American Journal of Hypertension
Volume 17, Issue 4 , April 2004, Pages 354-360

John W. Graves  and Sheldon G. Sheps

Doctors should stop measuring blood pressure in hypertensive patients

New York, NY - An editorial in the April 2004 issue of the American Journal of Hypertension argues that doctors should relinquish the responsibility for blood-pressure monitoring in their hypertensive patients, both because they're not very good at it and because it's a poor use of their expensive time.

Accurate BP measures are critical to the proper diagnosis and treatment of hypertension, but several studies have shown that in practice physicians often don't adhere to accepted standards when they take blood pressure, and their measurements are often compromised the "white-coat" effect, authors Drs John W Graves and Sheldon G Sheps (Mayo Clinic and Mayo Foundation, Rochester, MN) write.

"I would argue that it's a poor use of the most expensive person in the healthcare system to do that," Graves told heartwire. "I don't do it well, and I'm not going to get the right number, it doesn't compare to the trials, and I'm the most expensive one to do it. Why am I doing it?"

Applying the evidence

In all of the large hypertension trials since the early 1970s, including recent trials such as ALLHAT, STOP-2, and SYST-EUR, which provide the evidence base for the recent Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines, blood pressures were not measured by physicians but by nurses, "trained observers," or by validated ambulatory BP-monitoring devices, Graves and Sheps point out.

To ensure the applicability of trial results, it's critical that blood pressure be measured accurately, Graves told heartwire. "In hypertension, you're trying to establish whether the blood pressure is controlled and whether the patient needs to be on treatment, and there, small mistakes can make a big differenceit could throw somebody into the treatment category when they don't need it, or it can allow them to walk away undertreated."

A variety of studies have shown that measuring BP is not taught in a uniform way, and so, perhaps not surprisingly, doctors have performed poorly when studied in practice, they write. Instead, Graves and Sheps propose a system similar to that in diabetes, where a nurse-manager monitors patients. The physician would perform the initial assessment and draw up a treatment plan. The patient would then be followed by the nurse-manager and come back to the physician only if treatment proved ineffective.

Graves acknowledged that physicians have not received his message gratefully. "Doctors don't like to hear anybody say they don't do something well," he said wryly. Still, it takes up to 15 minutes to measure BP if proper procedures are followed: two measures in the right arm, one in the left, having the patient rest for five minutes before proceeding, and allowing at least a minute between measures. "I know they're not doing that in a 15-minute appointment."

He noted that new AHA guidelines on measuring blood pressure are in final draft and expected to be published later this year.

Abstract

Does evidence-based medicine suggest that physicians should not be measuring blood pressure in the hypertensive patient?

John W. Graves ^{a, ,} and Sheldon G. Sheps

American Journal of Hypertension
Volume 17, Issue 4 , April 2004, Pages 354-360

The most common reason for an outpatient physician visit is for the diagnosis and treatment of hypertension. The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) VII, which is increasingly evidence-based, advises the clinician to use studies of the mean response and benefit derived from reduction in blood pressure (BP) from antihypertensive therapy and to translate this data into recommendations for the individual hypertensive patient. We believe that the increasingly aggressive approach to hypertension mandated by JNC VII calls into question the use of physician-measured BP. Ample evidence has shown that phycisians have not been adequately trained to measure BP and, therefore, rarely measure BP to the standards asked for by JNC VII or the American Heart Association (AHA) guidelines. In addition, the white coat effect dilutes the validity and usefulness of physician-measured BPs. Finally, in the evidenced-based studies used to derive the JNC VII guidelines, BPs were measured by nurses, other "trained observers," or automated devices, not physicians. Accurate BP measurement is critical to diagnosis and management of hypertension. We recommend, therefore, that for this purpose physicians should not measure BP themselves but should rely on BPs from well-trained and monitored observers or validated automated devices to improve the quality of care of the hypertensive patient.

Dr.Yousef S.I Alkhettaly