Running Head: High Blood Pressure Screening 1
Running Head: High Blood Pressure Screening 1
Running Head: High Blood Pressure Screening 1
Alyssa Matulich
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, &
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
Early Detection
blood pressure greater than or equal to 90mmHg or a systolic blood pressure greater than or
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
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
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
Screening Techniques
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
(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
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).
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
HIGH BLOOD PRESSURE SCREENING 8
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
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 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
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
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
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/
Understanding-Blood-Pressure-Readings_UCM_301764_Article.jsp#.WXD4PxjMz-Y
Chobanian, A., Barkis, G., Black, H., Cushman, W., Green, L., & Izzo Jr, J. (2003). Joint
Kaczorowski, J., Chambers, L. W., Dolovich, L., Paterson, M., Karwalajtys, T., Gierman, T., ...
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
Myers, M. G., & Godwin, M. (2012). Review Automated Office Blood Pressure. Canadian
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).
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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
Spruill, T. M., Feltheimer, S. D., Harlapur, M., Schwartz, J. E., Ogedegbe, G., Park, Y., & Gerin,
U.S. Preventative Services Task Force. (2015). Screening for high blood pressure in adults: U.S.
Vera, A. J., Lingley, K., & Hinderliter, A. L. (2011). Tolerability of the Oscar 2 ambulatory
http://www.biomedcenteral.com/147-2288/11/59