When to Trust Those Home Blood Pressure Readings

Matthew F. Watto, MD; Paul N. Williams, MD


April 08, 2021

This transcript has been edited for clarity.

Matthew F. Watto, MD: This is The Curbsiders. I'm Dr Matthew Watto, here with Dr Paul Williams. We are going to be talking about high blood pressure. We recently spoke with a fantastic expert: Dr Wanpen Vongpatanasin, a cardiologist from UT Southwestern. Paul, what was your favorite pearl about hypertension?

Paul N. Williams, MD: It's one of my favorite topics, as an internist, and something I could talk about forever, so it's hard to pick my absolute favorite. I really like the fundamentals, and one thing she brought up was a reminder that in this age of telemedicine and using home blood pressure readings to make determinations, the correlation between home and in-office blood pressure readings isn't necessarily one-to-one. There's a really nice chart in the American College of Cardiology guidelines showing that blood pressure, at certain levels, tends to be a bit lower at home. So you can't use that exact home BP number to make your diagnosis and treatment decisions.

The other thing that I always find really helpful is revisiting this idea of the different types of hypertension.

Infographic by Edison Jyang. Courtesy of The Curbsiders.

We all know essential hypertension (sustained hypertension), where someone's blood pressure is high at home and in the office. That part's easy. And we all know about white coat hypertension (which is maybe not as benign as we thought it was), where blood pressure is high in the office and okay at home, and which may confer some cardiovascular risk. But it's important to remember that in addition to normotension, where you're fine in both settings, there's also masked hypertension, where you are hypertensive at home but not in the office. And that is not — as far as we can tell — a benign condition either. It also confers a fair amount of cardiovascular risk and warrants management. Reviewing those is always really helpful.

Watto: We spent a lot of time talking about blood pressure goals. One thing she said was that a clinic BP of 140 mm Hg is similar to a home BP of 135 mm Hg. But for patients who have a BP of 130 mm Hg in clinic, it was closer to 130 mm Hg at home, too. So if someone is 130 both in clinic and at home, you're good. I like the International Society for Hypertension guidelines because they really simplify things. An acceptable blood pressure is this, and an ideal BP is this. Pretty much what it boils down to is, if you can get the patient to 140/90, high fives all around.

And if you can get somebody under 130/80, and you can do it easily, that seems ideal for most patients. Where the question comes in is if you have someone at 135, are you going to escalate? Are you going to add another med? That's where the decision becomes a lot more nuanced. But in general, it's helpful to think about it like this: If they're under 140, that's acceptable; if they are under 130, that's ideal for a lot of our patients. But logistics, cost, and other things usually factor in there too.

Williams: One of the pearls that I seem to recall you liking is when we talked about not all home BP cuffs being the same. Dr Vongpatanasin gave us a nice online tool to see whether the device that the patient is using is validated or any good at all.

Watto: Yes, it was Whether you are working in a hospital or a clinic or are looking for home BP devices, they list those that are recommended by cardiologists and experts in hypertension. You can copy the model number and paste it into your favorite retailer.

Let's talk about treatment. Spironolactone has become my go-to fourth-line blood pressure medicine. But she gave me a little bit of pause. Both of us are middle-aged men; what did you think about her guidance on spironolactone?

Williams: It's a good and effective medication. We use it for lots of things. I'm with you. I actually think it's probably underutilized as a next-line medication when you've tried the usual suspects. But she did raise the point about the potential adverse effects. You mentioned our respective manliness, and particularly with men, you do worry about gynecomastia, which I think we're all aware of but sometimes forget to counsel patients about. And then the sexual side effects, and specifically things like erectile dysfunction and reduced libido, are probably also worth at least having some anticipatory counseling with patients if you are starting them on spironolactone.

Watto: She mentioned asking about breast tenderness or gynecomastia symptoms, which tend to happen at higher doses but still might push some men away from it. It just depends on the blood pressure and the patient.

This is just a taste of what was a fantastic podcast with a fantastic expert. If you'd like to hear the rest of it, you can check it out at #254 Hypertension Update with Dr Wanpen Vongpatanasin. And you can also join our mailing list and get a PDF copy of our show notes every week.

Thank you for watching.

The Curbsiders are a national network of students, residents, and clinician educators from across the country, representing 15 different institutions. They "curbside" experts to deconstruct various topics in the world of medicine to provide listeners with clinical pearls, practice-changing knowledge, and bad puns. Learn more about their contributors and follow them on Twitter.

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