How Long Wait Beforetaking Bp Again

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J Hypertens. Author manuscript; bachelor in PMC 2010 Sep 19.

Published in final edited form as:

PMCID: PMC2941726

NIHMSID: NIHMS233354

What is the optimal interval between successive home blood pressure readings using an automated oscillometric device?

Kazuo Eguchi

^a Partition of Cardiovascular Medicine, Department of Medicine, Jichi Medical University, Tochigi, Japan

Sujith Kuruvilla

^b Centre for Behavioral Cardiovascular Health, Columbia University Medical Center, Columbia University Medical College, New York

Gbenga Ogedegbe

^b Center for Behavioral Cardiovascular Wellness, Columbia University Medical Centre, Columbia University Medical Higher, New York

William Gerin

^b Center for Behavioral Cardiovascular Health, Columbia University Medical Middle, Columbia Academy Medical College, New York

Joseph Due east. Schwartz

^c Department of Psychiatry and Behavioral Science, Stony Beck Academy, Stony Brook, New York, United states

Thomas G. Pickering

^b Center for Behavioral Cardiovascular Health, Columbia University Medical Centre, Columbia Academy Medical Higher, New York

Abstract

Objectives

To clarify whether a shorter interval between 3 successive home claret pressure (HBP) readings (10 southward vs. 1 min) taken twice a day gives a better prediction of the average 24-h BP and amend patient compliance.

Design

We enrolled 56 patients from a hypertension clinic (hateful historic period: 60 ±14 years; 54% female patients). The study consisted of three clinic visits, with 2 4-week periods of self-monitoring of HBP between them, and a 24-h ambulatory BP monitoring at the 2d visit. Using a crossover design, with order randomized, the oscillometric HBP device (HEM-5001) could be programmed to take three consecutive readings at either 10-s or 1-min intervals, each of which was washed for 4 weeks. Patients were asked to measure out three HBP readings in the morning and evening. All the readings were stored in the retention of the monitors.

Results

The analyses were performed using the second–third HBP readings. The average systolic BP/diastolic BP for the x-s and one-min intervals at habitation were 136.ane ±15.8/77.5 ±9.5 and 133.2 ±15.5/76.9 ±9.3 mmHg (P = 0.001/0.nineteen for the differences in systolic BP and diastolic BP), respectively. The 1-min BP readings were significantly closer to the boilerplate of awake ambulatory BP (131 ±14/79 ±10 mmHg) than the 10-due south interval readings. At that place was no significant divergence in patients' compliance in taking adequate numbers of readings at the different time intervals.

Conclusion

The ane-min interval between HBP readings gave a closer understanding with the daytime boilerplate BP than the 10-s interval.

Keywords: convalescent BP monitoring, home BP, measurement interval, multiple BP measurements

Introduction

Home blood pressure (HBP) measurement is increasingly used in clinical practice. A number of studies and reviews [1] have demonstrated that abode BP is superior to clinic BP in its reproducibility [ii–iv], for predicting target organ harm [5–7] and futurity cardiovascular events in general populations [viii,9], hypertensive patients [10], and patients with kidney illness [11]. The international BP guidelines for the use of home BP [12–14] have stated that when a series of readings is taken, a minimum of two readings should exist taken at intervals of at to the lowest degree i min, and the average of those readings should exist used to stand for the patient's blood pressure.

Most of the currently bachelor home monitors take only one reading when the device is triggered, but the latest generation of monitors will accept multiple readings automatically at fixed intervals. All the same, doing this will take longer than taking a single reading, raising the possibility that compliance with the procedure will be less. Although an interval of 1 min between readings has been recommended, there is some evidence that an interval of less than 15 due south may be as accurate as the conventional 1-min interval [15,16]. Withal, these studies were performed in clinical settings past trained enquiry staff. Alternatively, at that place is the possibility that taking multiple BP measurements at shorter intervals is less accurate considering of hyperemia of the upper arm [17], which has been investigated during measurements made with the Korotkoff method, and this may be the source of the recommendation to await at to the lowest degree 1 min between measurements. In add-on, it has been observed that at that place is a progressive fall of BP with multiple readings, the extent of which varies according to the interval between successive readings. At the present fourth dimension, there accept been no studies comparing the feasibility and accuracy of brusk time intervals with the more conventional one-min interval for readings taken by oscillometric domicile monitors. We performed this study to test the hypotheses that repeated oscillometric dwelling house BP measurement using 10-s intervals are as accurate every bit those using the conventional 1-min intervals; and patient compliance is meliorate when 10-s intervals are used.

Methods

Patients were recruited from the hypertension dispensary at Columbia University New York-Presbyterian Infirmary. The inclusion criteria were a diagnosis of known or suspected hypertension, and, if treated, having been on a stable dose of medication for at least 1 month with no plan to alter handling for the side by side two months. Forty-two out of 56 patients were taking antihypertensive medications. Patients with major arrhythmias or with arm circumference greater than xl cm were excluded. The following variables were assessed at the initial visit: age, sex activity, race, trunk mass index, history of cardiovascular illness, and handedness. Arm circumference was measured, and the advisable cuff size was selected [12].

Clinic BP measurements

Clinic BP was measured at baseline and at the 4th and 8th week visits. Patients sat quietly with their backs supported, without crossing their legs, and with both arms supported at eye level for 5 min before the measurements were fabricated. Clinic BP was measured with auscultation past a physician (three readings) using a mercury sphygmomanometer and by an automated BP monitor [Omron HEM-5001 (Kyoto, Nihon), the home monitor used in the study] with three readings at ane min intervals, giving a full of half dozen clinic readings at each visit. The sequence of the clinic BP measurements was randomly assigned at each visit. Thus, each of the two types of clinic BP measurements used in the assay described below was based on the boilerplate of nine readings (iii on three occasions over an 8-week period) taken nether rigorously standardized conditions.

Abode BP measurement

The HBP monitor used for this report was an Omron HEM-5001 device, which can be prepare to automatically take iii readings, at either 10-s or i-min intervals. Although this device has not been subjected to a formal validation test, it uses the same algorithm equally the HEM-737, which has passed the Association for the Advancement of Medical Instrumentation (AAMI) validation protocol [xviii]. Patients were given a HBP monitor and instructed in its utilize. They were instructed to mensurate home BP afterward a five min rest. It was preset by the investigators to take iii readings at either 10-s or ane-min intervals, based on random assignment, for the initial iv-week home monitoring period. The 1-min (or 10-s) interval was betwixt the end of the starting time reading and the first of the side by side reading. They were asked to measure forenoon HBP and evening HBP on at least iv days/week for 8 weeks. The measurement results (date, time, BP, and pulse rate) were automatically stored in the memory of the monitor. Patients were asked to visit the investigator'due south role at the 4th and 8th week and bring the monitor, at which times the information were uploaded to a figurer. At the 4th calendar week visit, the interval setting of the home monitor was changed by the research staff from one min to x s (H1 group) or from 10 southward to 1 min (H2 grouping).

Convalescent BP measurement

Convalescent BP (ABP) measurement over 24 h was performed at the second visit. Patients were asked to continue a diary that included the time of going to bed, waking-upward, meals, and other events. ABP monitoring was performed with a Spacelabs 90207 device (SpaceLabs Medical, Inc., Redmond, Washington, U.s.a.). Blood pressure was measured every xv min between 0700 and 2300 h and every thirty min during the night. Patients were asked to send the device and diary dorsum to the investigator'southward office after completion of ABP monitoring. The boilerplate awake and sleep ABP value were calculated based on the patients' diaries. This report was approved by the Institutional Review Board of Columbia Academy, and written informed consent was obtained from all participants.

Statistical analyses

We used the hateful of the first–2nd, second–third, and the showtime–third readings for the analyses of the home BPs. BP readings labeled as 'morning' and 'evening' were used as morning and evening readings, but BP measurements taken at other times were excluded from the analyses. The averages and the differences between home BP readings taken at 10-s and ane-min intervals were compared using paired t-tests. Morning and evening BP readings were combined when 10-s and ane-min intervals were compared and when habitation BP was compared with clinic BP or ABP measures. The associations between abode BP, clinic BP and ABP were compared using the intraclass correlation coefficient (ICC) for agreement [19]. For all analyses, a significance level of P value less than 0.05, two-tailed, was used. The preliminary data processing of the HBP and ABP data was performed in SAS ix.one (SAS Institute, Research Triangle, North Carolina, USA). All statistical analyses were performed with SPSS, xiii.0 (SPSS, Inc., Chicago, Illinois, USA).

Results

Initially, 57 consecutive patients seen in the hypertension dispensary were enrolled for the study. Because one patient withdrew from the study at the second visit, 56 patients completed the study protocol. As shown in Table 1, the mean age of the patients was lx years, two-thirds were White, and 75% were on antihypertensive treatment. Office BP level measured by the HEM-5001 (131 ±15/76 ±9 mmHg) was similar to awake BP (131 ± 14/79 ±10 mmHg), but home BP average (135 ±fifteen/77 ±9 mmHg) calculated by both 10 and 1-min intervals) was college than function and awake ABP. The average of all three successive readings (first to third), across morning and evening assessments, was 136/78 mmHg, the average of the kickoff and 2d readings was 137/78 mmHg, and the average of the second and third readings was 135/77 mmHg when they were calculated by the average of both measurement intervals. Figure 1 shows the differences among the iii consecutive dwelling systolic BP readings in the morning, separately for the data assessed at ten-s and one-min intervals. At both sampling intervals, the second readings were significantly lower than the first readings, and the third readings were significantly lower than the first and the 2nd readings. The similar trends were observed for morning diastolic BP (DBP) and evening systolic BP (SBP)/DBP.

Changes of morning BP by measurement times and a comparing of home systolic BP in the morning across 3 consecutive readings taken at 10-south vs. 1-min intervals. *P <0.001 vs. offset readings, ^† P <0.001 vs. second readings.

Tabular array one

Baseline characteristics

Variables	Boilerplate or per centum
Number of patients	56
Historic period (years)	60.0 ±fourteen.4
Sex [number (%) of men]	26 (46.iv%)
White race (%)	34 (threescore.seven%)
Body mass index (kg/mii)	26.half-dozen ± six.4
Diagnosed hypertension (%)	51 (91.i%)
History of hypertension (years)	8.iii ± 9.ane
On antihypertensive treatments (%)	42 (75%)
Blazon II diabetes (%)	3 (5.4%)
History of cardiovascular illnessa (%)	8 (14.3%)
Patients with large adult gage (%)	viii (14.3%)

Bland–Altman plots for the averages of awake ABP and home BP showed that the deviation between awake and home SBP/DBP was similarly distributed beyond the BP range for both the x-s and one-min intervals and was less than 20 mmHg for all merely one participant (data are not shown).

Table 2 shows the boilerplate home BP levels, the differences from home BP to ambulatory awake BP, and the differences between the starting time and second, or the second and tertiary readings. All of the information are combined BP measurements of morning and evening. As shown, the average SBPs measured at 10-southward intervals were consistently higher than those measured at i-min intervals. The values of readings averaged from the first to second were significantly college than those averaged from the second to third (Table 2a). At that place were no significant differences in DBP levels between ten-s and one-min intervals. Tabular array 2(b) shows the comparisons between ABP and home BP readings. The boilerplate home BP measured at 10-s and 1-min intervals was consistently higher than the awake SBP, but there were no significant differences betwixt the dwelling house BP averages of the 2d–third readings taken at 1-min intervals and the awake SBP. These differences betwixt home SBP and convalescent awake SBP were significantly higher in the 10-due south intervals. The intraclass correlations of agreement between x-south and 1-min intervals of the home BP and awake SBP were 0.712/0.725 for SBP and 0.693/0.673 for DBP when two readings of the home BP were used each time. Table ii(c) shows the comparisons of the start vs. second and 2nd vs. third readings taken at 10-s vs. i-min intervals for the domicile BPs. The differences between the first and 2nd readings were significantly larger in 1-min intervals than in the 10-s intervals. The differences between the second and third readings were significantly larger when the interval between them was 10-s than when it was 1-min, for both systolic and diastolic BP.

Table 2

Comparison betwixt home BP readings taken at ten-s and 1-min intervals

	10-southward intervals	one-min intervals	P
(a) Average domicile BP levels
Offset–third SBP (mmHg)	137.0 ± 15.6	134.7 ± 15.4	0.005
First–third DBP (mmHg)	77.9 ± nine.iv	77.2 ± 9.1	0.15
First–second SBP (mmHg)	138.0 ± 15.5††	135.vi ± 15.4††	0.005
Kickoff–second DBP (mmHg)	78.2 ± ix.four††	77.iv ± 9.2†	0.07
Second–3rd SBP (mmHg)	136.1 ± 15.8	133.ii ± fifteen.5	0.001
2nd–tertiary DBP (mmHg)	77.5 ± 9.5	76.nine ± 9.3	0.xix
(b) Differences from dwelling house BP to awake SBP/DBP
First–third SBP (mmHg)	6.0 ± 10.four***	3.7 ± ten.vii*	0.005
Kickoff–third DBP (mmHg)	−ane.2 ± 7.7	−1.9 ± 7.6	0.15
First–2nd SBP (mmHg)	seven.0 ± 10.iv***	4.6 ± 10.vii**	0.005
Commencement–2d DBP (mmHg)	−0.9 ± 7.vii	−ane.8 ± seven.6	0.07
2nd–tertiary SBP (mmHg)	five.1 ± 10.5**	two.2 ± 10.9	<0.001
2nd–third DBP (mmHg)	−1.half dozen ± seven.vii	−two.2 ± 7.viii	0.xix
(c) Differences from outset to 2nd or second to third readings
Kickoff minus 2nd SBP	ane.4 ± two.5 (4)	3.seven ± 3.ii (16)	<0.001
Start minus second DBP	0.7 ± i.eight (0)	0.7 ± one.7 (1)	0.99
Second minus third SBP	2.iii ± one.5 (3)	1.2 ± 1.4 (1)	<0.001
Second minus tertiary DBP	0.vii ± 0.nine (0)	0.2 ± 0.nine (0)	0.002

Automatic measurement of clinic BP

Additionally, nosotros compared the clinic measurement of HEM-5001 and mercury sphygmomanometer. The average BP levels were 129 ± 15/77 ± 10 mmHg when taken by the mercury sphygmomanometer and 131 ± 15/76 ± 9 mmHg for the HEM-5001. The interclass correlations of understanding between mercury readings and HEM-5001 were 0.953 for SBP and 0.906 for DBP when 3 readings were taken each fourth dimension.

Patient compliance

Compliance was measured equally the number of each set of home BP readings taken per week. The numbers of occasions per week that three measurements were taken in the morning were v.2 ± 1.two days for the reading taken with ten-s intervals and v.3 ± i.4 days for the ane-min intervals (P = 0.91). There were no differences in the evening BP readings. So, the difference in compliance between the two measurement intervals was negligible (and not statistically significant).

Give-and-take

This study has shown that BP readings of a ten-s interval of multiple domicile BP measurements were higher than readings taken using the conventional 1-min interval. The ane-min interval of three measurements tended to give a better guess of the average daytime BP level, and, therefore, the 1-min interval would be better for clinical employ. This is the get-go study testing the validity of using very short time intervals betwixt BP measurements made at home.

The validity of using very short intervals between oscillometric BP measurements in the dispensary has been reported by two groups. Yarows et al. [15] reported that a 15-south interval betwixt BP measurements was as accurate every bit a 1-min interval in normotensive volunteers. Koehler et al. [16] showed that multiple BPs measured over a period of 10–15 s were like to those taken at i-min intervals using a sphygmomanometer and automatic devices (which were not cited as validated). Our results are consequent with these reports, merely the previous studies were performed only in clinical settings considering home monitors with preset measurement intervals were not bachelor. In contrast, with the appearance of new technology, we have been able to examine the results of using ii different and standardized measurement intervals for readings taken at home. We used the awake ABP as the comparator mensurate and also compared the abode readings with readings taken in the clinic under standardized conditions using both mercury sphygmomanometer readings and automated device readings. The main finding of the study was that though the intraclass correlations of agreement for the x-s and 1-min intervals at home with awake ABP were similar, the mean SBP levels taken at 10-s intervals were significantly higher than SBP taken at 1-min intervals, and the average home BP with 1-min intervals was closer to the daytime ABP. Because the BP measurements of x-due south and 1-min intervals were done in the same patients crossed over, the baseline BP level was similar, and arm size, cuff size, and deflation time were exactly the same for the ii measurement atmospheric condition. Therefore, we exercise not think that these factors affected the differences between the 10-due south and 1-min interval measurements.

The differences between the first and the second readings were larger for 1-min intervals than for 10-s intervals, and, conversely, the divergence of the second and the tertiary readings were larger for x-s intervals than for one-min intervals. Recent abode BP guidelines have stated that the boilerplate of the first and second readings should be used for clinical practice [thirteen,fourteen], but taking the average SBP of the second and third readings may all-time predict the awake SBP [20]. It should be pointed out that the device nosotros used had a relatively rapid inflation and deflation, and our findings do not necessarily apply to all other devices. There has hitherto been piddling investigation into how long the intervals betwixt measurements should be [15,16]. Hypertension guidelines have empirically recommended to wait for 1 or two min for the next measurement, which has been used for the Korotkoff technique [12]. Brook [21] has reported that the accurateness of HBP measurements, every bit adamant past their agreements with awake ABP, is similar regardless of substantial variations in HBP monitoring schedules, though the measurement interval effect was not discussed. Many of the patients in the present written report could accept started their measurements right after some activities without resting a few minutes. Consequently, their BP stabilized a few minutes after showtime the measurements. Namely, the second and the tertiary readings of the 1-min interval might have been measured in more than stable conditions than in the second and the third readings of the x-southward intervals during which the BP was nonetheless going down. For keeping patients' rest, 3 successive measurements of 1-min intervals would be better option in clinical practise. Our results can lead to a conclusion that the i-min measurement interval is preferable to the ten-southward interval for home BP measurement.

Accurateness of the HEM-5001

In the office BP measurement procedure, we compared the HEM-5001 with a mercury sphygmomanometer. The average office BP level taken past the HEM-5001 was very similar to function BP taken by a mercury manometer. The intraclass correlations of agreement in the HEM-5001 and mercury readings were excellent for both SBP and DBP. This is not an official validation study, but the HEM-5001 appears to be as accurate as a mercury sphygmomanometer.

Rationale for taking a ane-min interval between readings

In the American Center Association BP measurement guideline [12], the following statement was described without whatever citation: 'three readings should exist taken in succession, separated by at least 1 min. The showtime is typically the highest, and the average should be used as the blood force per unit area reading.' The rationale for taking 1 min intervals between multiple measurements appears arbitrary. Venous congestion or hyperemia has traditionally been idea to affect the BP measurement results when the Korotkoff method is used, merely in contempo reports, very curt time intervals betwixt readings did non produce unlike values from conventional intervals when oscillometric devices were used [15,xvi]. Ischemia in an arm distal to the measurement cuff tin can lower the recorded BP by v–15 mmHg if the ischemia is maintained at 20 mmHg to a higher place the systolic BP for 90 s, but it raises the BP much less if the ischemia is maintained for only 30 s [22]. As the proper technique is to inflate the cuff to 20 mmHg above the SBP and use a deflation charge per unit of 2 mmHg/s, the ischemia from total occlusion of the cuff should only concluding x southward, and is thus unlikely to change the measurement of the BP.

Compliance

The compliance mensurate was, unexpectedly, not statistically unlike between the ten-s and one-min intervals of BP measurement. We asked patients to measure out their BP on as many days as possible and at least 4 days/week. Because the patients in this study were from a hypertension clinic that unremarkably recommends that patients measure their home BP, the majority of them were used to taking frequent readings. Still, if nosotros had recruited patients who had never measured dwelling house BP, there might take been a difference in compliance between the 10-s and 1-min intervals, especially in the mornings when time is often most pressing. A further written report may be needed to resolve this issue.

Study limitations

In this study, average daytime ABP (131/79 mmHg) was equal to office BP (131/76 mmHg), and habitation BP (135/77 mmHg using 1 min intervals and the boilerplate of morn and evening readings) was college than office BP. The reason for the lower level of role BP than abode BP was that function BP was measured in the standard condition following the international guidelines afterward at least 5-min balance; measured by a research assistant (but a dr. in Japan) rather than by a doc and multiple measurements (more than half dozen readings) were taken in one occasion after seeing a doctor. The BP levels in the normal range were another reason for the relatively lower level of office BP as was reported in previous studies which have shown that office BP was the same or lower than the out-of-office BP when they were in normotensive range [23–26]. The use of large developed cuff (Due north = 8) may be another limitation of this study because the time of inflation and deflation is different from that of regular size cuff.

Determination

Although both the 10-s and 1-min intervals betwixt three successive domicile BP readings taken both in the forenoon and evening showed good correlations with the daytime average BP taken past ambulatory monitoring, and no divergence in patient compliance taking the readings, the one-min intervals gave average home BP levels that were closer to the daytime ABP and would therefore be recommended as optimal.

Acknowledgments

The report was supported in role by NHLBI grants PO1 HL 47540 and R24 HL76857 and Omron Healthcare.

Abbreviations

AAMI

the Association for the Advancement of Medical Instrumentation

ABP

Ambulatory BP

ABPM

ambulatory BP monitoring

DBP

diastolic claret pressure level

HBP

habitation BP

ICC

intraclass correlation coefficient

SBP

systolic blood pressure

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