Blood Pressure Measurement in Public Places

American Family Physician - Volume 71, Issue 5 (March 2005) - Copyright 2005
American Academy of Family Physicians - About This Journal
Editorials

Blood Pressure Measurement in Public Places

In recent years, many persons with undiagnosed or diagnosed hypertension have

begun checking their blood pressure in public places using devices that are provided as
a free service by pharmacies or other retail stores. These devices offer persons who
might not have the resources to own blood pressure monitors or to see their doctor
frequently the ability to check their blood pressure. Home blood pressure monitoring
has been established as an acceptable alternative and supplement to office-based
measurement. However, significant concerns about the blood pressure monitors
[1] [2]

available in public places have limited their value as a screening and monitoring tool
(see accompanying Table).

Advantages and Limitations of Public Blood Pressure Monitoring

Potential advantages Potential disadvantages
Increased screening for hypertension in No validated public blood pressure
persons without the resources to own a blood measurement devices
pressure monitor or to see their physician
frequently
Increased patient involvement in Cuff size of current devices is too small for
hypertension care and enhanced adherence to more than one half of hypertensive patients
therapy
Demonstrated patient and physician interest No established values for normal and
in the use of public blood pressure abnormal blood pressures taken in public
measurement devices for hypertension places
management
Lack of reliable mechanisms of referral to
medical care for persons whose blood
pressure is elevated

Although it is logical to think that public blood pressure measurement devices would
improve the detection and treatment of hypertension, the accuracy of these
measurements has not been established. Hamilton and colleagues have shown that
[3]

public blood pressure monitoring devices increase self-measurement rates. They

placed a validated home blood pressure monitor (Omron HEM-705 CP) in 13 public
places in lower socioeconomic areas of Exeter in England. Over six months, 758
persons measured their blood pressure for the first time; 221 (29.2 percent) had blood
pressure measurements above 135/85 mm Hg and were referred to their family
physician for further evaluation. However, a community-based study by Lewis and
[3]

colleagues in Canada found that neither the Omron HEM-705 CP nor the Vita-Stat
[4]

90550 provided accurate blood pressure measurement in a community pharmacy

setting.

Current information suggests that public blood pressure measurement devices are poor
screening tools for hypertension. One device overestimated the presence of systolic
hypertension, misclassifying 23 percent of normotensive persons as hypertensive.
More importantly, it misclassified as normotensive 16.4 percent of persons with
previously confirmed hypertension. This false-negative rate is far too high for a
[5]

screening tool.

The questionable accuracy of these devices suggests that they should not be relied on
for ongoing blood pressure monitoring. Over the past 25 years, several studies[5] [6] [7] [8] [9]

have evaluated the Vita-Stat devices, the most common blood pressure monitoring
[10] [11]

devices available in public places. Most of these studies have focused on the Vita-Stat
8000, which uses the auscultatory technique for blood pressure measurement. In all
studies, there was much better agreement for diastolic blood pressure (DBF) than for
systolic blood pressure (SBP). However, there was an unacceptably high variation in
SBP and DBF measurements; systolic readings in individual patients could be as much
as 60 mm Hg below to 58 mm Hg above the reference auscultatory mercury
measurement.

Salaita found that patient age significantly affects the accuracy of the device.
[8]

Compared with measurements using the random-zero auscultatory method, one

automated device overestimated SBP by a mean of 7.4 mm Hg in persons 25 years of
age and underestimated SBP by a mean of 6,3 mm Hg in persons 75 years of age (P < .
001). Similar differences in DBF measurements were discovered. This study also
found significant differences in measurements between the 10 machines that were
tested.

Another concern is whether arm circumference affects the accuracy of measurements

obtained with these devices. The Vita-Stat 90550 is clearly marked as being applicable
to persons with arm circumferences of 9 to 13 inches (22.9 to 33 cm). Using arm-
circumference data from the Third National Health and Nutrition Examination Survey,
this cuff size would be applicable to only 63 percent of the general population and
50.3 percent of hypertensive persons in the United States. The use of cuffs that are
[12]

too small can lead to a significant overestimation of SBP and DBF and a misdiagnosis
of hypertension. Thus, the size of the cuff used on some devices significantly limits
[13]

their use, especially in the hypertensive population.

Even if public devices were accurate, no data are available to help interpret the
measurements. To respond with appropriate treatment, more data are needed about the
effect these devices have on blood pressure measurements. These devices often are
 located in noisy, busy areas of a store, so it is unclear whether readings correlate best
with measurements taken in a physicians office (140/90 mm Hg or greater for a
diagnosis of hypertension) or in out-of-office settings (135/85 mm Hg or greater).
Conformational studies, such as comparison of public readings with daytime values
for 24-hour ambulatory blood pressure monitoring, would be required to settle this
issue. In addition, these freestanding devices do not connect patients with physicians if
readings are significantly low (SBP less than 100 mm Hg) or high (SBP greater than
200 mm Hg or DBP greater than 120 mm Hg). Advances in wireless Internet
technology could remedy this problem by allowing patients to enter their names and
blood pressure measurements. At the very least, patients could obtain a list of local
health care providers from a Web site run by local medical societies.

Blood pressure measurement outside of the physicians office may become a powerful
tool to improve the diagnosis of hypertension, aid in drug titration, improve control of
hypertension, and reduce long-term costs of hypertension management. However,
current devices for public blood pressure measurement fail to meet accuracy criteria.
Until manufacturers of these devices remedy the defects that cause inaccurate
measurements, patients should be discouraged from using these devices, and
physicians should not alter antihypertensive therapy on the basis of measurements
derived from these sources.

Address correspondence to John W. Graves, M.D., F.A.C.P., Division of Nephrology

and Hypertension, Mayo Clinic School of Medicine, 200 First St. SW, Rochester, MN
55908 (e-mail: graves.john@mayo.edu). Reprints are not available from the author.

JOHN W. GRAVES M.D. 1 2

1
Mayo Clinic School of Medicine Rochester, Minnesota
2
JOHN W. GRAVES, M.D., F.A.C.P., is associate professor of medicine in the Division of
Nephrology and Hypertension at the Mayo Clinic School of Medicine, Rochester,
Minnesota.

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Text

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