Abstract 106: Paradoxical Increase in Office-Based Blood Pressure Measurement After a Brief Patient Rest Period

Hypertension ◽  
2012 ◽  
Vol 60 (suppl_1) ◽  
Author(s):  
Keerthana Karumbaiah ◽  
Nidal Omar ◽  
Bassam A Omar
Keyword(s):  
Blood Pressure ◽  
Blood Pressure Measurement ◽  
Measurement Data ◽  
Rest Period ◽  
Public Health Problem ◽  
White Coat ◽  
White Coat Hypertension ◽  
Paradoxical Response ◽  
Minute Period ◽  
Cardiology Clinic

BACKGROUND: Office-based blood pressure (BP) measurement is a snapshot of a patient’s ambulatory BP, and is subject to variations which may influence management. OBJECTIVE: To assess the effect of a brief rest period on repeat BP measurement. METHODS: Patient charts reviewed in University-based cardiology clinic identified 170 encounters which contained BP re-measurement data due to elevated initial BP of > 130/80 mmHg. BP was measured initially by a nurse, with the patient in a sitting position and the arm resting at the level of the heart. If BP was > 130/80 mmHg, it was repeated by physician after resting the patient for 15 minutes. Mean age was 64 ± 12 years. Results: Among encounters with BP re-measurement, initial systolic BP (SBP) was 153 ± 27 mmHg, and diastolic BP was 87 ± 16 mmHg. Upon re-measurement, 106 of 170 patients (62%) had lower SBP of 143 ± 23 mmHg compared with initial SBP of 162 ± 28 mmHg; a mean drop of 18 mmHg. However, 53 of 170 patients (31%) had higher SBP of 149 ± 17 mmHg compared with initial SBP of 138 ± 14 mmHg; a mean increase of 10 mmHg. Eleven patients (7%) had no BP change. In 50% (85/170) of encounters, BP re-measurement necessitated hypertensive medication changes. Compared with the remaining patients, those with paradoxical increase in BP were younger (60 ± 9 years versus 66 ± 13 years; p < 0.01), more females (57% versus 47%), and with lower initial SBP (134 ± 14 versus 160 ± 28, p < 0.01). DISCUSSION: Hypertension is a challenging public health problem. JNC 7 guidelines recommend that prior to BP measurement, persons should be seated quietly for at least 5 minutes in a chair, with feet on the floor, and arm supported at heart level; this may decrease initially elevated BP. However, 30% of our patients exhibited a paradoxical response, with elevation of the SBP after a 15 minute period of rest. The cause of this paradox is not clear, but may have resulted from white-coat hypertension during the rest period, which may be more common in younger patients, especially females, as noted in our study. This underscores the importance of ambulatory BP monitoring, especially in subsets of patients prone to having labile or white coat hypertension, to avoid the cost and side effects of BP overtreatment.

Abstract 072: Paradoxical Blood Pressure Increase After Brief Patient Rest Period

Hypertension ◽  
2017 ◽  
Vol 70 (suppl_1) ◽  
Author(s):  
Abimbola Shofu ◽  
Timothy Kennedy ◽  
Bassam Omar ◽  
Christopher Malozzi ◽  
G. Mustafa Awan
Keyword(s):  
Blood Pressure ◽  
Rest Period ◽  
Public Health Problem ◽  
White Coat ◽  
White Coat Hypertension ◽  
Paradoxical Response ◽  
Minute Period ◽  
Number Of Patients ◽  
The Cost ◽  
Medication Changes

Background: Office-based blood pressure (BP) measurement is subject to variations which may influence management. Objective: To assess the effect of rest period on repeat BP measurement. Methods: Clinic charts were review identified 200 encounters with BP re-measurement due to initial BP of > 130/80 mmHg. BP was measured initially by a nurse, with the patient in a sitting position and the arm resting at the level of the heart. If BP was > 130/80 mmHg, it was repeated by physician after resting the patient for 15 minutes. Mean age was 64 ± 12 years. Results: Among encounters with BP re-measurement, initial systolic BP (SBP) was 154 ± 25 mmHg, and diastolic BP 87 ± 15 mmHg. Upon re-measurement, 135 of 200 patients (68%) had lower SBP of 144 ± 21 mmHg compared with initial SBP of 161 ± 25 mmHg; a 17 mmHg drop (P < 0.01). However, 53 of 200 patients (27%) had higher SBP of 149 ± 17 mmHg compared with initial SBP of 138 ± 14 mmHg; an 11 mmHg increase (P < 0.01). Twelve patients (6%) had no BP change. In 47% (93/200) of encounters, BP re-measurement necessitated medication changes. Compared with the remaining patients, those with paradoxical increase in BP were younger (60 ± 9 years versus 66 ± 12 years; p < 0.01), and with lower initial SBP (138 ± 14 versus 161 ± 25, p < 0.01). Discussion: Hypertension is a major challenging public health problem. JNC 8 guidelines recommend that prior to BP measurement, patients should be seated quietly for at least 5 minutes in a chair, with feet on the floor, and arm supported at heart level; this may decrease initially elevated BP. However, 27% of our patients exhibited a paradoxical response, with elevation of the SBP after a 15 minute period of rest. The cause of this paradox is not clear, but may have resulted from white-coat hypertension during the rest period, which may be more common in younger patients, as noted in our study. This underscores the importance of ambulatory BP monitoring, especially in subsets of patients prone to having labile or white coat hypertension, to avoid the cost and side effects of BP overtreatment. Studying larger number of patients, and including patient with normal initial BP, may help clarify the mechanism and clinical significance of this observation.

Abstract P338: Age and Gender Differences in Response to Repeat Blood Pressure Measurement after Brief Patient Rest Period

Circulation ◽  
2013 ◽  
Vol 127 (suppl_12) ◽  
Author(s):  
Keerthana Karumbaiah ◽  
Bassam A Omar
Keyword(s):  
Blood Pressure ◽  
Pressure Measurement ◽  
Blood Pressure Measurement ◽  
Measurement Data ◽  
Rest Period ◽  
The Elderly ◽  
Age And Gender ◽  
Significant Difference ◽  
Cardiology Clinic ◽  
And Gender

Background: Office-based blood pressure (BP) measurement is a snapshot of a patient’s ambulatory BP, and is subject to variations which may influence management. Objective: To assess the effect of age and gender on repeat BP measurement after a brief rest period in an outpatient cardiology clinic. Methods: Patient charts reviewed in University-based cardiology clinic identified 170 encounters which contained BP re-measurement data due to elevated initial BP of > 130/80 mmHg. BP was measured initially by a nurse, with the patient in a sitting position and the arm resting at the level of the heart. If BP was > 130/80 mmHg, it was repeated by physician after resting the patient for 15 minutes. There were 86 males (51%) and 84 females (49%); 113 (66%) elderly patients ≥ 60 years of age and 57 (34%) younger patients < 60 years of age. Results: Among all encounters, after a brief rest period, initial systolic BP (SBP) of 153 ± 27 mmHg decreased to 145 ± 27 mmHg (decrease of 8 mmHg; P = 0.003), and initial diastolic BP (DBP) of 87 ± 16 mmHg decreased to 83 ± 15 mmHg (decrease of 4 mmHg; P = 0.04). SBP decreased by 8 mmHg in both males (from 156 ± 30 to 148 ± 27 mmHg) and females (from 151 ± 23 to 143 ± 14) (NS, males versus females). DBP decreased by 5 mmHg in males (from 91 ± 18 to 86 ± 18 mmHg) and by 2 mmHg in females (from 83 ± 12 to 81 ± 12 mmHg) (P = 0.04, males versus females). SBP decreased by 11 mmHg in elderly (from 154 ± 23 to 143 ± 15 mmHg) and 2 mmHg in the young (from 153 ± 33 to 151 ± 30 mmHg) (P=0.02, old versus young). DBP decreased by 3 mmHg in elderly (from 82 ± 12 to 79 ± 12 mmHg) and 4 mmHg in the young (from 97 ± 18 to 93 ± 17 mmHg) (NS, old versus young). Discussion: Hypertension is a challenging public health problem. JNC 7 guidelines recommend that prior to BP measurement, patient should be seated quietly for at least 5 minutes in a chair, with feet on the floor, and arm supported at heart level. This resulted in a significant decrease in BP in our patients. In this study we show that while males and females decrease their systolic BP to the same extent after a brief rest period, males have a greater drop in their diastolic BP than females. Moreover, after the rest period, patients ≥ 60 years of age drop their systolic BP greater than patients < 60 years of age, while there was no significant difference in the drop of their diastolic BP. Given the high reported prevalence of White-coat hypertension in the elderly, between 15% and 25%, this is a clinically significant observation that reinforces that physicians should remeasure the blood pressure, especially the subset of males and the elderly, in whom a bigger decrement may be detected in blood pressure measurement after a brief rest period.

scholarly journals Resistant Hypertension Workup and Approach to Treatment

2011 ◽  
Vol 2011 ◽  
pp. 1-10 ◽  
Author(s):  
Anastasios Makris ◽  
Maria Seferou ◽  
Dimitris P. Papadopoulos
Keyword(s):  
Blood Pressure ◽  
Resistant Hypertension ◽  
Blood Pressure Measurement ◽  
Antihypertensive Agents ◽  
White Coat ◽  
Clinical Inertia ◽  
Uncontrolled Hypertension ◽  
White Coat Hypertension ◽  
Carotid Baroreceptor ◽  
Interventional Therapies

Resistant hypertension is defined as blood pressure above the patient's goal despite the use of 3 or more antihypertensive agents from different classes at optimal doses, one of which should ideally be a diuretic. Evaluation of patients with resistive hypertension should first confirm that they have true resistant hypertension by ruling out or correcting factors associated with pseudoresistance such as white coat hypertension, suboptimal blood pressure measurement technique, poor adherence to prescribed medication, suboptimal dosing of antihypertensive agents or inappropriate combinations, the white coat effect, and clinical inertia. Management includes lifestyle and dietary modification, elimination of medications contributing to resistance, and evaluation of potential secondary causes of hypertension. Pharmacological treatment should be tailored to the patient's profile and focus on the causative pathway of resistance. Patients with uncontrolled hypertension despite receiving an optimal therapy are candidates for newer interventional therapies such as carotid baroreceptor stimulation and renal denervation.

scholarly journals Blood Pressure Measurement in Peritoneal Dialysis: Which Method is Best?

2013 ◽  
Vol 33 (5) ◽  
pp. 544-551 ◽  
Author(s):  
Michelle M. O'Shaughnessy ◽  
Martin Durcan ◽  
Sinead M. Kinsella ◽  
Matthew D. Griffin ◽  
Donal N. Reddan ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Peritoneal Dialysis ◽  
Measurement Technique ◽  
Pearson Correlation ◽  
Blood Pressure Measurement ◽  
Time Of Day ◽  
White Coat ◽  
White Coat Hypertension ◽  
Population Potential ◽  
Optimal Approach

BackgroundThe optimal approach to monitoring blood pressure (BP) in the peritoneal dialysis (PD) population is unclear. Ambulatory BP monitoring reliably predicts prognosis, but can be inconvenient. The accuracy of home BP monitoring in this population is unproven. The automated BpTRU device (BpTRU Medical Devices, Coquitlam, BC, Canada), which provides an average of up to 6 successive in-office BP measurements, has not been studied in this patient group.MethodsWe studied 17 patients (average age: 54 ± 12 years; 12 men, 5 women; 94% on automated PD) attending a single center. All patients underwent office, home, BpTRU, and ambulatory BP measurement. The reference standard for analysis was daytime ambulatory BP. Correlation between the referent method and each comparator method was determined (Pearson correlation coefficient), and Bland–Altman scatter plots depicting the differences in the BP measurements were constructed.ResultsMean office BP (126.4 ± 16.9/78.8 ± 11.6 mmHg) and BpTRU BP (123.8 ± 13.7/80.7 ± 11.1 mmHg) closely approximated mean daytime ambulatory BP (129.3 ± 14.8/78.2 ± 7.9 mmHg). Mean home BP (143.8 ± 15.0/89.9 ± 28.1 mmHg) significantly overestimated mean daytime systolic BP by 14.2 mmHg (95% confidence interval: 4.3 mmHg to 24.1 mmHg; p = 0.008). Bland–Altman plots demonstrated poorest agreement between home BP and daytime ambulatory BP. No patient had “white-coat hypertension,” and only 1 patient had false-resistant hypertension. Most patients showed abnormal nocturnal dipping patterns (non-dipping: n = 11; reverse-dipping: n = 5; normal dipping: n = 1).ConclusionsWe report a novel finding that BP measurement using the BpTRU device is more accurate than home BP measurement in a PD population. Potential explanations for this observation include poor home BP measurement technique, use of poorly validated home BP measurement devices, or a reduced prevalence of white-coat effect among PD patients. Our study also confirms that, in the PD population, BP measurements vary considerably with patient location, time of day, and measurement technique.

scholarly journals Identification and management of resistant hypertension

2021 ◽  
Author(s):  
Abass Mahamoud Ahmed ◽  
Xiaochen Yuan
Keyword(s):  
Blood Pressure ◽  
Resistant Hypertension ◽  
Antihypertensive Drugs ◽  
Blood Pressure Measurement ◽  
Optimal Dose ◽  
Secondary Hypertension ◽  
White Coat ◽  
Clinical Inertia ◽  
White Coat Hypertension ◽  
Hypertension Detection

Resistant hypertension is defined as blood pressure being higher than the patient's target blood pressure despite the use of three or more different types of antihypertensive drugs at the optimal dose, and one of them should be a diuretic. The evaluation of patients with resistant hypertension should first confirm that they have true resistant hypertension. By eliminating or correcting false resistance factors, such as white coat hypertension, poor blood pressure measurement technique, poor drug compliance, improper dosage or combination of antihypertensive drugs, and white coat effects and clinical inertia. Resistant hypertension therapy includes improved compliance with the use of drugs, secondary hypertension detection and treatment, use of lifestyle measures and treatment of obesity, and other comorbidities. switching to a long-acting diuretic type of thiazide like chlorthalidone could improve the BP from the patients taking hydrochlorothiazide. This review paper illustrates briefly the identification of the underlying causes of resistant hypertension and therapeutic strategies, which may contribute to the proper diagnosis and an improvement of the long term management of resistant hypertension.  

Sign in / Sign up

Export Citation Format

Share Document