Health Editor’s Note: Have you ever felt uneasy/nervous/anxious when going to a doctor’s appointment? We all do. When you arrive at the waiting room, you may have a long wait. You rushed there, perhaps breaking speed limits, to get there on time. You adjusted your schedule to accommodate your appointment time. You put some planning into this event, but you might still feel pressure or rushed. This has happened to me on more than one occasion.
Now that you are in the office, you have time to think about why you are there. Maybe you are there for a yearly physical, maybe for a health issue. You might be in pain, but perhaps more than anything else, you are worried that something really big will be wrong with you. You do not like to be stuck with needles, and anticipate a possible blood draw if you did not have one done before the appointment. You do not like the smell of the office as it reminds you of other visits.
You WILL have a blood pressure taken as part of your vital statistics for this visit. Add your rushing to the appointment, your fear of needles, your concerns that you are really, really sick, that you may be nauseated, very tired from not sleeping normally due to being ill or being worried, and you can be just plain scared of what could be wrong with you……You are pumping adrenalin that is being over released due to your emotional state. High blood pressure due to being in a doctor’s office, being upset while being in a doctor’s office, etc. is called “white coat syndrome.”
Your blood pressure is taken at the beginning of the visit, and perhaps the person taking it will mention that the reading is a bit high. So the result of your visit may be a blood pressure reading that will be higher than it should be. Add this to why you were there already, and see a reason for your blood pressure to rise.
High blood pressure is a concern to your health care provider because chronic elevation of blood pressure can lead to memory loss, loss of consciousness, heart attack, damage to kidneys with resulting loss of kidney function (kidneys are very sensitive to blood pressure), hurt your eyes, cause fluid to back up into the lungs, etc. Some health care providers will leap to labeling you has someone who is now hypertensive (has a high blood pressure) and suffering potential harm to your body.
There may be the mention of you taking blood pressure medications to try to subdue your “high” blood pressure. You might even be given a prescription for one of the blood pressure medications. Maybe you did not need blood pressure lowering medication because your blood pressure was high because that is what happens when you are upset and are pumping extra adrenalin.
Hopefully the scenario of being given blood pressure medications, for falsely high blood pressure readings will be a thing of the past. A wise move on the clinician’s part is to take a blood pressure reading at the end of the appointment, or to turn off the lights, allow you to relax and take another blood pressure reading or two. You might even be asked to have to have a blood pressure taken outside the medical office.
Of course, to prepare yourself for the blood pressure reading, you should not smoke (you should not be doing that anyway), drink coffee or other caffeineated beverages and foods, empty your bladder, sit quietly. Mostly, just be aware that this scenario can and does happen, and be able to mention what you know about this process and make suggestions as to how you might be treated so your blood pressure reading will be at its most accurate…….Carol
Second BP Measurement Often Brings Better News
Repeat measurement in same office visit is on par with adding a drug
by Nicole Lou, Contributing Writer, MedPage Today
The first in-office blood pressure reading is often misleadingly high, one study suggested.
Patients who initially had high blood pressure readings had a median drop of 8 mm Hg in systolic pressure when they got a repeat measurement — and the greater the initial systolic blood pressure, the greater the difference, according to a group led by Douglas Einstadter, MD, MPH, of Cleveland’s Case Western Reserve University and MetroHealth Medical Center.
Moreover, 36% of repeat readings fell under the old hypertension threshold of 140/90 mm Hg, which is now the threshold for antihypertensives in lower-risk individuals. Overall, repeat measurements brought the hypertension control rate up from 61% to 73%, the investigators reported online in JAMA Internal Medicine.
“While much of the change in systolic blood pressure may be attributed to regression to the mean, the observed decrease remains clinically important, comparable with that associated with addition of an antihypertensive medication,” Einstadter’s group noted.
Having patients go on blood pressure drugs when they don’t need them means they are taking “medications that add little or no benefit to their clinical well-being or clinical outcome,” said Robert Baron, MD, of the University of California San Francisco, writing in an invited commentary.
This becomes an especially relevant problem as the U.S. health care system moves toward value-based care initiatives, such as accountable care organizations and shared savings programs, the study investigators suggested.
Their study was based on the records of the MetroHealth urban safety-net health system’s patients with a problem list diagnosis of hypertension who were seen at a primary care clinic in 2016 (n=38,260).
Of note, these clinics utilize an electronic health record system with a built-in reminder for healthcare providers to remeasure blood pressure when the first reading exceeds 140/90 mm Hg in the clinic, which happened 83% of the time.
Baron suggested that primary care practices develop a clear strategy for best-practice office measurement that may include changes in staff training, work flow, and physical settings to comply with current American guideline recommendations.
“Despite the clinical trial emphasis on office-based measurements, most new practice guidelines now also recommend out-of-office measurement to confirm office-based high blood pressure and for ongoing management of hypertension. Unfortunately, this practice is neither standardized nor fully evidence based,” according to Baron.
Nonetheless, “ABPM [ambulatory blood pressure monitoring] should be used more than it currently is. It is not clear that it is needed in every patient (as suggested by current guidelines), but it certainly can be useful in a larger number of patients,” the editorialist said. “Finding even a few patients in each primary care practice who do not need medications is well worth it. This may be especially true in patients with lower cardiovascular risk.”
Moreover, ABPM can help confirm good control throughout the day in high-risk patients, especially those with existing cardiovascular disease, he added.
“As we continue to debate the thresholds and goals of high blood pressure treatment, we will need to better explain to patients the benefits and harms of each approach and solicit their preferences. The least we can do is better define their risk with better measurement of blood pressure,” Baron concluded.
The work was funded by the Centers for Disease Control and the Mount Sinai Health Care Foundation of Cleveland.
Einstadter and Baron disclosed no relevant conflicts of interest.
JAMA Internal Medicine
Source Reference: Einstadter D, et al “Association of repeated measurements with blood pressure control in primary care” JAMA Intern Med 2018; DOI: 10.1001/jamainternmed.2018.0315.
JAMA Internal Medicine
Source Reference: Baron RB “Treating blood pressure correctly by measuring it correctly” JAMA Intern Med 2018; DOI: 10.1001/jamainternmed.2018.0311.