Checking Your Blood Pressure the RIGHT WAY

Well, I went from not having hypertension, to suddenly having hypertension recently. I did not physiologically change but the parameters of what is considered to be healthy for the long-haul of life changed. Hypertension is no joke though. It is death by a thousand cuts, not something that will  kill you in the short term (usually, anyway--although is a common cause of hemorrhagic strokes and delirium-related seizure/injury for instance), but it is THE LEADING CAUSE OF DEATH AND DISABILITY OVER TIME by leading to stroke, heart disease, kidney disease, other vascular disease. That is beyond the scope of what I want to talk about here, but this below is the change:           

New guidelines 

(Essentially, they lower/shift the ranges of concern to emphasize earlier treatment for better long-term health outcomes and get rid of prehypertension, which semantically minimized something that should be addressed)

Normal: Less than 120/80 mmHg

Elevated: 120-129 systolic AND less than 80 diastolic 

Stage 1: 130-139 systolic OR 80-89 diastolic 

Stage 2: 140+ systolic OR 90+ diastolic

Hypertensive crisis: 180+ systolic AND/OR 120+ diastolic

What I want to discuss here briefly, are common mistakes I come across in actually checking blood pressure which can add to erroneous treatment. I strongly believe patients should be their own advocates and at least in part responsible for keeping track of their own health, and checking blood pressure should be a part of that.

Blood pressure monitoring devices are easy to come by these days and most people can save a little for 1 to 2 months (drop a soda/coffee habit for a month, for example), to pay for a quite reasonably-accurate $60 device.

Common mistakes I see:

Not calibrating: Ask your doctor if you can bring your home blood pressure monitoring device by the office to calibrate against theirs. I recommend an independent visit for this, so you aren't "rushed" like you might be during a routine visit where they are trying to keep the doctor on schedule as well, bending you into their day, and you might feel less anxious since you aren't having to see a doctor that day.

Not accounting for "white-coat hypertension" by the nurse who checks blood pressure at the primary care doctor, which may make the blood pressure seem higher than it is.

Not checking throughout the day for a realistic average. Checking first thing in the morning, before lunch, and before bed, can help identify sources of provocation, provide a more realistic blood pressure average, and help guide timing and dose of potential blood pressure medications (for instance, what if you are always high just before bed, but normal in the morning?). Doing this (slightly tedious) assessment three times a day for a week or 2 can be quite helpful in guiding your primary care doctor in creating a custom treatment plan.

Cuff over clothing: This can add up to 50 mmHg to the reading. If you roll up your sleeve but the roll is tight, this can also alter the reading. So wear a loose long-sleeve & roll it up, or just where a loose short sleeved shirt if you can.

Not resting a bit. I see this happen at my local pharmacy; a person is walking by with a bag of groceries and then just drops down, pushes the button, and then frowns at the results. You are supposed to rest quietly for 3-5 minutes before blood pressure assessment. Checking blood pressure in the middle of traffic... or 30 seconds after you walked down a long hallway from the waiting room, got off a scale, and hopped up on an exam table is not the standard by which blood pressure should be measured.

Cuff size: If you use a cuff too big, it will make your blood pressure seem artificially lower. Conversely if you use a cuff too small, it will make your blood pressure seem artificially high. Use the right size.

Talking: Answering your nurses questions or talking in general because you can't handle "uncomfortable silence" can increase your blood pressure up to 10mmHg. Be still and quiet.

Poor body position: Crossing your legs can raise systolic. An unsupported back can raise your diastolic. A generally tense/uncomfortable position can raise both. You aren't supposed to check blood pressure perched up on an examination table or slumped over in your armchair at home.

Timing of smoking: Don't smoke. But if you must, or you vape/chew nicotine gum, don't do it 30 minutes before you check your blood pressure. Nicotine temporarily raises blood pressure.

Pee: If you have a feeling of a need to urinate, that can artificially raise your blood pressure, just like general anxiety or a specific stress in your day/life.

Things Called TIA (transient ischemic attack) ...
but Are NOT

In my recent post, I addressed some terminology such as TIA versus “mini-stroke” versus small stroke. A TIA means that the CAUSE of your symptoms was a lack of blood flow to some part of your brain that returned BEFORE permanent damage was done (which would be called a stroke). I see patients all the time that were told they had a TIA but retrospectively did not.

They may have had transient neurologic symptoms.... but the "I" in TIA (ischemic--lack of blood flow) may not have been the problem.

A key word above is: RETROSPECTIVELY. At the time of symptoms, the clinician who evaluated the patient may not have had all the necessarily tools to be completely sure, so erred on the potential diagnosis that allowed for more generous, non-debated testing per your insurance company, or that allowed for the more generous level of cautious concern (both for your benefit) in case you really are having a TIA that could turn into a stroke… Or the presentation is confusing and we just can’t know for certain at the time what the cause was; you may have risk factors for a TIA or stroke but just be having an anxiety attack, for instance. Or your medical situation is complicated; maybe you have risk factors for TIA or stroke and a history of complex migraines that can appear stroke-like.

But when I hear about a patient having a TIA, I keep these other possibilities lingering in my mind, and you should know about these mimics too. That doesn’t mean you should avoid going immediately to the ER if you are having stroke-like symptoms, since up to a 3^rd of strokes are preceded by a TIA, often that same day (Most strokes DON'T give you a warning at all).
But AFTER you get out of the hospital, if there was some question of whether you really experienced a TIA, these things should be considered as well, primarily because it may have longer-term implications regarding what medications you are on or should be on.

In order, these are the most common mimics of TIAs:

Complex migraines

Syncope (passing out)

BPPV/peripheral vestibular disturbance (inner ear problem that causes dizziness or vertigo, sometimes with additional complaints like nausea, falling, mildly blurred vision, perceived change in hearing)

Seizure (usually simple or complex partial seizures, not the more dramatic generalized shaking kind)

Anxiety or a psychological cause otherwise

Transient Global Amnesia

Bell’s Palsy (weakness of one side of the face due to a viral insult to the 7th cranial nerve)

Peripheral nerve disease from various causes

Postural hypotension (brief diminished blood supply to your brain as you stand due to a heart or vascular issue in your body)

Tumor

Viral illness

Cardiac arrhythmia (kind of the same issue as postural hypotension)

Multiple Sclerosis

Drug/Medication related

Hypoglycemia

Parkinson’s Disease symptom fluctuation

Retinal/Ocular pathology

Spinal pathology

Trigeminal neuralgia

UTI

Delirium

“Mini-stroke,” I Hate You

When I discuss strokes, stroke-like symptoms, “mini-strokes”, TIAs with patient, I realize that there is a lot of misinformation out there, not only from the internet, but also due to the patient’s lack of medical training (which makes sense of course) and, frankly, coming from us doctors.

All doctors have different ways of explaining things, some better than others, either because they misjudge what the patient is willing to understand or is capable of understanding overall or understanding just in the complicated moment, or because maybe they themselves are not completely confident in the cause of symptoms or proper neurologic terminology or actual proper pathophysiology.

I present an example that I particularly hear quite frequently:

“Mini-stroke”

I don’t know what this means.

I don’t know if the person had a SMALL stroke, or transient ischemic attack (TIA) that someone has called a mini-stroke or they are interpreting as a mini-stroke. Or I don’t if they didn’t have anything clot/stroke/TIA-related at all and maybe they just had some temporary symptoms that were related to, say, a urinary tract infection that got out of hand, too much cold medication, the wrong medication/medication side effect, an anxiety attack, etc.

I wish the term mini-stroke would go away.

Either you had a stroke (which is permanent and NOT temporary or transient).

Or you didn’t.

If you have a TIA, by definition it is transient (since the “T” always stands for transient) and therefore NOT permanent (I guess we would call that a PIA—PERMANENT ischemic attack—but we don’t use that terminology) and a TIA is therefore NOT a stroke, so a mini-stroke cannot be a TIA. That’s like saying it was a…. “small-permanent-non-permanent lack of blood flow to my brain”… which inherently makes no sense.

I admit I am biased by profession. But am I splitting hairs? Does it matter if I understand what happened as a TIA or mini-stroke or small stroke? Of course it does. Why would we worry about funny moles on our skin or our fat or wrinkles or kidney function but not the details of what is or isn’t happening regarding the blood supply to our brain that we are conscious with?

Now, someone can be told they had a “small” stroke, but that is like saying I only got shot with a small gun versus a big gun. A .22 in the head is a great tool of the assassin and a .44 magnum bullet shot into your foot by Dirty Harry is problematic but theoretically you could still run a marathon after it healed. Like real estate, it is all about location, location, location.

A “small” stroke in your brainstem can kill you or devastate you. A “small” stroke in your speech center can prevent you from understanding language or speaking language forever.

If you have ANY stroke, of ANY size, you are definitively more likely to have more strokes unless something changes… so ANY stroke to me is LARGE in its implication. And TIAs are associated with a much higher risk of subsequent stroke within the following hours, days, and months, so calling either of these phenomenon “mini-strokes” does the patient a severe disservice.

In summary:

A stroke is permanent and is a big deal no matter how big or small it is.

A TIA is NOT a mini-stroke; it is a NON-permanent lack of blood flow that did NOT permanently damage the brain but suggests you are HIGHLY likely to have a stroke in the near future if something isn’t done.

There is no such thing as a mini-stroke in my book.