Running head: HIGH BLOOD PRESSURE SCREENING 1

High Blood Pressure Screening

Alyssa Matulich

University of Tennessee Chattanooga

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High Blood Pressure Screening

According to the American Heart Association (2014) around 85 million Americans or

every one out of three adults over the age of 20 have high blood pressure. Most importantly one

out of six people who have high blood pressure do not know they have this condition and high

blood pressure that remains uncontrolled or undetected can lead to other health complications

that can be life-threatening (American Heart Association, 2014). The American Heart

Association lists heart attack, stroke, heart failure, kidney disease or failure, vision loo, sexual

dysfunction. Angina and peripheral artery disease are just a few of the serious health

complication that can be related to uncontrolled high blood pressure. When diagnosing high

blood pressure attention most often is focused on systolic blood pressure, which indicates the

amount of pressure blood is exerting on artery walls as a heart beats as opposed to the diastolic

blood pressure which indicates the pressure blood is exerting on the artery wall while the heart is

resting (American Heart Association, 2014). Both systolic and diastolic pressures can be used

alone to diagnosis high blood pressure but systolic blood pressure, which rises steadily with age,

that is elevated increases the risk for cardiovascular disease for adults over fifty (American Heart

Association, 2014). Sheridan, Pignone, and Donahue (2003) note that 35% of all cardiovascular

events, 49% of all events of heart failure, and 24% of all premature deaths are caused by high

blood pressure. “This substantial burden of suffering from hypertension, in combination with

feasible and accurate means of detection, and a clear benefit from treatment, have led to a

widespread recommendation for screening for hypertension (Sheridan, Pignone, & Donahue,

2003, p. 151).
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The U.S. Preventative Services Task Force (USPSTF) “makes recommendations about

the effectiveness of specific preventative care services for patients without related signs or

symptoms” (U.S. Preventative Services Task Force [USPSTF], 2015). The recommendations

made by the USPSTF are based on evidence and cost is not considered in the assessment. The

recommendation made by the USPSTF for high blood pressures states screening should be

made in adults 18 years or older and the measurements should be obtained outside of clinical

setting for diagnostic confirmation before beginning treatment (USPSTF, 2015). The USPSTF

has concluded that the benefits of screening for high blood pressure is substantial with little

harmful side effects (2015). The screening interval differs depending on age and risk

assessment of the patient. Adults who are forty years or older with increased risk should be

screened annually while adults ages 18-36 with normal blood pressure, defined as <130/85, and

no risk factors should be screened every 3-5 years (USPSTF, 2015). Most of the research

conducted discusses the screening techniques can be done through office measurements,

ambulatory, and home blood pressure monitoring. There is little discussion in the research about

prevention and screening blood pressures once treatment for hypertension has begun. This paper

will review the literature and discuss the screening and treatment methods discussed in the

recommendation by the USPSTF.

Screening Techniques

Office Manual Blood Pressure Measurement

An office blood pressure measurement is achieved in a clinic setting using an

appropriately side upper arm blood pressure cuff used in combination with a mercury or aneroid

sphygmomanometer (Sheridan et al., 2003). Sheridan et al. (2003) notes that although office
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blood pressure measuring is a standard way of monitoring blood pressure there are limitations

that come along with it, but ensuring correct measurement will yield a blood pressure that

correlates with intra-arterial measurement which will be highly predictive of cardiovascular risk.

USPSTF recognizes that manual measurement error can include manometer dysfunction,

pressure leaks, stethoscope defects, and cuffs of incorrect width of length according to patient

arm size, observer sensory impairment, inattention, inconsistency recording Korotkoff sounds,

and subconscious bias. Manual blood pressure is gradually being replaced in the clinical setting

in favor of other blood pressure screening techniques. The two primary reasons manual blood

pressure being replaced are mercury, being considered an environmental hazard, and the

clinician error that manual blood pressure is subject to (Myers & Godwin, 2012). Government

bodies worldwide are expressing concern with the use of mercury and gradually banning its use.

In Europe, at least 2 European countries have banned the use of mercury and a European

committee has specifically recommended the elimination of the mercury sphygmomanometer

(Myers & Godwin, 2012). Myers and Godwin (2012) note that in Canada, a directive has been

issued to eliminate mercury from the workplace, though it currently exempts “scientific devices”

which likely would include the mercury sphygmomanometer and in the United States, many

major hospitals no longer use mercury devices. The use of manual blood is also being reduced

because it is subject to human error. The majority of studies conducted on the efficacy and

interpretation of manual blood pressure utilized specifically trained personnel. A research study

was conducted comparing manual blood pressure readings obtained in the community with non-

trained personal and compared results with those taken in the same patient in research studies.

The study found that readings taken in the community setting where on average 10/5 mm HG

higher than those taken in the research study setting (Myers & Godwin, 2012). Organizations
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such as the Canadian Hypertension Education Programme and American Heart Association have

tried to train healthcare professionals to more accurately take manual BP readings, but their

efforts have not been successful. Because of the limitations in manual office blood pressure

measurement Sheridan et al (2003) recommends that if manual blood pressure is being used in

the diagnosis of hypertension, two or more readings of elevated blood pressure at two or more

visits of a period of several weeks is required and the more measurements obtained will increase

the precision of diagnosis.

Another important factor to take into consideration when using manual office blood

pressure measurements is the presence of white coat hypertension. Martinez et al (1999) defines

white coat hypertension as blood pressure that is increased in a clinical setting but is found

within normal range at other time outside if the clinic. White coat hypertension has been

estimated to the prevalent between twenty and forty percent of patients who have mild to

moderate hypertension (Martinez et al., 1999). In the study done by Martinez et al it was found

that the frequency of white coat hypertension is inversely proportional to the severity of clinic

blood pressure values and more often associate with females and low education level (1999).

Automated Office Blood Pressure Monitoring

A study by Myers and Goodwin (2013) evaluated the use of automated blood pressure

monitoring as a replacement for manual blood pressure. Automated office blood pressure

monitoring (AOBPM) is the practice of patients taking their own blood pressure in an office

setting using an automated blood pressure machine (Myers & Godwin, 2012). Patients use the

fully automated machine while resting alone in an exam room. The study was conducted to

determine if AOBPM reduced the effects of white coat hypertension and to test the accuracy of

the readings. The readings were specifically compared to automated ambulatory blood pressure
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monitoring readings, which are considered the gold standard. The BpTURU automated blood

pressure machine set to take readings at 2 minute intervals reduced or eliminated the white coat

response with manual office BP readings and produced similar readings as the awake ambulatory

BP method. Readings taken over 5-10 minutes in two minute intervals reduced office BP by

10.8/3.1 mm HG. Approximately 75% of the decrease was observed within two minutes of the

patient being left alone (Myers & Godwin, 2012). AOBP readings were similar when taken

inside or outside the treatment setting, a significant improvement compared to manual blood

pressure (Myers & Godwin, 2012). Multiple trials found AOBPM readings to be similar to

automated ambulatory blood pressure readings (with in 1 to 2 mm Hg) whereas manual BP

readings were 10 to 20 mm HG higher (Myers & Godwin, 2012). AOBP is a solution to dealing

with the difference between readings taken inside and outside the trial setting and white coat

hypertension.

Home Blood Pressure Monitoring

Home blood pressure monitoring compared to office blood pressure monitoring can be

more beneficial because home blood pressure assessment provides a better average instead of

periodic monitoring of office measurement (Sheridan et al., 2003). The Canadian Hypertension

Education Program recognizes home blood pressure as superior over office blood pressure

because of the ability to take an average of multiple readings (Myers & Godwin, 2012). In theory

using an automated home blood pressure device at home would decrease the occurrence of white

coat hypertension and allow for more accurate diagnosis of hypertension, but Myers and

Goodwin (2013) found that there was a failure to observe a lower BP when the blood pressure

was taken with a home blood pressure device at home which could be a result of states

stimulation of the patient caused by taking their own blood pressure. Piper et al (2014) states that
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home monitoring is beneficial because “self-monitoring may improve adherence to treatment and

has been associated with small improvements in BP control, even in the absence of additional

self-management support interventions. It is noted that home blood pressure monitoring can be

“a similar predictor of outcomes” as compared with ambulatory blood pressure, but few studies

have been done to confirm (Piper et al., 2014).

Ambulatory Blood Pressure Monitoring

Ambulatory blood pressure monitoring is a twenty-four-hour average of blood pressure

and has been found to be a good predictor of clinical cardiovascular outcomes (Sheridan et al.,

2003). Viera, Lingley and Hinderliter (2011) state that because ambulatory blood pressure is

closely associated with prognosis it is considered the gold standard method for determining and

individuals true blood pressure. Piper et al (2014) agrees that ambulatory blood pressure should

be the reference standard for blood pressure monitoring. Ambulatory blood pressure is valuable

because it can confirm suspected white coat hypertension, detect masked hypertension, give an

estimate on how treatment is going among currently treated hypertensive patients and give blood

pressure reading during night-time sleeping hours (Vera, Lingley, & Hinderliter, 2011). As with

the above methods of blood pressure monitoring, ambulatory blood pressure monitoring also has

its limitations. In order to acquire an ambulatory blood pressure assessment, the patient has to

wear a blood pressure cuff on their arm for an entire twenty-four-hour period as well as a

monitor unit on their waist. In the study completed by Viera et al (2011) patients complained that

the monitor kept them from falling asleep and woke them up from sleep with blood pressure

measurement. Skin irritation, pain and bruising were also common complaints found by patient

who completed the study which lead to removal of the blood pressure monitor (Vera et al.,

2011). Another factor to take into consideration when using ambulatory blood pressure is the
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high monetary cost associated with the assessment. Sheridan et al (2003) noted that because of

the high monetary costs research done of ambulatory blood pressure is limited. Even with the

high costs of doing the ambulatory blood pressure Sheridan et al (2003) does note the benefit of

determining patient with white coat hypertension because, “many patients who have elevated

clinic blood pressures had normal ambulatory blood pressure.” Overall the studies conducted on

ambulatory blood pressure found that the measurements acquired were more reliable but the

method in which the measurements were achieved were the least preferred method of measuring

blood pressure by the patient.

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References

American Heart Association. (2014). Understanding Blood Pressure Readings. Retrieved from

http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/KnowYourNumbers/

Understanding-Blood-Pressure-Readings_UCM_301764_Article.jsp#.WXD4PxjMz-Y

Martinez, M. A., Garcia-Puig, J., Martin, J. C., Guallar-Castillion, P., Aguirre de Carcer, A.,

Torre, A., ... Madero, R. S. (1999). Frequency and determinants of white coat

hypertension in mild to moderate hypertension a primary care-based study. American

Journal of Hypertension, 12, 251-259. Retrieved from

Myers, M. G., & Godwin, M. (2012). Review Automated Office Blood Pressure. Canadian

Journal of Cardiology, 28, 341-346.

Piper, M. A., Evans, C. V., Burda, B. U., Margolis, K. L., O'Connor, E., SMith, N., ... Whitlock,

E. P. (2014). Screening for high blood pressure in adults:a systematic evidence review for

the U.s. Preventative Services Task Force. Agency for Healthcare Research and Quality,

13(121).

Sheridan, S., Pignone, M., & Donahue, K. (2003). Screening for high blood pressure a review of

the evidence for the U.S. preventative services task force. American Journal of

Preventative Medicine, 25, 151-150. Retrieved from

Spruill, T. M., Feltheimer, S. D., Harlapur, M., Schwartz, J. E., Ogedegbe, G., Park, Y., & Gerin,

W. (2013). Are the conswquences of labeling patients with prehypertension? an

experimental study of effects on blood pressure and quality of life. Journal of

Psychosomatic Research, 74, 433-438.

U.S. Preventative Services Task Force. (2015). Screening for high blood pressure in adults: U.S.

Preventative Services Task Force recommendation statement. Retrieved from

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Vera, A. J., Lingley, K., & Hinderliter, A. L. (2011). Tolerablitiy of the Oscar 2 ambulatory

blood pressure monitor among research participants: a cross-sectional repeated measures

study. BMC Medical Research Methodology, 11. Retrieved from

http://www.biomedcenteral.com/147-2288/11/59