Of Signal and Noise
Overcoming Challenges in Blood Pressure Measurement to Optimize Hypertension Care
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Elevated blood pressure (BP) is the leading global contributor to preventable death.1 Although there has been tremendous progress in improving rates of BP control in the United States, this progress has stalled in recent years with >50% of Americans still having BP >140/90 mm Hg.2 The American College of Cardiology/American Heart Association hypertension guidelines released in November 2017 lower the thresholds for stage 1 hypertension from 140–159/90–99 to 130–139/80–89 mm Hg and present a goal of <130/80 mm Hg for all patients.3 These changes expanded the portion of the general population that has hypertension and added many formerly controlled hypertensive patients to the rolls of the uncontrolled.4 Clearly, our healthcare systems and primary care workforce will be challenged to meet these new goals.
Although much of the attention on the new American College of Cardiology/American Heart Association guidelines have been placed on these lower BP thresholds, of equal importance is the renewed focus on BP measurement. BP is a biological variable whose measurement is seemingly straightforward. However, in addition to inherent variability, BP is prone to measurement error, such that BP readings are less reliable and more prone to misinterpretation than perhaps any other measure used in the practice of medicine.5 This makes it challenging for providers to accurately identify and treat hypertension. Herein, we review the manifestations and consequences of BP mismeasurement and misinterpretation in clinical practice and draw on recent research to propose a set of solutions that leverage available technologies to optimize hypertension care.
BP fluctuates substantially because of biological as well as ecological (ie, contextual) factors. Biological factors include season, time of day, body position, bladder distension, and recent physical activity, whereas ecological factors include physical and social circumstances (medical facility, workplace, or home), and chronic or acute psychological distress or pain.5 BP …