Hme Bld Pressure Mnitring Prtcl Intrductin Hme Bld Pressure Mnitring (HBPM) is being increasingly used in many health systems wrldwide and is well accepted by patients. A recent survey undertaken in the UK fund that arund 30% f patients with hypertensin mnitr their wn bld pressure at hme. In ther cuntries, this figure stands at ver 70%. T realise the full value f HBPM, hwever, it is imprtant that HBPM is carried ut in a way that is cnsistent with the current evidence base and therefre in line with this prtcl. All healthcare prfessinals (e.g. dctrs, nurses, healthcare assistants, pharmacists) using HBPM with their patients shuld be adequately trained and have their perfrmance reviewed peridically. *Please nte that the guidance belw frequently makes reference t patients with hypertensin. Hwever, there will be a grup f patients wh d nt meet the diagnstic criteria fr hypertensin, but wh have bld pressure t high fr their clinical cnditin (e.g. CKD, type 2 diabetes). In such cases, HBPM shuld be used as per the guidance fr patients with cnfirmed r suspected hypertensin. 1. Clinical indicatins fr HBPM 1.1. HBPM prvides a useful additin t clinic bld pressure measurement in a number f circumstances, including in the: 1.1.1. Diagnsis f hypertensin, where ambulatry bld pressure mnitring (ABPM) is nt tlerated, including in the detectin f: Pssible white cat hypertensin (bld pressure in the hypertensive range when taken in a clinical setting, but nt when taken at hme) Pssible white cat effect in patients with hypertensin (a difference f mre than 20/10mmHg between clinic bld pressure and average hme bld pressure, but where hme readings are still in the hypertensive range. Such patients are at risk f receiving mre bld pressure medicatin than they need) Pssible masked hypertensin (bld pressure in the hypertensive range when taken at hme, but nt when taken in a clinical setting) Unusual variability f bld pressure. 1.1.2. Treatment f hypertensin, t: This resurce is a jint prductin f the NIHR Cllabratin fr Leadership in Applied Health Research and Care (CLAHRC) Greater Manchester and the British Hypertensin Sciety
Infrm unclear/equivcal treatment decisins Determine the efficacy f antihypertensive therapy and supprting apprpriate adjustment, particularly in hypertensive patients with white cat effect Supprt the apprpriate adjustment f drug therapy fr patients wh have been previusly misdiagnsed r ver-treated Prmte medicatin adherence (cmpliance) and lifestyle changes and t make patients mre aware f their cnditin Evaluate bld pressure cntrl in patients discharged hme frm hspital with newly cmmenced r altered antihypertensive therapy Evaluate drug resistant hypertensin Evaluate symptmatic hyptensin. 1.1.3. Lng term mnitring f patients n stable treatment fr hypertensin (i.e. hypertensive patients wh have well cntrlled bld pressure). 1.2. HBPM perfrmed with mst autmated devices is cntraindicated in patients with pulse irregularities, such as atrial fibrillatin (AF) [see manufacturers instructins fr further infrmatin]. Prir t intrducing HBPM, therefre, in patients nt knwn t have an irregular pulse, it may be apprpriate t check fr any pulse irregularities (rate and rhythm). Sme HBPM devices will d this autmatically. 1.3. HBPM shuld nt be cnsidered universally cntraindicated in sme patient grups such as thse with mtr disabilities r cgnitive impairments. These patients may be able t undertake HBPM with additinal supprt, either frm a trained healthcare prfessinal r family member. 2. HBPM devices and cuffs 2.1. Devices used fr HBPM shuld be clinically validated fr hme use. An up t date list f such devices is available at www.bhsc.rg and www.bldpressureuk.rg. Where patients wish t purchase their wn device, they shuld be specifically advised t purchase a mnitr frm this list. If the patient has already purchased a mnitr that is nt validated fr hme use, this shuld nt be used fr clinical purpses and the patient shuld be advised that this is the case. 2.2. An apprpriately sized cuff, cntaining the crrect sized inflatable bladder, must be used (see bx belw) and upper arm mnitrs are preferred t wrist r watch devices. 2.3. All devices, including thse that belng t patients and thse available t lan t them, shuld be maintained and calibrated accrding t manufacturers instructins. Where patients are using their wn device fr HBPM, it is imprtant t check when the mnitr was purchased and/r last calibrated. If utside the recmmended timeframe fr calibratin/recalibratin, the This resurce is a jint prductin f the NIHR Cllabratin fr Leadership in Applied Health Research and Care (CLAHRC) Greater Manchester and the British Hypertensin Sciety
mnitr shuld nt be used fr clinical purpses and it shuld be recmmended that the mnitr is recalibrated accrding t the manufacturer s instructins r replaced. It is als gd practice t ccasinally check patients mnitrs against ther validated devices. 2.4. If devices are laned t patients, frm an infectin cntrl pint f view, it is imprtant t ensure that cuffs and inflatable bladders are cleaned accrding t the manufacturers instructins and in cmpliance with lcal infectin cntrl prcedures. Bx 1. Cuff and Inflatable Bladder Size Cuff Sizes Indicatin Width (cm)* Length (cm)* BHS Guidelines inflatable bladder width and length (cm)* Small Adult/Child Arm circumference (cm)* 10-12 18-24 12 x 18 <23 Standard Adult 12-13 23-35 12 x 26 <33 Large Adult 12-16 35-40 12 x 40 <50 Adult Thigh 20 42 <53 Cuff** * The range f clumns 2 and 3 are derived frm recmmendatins frm the British Hypertensin Sciety (BHS), Eurpean Hypertensin Sciety (ESH) and the American Heart Assciatin. Clumns 4 and 5 are derived nly frm the BHS guidelines. ** Large inflatable bladders fr arm circumferences ver 42cm may be required. 2.5. Manufacturers instructins shuld be referred t fr further infrmatin e.g. setting up the mnitr, trubleshting, battery replacement, calibratin, using memry/strage functins. 3. Using HBPM upper arm devices 3.1. Prir t starting HBPM, patients shuld measure their bld pressure in bth arms t determine which arm shuld be used fr future measurements. The arm that gives the higher systlic reading (the tp number) shuld be used fr all future testing. 3.2. Patients shuld place the cuff n their arm with the lwer edge f the cuff apprximately 2cm abve the bend in their elbw. The centre f the inflatable bladder shuld be psitined ver the brachial This resurce is a jint prductin f the NIHR Cllabratin fr Leadership in Applied Health Research and Care (CLAHRC) Greater Manchester and the British Hypertensin Sciety
artery n the arm s interir surface. The frearm shuld be supprted n a firm surface and shuld be level f the lwer end f the breast bne. 3.3. N tight r restrictive clthing shuld be wrn arund the arm. 3.4. Patients shuld be seated, remain silent and be at rest fr a minimum f five minutes befre taking a measurement and shuld nt have smked, eaten, drunk a caffeinated drink r undertaken physical activity within the past thirty minutes. Patients shuld als avid measuring their bld pressure with a full bladder. 3.5. Measurements shuld be taken in silence when the patient is relaxed, with bth feet flat n the flr and their back and arm supprted. Many patients autmatically crss their legs, which raises their bld pressure, s it is particularly imprtant t emphasise the need fr the patient t uncrss their legs when taking their bld pressure. 3.6.The device shuld then be used as per the manufacturer s instructins t prduce a bld pressure reading. The manufacturer s instructins may als prvide further specific guidance in relatin t the apprpriate use f the device. 4. Patient educatin fr HBPM 4.1. All patients undertaking HBPM shuld receive adequate educatin and training/teaching. At a minimum, this shuld cnsist f infrmatin relating t: The imprtance f using a validated and calibrated mnitr, with the right sized cuff Where the bld pressure cuff shuld be psitined n the arm Hw t sit when taking bld pressure readings (e.g. feet flat n the flr, back and arm supprted) Factrs that may affect the accuracy f bld pressure readings (e.g. exercise, caffeine, smking, eating fd) The imprtance f taking mre than ne bld pressure measurement each time, leaving at least a minute in between each measurement Hw lng fr, hw ften and at what time f day bld pressure measurements shuld be taken Hw t dcument bld pressure readings and share them with a healthcare prfessinal. This shuld include the imprtance f nt runding readings up r dwn and recrding the time at which medicatins are taken The ptential fr there t be natural variatin in bld pressure readings The circumstances under which individuals shuld cntact a healthcare prfessinal (and hw they shuld d this) The imprtance f nt checking bld pressure t ften This resurce is a jint prductin f the NIHR Cllabratin fr Leadership in Applied Health Research and Care (CLAHRC) Greater Manchester and the British Hypertensin Sciety
The imprtance f cntinuing t take medicatin as prescribed, regardless f hme bld pressure readings If the mnitr has been laned, the imprtance f caring fr and returning the equipment. 4.2. Where pssible, the abve educatin and training/teaching shuld cnsist f a practical demnstratin with the patient f hw t use the bld pressure mnitr. 4.3. In additin t verbal and practical educatin and training, written infrmatin shuld be prvided in relatin t the abve pints [see Patient Infrmatin Leaflet: Hme Bld Pressure Mnitring Explained ]. 4.4. Patients shuld be prvided with infrmatin abut hw they can seek further supprt if required. 5. Mnitring schedule: timing, frequency and duratin f HBPM 5.1. The apprpriate timing, frequency and duratin f HBPM is dependent n the reasn fr which HBPM is being used: 5.1.1. Diagnsis f hypertensin: Fr each bld pressure recrding, at least tw cnsecutive measurements shuld be taken, at least ne minute apart. Additinal measurements shuld be taken where the first tw measurements are quite different Bld pressure shuld be recrded twice daily, ideally in the mrning (06:00-12:00) and evening (18:00-00:00) Bld pressure recrding shuld cntinue fr at least fur cnsecutive days, ideally seven The average f the abve readings shuld be calculated, ignring the first day, and made available fr decisin making, as well as having the raw readings available fr review. 5.1.2. Treatment f hypertensin: Fr each bld pressure recrding, at least tw cnsecutive measurements shuld be taken, at least ne minute apart. Additinal measurements shuld be taken where the first tw measurements taken are quite different Bld pressure shuld be recrded twice daily, ideally in the mrning (06:00-12:00) (befre drug treatment, if apprpriate) and evening (18:00-00:00) Bld pressure recrding shuld be undertaken ver the curse f fur, ideally seven, cnsecutive days prir t the next clinic appintment The average f the abve readings shuld be calculated, ignring the first day, and made available fr decisin making, as well as having the raw readings available fr review. This resurce is a jint prductin f the NIHR Cllabratin fr Leadership in Applied Health Research and Care (CLAHRC) Greater Manchester and the British Hypertensin Sciety
The medicatin taken at the time f the recrdings including name f drugs, dse and time when taken shuld be recrded and be available fr review. 5.1.3. Lng term mnitring f hypertensive patients n stable treatment fr hypertensin: Fr each bld pressure recrding, at least tw cnsecutive measurements shuld be taken, at least ne minute apart. Additinal measurements shuld be taken where the first tw measurements taken are quite different Bld pressure can be taken less frequently than abve, fr example, a maximum f nce r twice per week, althugh this culd be inapprpriately intensive fr sme. Overuse f HBPM shuld be avided Where bld pressure has been stable fr a lng time, intermittent checks, 2 readings twice daily fr 4-7 cnsecutive days (with average recrded), every 4 t 6 mnths are advised Fr patients n stable treatment, immediately prir t the patient s annual hypertensin review, cnsider asking the patient t recrd their bld pressure fr a curse f fur, ideally seven, days in accrdance with the schedule utlined in 5.1.2. It is imprtant that the recrds f the bld pressure and all medicatin are made available fr any clinical review It is recmmended that the patient brings their bld pressure machine with them t reviews s that an apprpriately trained healthcare prfessinal can check that a validated device and the right sized cuff are being used, and als that the device is being used in the crrect way. Equivalence with clinic bld pressure readings can als be checked. 6. Recrding HBPM readings 6.1. Patients shuld systematically dcument all hme bld pressure readings immediately after each recrding/ measurement. Fr each measurement they shuld clearly nte the date, time f day, systlic and diastlic bld pressure and anything that may have affected the reading, such as changes in treatment and episdes f illness, and any symptms being experienced at the time, such as headaches and dizziness [see Patient Diary: Hme Bld Pressure Diary - paper and electrnic versins available]. 6.2. Fr any clinical review, the patient shuld be asked t bring alng all their dcumented bld pressure readings and a list f their medicatin, highlighting any changes that have been made. 6.3. Where the bld pressure device being used has an internal memry that stres the patient s bld pressure readings, patients may bring the mnitr t their clinical review. Hwever, nt all mnitrs recrd the dates and/r times at which the measurements were taken, s a separate recrd f bld pressure readings shuld als be kept by the patient and brught alng t the review/appintment. This is particularly imprtant, as mre than ne persn may This resurce is a jint prductin f the NIHR Cllabratin fr Leadership in Applied Health Research and Care (CLAHRC) Greater Manchester and the British Hypertensin Sciety
use the same mnitr and it is vital nt t cnfuse which readings belng t each patient. It is als gd practice t clear the memry f any mnitr between patients, particularly where devices are laned t patients. 7. Interpretatin f HBPM readings 7.1. Where HBPM is used shrt-term fr diagnstic purpses r t mnitr the treatment f hypertensin, readings taken n the first day shuld be discarded and an average f the remaining values- systlic and diastlic individually- taken. 7.2. Where patients have been mnitring their bld pressure at hme previusly (e.g. previusly fr diagnstic purpses and nw t mnitr treatment respnse), it may nt be apprpriate t discard the readings taken n the first day, althugh this issue is still a matter f debate. 7.3. If patients have taken mre than tw measurements at each recrding, due t their first tw readings being vastly different, cnsider including nly the last tw measurements when calculating the average. 7.4. T achieve equivalence with clinic-measured bld pressure, hme bld pressure readings shuld be adjusted by -5/5mmHg. Fr example, a bld pressure reading f 135/85 taken at hme is equivalent t a reading f 140/90 in a clinic setting. IT IS VITALLY IMPORTANT THAT HOME BLOOD PRESSURE READINGS ARE ADJUSTED IN THIS WAY AS FAILURE TO DO SO CAN RESULT IN AN UNDERTREATMENT AND UNDERDIAGNOSIS OF HYPERTENSION. 7.5. Healthcare prfessinals shuld explain the interpretatin f the hme bld pressure measurements prvided, and their implicatins fr management, with the patient and, where apprpriate, his r her carer. This resurce is a jint prductin f the NIHR Cllabratin fr Leadership in Applied Health Research and Care (CLAHRC) Greater Manchester and the British Hypertensin Sciety
Accrding t lcal agreement: Recrding and cding HBPM infrmatin in the patient s recrd (e.g. using recgnised Read cdes in GP practices) Prcesses fr administering HBPM devices t patients Other HBPM resurces available in this series: Why cnsider HBPM fr yur patients? HBPM in yur practice. Getting started.. NICE bld pressure treatment targets Intrducing patients t HBPM Patient HBPM infrmatin leaflet and vide [Hme Bld Pressure Mnitring Explained] Patient HBPM diary [Hme Bld Pressure Diary] Additinal patient resurces [ Why mnitring my bld pressure at hme? and Mnitring my bld pressure at hme. Getting started ] Related guidance/resurces: Natinal Institute fr Health and Clinical Excellence (NICE), (2011). The clinical management f primary hypertensin in adults: Clinical Guideline 127. NICE: Lndn. Parati et al., (2010). Eurpean Sciety fr Hypertensin Practice Guidelines fr hme bld pressure mnitring. Jurnal f Human Hypertensin, 24(12), pp. 779-785. www.bldpressureuk.rg This resurce is a jint prductin f the NIHR Cllabratin fr Leadership in Applied Health Research and Care (CLAHRC) Greater Manchester and the British Hypertensin Sciety