wrist model is selected, it is important that the cuff fits properly. Some blood pressure monitors come with more than one cuff size or the ability to purchase cuffs of different sizes. Other monitors have cuffs that are designed to fit properly on a range of arm sizes. Individuals with very large arms may prefer a wrist model as wrist size does not usually change that much, even if a person does have a very large arm.

Most monitors display the systolic and diastolic blood pressures and heart rate. Many include other features, such as date and/or time stamp, memory and averaging. Indicators of irregular heart beat and/or alerts when the blood pressure reading is in a risk category also can be found on some monitors. Among monitors with memory functions, those that enable separate recording of results from two individuals may be of interest to couples. Most models come with AC adaptors, although some models rely on batteries.

directions for proper use of their home blood pressure monitor. Also, pharmacists should educate patients that small variations in blood pressure should be expected— because blood pressure does indeed vary somewhat throughout the day and from day to day. This is why measuring blood pressure at the same time of the day and/or under similar conditions is so important. This is also why it is beneficial to take two or three readings separated by a few minutes. Perhaps the first reading was a bit high because the person took it right after he or she sat down. After that person remains seated and relaxed for even a few minutes, the blood pressure reading is likely to be lower.

Patients should also be reminded that the home blood pressure monitor is just that—a monitor, not a diagnostic tool. However, the information from home blood pressure monitoring can help the physician with a diagnosis. So communication of home blood pressure results with the physician is very important.

 

Hypertension remains a significant problem in the

United States. With nearly half of patients not

achieving blood pressure goals, the pharmacist

needs to step forward to assist patients to manage

hypertension and minimize the risk

for cardiovascular complications.

 

Manufacturers seeking to market home blood pressure monitors in the United States are required to obtain a 510(k) approval from the FDA. The 510(k) is a premarket submission that demonstrates that the device is at least as safe and effective (substantially equivalent) to a device that was legally marketed prior to May 28, 1976, or a device that has previously been cleared under 510(k). The FDA’s guidance regarding the process recognizes standards set forth by the Association for the Advancement of Medical Instrumentation, (AAMI SP10:2002, AAMI 60601-2-30) as consensus standards. ^{21, 22}

Of course, even the most accurate home blood pressure monitor will not provide accurate results if it is not used properly. The pharmacist should play an active role is assuring that patients are following the

When educating patients on using a blood pressure monitor, the pharmacist should provide the patient with some general recommendations to improve accuracy. Patients should be encouraged to:

• Avoid the consumption of caffeine or alcohol, or the use of tobacco products, for at least 30 minutes prior to taking a reading because these can increase blood pressure levels.

• Go to the bathroom before taking a reading, because a full bladder can increase blood pressure levels.

• Sit still for five minutes before the first reading.

• Sit in a chair that supports the back and allows the feet to rest uncrossed on the floor.

• Place the arm used for the reading on a table or pillow at heart level.

• Take two readings, separated by two to three minutes.

Patients often are concerned by the

variability of blood pressure readings.

TABLE 3

Organizations with standards for home blood pressure monitors

The pharmacist should educate the patient that it is normal for blood pressure to vary throughout the day. Blood pressure can even vary slightly with each heartbeat. It increases with activity and decreases at rest. It even is higher in cold weather and during periods of stress. The way to get an accurate reading is to monitor blood pressure at the same time of day. A single elevated blood pressure reading is not an immediate cause for alarm.

Organization Web site Association for the Advancement www.aami.org of Medical Instrumentation

British Hypertension Society

European Society of Hypertension

www.bhsoc.org www.eshonline.org

The patient should keep a log of blood pressure readings that he can bring to his physician. The pharmacist also should offer to review the readings with the patient to evaluate if he has met his blood pressure goals and review for possible causes of not achieving these goals.

 

CONTINUED MONITORING

FOR ACHIEVEMENT OF GOALS

The pharmacist’s intervention to improve the patient’s outcomes should not end at education about lifestyle modifications and blood pressure monitoring. The pharmacist should remember to continue to evaluate the achievement of blood pressure goals. As mentioned earlier, 90 percent of Framingham participants achieved a diastolic blood pressure goal of <90 mmHg, but only 49 percent achieved a systolic blood pressure goal of <140 mmHg. ¹⁰ The strongest predictors of lack of systolic blood pressure control were age over 75 years, the presence of left ventricular hypertrophy and obesity. The strongest predictor of lack of diastolic control was obesity, with blood pressure being controlled one-third less than lean participants.

Poor adherence with medications can lead to lack of blood pressure control. Studies have found that approximately 40 percent of patients with newly diagnosed hypertension will discontinue therapy during the first year. ¹⁹ Poor adherence rates are lower ( 16 percent) among patients who are seen by a specialist, than those seen by a primary care provider. ²⁰ As a condition without symptoms, patients have difficulty understanding its significance. The medications may actually make the patients feel worse than they felt with high blood pressure, making them not want to take the medication. The pharmacist can utilize pharmacy filling records to assess if the patient is filling the prescription at appropriate intervals. Without valuable information about adherence, which the pharmacist can provide, a physician might simply increase the dose or add another medication to the regimen.

 

CONCLUSION

The ALLHAT study demonstrated similar results with 92 percent achieving diastolic blood pressure goals, while only 67 percent achieved systolic goals. ¹⁸ The study found that older age, higher baseline systolic blood pressure, left ventricular hypertrophy, chronic kidney disease and obesity were predictors of needing two or more antihypertensive medications. Other predictors of the need for multiple medications included diabetes mellitus and African-American race, particularly in women.

Hypertension remains a significant problem in the United States. With nearly half of patients not achieving blood pressure goals, the pharmacist needs to step forward to assist patients to manage hypertension and minimize the risk for cardiovascular complications. As the healthcare provider who interacts most often with hypertensive patients, the pharmacist should utilize this opportunity to make a difference in these patients’ outcomes. The pharmacist should work with the patient to identify concerns or issues that present barriers to adherence with medication regimens and lifestyle modifications. Pharmacists also can offer blood pressure screenings, educate patients on the importance of home blood pressure monitoring and help patients select a home blood pressure monitor that meets their needs.

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