Objective: To determine the difference in Blood Pressure (BP) readings taken before, during and after the clinic encounter.
Study Design: Descriptive study.
Place and Duration of Study: Cardiology Clinic, The Aga Khan University Hospital, Karachi, from January to August 2013.
Methodology: Hypertensive and normotensive participants aged ≥ 18 years were recruited. Pre-clinic BP was measured by a nurse and in-clinic BP by a physician. After 15 minutes, two post-clinic BP readings were taken at 1 minute interval. All readings were taken using Omron HEM7221-E.
Results: Out of 180 participants, males were 57% and 130 (71%) were hypertensive. Mean SBP (Systolic BP) taken preclinic, in-clinic, post-clinic 1 and post-clinic 2 were: 126 ± 20 mmHg, 131 ± 23 mmHg, 126 ± 20 mmHg and 121 ± 21 mmHg respectively (p \u3c 0.001). Mean DBP (Diastolic BP) taken pre-clinic, in-clinic, post-clinic 1 and post-clinic 2 were 77 ± 12 mmHg, 81 ± 13 mmHg, 79 ± 12 mmHg and 79 ± 11 mmHg respectively (p \u3c 0.001).
Conclusion: BP taken in the post-clinic setting may significantly be the lowest reading in a clinic encounter, making in-clinic BP unreliable to diagnose or manage hypertension

Almas, Aysha

Khan, Aamir Hameed

Khan, Hamza Sohail Kan2

Khan, Sohail Abrar

Shahab, Hunaina

English

eCommons@AKU

eCommons@AKUDepartment of Medicine Department of MedicineMarch 2015Are BP readings taken after a patient-physicianencounter in a real-world clinic scenario the lowestof all the readings in a clinic visit.Hunaina ShahabAga Khan University, hunaina.shahab@aku.eduHamza Sohail Kan2 KhanAysha AlmasAga Khan University, aysha.almas@aku.eduSohail Abrar KhanAamir Hameed KhanAga Khan University, aamir.hameed@aku.eduFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_med_medPart of the Cardiology CommonsRecommended CitationShahab, H., Khan, H. S., Almas, A., Khan, S. A., Khan, A. H. (2015). Are BP readings taken after a patient-physician encounter in a real-world clinic scenario the lowest of all the readings in a clinic visit.. JCPSP: Journal of the College of Physicians and Surgeons--Pakistan,25(3), 206-209.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_med_med/197206 Journal of the College of Physicians and Surgeons Pakistan 2015, Vol. 25 (3): 206-209INTRODUCTIONHypertension is a chronic disease of great publicconcern.1 The National Health Survey reports that everythird person in Pakistan, over the age of 45 years hashypertension.2 This accounts for 25% of all deaths in thecountry.3Blood Pressure (BP) reading taken in a physician's clinicbecomes less reliable due to various reasons. White-coat effect is defined as an alert reaction that occurswhen BP is measured by the physician, increasing thepatient's basal BP and affects normotensive patientsand those with sustained hypertension.4 It leads topersistently higher office BP compared with the readingstaken outside clinic.5 Upto 33% of the patientsexperience this white-coat effect.6,7 Anxiety associatedwith physician's interaction has been implied as thecause of difference in BP between nurse and physician'smeasurements and this is a recurrent theme in multiplewell-designed studies.8 Therefore, diagnostic andtreatment decisions should not be based on the readingtaken by the physician in the first encounter.8 The recentNICE guidelines 2011 for hypertension recommendedthe use of Ambulatory Blood Pressure Monitoring(ABPM) as part of the work-up protocol to diagnosehypertension,9 aimed to minimize white-coat effect. Thisrecommendation is being questioned due to its expense,24-hour length, inconvenience and lack of widespreadavailability,10 especially in developing countries.The medical environment affects BP readings;11 as wellas the observer taking the readings as shown by thehigher BP readings taken by the physician comparedwith those taken by the nurses.8,12,13 It washypothesized that the exact time within each clinic visitat which BP is measured may also affect reading; BPtaken post-clinic may be lower as anxiety associatedwith the clinic visit decreases.14Hence, this study was conducted to determine the meandifference in BP taken before, during, and after a regularclinic encounter in an attempt to find the lowest BPreading over the course of a routine clinic visit.METHODOLOGYIt was a descriptive study conducted from January toAugust 2013 in the Cardiology Clinic at the Aga KhanUniversity Hospital, Karachi. All hypertensive ornormotensive patients, aged ≥ 18 years, were asked toparticipate. Pregnant females, patients with volume lossCLINICAL PRACTICE ARTICLEAre BP Readings Taken After a Patient-Physician Encounter in a Real-World Clinic Scenario the Lowest of All the Readings in a Clinic VisitHunaina Shahab1, Hamza Sohail Khan2, Aysha Almas3, Sohail Abrar Khan4 and Aamir Hameed Khan5ABSTRACTObjective: To determine the difference in Blood Pressure (BP) readings taken before, during and after the clinic encounter.Study Design: Descriptive study.Place and Duration of Study: Cardiology Clinic, The Aga Khan University Hospital, Karachi, from January to August 2013.Methodology: Hypertensive and normotensive participants aged ≥ 18 years were recruited. Pre-clinic BP was measuredby a nurse and in-clinic BP by a physician. After 15 minutes, two post-clinic BP readings were taken at 1 minute interval.All readings were taken using Omron HEM7221-E.Results: Out of 180 participants, males were 57% and 130 (71%) were hypertensive. Mean SBP (Systolic BP) taken pre-clinic, in-clinic, post-clinic 1 and post-clinic 2 were: 126 ± 20 mmHg, 131 ± 23 mmHg, 126 ± 20 mmHg and 121 ± 21 mmHgrespectively (p < 0.001). Mean DBP (Diastolic BP) taken pre-clinic, in-clinic, post-clinic 1 and post-clinic 2 were 77 ± 12mmHg, 81 ± 13 mmHg, 79 ± 12 mmHg and 79 ± 11 mmHg respectively (p < 0.001).Conclusion: BP taken in the post-clinic setting may significantly be the lowest reading in a clinic encounter, makingin-clinic BP unreliable to diagnose or manage hypertension.Key Words: Hypertension.   White-coat hypertension.   Ambulatory blood pressure monitoring.   Blood pressure.1 Resident, Department of Medicine, The Aga Khan University,Karachi.2 Intern, Ziauddin University, Karachi.3 Department of Medicine, The Aga Khan University, Karachi.4 Department of Cardiology, Tabba Heart Institute, Karachi.5 Department of Cardiology, The Aga Khan University, Karachi.Correspondence: Dr. Aamir Hameed Khan, Faculty OfficersBuilding, Second Floor, Cardiology Section, Department ofMedicine, The Aga Khan University, Stadium Road, Karachi.E-mail: aamirhameedkhan@yahoo.comReceived: November 11, 2013;   Accepted: November 11, 2014.(e.g. diarrhea), taking an extra dose of antihypertensivemedication or taking NSAID’s were excluded.15A minimum sample of 101 participants was required toestimate a mean difference8 of 7.5 mm SBP (SystolicBP) and 2.9 mm DBP (Diastolic BP) at an alpha of 5%and a beta of 80% in BP before and after clinic visit.Keeping a dropout rate of 10%, the total minimumsample size was calculated to be 110.Ethical approval (1994-Med-ERC-11) for the study wastaken from AKUH, Ethical Review Committee. BP andpulse readings were taken at three different points in asingle clinic visit. The pre-clinic reading was taken by theassessment nurse after the patients waited for 16 ± 1.7minutes before being seen. The in-clinic reading wastaken by the physician inside the clinic room after15 ± 2.1 minutes wait. This waiting time was unavoidabledue to the high patient load in each clinic and applied toeach participant. After the clinic encounter was over,participants were asked to be seated, with a prohibitionof smoking or exertion, for another 15 minutes in thewaiting area. An interval of 15 minutes based waschosen on a study that suggested that SBP reaches aplateau phase within the first 15 minutes16 and to matchthe time interval that the patients waited before pre-clinicand in-clinic readings were taken. After 15 ± 1.3 minutes,participants were called back to another clinic roomwhere post-clinic readings were taken. Two post-clinicreadings were taken by a research officer at an intervalof 1 minute (post-clinic 1 and post-clinic 2). A standardBP measurement was observed for all four BP readings.BP was measured in the right arm at heart level, whileparticipants were seated in a chair with a back-rest.They were asked not to talk during the time the readingswere taken. All BP readings were taken using anautomated and validated Omron HEM7221-E to avoidinter-observer variability. The observers taking BP forthe study were the same as in a routine clinic toemphasize the clinic scenario in this study. Since thesame standard procedures were followed for eachreading and an automated apparatus was used, wecould appreciate the changes in BP being attributed tothe point in time of a clinic visit at which the readingswere taken.Statistical Package for Social Sciences (SPSS), version19 was used for analysis. Mean and SD were used forquantitative variables, and frequency and percentage forcategorical variables. The repeated-measure analysis ofvariance (ANOVA) was used to compare the mean BP atfour different intervals.The p-values were calculatedusing greenhouse-geisser method. The differences wereconsidered statistically significant when p < 0.05.RESULTSA total of 200 patients were approached. Of these, 12(6%) refused to participate and 8 (4%) left before the 15minutes wait was over, the main reason beingparticipants' shortage of time. Total sample size was180. The mean age of participants was 57 ± 15 years;57% were males and 71% were hypertensives.The mean SBP, DBP and pulse values taken pre-clinic,in-clinic, post-clinic 1 and post-clinic 2 are shown inPost-clinic blood pressure readingsJournal of the College of Physicians and Surgeons Pakistan 2015, Vol. 25 (3): 206-209 207Figure 1 (a,b,c): (1a). Trends of mean Systolic Blood Pressure (mmHg)amongst participants, pre-clinic, in-clinic, post-clinic 1 and post-clinic 2.(1b). Trends in mean Diastolic Blood Pressure (mmHg) amongst participants,pre-clinic, in-clinic, post-clinic-1 and post-clinic-2.(1c). Trends in mean pulse values (beats per minute) amongst participants,pre-clinic, in-clinic, post-clinic-1 and post-clinic-2.   Figure 1. A comparison amongst these values along withtheir values of significance is shown in Table I.The post-clinic 2 SBP and DBP were 10 mmHg and 2mmHg lower than the in-clinic SBP and DBP,respectively. The in-clinic SBP and DBP were observedto be 7 mmHg higher compared to the pre-clinic SBPand DBP. Pulse values showed a significant decrease of4 beats per minute (bpm) from pre-clinic to post-clinic 2.DISCUSSIONThis study showed that BP in the post-clinic setting maybe the lowest out of all readings in a real-world clinicscenario. Extensive literature is available on the in-clinicBP rise, clinic BP being higher than ABP or self-measured BP readings.13,17,18 Similarly, the serialdecrease of BP readings over the course of a clinic visithas been studied.19,20 However, the effect on patient'sBP and pulse in an actual clinic, once their physicianencounter ends, has not been researched thoroughly.This study showed that there was a clear cut rise in BPbetween pre-clinic and in-clinic readings, andsubsequently, when the alert period associated with thephysician's meeting was over, there was a substantialand significant decline in BP in the post-clinic period.The significantly lowered pulse readings post-clinicsignified a trend towards a decrease in the alert reactionthat the patient experienced initially on entering a health-care setup.The present study results agreed with those ofOgedegbe et al. where the researchers had measuredBP and state anxiety scores amongst patients in ahypertension clinic, stating that white-coat effect is aconditioned response.14 The pattern of BP readingsfollowed the same trend as the white-coat hypertensivesin the aforementioned study, showing an almost similardrop in BP between readings taken by the physician andthose taken after the physician encounter. They hadshown that the state anxiety score measured in theabsence of the physician is the lowest and thiscorrelated with the lowest BP taken post-clinic shown inthis study. With their findings, Ogedegbe et al.suggested the use of ABPM whereas we propose theuse of post-clinic BP as it may overcome the BP risebelieved to be associated with the anxiety related to thephysician's encounter.These results compared with those of Van der Welet al. study, which showed that thirty-minute Office BloodPressure Monitoring (30-minute OBPM) is an alternativeto the 24-hour ABPM.16 In this study setting where costand logistic constraints are cardinal, this 30-minuteOBPM may not be viable. Firstly, it required a validatedABPM device which may not be universally available inmost developing healthcare setups. Secondly, in a busyclinic, arranging for a separate, quiet room where BP ismeasured over 30 minutes may be logisticallychallenging. Furthermore, 30 minutes wait may notagree well with patients whereas BP readings taken 15minutes after the patient-physician encounter, shortensthe clinic stay making it a better option.The study was conducted in an actual clinic so ourmethodology and results can be applied to any routineclinic. Standard and validated instruments were used toimprove internal validity and to prevent inter-observervariability. Different observers recorded BP at differentpoints in time replicating the scenario in a real clinicwhere one observer cannot take pre-clinic and in-clinicBP on all patients.Hypertensive patients may behave differently withdifferent anti-hypertensive drugs which we did notaddress. No reading was higher in the post-clinic periodcompared to in-clinic. It is possible that since all thereadings were taken within the clinic, any patientexhibiting masked hypertension may not be evident inthe post-clinic reading.If the patient's post-clinic BP has decreased significantly,he/she can be seen by the physician again to make therequired changes in management. Additionally, thosepatients with a significant post-clinic drop may bereinforced to check their BP frequently. In order todecrease the need of using the expensive and effort-intensive ABPM to diagnose hypertension, we may needto make some changes in the regular clinic logisticsespecially in developing countries.In order to determine if post-clinic BP is as reliable andrepresentative as ABPM, further studies assessingcorrelations with ABPM are required. This may helpin validating this study and furthermore, reducedependence on ABPM.CONCLUSIONBP taken in the post-clinic setting may be the lowest ofall readings taken within a clinic. Therefore, it may bebetter than the falsely elevated in-clinic BP in diagnosinghypertension or assessing its control.REFERENCES1. Campbell NR, Niebylski ML. Prevention and control ofhypertension: developing a global agenda. Curr Opin Cardiol2014; 29:324-30.Hunaina Shahab, Hamza Sohail Khan, Aysha Almas, Sohail Abrar Khan and Aamir Hameed Khan208 Journal of the College of Physicians and Surgeons Pakistan 2015, Vol. 25 (3): 206-209Table I: Comparison of initial, in clinic, post-clinic-1 and post-clinic-2 blood pressure and pulse values.Initial reading Clinic reading Post-clinic reading # 1 Post-clinic reading # 2 p-valueMean (SD) Mean (SD) Mean (SD) Mean (SD)SBP (mmHg) 125.6 (20.23) 130.9 (22.79) 125.52 (20.00) 120.92 (21.45) < 0.001DBP (mmHg) 76.63 (11.98) 81.33 (12.65) 79.06 (11.83) 78.78 (11.18) < 0.001Pulse (bpm) 75.16 (14.51) 75.25 (13.93) 72.77 (13.22) 71.47 (13.21) 0.0082.  PMRC. National Health Survey of Pakistan. Islamabad: PMRC;1994.3. Hyder AA, Morrow RH. Applying burden of disease methods indeveloping countries: a case study from Pakistan. Am J PublicHealth 2000; 90:1235-40.4. Martin CA, McGrath BP. White-coat hypertension. Clin ExpPharmacol Physiol 2014; 41:22-9.5. Verdecchia P, Angeli F, Mazzotta G, Gentile G, Reboldi G.Home blood pressure measurements will or will not replace24-hour ambulatory blood pressure measurement. Hypertension2009; 54:188-95.6. Godil SS, Tabani H, Khan AH, Almas A. White coathypertension is not a benign entity: a cross-sectional study ata tertiary care hospital in Pakistan. J Pak Med Assoc 2011; 61:938-43.7. Elliott WJ. High prevalence of white-coat hypertension inSpanish resistant hypertensive patients. Hypertension 2011;57:889-90.8. Gunes UY. Comparison of agreement between differentmeasures of blood pressure in normotensive females. ApplNurs Res 2010; 23:159-63.9. McManus RJ, Caulfield M, Williams B. NICE Hypertensionguideline 2011: evidence based evolution. BMJ 2012; 344:e181.10. White WB, Maraka S. Is it possible to manage hypertensionand evaluate therapy without ambulatory blood pressuremonitoring? Curr Hypertens Rep 2012; 14:366-73.11. Alpert B, McCrindle B, Daniels S, Dennison B, Hayman L,Jacobson M, et al. Recommendations for blood pressuremeasurement in human and experimental animals; part 1:blood pressure measurement in humans. Hypertension 2006;48:e3; author reply e5.12. Coll De Tuero G, Sanmartin Albertos M, Vargas Vila S, TremolsIglesias S, Saez Zafra M, Barcelo Rado A. Does bloodpressure change in treated hypertensive patients dependingon whether it is measured by a physician or a nurse? BloodPress 2004; 13:164-8.13. Little P, Barnett J, Barnsley L, Marjoram J, Fitzgerald-Barron A,Mant D. Comparison of agreement between differentmeasures of blood pressure in primary care and daytimeambulatory blood pressure. BMJ 2002; 325:254.14. Ogedegbe G, Pickering TG, Clemow L, Chaplin W, Spruill TM,Albanese GM, et al. The misdiagnosis of hypertension: the roleof patient anxiety. Arch Intern Med 2008; 168:2459-65.15. Snowden S, Nelson R. The effects of nonsteroidal anti-inflammatory drugs on blood pressure in hypertensive patients.Cardiol Rev 2011; 19:184-91.16. van der Wel MC, Buunk IE, van Weel C, Thien TA, Bakx JC.A novel approach to office blood pressure measurement:30-minute office blood pressure vs. daytime ambulatory bloodpressure. Ann Fam Med 2011; 9:128-35.17. Wang W, Xie JX, Liu L, Ai XH, Zhang J, Sun JY, et al.Agreement comparison between home and clinic bloodpressure measurements in 200 Chinese participants. BloodPress Monit 2011; 16:277-81.18. Espinosa R, Spruill TM, Zawadzki MJ, Vandekar L, Garcia-Vera MP, Sanz J, et al. Can blood pressure measurementstaken in the physician's office avoid the 'white coat' bias? BloodPress Monit 2011; 16:231-7.19. Bovet P, Gervasoni JP, Ross AG, Mkamba M, Mtasiwa DM,Lengeler C, et al. Assessing the prevalence of hypertension inpopulations: are we doing it right? J Hypertens 2003; 21:509-17.20. Sala C, Santin E, Rescaldani M, Magrini F. How long shall thepatient rest before clinic blood pressure measurement? Am JHypertens 2006; 19:713-7.Post-clinic blood pressure readingsJournal of the College of Physicians and Surgeons Pakistan 2015, Vol. 25 (3): 206-209 209

Are BP readings taken after a patient-physician encounter in a real-world clinic scenario the lowest of all the readings in a clinic visit.

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Are BP readings taken after a patient-physician encounter in a real-world clinic scenario the lowest of all the readings in a clinic visit.

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