Hello, everyone. My name is Eugene Yang. I'm a cardiologist at the University of Washington and professor of medicine. I'm also the chair of the ACC Prevention of Cardiovascular Disease Section and co-chair of the ACC Hypertension Working Group. Today, we're going to talk about misunderstandings and continuous mismeasurement of blood pressure. The reason why we felt this topic was important is that, as we know, hypertension is a leading cause of cardiovascular morbidity and mortality. And a lot of times, what we focus on are the guidelines and medications and treatment. But probably one of the key elements that we really don't focus enough attention on is how to measure blood pressure correctly and accurately. And the two locations where this is really most important are when we measure the blood pressure in the office for our patients, and then, secondly, how we educate patients how to measure blood pressure at home. So the purpose of this webinar is really to focus on how do we measure blood pressure correctly and what are some of the pitfalls and opportunities to make improvements so that we're getting accurate measurements that we can then use to both diagnose hypertension as well as to treat it for patients who have blood pressure disorders. So here are my disclosures, and none of these are relevant to the discussion today. So what we're going to do here, we have three really outstanding speakers, and we're going to have them give about a 10-minute presentation. The first talk will be focused on the epidemiology and the current contemporary guidelines for hypertension management that will be given by Dr. Ebinger from Cedars-Sinai. The second talk will really focus specifically on how to measure blood pressure correctly in the office. And then finally, we'll have a presentation about how to educate patients on proper equipment and technique for blood pressure measurement by Dr. Davis. So with that start, I'm going to have our first presentation begin. Thank you. Hello, everyone. My name is Joe Ebinger. I'm an associate professor of cardiology at Cedars-Sinai in Los Angeles. I'm happy to discuss with you today the epidemiology and contemporary guidelines of hypertension management. These are my disclosures. It's important to understand both the epidemiology and the recommendations for hypertension treatment in the context of really the last 100-plus years of hypertension management in the United States and abroad. Using FDR as an example, during his second administration, he was noted to have an elevated blood pressure of 162 over 98. However, based on the contemporary and leading medical thoughts at the time, this was untreated as it was felt to be a compensatory mechanism, and tampering with it could actually end up leading to worse outcomes. His blood pressure continued to rise, reaching systolic up to 188 over 105 at the time of the U.S. entry into World War II, and varied between 180 to 230 over 110 to 140 throughout most of World War II. By the time of the conference at Yalta in 1945, Roosevelt appeared visibly ill and was found to have a blood pressure of 160 over 150. Unfortunately, this continued to progress, reaching 300 over 190, which was found just before he sat for a portrait in April of 1945, during which time he's collapsed and passed away due to a presumed intracranial hemorrhage. Now, fortunately, our treatment and identification of blood pressure has advanced greatly since the 1940s. However, unfortunately, we do continue to suffer from a great amount of hypertension worldwide. What you're looking at is a temporal analysis of hypertension prevalence, diagnosis, treatment, and control from the noncommunicable disease risk factor collaboration data from between the years of 1990 and 2019. What you'll see is that for individuals, the prevalence of hypertension has doubled over this time period, originally approximately 131 million women and 317 million men, up to 626 million women and 652 million men, equating to over 1 billion individuals suffering from hypertension worldwide. Now, this hypertension prevalence has surpassed 50% for women in two different countries and greater than 9 countries for men, mostly located in Central and Eastern Europe, as well as Central Asia, Pacific Island nations, and Latin America. While control rates have been relatively poor overall, treatment and control is higher in certain nations like South Korea, Canada, and Iceland. But conversely, treatment rates are lowest among nations such as Nepal, Indonesia, Sub-Saharan African nations, and Pacific Island nations. Examined geographically, the disparities in blood pressure control are even more apparent. As you can see, systolic blood pressure is slightly lower for women on the right than it is for men on the left. The large geographic variations do exist for both groups. Examined from a historical perspective, mean blood pressure and the prevalence of raised blood pressure have generally stabilized in high-income countries. While in contrast, blood pressures continue to rise in East, South, and Southeast Asian nations, Pacific Island nations, as well as in Sub-Saharan Africa. Given these trends, the prevalence of hypertension is now higher in low- and middle-income countries than it is in high-income countries. So what does this all tell us for health outcomes? Well, in 2015, an estimated 8.5 million deaths were attributed to systolic blood pressures greater than 115 mmHg, 88% of which occurred in low- and middle-income countries. These graphs demonstrate sex-stratified deaths attributable to hypertension in 1990 and 2015. For men, hypertension-attributable deaths increased from 3 million to 4.5 million, and for women, from 3 million to 4 million. The increase was a result of doubling of deaths attributable to high blood pressure in East, South, and Southeast Asian countries, as well as in Sub-Saharan Africa. Of note, while ischemic heart disease does continue to represent the largest downstream driver of hypertension attributable to mortality, in relative terms, deaths from chronic kidney disease increased more than deaths from cardiovascular disease. Given the recognized global variability in which end-organ damage is most prominent, we can expect that these distributions will continue to change if hypertension prevalence continues to expand across developing nations. So looking at this at a population level from a clinician perspective, what we recognize is that of all of our patients who we see on a given day, about 50% of them will meet ACC definitions for hypertension. Of that population, there is only a portion of them who are diagnosed. Of that undiagnosed population, there is only a portion that are controlled. And that controlled population is far smaller than we would like. What we also know, looking at this more granularly, is that 36% of that uncontrolled hypersensitive population is completely unaware of their diagnosis. And 82% of that group have a routine place of care, nearly two-thirds of whom have been seen at least twice in the last year. What this tells us is it's not just an access of care issue, but it's a treatment issue that needs to be addressed. A recent analysis of hypertension control rates has demonstrated that about 116 million U.S. adults suffer from hypertension, and 80% qualify for medication therapy. Of this group, though, nearly three-quarters are uncontrolled, and of those, only about half of them are treated. This meta-analysis now goes on and looks at the NHANES data and found that control rates for blood pressure were lower for individuals who are Hispanic, non-Hispanic black persons, and Asian individuals compared to their non-white counterparts. Additionally, non-Hispanic white counterparts, excuse me. Additionally, non-Hispanic black individuals were diagnosed with hypertension at an earlier life age, experienced greater hypertension-related morbidity and mortality, and had 30% higher risks of fatal stroke, 50% higher risk of cardiovascular mortality, and a greater than four times increased risk of end-stage renal disease. Looking at the data more granularly, this is a primary analysis of NHANES data between 2013 and 2018, and found additional disparities in hypertension prevalence, treatment, and awareness. Specifically, there was a higher prevalence noted of hypertension among black and African-American individuals, with lower awareness and lower treatment rates among Hispanic and Asian men. Overall, lower control was appreciated amongst these three populations, including African-Americans, Hispanic individuals, and Asian individuals across America. Now, considerable challenges remain in understanding and overcoming racial and ethnic disparities in the prevalence and treatment of hypertension. Social determinants of health, such as educational attainment, access to healthcare, and financial limitations play a key role in hypertension prevalence and control. Implementation of healthcare policies at the state and national levels seek to address these issues and will be essential to reducing these disparities. And while certain genetic and environmental factors may contribute, the evolution of precision medicine and the development of more refined risk models to help us optimize appropriate risk adjustment, blood pressure management, and targets is vitally important. Examining these factors more in depth, ample research has demonstrated that where you live has a profound influence on your blood pressure and cardiovascular health. These data come from the Dallas Heart Study, a multi-ethnic cohort of Dallas County residents designed to study cardiovascular disease and outcomes. The group specifically examined the association of incident hypertension with neighborhood-level characteristics, including the Neighborhood Deprivation Index, variables of socioeconomic status, and surveys examining neighborhood perceptions of factors such as social cohesion, safety, crime, and the physical environment. In multi-variable adjusted analyses using both the JNC-7 and the ACC's 2017 Hypertension Guideline Thresholds, the authors found that compared to living in less deprived areas, individuals living in more deprived neighborhoods were nearly 70% more likely to develop hypertension during follow-up, even when controlling for baseline demographic and clinical characteristics. Importantly, the makeups of these high Neighborhood Deprivation Index locations included more non-Hispanic Black individuals, as well as residents with on average lower educational attainment, lower incomes, and higher BMIs. These findings clearly indicate that not only do risk factors cluster geographically, but that the resources available in a given neighborhood directly impact hypertension risk and the future cardiovascular events. Now, there are innovative methods that can be used to tackle some of these factors by engaging with patients in their community and leveraging strong social bonds to enhance care delivery. These focus on factors such as patient-centeredness, team-based care, and standardized protocols, all towards the goal of improving hypertension control. This was most notably done in a large cluster randomized control trial known as the Los Angeles Barbershop Blood Pressure Study. In this analysis, pharmacists in intervention barbershops were implanted into the shops and worked in conjunction with barbers who are trusted members of the non-Hispanic Black community to help patrons become aware of their diagnosis of hypertension and to control it. And what they found was that the shops with intervention, those who received a pharmacist to help lower blood pressure, achieved nearly a 22mm reduction in systolic blood pressure and a 15mm reduction in diastolic blood pressure compared to the control shops. So bringing this all together, where are we currently with the guidelines? Well, the most recent updated ACC 2017 hypertension guidelines defining normal blood pressure is a systolic less than 120mm of mercury and a diastolic less than 80mm of mercury. Elevated blood pressures begin with systolic between 120 and 129 and diastolic less than 80. In stage 1, hypertension now begins with systolic in the 130 to 139 range or a diastolic between 80 and 89. Stage 2 hypertension is systolic blood pressures of 140 or greater or diastolics of 90 or greater, with hypertensive crisis being defined as either a systolic or diastolic greater than 180 or 120 respectively. The guidelines also provide very clear pathways of how to treat individuals within each of these groups. For those with normal elevated blood pressure, non-pharmacologic therapies and reassessments of either 1 year or 3 months respectively are indicated. For individuals with stage 2 hypertension, pharmacologic therapy is indicated right away. Now, for those with stage 1 hypertension, the initiation of pharmacologic therapy is based on an estimated risk score of less than or greater than 10%. This risk score can be easily calculated from the ACC's online ASCBD risk module. Now, output from the pooled risk cohort equation has been assessed using several cohorts, including in the REGARD study. In this analysis, researchers examined the predictive capacity of the risk score by comparing observed and expected cardiovascular event rates over a 5-year period. They found that using the pooled cohort risk equations, observed and predicted 5-year cardiovascular event risks were similar, indicating that the risk equation is well calibrated for the population and demonstrates good discrimination. But why do we care about assessing risk in the first place? Well, it's important to recognize that the degree of benefit obtained from blood pressure reduction changes based on the estimated risk of future cardiovascular events. This is well demonstrated in this meta-analysis published in The Lancet in 2014, in which researchers examined studies that used pharmacotherapy to reduce blood pressure in over 50,000 individuals. They stratified the study to participants by both an absolute reduction in systolic blood pressure and by their 5-year risk of suffering a cardiovascular event. They then calculated the number of events avoided per 1,000 people treated in each group. What they found was that lower blood pressure decreased or prevented cardiovascular events across all groups, but the benefit was much greater for individuals in the highest risks populations. For example, reducing systolic blood pressure by 4 mmHg in the lowest risk cohort prevented 5 cardiovascular events per 1,000 individuals treated. By comparison, this number was nearly 4 times greater in the high-risk cohort. Examined another way, reducing systolic blood pressure by 4 mmHg in the highest risk cohort obtained a similar benefit in reducing systolic blood pressure by 16 mmHg in the lowest risk cohort. Bringing this all together, what the ACC recommends, based on the ample amount of literature now available, is that for individuals with low risk and no recognized cardiovascular risk factors, that blood pressure targets for standard office blood pressures should be between 130 and 139 to less than 90. And for unintended office blood pressures or out-of-office blood pressures, the value should be between 125 and 135 systolic over less than 90. For individuals who are high risk, who have established cardiovascular disease, heart failure, diabetes, chronic kidney disease, age greater than 65, or a risk score greater than 10%, standard office blood pressure should be targeted to less than 130 over 80, or unattended or out-of-office blood pressures to less than 125 over less than 80. In conclusion, the epidemiology of hypertension has demonstrated a growing global burden, particularly amongst low- and middle-income countries. Social determinants of health represent key factors affecting hypertension control, and diagnosis should be made across these populations using contemporary guidelines. Assessment of cardiovascular risk should be accomplished for each individual, and treating to target thresholds can help reduce cardiovascular events amongst this patient population. Thank you very much for your time. Great. Thank you, Dr. Ebinger, for a fantastic presentation. I think that was a really good summary that really sets the stage in terms of understanding the importance of hypertension, how we diagnose it. And so I think that's a really great segue into our next speaker, Dr. Tammy Brady from Johns Hopkins, who's really going to focus on how do we measure blood pressure accurately in the clinic. So, Dr. Brady, thank you for joining us. My name is Tammy Brady. I am a pediatric nephrologist at Johns Hopkins, and I really focus my research and clinical career on cardiovascular health promotion across the lifespan. And key to that is screening blood pressure for hypertension, which often happens in the office. And so the focus of this part of the webinar is how to measure blood pressure correctly in the office. So I have no disclosures. So when you think about blood pressure measurement, or at least what I do, I think about the three required elements. So you need to make sure that your patient is properly prepared and positioned. You need to make sure that they have a cuff that is selected just for them based on their mid-arm circumference. And, of course, you need to have mastery of the blood pressure measurement. In the most recent blood pressure, adult blood pressure, or hypertension guidelines, they have this wonderful table that describes all the various sources of inaccuracy in the measurement of blood pressure in a clinical setting. And, again, I like to think of this table in those three buckets of patient preparation, cuff selection, and measurement technique. And it may seem some of these things that we are required to do to get a good blood pressure may seem obvious, but there have been many studies to show that we as medical providers don't always conduct these or adhere to these techniques optimally. This was a study several years ago of medical students. You would maybe argue that they were most proximal to learning how to measure blood pressure properly. And these almost 160 students were assessed on all of the steps required to measure blood pressure up to the part of actually measuring the blood pressure. And as you can see on this slide, only one student was proficient in all 11 skills. And, in fact, on average, the students only adhered to four of the 11 skills in their blood pressure measurement or preparing for the measurement. Things like resting for five minutes before measurement, making sure their feet are on the floor, making sure that the arm was checked in both—the blood pressure was checked in both arms, not talking to the patient. All of these things were really suboptimally adhered to and will, as you will see, can significantly impact measurement. So thinking about patient preparation. So before even attempting to measure their blood pressure, you really should try to make sure that the patient hasn't had any nicotine or caffeine for at least 30 minutes prior to the measurement. They should really have an empty bladder prior to measuring it. And they should be in a room that is comfortable in terms of the temperature. You want to make sure you avoid having too cold of a room, which I keep telling my patients are in the cold hand phase of the year. And so making sure that the room's not too cold. And the reason these things are important is because, as you can see on this table, which was drawn from the blood pressure guideline manuscript, that each one of those steps can lead to very significant elevations in blood pressure if they're not adhered to. So acute caffeine consumption can lead to an increase in 14 millimeters of mercury systolic, acute nicotine use up to 25. And if your patient doesn't empty their bladder and they have a full bladder, their blood pressure can be overestimated by 33 millimeters of mercury. So then in terms of positioning, you want to make sure that your patient is sitting in a chair that has back support that allows for their legs to be flat on the ground. Make sure their legs are uncrossed and that their arm is supported so that the middle of the cuff can be at mid-heart level. And each of these things by themselves is important for accuracy. As you can see in the table here, if any one of these steps is not adhered to, your blood pressure can be pretty elevated, at least the reading can be. So this is what happens when I typically walk in a room. So I walk in and I'll see a patient that's sitting on the examination table. And so that is not the right place to measure their blood pressure. Sometimes I will see them sitting in a chair and getting better, but you'll see that their feet can be dangling. And this is, you know, I'm a pediatrician. I see this more often in my young kids, but some older individuals may also have some struggles with keeping their feet on the ground depending on the chair. So that's also not optimal. And so the two pictures on the right are really more getting in line with what you should be trying to do. You want to make sure that their feet are supported and actually all the way to the right, you can see that the arm is nice and supported. That is really a much better way to have your patient positioned for blood pressure measurement. So what I often will do is before I even tell the patient that I am going to measure their blood pressure, I walk into the room and I introduce myself and I say, I'm Dr. Brady. I'm going to measure your blood pressure in a little bit. Is there any chance that you might have to use the restroom? And if so, then I make sure that they go. And then when they come back, I make sure that they're seated in a way that they will be positioned properly, like you'll see in the picture to the right. And then when I'm getting ready to measure their blood pressure, I give them anticipatory guidance about what's going to happen next. So we need to keep the room quiet. We need to have the, you know, kind of refrain from talking, reading, using their smartphones and making sure that they rest for three to five minutes prior to measurement. And the reason for these things, again, if you do not adhere to each of these things, the blood pressure reading that you get can be significantly elevated. And so when I'm ready to measure the patient's blood pressure, I tell them, okay, so I'm going to measure your blood pressure. And in my practice, I've measured it three times. I'm going to measure your blood pressure three times. I'm going to keep the room nice and quiet. I'm not going to tell you the blood pressures in between, but I'll tell you them all at the end. So I don't want you to be worried about, why am I not talking? Why am I repeating again? These are all the things that I normally do. And then, you know, I take care of children and adolescents. So I take their phone. I say, I'm going to move your phone over here so there's no distractions. And honestly, by just giving them the anticipatory guidance about how I'm going to approach it, I really have no trouble. They sit and they allow their blood pressures to be measured in a quiet setting and we get our measurements. So the next thing to really focus on is making sure that the cuff you use while measuring blood pressure is appropriately sized for your patient. And I can't overestimate this enough or overemphasize this enough. If your cuff is too small or your cuff is too large, you will get an inaccurate blood pressure reading. And you're making sure that the cuff is appropriately sized for their mid-upper arm circumference. Now, I think many of us have been taught about the importance of bladder length and width, right? So we've been taught that the width needs to be at least 40 percent of the upper mid-arm circumference and the length needs to be at least 80 percent of the mid-upper arm circumference. But I want you to know while that is true, that is really only true when you're measuring blood pressure by manual auscultation. These dimensions were based on studies done in the 70s and based on what cuff can give equal compression to the brachial artery to allow us to hear the cough sounds. When you're measuring blood pressure with an automated device, these dimensions are not required. Manufacturers can innovate and make cuffs of any sizes. And when they do their validation testing, they are validating it to a reference measurement, which is done by manual auscultation with a cuff that does adhere to these dimensions. So the correct cuff size really is. Talking about what is the circumference and it's the cuff you're using intended for that arm size. So, again, when I do this every day, I measure their mid arm circumference. So here on the left upper panel, you'll see be very scientific about finding where the middle of the arm is and then the lower left panel, getting the mid arm circumference and. Looking to see how many centimeters and then looking at your family to find the cuff that has a range that fits your arms, the patient's mid arm circumference. And I would love for us all at the end of this to understand the need to not be swayed by the cuff labeling. Everything comes with this qualitative label from infant up to thigh cuff. And really, we should be focusing on the arm measurement and the arm circumference range that is demarcated on the cuff. I can tell you that there are very many children that I take care of. Who need adult large adult and by cops so again, please don't be swayed by what the cuff says on the label other than the arm circumference ranges. And, in fact, this is really important for adults too, because when looking at any data, this is the more contemporary and data a 3rd to almost half of us adults require a large adult or by extra large. And so this again is a significant problem and emphasizing the need for accurate cuff or appropriate cuffs. So, I recently completed a study with some colleagues here at Hopkins to look to see how impactful it is when we use an inappropriately sized cuff. In this study, we were wondering, well, you know, oftentimes in triage, there's a pressure device there that has 1 cuff sitting there with it. What would be the impact on measurement accuracy? If that 1 regular adult cuff was used for all comers. And so to orient you to the part of the slide, or the part of the table and circle. So, here you can see what the regular adult cuff that was the reference measurement. When an individual who needed a small adult cup was sitting in the chair using a regular adult cuff, you can see that that was 1 size too large and it. I underestimated their blood pressure by 3.6 millimeters of mercury, but what more often happens, I think, and at least in the United States, when you have an individual who requires a large adult cuff or an extra large adult cuff. Which is 1 and 2 sizes too small, you can overestimate their blood pressure by almost 5 and 20 millimeters of mercury respectively. And you can imagine that that gives very different interpretations of what that individual's blood pressure might be. Okay, so once you've selected the cuff to use, you also need to make sure you apply it properly. And so, again, you're trying to get equal compression of the brachial artery. And so you want to make sure that you palpate the brachial pulse, and then I will fold the cuff in half to find the midpoint of the inflatable portion of the cuff. Because sometimes that artery marking isn't always accurate, and then I make sure that I put it on their arm so that the middle of the cuff, or the middle of the midpoint of the bladder is right above the brachial artery. And then I make sure that it's at least 2 finger breaths above the brachial artery, and make sure that the cuff is on snugly so that no more than 2 finger breaths can fit underneath the cuff. And sometimes I need to have their arms put out to the side in order to get that really snug fit. But all of those things, again, are super important to get good fit to get good, accurate measurements. And once the cuff is placed, you want to make sure that the middle of that cuff is at mid heart level. And that's why I always make sure that my patients are situated in a way that there's an arm rest there to facilitate that positioning. And if that positioning isn't adhered to, you know, if you have the arm lower than heart level, which often will happen if the arm is sort of hanging at the side, you can significantly overestimate what their true blood pressure is. And then another thing I wanted to emphasize, and I think that not many people recognize the importance of using brand name cuffs. So whatever cuff comes with your automated device is the cuff you need to use to measure blood pressure. The accuracy of the device you are using is linked to the cuff. When you use an off-brand cuff, you are not assured that that device is providing you an accurate measurement. And that's because the cuff is what's actually sensing the oscillations in the artery and is feeding it into the algorithms. And so if you start switching out cuffs, any validation testing that has been done on the cuff, you cannot be assured transfers. And so, again, you can't be assured that the measurement you get is accurate. So, in summary, when measuring blood pressure in the office setting, you want to make sure that your patient is properly positioned and prepared. So, again, making sure that they've emptied their bladder, that they're seated in the right place. Their back legs are supported, their feet are flat on the floor and I should mention if you don't have a stool available, you know, sometimes I just take the garbage can and I roll it to the side or put it on its side and slide it under their feet. That's sort of a makeshift way to keep their feet supported. You want to make sure that you select a cuff that is appropriately sized for their mid-arm, mid-upper arm. You want to make sure that the cuff is in the correct position and that the arm is supported on a flat surface to allow the middle of the cuff to be at mid-heart level. And then you want to make sure your patient rests quietly for 2 to 5 minutes before and during the measurement. With that, I will end. So thank you very much. Great, thank you. That was a fantastic presentation, Dr. Brady, on really educating clinicians as well as staff on how to really understand the importance of how to measure blood pressure accurately in the clinic. And I can tell you that, in general, in our own clinics, I think we struggle with providing proper techniques and ways for us to measure correctly for our own staff. So, I think that's a fantastic segue into our last presentation today. So we now heard how to do it correctly in the office, but I think probably even more important is that we really need to educate patients on how to do it correctly when they go home. So, we have guidelines telling us that we should use home blood pressure monitoring as a way to guide both diagnosis and treatment. And so what we really need is to understand those specific details. So, our next speaker is Dr. Leslie Davis from University of North Carolina, who's going to share with us on this important topic. Thank you, Dr. Davis. Thank you very much. So, I'm Leslie Davis. I'm a nurse practitioner and part of my clinical responsibilities are to work in a clinic where we see difficult to control or challenging blood pressures to evaluate whether the blood pressure is resistant hypertension. I see adults only, so a natural segue, not only to educating patients and their care partners, but also to the more adult population. So I'm going to speak to you about how to educate patients on using the proper equipment and technique for blood pressure measurement. So, I have no disclosures relevant to this presentation. So, today I'm going to talk to you about 4 general problems that I encounter a lot when I'm doing education for patients and their family members or care partners. The 1st, and these have already been spoken about by Dr. Brady in the office setting, but I'd like to speak to them relevant to teaching patients. The 1st is miscuffing. We'll talk about under or over cuffing. That's very common. Talk about the variation in blood pressure cuff size among home monitors. We will talk also about that many blood pressure monitors on the market are not validated. So how to find those and just the proper technique. So a problem with improper technique for home blood pressure monitoring. So, the 1st problem miscuffing now, miscuffing is, as the name implies using the wrong size cuff to measure your blood pressures. So we teach patient that 1, 1 cuff doesn't work for everybody in the household or just because it's in the 1 that was given to them as a gift and the problem arises as we've seen if you under cuff, which means you're using too small of a cuff, which I think is more common is that systolic blood pressure cuff. Can be falsely elevated 19 and a half millimeters. And if you think about the reason, we're asking folks to collect these numbers and to bring them in is that we, as clinicians can use those numbers to evaluate the effectiveness of the blood pressure treatment management plan. And what next steps to do, we, we do a lot with these numbers. So it's important for them to be accurate. So, if they have the wrong size cuff, especially using a cuff too small, it can be quite elevated. The other is over cuffing, which is not as common, but if you use a cuff, that's too big. So we want to teach them. So the solution is, let's help the patient measure their mid upper arm circumference. So, 1st, things 1st is to measure their circumference and know which cuff size. And so this was very much of what Dr Brady talked about, whether it's centimeters or inches. And most will refer to a centimeters, but measuring the cuff or measuring the mid arm circumference and making sure it's the right cuff size. So, the cuff size would either be small adult, adult, large adult, or extra large adult. And those in this table here, you can see which size cuff matches that arm circumference. So, following into that is not just making sure the cuff size matches that measurement is actually measuring that mid arm circumference correctly. And so I find that we, 1st of all, need to teach our rooming staff or whoever does the patient education, how to do this correctly. So they can not only model, but teach the patient how to do it. And in fact, if the staff can actually measure the patient's arm circumference in the rooms and write it down for them, that's 1 step that we can actually measure it for them. But if not teach them how to measure it. And I find, like, many of our rooming staff over the years, there's turnover. So we have to train our staff on a regular basis and check them off for doing so if they're the ones teaching the patients. And so there's a lot of errors in exactly how to measure this. There's a picture here to the left, finding the acromion process on that scapula, finding which bone on the elbow to to measure that. So, both palpating both of these spots, frequent error, measuring the length and dividing that in half to find the mid arm and then wrapping the tape measure around that mid arm and measuring it in centimeters. So, select selecting the correct size cuff is based on this measurement. So both of these can become a frequent error. And so you need both of these to be correct. All right, so the 3rd problem I want to speak to is. Just let's say, you found the right place to measure that mid arm circumference. You've measured it correctly. You match up that measurement to what size cuff you need. Whether it's a small adult, an extra large, you know, which size you need. Now, we need to teach patients that. Don't believe everything you read and so here's a study that was done in 2023 and published in the American Journal of hypertension. There was a study of 42 home validated blood pressure devices from 13 manufacturers. And what they got these, these device companies and listings were off the U. S. blood pressure validated device listing website. And the researchers compared this against American Heart Association recommendations that table I showed earlier of what was considered small adult at 22 to 26 centimeters. Adult size, 27 to 34 centimeters large, 35 to 44 and extra large 45 to 52. so they line those up of those 42 home validated blood pressure devices from 13 manufacturers. None offered cuffs that were aligned with the American heart recommendations. And in a 2nd, I'm going to show you a figure of that. Over half 52% or 22 of those 42. We're compatible only with a broad range. Of the cuff, generally excluding the arm size is larger than 44 centimeters. So, excluding that extra large size cuff, the adult that needs that only 5 cuffs from the, from 4 manufacturers offered a cuff that was labeled extra large. And only 3 actually offered something that match the American Heart Association extra large range. So, there's a problem in both the terminology that's used by the companies or manufacturers and the different labeling. So Dr Brady had talked about the labeling on the cuff. So it's more about the centimeters and some cuffs would be labeled large. But yet they weren't large size adults, according to the American Heart Association. So I'll show you this in a graphic. So, this is very busy, but this came from this 2023 publication to the left. There's different companies listed. On Ron, different ones, a, and D, medical, various ones and different models across the top. There's the American Heart Association recommendations a small adult. The regular adult large and extra large and as you can see, most of these that that blue I'll call Carolina blue, but it's, it's where it says standard. That's what the cuff was labeled or adult or integrated that it covers pretty much that. But if you happen to have a patient that would measure to the American Heart Association, small, or the extra large, you're sort of out of luck with that. So, we have problems that the manufacturers of these US home blood pressure devices employ inconsistent terminology and the thresholds for which cuff sizes would be matched or in this case, not aligned with the American Heart Association recommendations. So, this is very challenging for patients. Now, 1 solution for that that we do in our clinic, and that's recommended and in fact, recommended by the American College of cardiology is bring those home devices in there. If we measure their arm and look at the cuff size, they're using as Dr Brady suggested. We want to make sure that the cuff actually came with the device, but we can see what cuff size. They're using what the labeling says and match it up to the measurement. So, the 4th and last problem I wanted to discuss is what about the blood pressure? So we've talked about the cuff the arm, making sure the cuff size is correct. But, but what about the blood pressure monitor itself? Are they using a validated monitor? Did someone give them this cuff? Did they pass it down? Is it so old? Are they just using any cuff? So, in fact, studies have shown only 6 to 15% of blood pressure cuffs currently on the market are validated and patients. It's a wonder they can't distinguish between validated and non validated monitors. They consider if they're on the shelf and I can purchase them, they must be validated. And some of the labeling even says validated. They're more likely to actually buy a non validated monitor resulting in inaccurate blood pressure measurement. Then the odds are sort of stacked against them. And so 1 solution to this, so I'm not just identifying problems, but trying to help with solutions in the United States, a website that is validate blood pressure or validate VP dot org. That is something where you can go in there and you enter a precise model model for the monitor that they're either interested in buying, or if they've already have it, the manufacturer and scroll down to find the model. If it's not listed, it's not validated. We've used this in our clinic. In fact, we have a study going on right now. That's run by medical students that they do motivational interviewing and self care. And we give patients monitors, and we were considering buying some monitors recently, and we looked up and this to use this validate dot org. We were making sure the monitors we could buy actually offer different size cuffs, but also that it was listed as a validated model. And so the 5th and last problem is improper technique. Much of this has already been discussed by Dr Brady just as important as doing a proper technique in the office by our clinicians is also proper technique at home. And I would dare say there's more distractions or more problems at home. Same principles of what could happen, but having the proper equipment. A validated device, a proper size cuff is not enough technique matters. Now, this is something we offer through cardio smart on the left through the American College of cardiology. There's infographs and we post these actually in our clinic, even in the clinic. It's not seeing patients with hypertension. We post this everywhere of just having an infograph. I love the way it's got the guideline or the goals and what's considered the different categories and definitions of hypertension. But the important things about selecting a device is accurate the things you do before taking a reading how to sit correctly how to place that cuff above the bend of the elbow. And these are written in lay person's language and taking at least 2 readings and recording the results. So, let's go through. We don't just give them an infograph. We actually, in our clinic, show them a video. We actually observe their technique and then give them feedback, but talking through this. And so, if we adapt this to the home setting, because, or wherever they live, and I speak to the patient by extension family or care partner, I don't always call it caregiver because many of patients we say your partners with this. But we talk about the appropriate size cuff. I've already mentioned and Dr Brady's talked about that and measuring blood pressure with a validated device. It's more tempting at home if they're in the clinic, they might be on their best behavior and I'm not trying to be patriarchal about that, but really emphasize that no smoking, no caffeine or exercise at least 30 minutes before the measurement having that empty bladder. We've talked about most of the things if you don't follow, this will be falsely elevated systolic blood pressure. And it was amazing to me when I saw the literature several years ago that it could be as much as 10, 15, 20 millimeters mercury higher falsely elevated. And that's a big deal. That's a big deal. And if you're trying to get blood pressure to go, and if you're getting these incorrect numbers, it takes a lot to get that blood pressure down. You're going to have them rest for 5 minutes before measurement. Now, that requires at home having something to measure that time with people aren't always the best judge of what 5 minutes is sit quietly in a firm chair. I have a lot of patients that I always say, tell me how you measure your blood pressure. They sit on the sofa and put the left arm if that's what they're putting the cuff around on a pillow. And so, as we've described, I said, maybe go to the kitchen, maybe have it on the dining room table feet flat on the floor. That blood pressure cuffed around the bear arm I've seen patients put it over a sleeve. I try not to preface with let's correcting them before they do it. I have them in the clinic show me how they do bring in your device and show me how you do it. And then I talk to them about this measuring to 2 measurements, at least a minute apart. Now, before I get to that, I want to emphasize that part about no talking as Dr. Brady said. And it's not on the slide, but I want to make sure I verbally talk about it. The no talking the no texting that that pertains to things at home too. So they'll say, I always measure it. So, I remember to measure it during the 6 PM evening news or 630 national news. And I said, do you have the TV on? So, if the TV, they're listening to that. That is not quiet as if they're not talking. So I say, you know, mute the TV and frankly, this time of year, I say, just cut the TV off. So making sure they're not only not texting, but not watching TV or screen right back to this taking the measurements at least 1 minute apart twice daily. In the morning before taking blood pressure meds, and in the evening before a meal, and sometimes you have to accommodate that. If folks are shift workers, write down those measurements and share with the healthcare team. And as I've mentioned for a few things, because they return, they demonstrate what they do is bringing in that device and measurements to the next clinic appointment 1. so we can. Check the blood pressure device with our device. There's a whole protocol to do that, but 2, just to make sure it's the right size cuff and that they're measuring it correctly. And here are my references, I guess I'll pass the baton back and just thank you very much for including me. All right. Thank you for an outstanding presentation. All of the speakers really highlighted very important topics. I think getting setting the stage around the epidemiology and the challenges with hypertension by Dr. Ebinger was fantastic leading to really the way to measure blood pressure correctly in the office. And finally, with Dr. Davis's presentation on how to educate our patients, I really hope that all of you have learned a lot from this. I know I certainly have. And hopefully this information can be used by both the clinicians who are participating in this as well as for our patients who can learn from from this very important educational webinar. So, thank you to all the faculty for participating in today's series and again, thank you for your attention.

Dr. Yang

cardiologist

measuring blood pressure

cardiovascular health

hypertension

cuff size

patient positioning

validated devices