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Improving Hypertension Diagnosis: How To Get Accurate Blood Pressure Readings

Cardiovascular nurse specialists Michaela Nuttall and Joanne Haws explain the importance of obtaining accurate blood pressure readings and how to measure blood pressure correctly

Almost a third of adults in the UK have persistently high blood pressure (hypertension), which remains one of the most important modifiable risk factors for cardiovascular disease.1

Hypertension is the third biggest risk factor for premature death and disability after smoking and poor diet.2

Approximately 54% of strokes and 47% of coronary heart diseases, worldwide, are attributable to high blood pressure.

The prevalence of hypertension is higher in more deprived areas, in people who are older and in people with global majority background.3 And yet, 4.2 million people in England alone have undiagnosed hypertension.4

Detection

Most people with high blood pressure do not experience symptoms and will only be found through opportunistic case finding or other health consultations.

Nurses in primary care play a key role in hypertension detection and assessment. Getting the practicalities of blood pressure measurement right is vital to ensuring patients with possible hypertension are assessed in an appropriate, effective and timely fashion. Knowing the importance of good techniques for both clinical and home monitoring is essential.

Assessment – measuring blood pressure in clinic

Blood pressure measurement is a common and important clinical assessment, but unfortunately is often performed sub-optimally in practice.5 Accurate and reliable measurement is essential for the correct diagnosis and management of hypertension to improve outcomes for patients.

The environment should be standardised wherever possible in terms of temperature and the position of the patient – a separate consulting room, with a chair and somewhere to rest the arm is ideal. The patient should be seated and relaxed for at least 5 minutes prior to measurement, with their arm supported and the cuff at heart level. They should not talk or move during the measurement and should keep their legs uncrossed, as these actions can all increase the blood pressure.

To optimise accuracy, ensure the blood pressure monitor is a validated model, is calibrated in line with the manufacturer's recommendations and the correct cuff size is being used. A standard cuff size is suitable for most patients, but check that the bladder inside the cuff encircles 80% of the top of the arm being measured. Large and small size cuffs should be available, and the arm measured where the required size is unclear. If the cuff is too big the blood pressure reading will be falsely low, and if it is too small the reading will be falsely high, both potentially leading to misdiagnosis and inappropriate management.6

A list of validated monitors, along with further resources on the measurement of blood pressure, can be found on the British and Irish Hypertension Society website.

Diagnosis of hypertension

NICE advises that in the clinic, blood pressure should initially be measured in both arms; if the difference in readings between arms is more than 15mmHg then measurements should be repeated.7 If the difference in readings between arms remains more than 15mmHg at the second reading, the arm with the higher reading should then be used for subsequent blood pressure measurements.

A single raised clinic blood pressure reading (>140/90mmHg) should always be followed up with Ambulatory Home Blood Pressure Monitoring (ABPM), or Home Blood Pressure Monitoring (HBPM) if ABPM is unsuitable or not tolerated.7

NICE states that a diagnosis of hypertension is confirmed by:• clinic blood pressure of 140/90mmHg or higher and• ABPM daytime average (or HBPM average) of 135/85mmHg or higher.

When ABPM first recommended by NICE as an essential step in the diagnostic pathway it was on the basis that it was more accurate than standard clinic monitoring as a predictor of blood pressure related clinical events, and that it would reduce unnecessary treatment in those who do not have true hypertension.

It remains the gold standard for diagnosing hypertension in adults due to the wealth of evidence supporting its use, and its ability to record large numbers of readings within a set time period, giving an in-depth profile of the individual's blood pressure.7

ABPM is not without limitation in terms of resources – including equipment cost and fitting time – and its acceptability to patients, however;8 use of HBPM is included in most international guidelines and recommended by NICE as an alternative to ABPM where the latter is unsuitable or not tolerated by the patient.7

In particular, these approaches help to avoid overdiagnosis as a result of so-called 'White Coat' hypertension (where a person's blood pressure is raised in the clinic environment, but normal elsewhere) and user variance.5

Obtaining and interpreting accurate ABPM readings

For ABPM, a well fitted device coupled with appropriate information for the patient will lead to successful acquisition of readings, reduce the need for repeated tests and ultimately to more timely diagnosis and treatment for the patient.

Patients should be advised to wear a shirt with short, loose sleeves for fitting of the device and given written advice on wearing the device and activities. Information sheets can be downloaded from the British and Irish Hypertension Society and Blood Pressure UK (see further reading and patient resources).

A diagnosis of hypertension should be confirmed or refuted based on the average daytime reading from ABPM. The first day's readings should be discarded to allow for patients to have familiarized themselves with the equipment.According to NICE, the average daytime reading should be calculated from:• At least two measurements per hour during the person's usual waking hours, taking the average of at least 14 measurements.

Most ABPM equipment will allow for the download of readings onto a practice computer and the average daytime reading will be automatically calculated.

Helping patients obtain accurate HBPM

As well as information around the device itself and what the process involves, the patient needs to be aware of the importance of using the correct technique to monitor blood pressure. Although the patient will be in their own home there still needs to be a standardized procedure, as discussed in regard to clinic readings, to obtaining blood pressure readings, particularly where the patient is in control of their own measurement in HBPM.

NICE advises that when using HBPM to confirm hypertension:• for each BP reading, two consecutive measurements should be taken, at least 1 minute apart and with the person seated and• blood pressure should be recorded twice daily, ideally in the morning and evening and• blood pressure recording continues for at least 4 days, ideally for 7 days.

If the patient is responsible for recording their measurements, they should be provided with a diary sheet on which to do so and reminded of the importance of accurate recording. Patient diaries and advice sheets can be downloaded from the British and Irish Hypertension Society and Blood Pressure UK (see further reading and patient resources).

The measurements taken on the first day, while the patient is still getting used to wearing the device, should be discarded and the average value of all remaining daytime measurements used to confirm a diagnosis of hypertension. This can be calculated manually by adding firstly the systolic readings together and dividing by the number of readings taken, followed by the same process for the diastolic readings.

Once a diagnosis of hypertension has been made further interventions and investigations are based on the stage of hypertension (see box below).

Stage 1 hypertensionClinic blood pressure ranging from 140/90mmHg to 159/99mmHg and subsequent ABPM daytime average or HBPM average blood pressure ranging from 135/85mmHg to 149/94mmHg.Stage 2 hypertensionClinic blood pressure of 160/100 mmHg or higher but less than 180/120 mmHg and subsequent ABPM daytime average or HBPM average blood pressure of 150/95mmHg or higher.Stage 3 or severe hypertensionClinic systolic blood pressure of 180 mmHg or higher or clinic diastolic blood pressure of 120mmHg or higher.

In most cases the next step is to assess for organ damage and undertake a full cardiovascular risk assessment using QRISK2 or other recognised risk calculator.7 This is an essential part of the diagnostic pathway and should be used to inform and guide shared decision making on treatment strategies with the patient.

Joanne Haws and Michaela Nuttall are registered cardiovascular nurse specialists

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