upper arm to be supported at heart level, while ESH only requires the cuff to be placed at heart level. In a recent study by O’brien et al. from 2003, it was found that the forearm also should be at the level of the heart as denoted by the mid-sternal level. Dependency of the arm below heart level leads to an overestimation of systolic and diastolic pressures and raising the arm above heart level leads to underestimation. According to O’brien et al. the magnitude of this error can be as great as 10 mmHg for systolic and diastolic readings, underlining that the source of arm position errors are especially important for the sitting and standing positions. Furthermore, there is evidence that even with a patient in the supine position, an error of up to 5 mmHg for diastolic pressure may occur if the arm is not supported at heart level (O’Brien et al. 2003).
BP measurement results should be reported in a paper schema or logbook format immediately after each measurement according to both ESH and AHA guidelines (Parati et al. 2010; Pickering et al. 2005b). Alternatively, memory equipped devices can store the readings with time and date for each measurement. BP devices designed for telemedicine and telemonitoring purposes are also capable of sending data to a computer or tablet device, and even to an online record system, such as the OpenTele telemedicine system (Wagner 2015). Such systems can distinguish data originating from different device users, removing such bias. Sometimes devices are used to measure BP in other family members and it is important to ensure that these are not erroneously included into a patient BP measurement data set (Parati et al. 2010). Finally, in the rare case of a significant and consistent BP difference between arms, defined as more than 10 mmHg, the physician should advise the patient to use the arm with the highest BP values for HBPM and BPSM purposes (Pickering et al. 2005b).
As may be seen in the comparison of ESH vs AHA guidelines in Tables 1 and 2, there are several differences in measurement procedure and schedule as well as measurement recommendations. For instance, the ESH highlight the need to take the measurements before drug intake (in the morning) and before eating (in the evening). Guidelines from other organizations differ even more, including guidelines from the British Hypertension Society that recommends two measurements be taken in the seated position with 1 min apart in the morning and evening for 4–7 days, ensuring a relaxed, temperate setting, with the patient quiet and seated, and their arm outstretched and supported. No other indications are provided, e.g. on rest time before the first measurement (NICE 2011).
Table 2
Comparison of ESH and AHA guidelines on HBPM recommendations
ESH guidelines | AHA guidelines |
|---|---|
Measurement recommendations: | Measurement recommendations: |
At least 5-min rest, 30 min without smoking, meal, caffeine intake or physical exercise. Seated position in a quiet room, back supported, arm supported (for example, resting on the table). Subject immobile, legs uncrossed, not talking and relaxed. Correct cuff bladder placement at heart level. Results immediately reported in a specific logbook or stored in device memory. | Make sure the cuff fits. Measure around your upper arm and choose a monitor that comes with the correct size cuff. Be still, do not smoke, drink caffeinated beverages or exercise within the 30 min before measuring your blood pressure. Sit correctly. Sit with your back straight and supported (on a dining chair, for example, rather than a sofa). Your feet should be flat on the floor; do not cross your legs. Your arm should be supported on a flat surface (such as a table) with the upper arm at heart level. Make sure the middle of the cuff is placed directly above the eye of the elbow. Check your monitor’s instructions for an illustration or have your healthcare provider show you how. |
6.3 Interpretation of HBPM
The average of a series of measurements taken following the chosen set of guidelines should be used for the clinical decisions based on HBPM and BPSM readings. Casual, isolated home measurements can be very misleading and should not by themselves constitute the basis for clinical decisions. The users should be informed that BP may vary between measurements and be instructed not to be alarmed by lone standing high or low BP measurements. Optimal blood pressure is defined as systolic pressure less than 120 mmHg and diastolic pressure less than 80 mmHg. Average systolic home BP greater than or equaling 135 mm Hg and/or diastolic greater than or equaling 85 mm Hg indicates elevated BP. The levels of ‘normal’ and ‘optimal’ home BP are still under investigation, provisionally suggested values being below 130 mmHg systolic and below 80 mmHg diastolic for normal home BP (Parati et al. 2010) (Table 3).
Table 3
Comparison of ESH and AHA guidelines on interpretation of measurements
ESH guidelines | AHA guidelines |
|---|---|
Interpretation of measurements: | Interpretation of measurements: |
Average BP from several monitoring days should be considered. BP values measured on the first monitoring day should be discarded.. Mean home systolic BP greater than or equal to 135 mmHg and/or diastolic BP greater than or equal to 85 mmHg should be considered as elevated. Systolic and diastolic home BP less than 130 and less than 80 mmHg, respectively, should be considered normal in most subjects. In high-risk subjects home BP targets should probably be lower. | Optimal blood pressure is less than 120/80 mmHg (systolic pressure should be less than 120 mmHg and diastolic pressure should be less than 80 mmHg). Consult your healthcare professional if you get several high readings. A single high reading of blood pressure is not an immediate cause for alarm. However, if you get a high reading, take your blood pressure several more times and consult your healthcare professional to make sure you (or your monitor) do not have a problem. When blood pressure reaches a systolic (top number) of 180 or higher OR diastolic (bottom number) of 110 or higher, emergency medical treatment is required. |
7 Challenges of HBPM and BPSM
7.1 Patients Ability to Report Self-Measured BP Data
There are several well-known challenges associated with both BPSM in general and HBPSM in particular, including failure to correctly report self-measured data, as well as failure to comply with one or more recommendations as described in the guidelines provided by the healthcare professional. A recent study by Wagner et. al. of 113 chronic kidney disease patients self-measuring in the outpatient clinic, in a special purpose self-measurement room, found that over a third of the participants failed to self-report accurately, either omitting, doubling, rounding, or even fabricating one or more parameters in one or more of their measurements. This represents a challenge to the validity of the data being self-reported by patients (Wagner et al. 2013a). These findings are in line with previous work in the area studying HBPM (Johnson et al. 1999; Mengden et al. 1998; Myers 1998). In these studies patients were equipped with home BP devices, but where not informed that the devices were capable of storing the measurements automatically in device memory. This was done in order to investigate the participant’s ability to correctly self-report measurements. After a period of self-monitoring and filling out of the paper records, these records were compared with BP device memory values. In total, more than half the patients had either omitted or fabricated readings indicating unacceptable levels of reporting bias, in line with previous work (Wagner et al. 2013a). In a later study on HBPM using a telemedicine web-based system and a home BP device, 161 patients’ ability to accurately report self-measured BP data was investigated (Santamore et al. 2008). The study compared the self-reported data from the web, being manually input by the patients after each measurement, with the data stored in the memory of the devices. The authors found that around 16 % of the reported data deviated from the actual data stored in the device memory, which is significantly less reporting error compared with previous work (Johnson et al. 1999; Mengden et al. 1998; Myers 1998). Also, the study found the average reporting error to be below 4 mmHg, and thus not of major importance to the prognostic value for diagnostic or monitoring purposes (Santamore et al. 2008). The lower error rate reported in this study could be due to participants entering data into a web solution rather than keeping a paper logbook. This implies that the participants were aware of technology being involved and thus presumably less likely to be tempted to misreport. Also, as we cannot expect all patient types to be able to utilize a web solution for self-reporting of data, it could indicate that the Santamore study included a population with higher competencies than was the case in the four related studies. Of the five presented studies, only the first investigated adherence to the recommendations, such as rest time before measurement, talking, and noise levels, the other four focusing solely on the patients’ ability to correctly and accurately self-report BPSM data. These findings provides us with an indication of the challenges related to relying on HBPM and BPSM obtained in the unsupervised setting with regard to patients’ ability to accurately report self-measured data, but not on their ability to self-measure reliably.
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