Once a system is in place for making certain that the blood pressure is measure correctly, it is possible to define the steps necessary to enable a patient to determine if they are receiving excellent care in regard to blood pressure management.
Remember, one of the keys to correct blood pressure measurement is the relationship between the size of your arm and the size of the blood pressure cuff. In order to make certain this relationship is correct, SETMA has devised the following:
- Every patient has their mid-arm circumference measured. The date and results of that measurement are recorded. If a patient loses or gains a great deal of weight or in the case of a pediatric patient, as the patient grows, that measurement will be repeated.
- Based on that measurement the appropriate blood pressure size is automatically displayed on the patient's chart.
- When the nurse checks the blood pressure she/he records the size of the blood pressure cuff used.
A national organization, The Consortium for Physician Performance Improvement, whose members include the AMA, National Institute of Medicine, Medical and Surgery specialty Societies, CMS and others, has defined the following eight measures as the minimum standards for excellent care of high blood pressure. They are entitled the "Physician Role in Hypertension Management."
At SETMA, whether or not these standards are met is automatically captured based on the healthcare provider's treatment of high blood pressure. These eight responsibilities for the physician and/or healthcare provider are:
- Blood pressure measured at least once this visit - this may seem elementary, but it is the first step to excellence. The blood pressure must be measured and as indicated in our previous column on excellence in treating blood pressure, it must be measured accurately. If any of these measures are not followed when you see the doctor, ask that they be done. A good doctor will appreciate your request.
- Blood pressure measurement repeated if elevated - this is less obvious, but critical. If your blood pressure is elevated when first measured, it MUST be repeated after an eight to ten minute interval of sitting quietly. You will be amazed at how much difference this can make in the reading. Remember, the normal response to exercise, even walking into an office, is for your blood pressure to go up. When your heart rate goes up, either due to anxiety or exercise, your blood pressure will go up. Retaking the blood pressure allows for your body to adjust to both stresses and gives a more accurate picture of your actual pressure.
- Blood pressure classification determined - after your blood pressure has been taken correctly, and after it has been repeated if elevated, it is important to know the classification of that pressure. This will let you know the risk which your pressure represents for your future well-being. It will also let you know how imperative it is for you to get your blood pressure under control and consequently how aggressively the following five measures must be pursued.
In addition to the classification, it is possible to tell you the recommended follow-up interval, the risk group into which you fall, and the treatment recommended on the basis of your classification and risk group. At SETMA, each one of these is automatically calculated and is given to you in a "Hypertensive Follow-up Document." Please be sure and ask for it, if it is not given to you.
Classification of Blood Pressure |
| Adults > 18 Years of Age |
|
| Category | Systolic (mmHg) | | Diastolic (mmHg) |
| Optimal |
< 120 | and | < 80 |
| Pre-Hypertension |
121 - 130 | or | 81 - 85 |
| High |
131 - 139 | or | 86 - 89 |
Hypertension |
| Stage 1 |
140 - 159 | or | 90 - 99 |
| Stage 2 |
160 - 179 | or | 100 - 109 |
| Stage 3 |
> 179 | or | > 109 |
- Weight reduction discussed/recommended - It may not be obvious, but one of the most common causes of high blood pressure is being overweight or obese along with the inflammatory changes associated with excess weight. This is such an important issue because a twenty pound weight reduction will change your blood pressure by 5-20 mm Hg. This is the same effect as one blood pressure medication.
That is why we say, "Taking a walk will do more for your health than talking a pill." If you exercise enough, you will lose weight and your blood pressure will go down. It should not therefore be surprising that one of the measures of excellence in blood pressure control is that your healthcare provider should encourage you to lose weight. At SETMA, this is one of the reasons for the LESS Initiative. Every patient is given a weight assessment, an exercise prescription and is confronted with the issue of smoking, thus the acronym LESS which stands for L (lose weight) E (exercise) SS (stop smoking). No matter what your chronic illness, it will respond positively to proper diet, weight reduction and exercise. (For more on this see the six part series on Chronic Disease: Diet and Exercise below.
- Sodium intake discussed/changes recommended. if you have water going through a pipe, you will increase the pressure on the pipe if you increase the amount of water in the pipe. The same is true of your blood pressure. Often, particularly among African Americans, increased blood pressure is a function of increased fluid in the vessels. That increase fluid is often cause by the high salt content of our diet. Thus, for your healthcare provider to get credit for excellence in the care of your blood pressure and for you to judge whether or not you are receiving excellent care, salt reduction must be discussed.
By reducing your salt intake to no more than 2.4 grams a day, your blood pressure will be decreased by 2-8 mm Hg, again almost as much as one medication. The average American consumes 2-3 times this amount of salt a day. 70% of the salt you consume is found in processed (canned and packaged) foods you buy at the grocery store.
At SETMA, every person with high blood pressure or with pre-hypertension is given a DASH (Dietary Approach to Stop Hypertension) diet and a Sodium document which allows you to learn about the salt content of typical foods.
- Alcohol intake discussed/changes recommended - anyone concerned about avoiding high blood pressure should be aware that excessive alcohol consumption will result in hypertension. If you eliminate alcohol all together, or reduce your alcohol consumption to one drink a day (6-ounce glass of wine, one beer, or one ounce of 90 proof alcohol), you will reduce your blood pressure by 2-4 mm Hg.
When you see the effect of weight loss, sodium reduction and eliminating alcohol, you can see how life-style modification can have a greater effect on your blood pressure than taking two or three medications. Thus to receive excellent care for your blood pressure, your healthcare provider MUST discuss alcohol consumption with you
- Exercise discussed/recommended - a moderate intensive exercise program (walking three miles briskly - 14-15 minutes per mile - four days a week) will reduce your blood pressure by 4-9 mm Hg. This effect of exercise is apart from weight reduction, but which when combined with weight reduction, salt restriction and elimination of alcohol, can enable many people with hypertension to stop taking their medications.
You should never stop taking your medication without your physician's supervision and then only after weight loss, dietary modifications and an exercise program have been in place long enough to affect a reduction in your blood pressure. Once again, it is for these reasons that excellent in treating blood pressure requires a healthcare provider to give you an exercise prescription and it requires that you be encouraged to maintain an exercise program every time you see the provider.
- Appropriate follow-up scheduled - The eighth element in the excellent treatment of high blood pressure is that you should be seen at appropriate intervals. For instance if your blood pressure is 156/98, your classification is Stage I. You are at moderate risk and you should be seen within two months. If your blood pressure is 180/110, you have stage 3 hypertension, which places you at moderate risk and you should be re-evaluated immediately, or within one week. To receive excellence in the care of your blood pressure your healthcare provider needs to be able to calculate the classification and risk level of your current blood pressure and to give you a follow-up appointment appropriate to your classification and risk group.
Three Questions
The following three questions and their answers will give you some indication how important excellence in the care of your blood pressure is to your future health.
Question: If you are 55 years of age and if you do not have high blood pressure -- hypertension -- what is your risk of developing blood pressure in your life time?
Question: If your blood pressure is 135/85, what is your risk of cardiovascular disease as compared to a person whose blood pressure is 115/75?
Question: In societies where there is no dietary sodium chloride -- table salt -- what is the incidence of hypertension?
If you answered zero or very low to the first question, you are wrong. The probability of a person developing hypertension after age 55 is slightly over 90%. That's not the obvious answer, is it? It would seem that if you don't have high blood pressure by age 55, then you would be unlikely to develop it. The reality is that high blood pressure is so related to conditions which are rampant in America, that almost everyone will develop it, unless you take positive steps to avoid it.
If you answered 100% increase to the second question -- i.e., the person whose blood pressure is 135/85 has twice the risk of developing heart disease as the person whose blood pressure is 115/75 -- you are right. Increasingly, we are finding that whether it is in blood sugar with diabetes, cholesterol levels, or blood pressure, maintaining your health requires much stricter control than is commonly thought.
And, now we turn our attention to the ultimate culprit, salt. Do you add salt to your food without tasting it? Do you eat large amounts of Chinese foods with monosodium glutamate preservative? Do you heavily salt your corn-on-the-cob, pop-corn, French fries, etc. etc? Then you would answer the above question incorrectly, or you might say, I don't care about the answer. The fact is that in societies where there is not salt added to the food and where there is no naturally occurring salt, there is NO hypertension.
Life-style changes for excellent in treating your blood pressure
Let's review the life-style changes which can control, eliminate or prevent high blood pressure. Remember, while your healthcare provider should give you excellent care for your blood pressure, whether you get that care is ultimately up to you and the life-style choices you make every day.
- Eliminate or reduce alcohol consumption to one drink per day. A reduction in alcohol intake may reduce your systolic blood pressure 2-4 mmHg.
- Eliminate or reduce caffeine intake.
- Take measures to reduce and control stress.
- Weight Loss For each 20 pound reduction in body weight you may reduce your systolic blood pressure 5-20 mmHg. Your current body mass index (BMI) is 31.12. A BMI of 25 or less is desirable.
- Exercise
- Quit Smoking
- Modification of dietary habits
- Increase potassium intake.
- Increase calcium intake.
- Maintain adequate magnesium intake.
- Increase fish oil intake.
- Reduce sodium intake to no more than 2.4 grams per day. Following a low sodium diet may reduce your systolic blood pressure 2-8
mm Hg.
- Adhere to the principles of a DASH diet. Following the DASH diet may reduce your systolic blood pressure 8-14 mmHg.
- Increase potassium intake.
- Self-monitoring and recording of blood pressure.
- Keep all scheduled appointments.
- Take all medications as indicated.
Excellence in treating your blood pressure is a function of your healthcare provider's performance and your choices. Remember, it is your Life and it is your health.
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