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High Blood Pressure Screening: Literature Review

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 as just a few of the serious health

complications 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 when systolic blood pressure, which rises steadily

with age, is elevated there is an increased risk for cardiovascular disease in 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.

High Blood Pressure Prevention

Early Detection

High blood pressure, also referred to as hypertension, is defines as a diastolic

blood pressure greater than or equal to 90mmHg or a systolic blood pressure greater than or

equal to 140mmHg (Sheridan et al., 2003). Another category important to mention is

prehypertension which is defined as a blood pressure in the range of 120-139/80-89 (Spruill et

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al., 2013). According to Spruill et al., one-third of adults in U.S. have prehypertension. So, in

total two-thirds of the United States population suffers from some category of hypertension and

have an increased risk of cardiovascular disease. Risk factors for high blood pressure include

age, African American race, genetic factors, excess weight and obesity, excess alcohol intake,

and dietary habits such as high sodium intake (Piper et al., 2014). “In 2009, the estimated direct

medical costs of treating hypertension in the United States was $47.5 billion,” ((Piper et al.,

2014). Current guidelines for prehypertension just suggest counseling on the importance of

lifestyle changes so that blood pressure is decreased which in turn would delay the progression to

hypertension (Spruill et al., 2013). Because prehypertension is associated with poor lifestyle

behaviors, targeting induvial with prehypertension could be substantially beneficial.

Unfortunately, currently there are no information on physician use of the prehypertension and the

calculated benefits. Authors of the studies used to conduct this research question the benefit of

early diagnosis and treatment of hypertension. The overall question seems to be would early

treatment result in better outcomes than later treatment because diagnosis of prehypertension had

no negative effects of the patients (Spruill et al., 2013).

Primary Prevention

Primary prevention to decrease blood pressure is critical in the prevention of high blood

pressure. Primary prevention techniques include lifestyle changes like weight loss dietary

modifications and quitting smoking (Chobanian et al., 2003). A weight loss of as little as ten

pounds aids in the reduction of blood pressure and prevents hypertension in a large proportion of

overweight people (Chobanian et al., 2003). As for diet modifications, the Dietary Approaches to

Stop Hypertension diet plan (DASH) is a good set of guidelines. This dietary plan is rich in

fruits, vegetables, and low-fat dairy products, potassium and calcium while reducing cholesterol,
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saturate fat, total fat, and dietary sodium (Chobanian et al., 2003). Chobanian et al (2003) points

out that adopting the DASH diet can lead to a reduction of 8-14mmHg in the systolic blood

pressure and reducing dietary sodium reduces systolic blood pressure 2-8mmHg.

A study done that look at the CHAP intervention program which was a ten-week program

that consisted of three-hour weekday blood pressure and cardiovascular risk factor assessment

and education sessions in 20 communities found some benefit to the program (Kaczorowski et

al., 2010). The study found that there were 3 fewer annual cardiovascular-related hospitalizations

per 1000 people in the intervention group (Kaczorowski et al., 2010). These results support the

benefit of screening for high blood pressure in adults sixty-five years of age and older. More

research is needed to support high blood pressure screening in adults over the age of eighteen.

Community based programs can be beneficial in helping reduce the incidence of hypertension

and should be considered a key part of primary prevention strategies.

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

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,
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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

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
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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

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
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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

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).

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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

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
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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.

Conclusion

In 2010, high blood pressure was listed as a primary or contributing cause for death for

more than 362,000 Americans (Piper et al., 2014). The detrimental effects of hypertension can be

prevented through healthy life style choices. It is therefore imperative that increased efforts are

made to educate the community on the impact that life style choice can make on their health,

specifically with reducing hypertension. The U.S. Preventive Task Force (USPTF) “found good

evidence that screening for and treatment of high blood pressure in adults substantially reduces

the incidence of cardiovascular events” (USPSTF, 2015). This demonstrates the importance of

accurate screening in order to properly diagnosis hypertension. Automated office blood pressure

monitoring, home blood pressure monitoring and automated ambulatory blood pressure

monitoring have all been shown to be more effective in producing accurate results than manual

office blood pressure monitoring. The USPTF concluded, “with high certainty that the net

benefit of screening for high blood pressure in adults is substantial” (USPSTF, 2015). Given the

magnitude of people in the U.S. that have hypertension and the clear benefits of screening per the

USPSTF guidelines it is important to continue researching and addressing gaps for best

screening practices.

Although the USPSTF guidelines are thorough, more research is necessary to close the

gaps in current studies. Automated ambulatory blood pressure monitoring is considered to be the

gold standard, there needs to be further research on its cost effectiveness compared to the other

screening techniques. Another gap in the research for automated ambulatory blood pressure
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monitoring is the accuracy of only monitoring a patient’s blood pressure for a twenty-four-hour

period and the diagnosis of hypertension. A method of blood pressure monitoring not mentioned

in the research is the use of automated kiosk that are available to the public in places like a

pharmacy. These kiosks are not FDA regulated but used often by the public. Research about the

accuracy of these blood pressure monitoring systems and primary prevention would be

beneficial. Further research is also needed on the impact early detection and treatment would

have on patient outcomes. It is important to find out if doctors are using the classification of

prehypertension with their patients and how to effectively educate the pre-hypertensive patients

in order to prevent the future diagnosis of hypertension. Another area that needs more research is

the screening interval for a hypertensive patient who is currently under treatment. Research is

lacking that states yearly rechecks are adequate for these patients. With such a large number of

Americans being affected by hypertension it is important to close the gaps in the research to

reduce the number of deaths hypertension attributes to.

Piper et al (2014) points out that 55 million physician offices, emergency department, and

outpatient visits with essential hypertension as the primary diagnosis code were reported in 2010.

With this staggering number of patients who are seeking treatment for hypertension we will with

no doubt encounter patients in our practice who have high blood pressure. Staying educated on

the best ways to screen for high blood pressure and their accuracy in diagnosis will help us

provide our patients with a high quality of care. Reviewing journals and evidence-based studies

is the best way to stay educated on proper diagnostic techniques. Because of the prevalence of

high blood pressure in our society research to develop, analyze and close the gaps in research

should continue for the best way to screen and treat high blood pressure to be determined.
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References

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

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

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Chobanian, A., Barkis, G., Black, H., Cushman, W., Green, L., & Izzo Jr, J. (2003). Joint

National Committee on prevention, detection, evaluation, and treatment of high blood

pressure. Hypertension, 42.

Kaczorowski, J., Chambers, L. W., Dolovich, L., Paterson, M., Karwalajtys, T., Gierman, T., ...

McDonough, B. (2010). Improving cardiovascular health at population level: 39

community cluster randomized trials of Cardiovascular Health Awareness Program

(CHAP). British Medical Journal, 342.

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

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

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

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

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