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October 17th, 2011

Checking It Twice

Gopi Astik, MD

I always remember my mother trying to teach me things I didn’t agree with. Being the bigmouth that I was (am), I would voice my disagreement, and she would tell me that, one day, I would tell my kids the same thing. I, of course, did not agree. I felt the same way about some of the tedious things I learned to do in medical school. I didn’t understand why my attending always made me recheck blood pressures on patients when I saw them, after a nurse had already done that precise thing. I would recheck the blood pressure and mindlessly report the measurement back to my staff. I started noticing that the levels were usually lower when I checked them again in the room, and I thought this was because I was so good at checking them.

The study regarding clinic-based BP measurement discusses this issue in more detail. It states that many people who are  diagnosed with hypertension by clinic-based measurements alone are not truly hypertensive. It proves the validity of “white coat hypertension” and the importance of serial blood pressure measurements prior to initiation of therapy. If patients are not truly hypertensive, we are putting them at risk for hypotension with BP-lowering medications and subjecting them to risk for adverse effects and the associated cost-burden.

I was recently in clinic and asked my student what a patient’s blood pressure was when she rechecked it in the room — to which my student rolled her eyes and went back to check. I had to laugh — I realize how things really do come full circle.

11 Responses to “Checking It Twice”

  1. Yair Yodfat M.D. says:

    America was discovered again!!
    I have been telling unsuccessfully for years my colleagues, students and nurses to measure BP at least 3 times. The recent British NICE recommend referring every patient with BP above 140/90 mmHg on 2 clinic measurements for ABPM for at least 7 hours to establish the real diagnosis of hypertension. This will save many patients with “psudo-hypertension” from unnecessary labeling and treatment.

  2. John O'Brien, PA-C says:

    In my experience,the very existence of “white coat” hypertension is frequently poo-poo’ed by many healthcare professionals. Personally, it’s easy to verify oneself. The person with experience is never at the mercy of one armed only with an opinion. Incidentally, for me personally (I am under treatment for hypertension), it’s the device not the coat. I consistently get lower readings on myself on second and subsequent measurement. I suspect there is a subset of “hyper” and “pre-hyper” tensives sensitive to sympathetic lability. Meds can be selected accordingly.

  3. michael loren says:

    It is even more valid having the patient check it at home multiple times. I have white coat hypertension. When I take my white coat off, my bp also goes down.

  4. Anthony Musci says:

    There has been a lot of online discussion about the perils of overdiagnosing hypertension. Please remember in all this, that there is evidence that patients with white coat effect are prognostically worse off than patients with unmuddled normotension. If nothing else, these patients warrant more careful followup for progression to hypertension.

    • Gopi Astik, MD says:

      I agree. Even if a patient’s bp improves upon rechecking, they are still at risk for hypertension or maybe prehypertensive. Close follow up is definetely recommended.

  5. Larry DeLuca, EdD, MD says:

    In a study my colleagues and I published in Academic Emergency Medicine a few years ago we demonstrated a) that simply taking the patient to a quiet room and waiting 5 minutes before repeating the BP measurement resulted in clinica
    Ly significant reductions in blood pressure for a large proportion of patients; and b) automated BP measurement devices in triage had poor agreement with measurements made by trained observers.

    Cienki JJ, DeLuca L, Daniel N. The validity of Emergency Department Triiage Blood Pressure Measurement. Academic Emergency Medicine. 2004; 11:237-243.

    • Gopi Astik, MD says:

      Thanks for the article. I do agree that some of the discrepancy between bp might also be due to automated machines used at triage as opposed to manual measurements in the clinic.

  6. Martie Lynch PA-C says:

    Several years ago I attended a seminar on the Total Management of the Hypertensive Patient. The first talk was given by a professor of medicine (Cardiology) who described the physiology of blood pressure. At the end of his talk he advised the audience that any provider can read and learn what he had just described. He said, “Here are the Five R’s you need to remember at the bedside from this discussion:

    REMOVE your white coat before you go in to see a patient with hypertension (wear the yellow isolation coat in the hospital if needed).

    RECOGNIZE that size does matter. (Normal adult cuff size on even a minimally overweight patient almost always gives an elevated reading). Get the right cuff!

    REPOSITION the patient in a chair or on the exam table with their back supported, feet on the floor or in supine position and ankles or legs uncrossed (all factors which have been found to elevate blood pressure).

    RELAX yourself while examining the patient. (They sense your tension and hurry.)

    REPEAT the whole process before the end of the patient visit. (Hopefully, you will have been with them at least five minutes before you re-check the BP.)”

    I’ve been employing these techniques since 2006 and have never found them to be a waste of my time.

  7. Coach Mike, PhD says:

    It’s probably not just the “white coat” but also a stressful, busy, and noisy environment. Often the BP is taken immediately on arrival with no period of quiet sitting. Many people don’t even remove the cuff and retake the BP immediately after the first reading. I’ve examples where the first measurement is 180/110, the second is 150/80 and when I take it it is 110/70. Heart rate also declined comparably. Fit, muscular people with high lean body mass often show a high intiial blood pressure reading. Power/weight training and power cycling (e.g. at ~350W and above) can lead to 20 mm Hg higher DBP on first reading for several days.

  8. Peter Cone says:

    Great advice – wish more health care professionals were better educated about this.

    I’d love to see comments on Masked Hypertension – something I exhibited for years before a PCP took notice of the patient’s input.

    PC

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