Shawna Nesbitt, MD

Disclosures

September 04, 2015

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One of the major challenges in hypertension management is patients who present with high blood pressure in the office but normal blood pressure at home. These patients do not want to take medication, and they use this discrepancy in blood pressure readings as a reason for not being consistent with their antihypertensive regimens.

As clinicians, we wonder whether the blood pressure is truly normal at home or is elevated but the home measurements are inaccurate. In truth, the blood pressure measurements that are taken outside the office are more often associated with heart disease, stroke, and other negative outcomes than blood pressure measurements taken at the clinician's office. This is a quandary for the clinician.

The best approach to this quandary is first to assess whether the patient with inconsistent blood pressure measurements has target organ damage. The presence or absence of target organ damage will help ascertain whether to be more aggressive with treatment.

Second, it is important to obtain more consistent blood pressure readings. This can be achieved in two ways. You can use a 24-hour ambulatory blood pressure monitor. The monitoring device is placed on the patient in the office; then the patient wears it for 24 hours, providing the clinician with objective data. Or the patient can check his or her blood pressure at home. Almost every clinical trial of hypertension now includes home blood pressure measurements via some mechanism.

Blood pressure measurements can be taken at home in a standardized way, similar to the way we take blood pressure measurements in the office. The patient sits for 5 minutes, takes two to three measurements, tabulates the average of the three or records the third measurement, and brings in the records to allow the doctor to assess them. This can be done for 2 weeks, with one or two measurements a day, recording the time of day that the measurements were taken. This approach has a very strong relationship to ascertaining whether the patient has hypertension outside the office and whether their risk of having an event is high.

You can buy the home monitoring devices in almost any drugstore and at Walmart, Target, and such. Many good devices are on the market now. The most accurate devices have been validated by the Association for the Advancement of Medical Instrumentation, [the British Hypertension Society, or the European Society of Hypertension] on a website where they list and grade many of them from A to D. Simply go to dableducational.org and search the list of blood pressure monitoring devices that have been tested.

I ask patients to bring their home devices to the office, and we test their devices against ours within a few minutes of each other. In that way, we can assure that the measurements from the two devices are similar. People who cannot afford to own their own device can go to the local pharmacy or the local fire station, which will provide blood pressure checks for free.

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