Loading...
When was the last time you visited a doctor’s office? Whether it was last month or a few years ago, you almost assuredly experienced the same routine: 1) you were weighed, 2) your blood pressure was measured and 3) your temperature was monitored. Your weight may have been off by a bit because you were probably wearing your shoes and clothes. Men probably have wallets in their back pocket along with a cell phone, but that’s not a big deal. Temperature readings are generally accurate. On the other hand, blood pressure measurement mistakes are common! No one seems to care, even though this key biological metric is really important.
Who’s Measuring Your Blood Pressure?
Blood pressure is an important risk factor for cardiovascular disease. In recent years the recommended threshold for treating hypertension has been lowered. Health professionals are expected to help people get their systolic blood pressure below 130 and their diastolic blood pressure readings below 80. So-called normal blood pressure is 120/80 or below.
There was a time when nurses and doctors measured blood pressure. They still do…occasionally. But if you go to a typical clinic these days the chances are good that the metrics mentioned above will be taken by a lower-paid technician. It has been our experience that these individuals have not been adequately trained. Blood pressure measurement mistakes are common!
Measuring blood pressure is not as simple as it seems. Doctors and nurses sometimes make errors. The technicians we have encountered in recent years rarely get the entire process correct. And that is at top-notch medical facilities where administrators should know better.
Cuff Size: One of the Most Common Blood Pressure Measurement Mistakes!
Researchers from Johns Hopkins University reported on a fascinating randomized crossover trial to determine the “Effects of Cuff Size on the Accuracy of Blood Pressure Readings” (JAMA Internal Medicine, August 7, 2023). The authors examined the effects of using a single standard-size blood pressure cuff to measure blood pressure in 195 adults with a wide range of arm sizes.
People with thin arms ended up with a reading lower than their actual blood pressure. In contrast, those with large arms had blood pressure readings substantially higher when measured with the standard cuff compared to a large cuff.
If people who needed an extra-large cuff were measured with a regular-sized cuff, the average blood pressure reading was 144/88. When these same individuals were measured with an appropriately-sized cuff, the readings averaged 125/79. The wrong-size blood pressure cuff for such individuals could lead to unnecessary treatment and more adverse drug reactions.
Please hit your internal pause button. When was the last time a technician (or a doctor or nurse for that matter) actually measured the circumference of your arm? I would bet it would be rare to never.
Everyone is in a hurry these days and most exam rooms do not have a way to measure arm size. More important, most exam rooms do not come equipped with various-sized blood pressure cuffs.
The Authors of This Study Introduce the Problem:
“Hypertension is the leading cause of cardiovascular disease worldwide. Accurate measurement of blood pressure (BP) is used to screen for hypertension and to diagnose and treat hypertension. Although there are several preparatory and positioning steps required for accurate BP measurement, individualized selection of appropriate cuff size is often overlooked, despite clinical practice guidelines.”
In other words, doctors have been told exactly what they are supposed to do prior to measuring a patient’s blood pressure. Many of those steps are ignored, especially the part about selecting “appropriate cuff size.”
Here is the “meaning” of this study according to the researchers:
“Using a regular BP cuff size for all individuals regardless of arm size resulted in strikingly inaccurate BP readings with an automated device; a renewed emphasis on individualized BP cuff selection is warranted, particularly in individuals with larger arm sizes.”
Let’s be really honest for a moment. A lot of Americans now come with “larger arm sizes.” We are a nation that is largely overweight. If a technician uses a “standard” cuff size on someone with a larger arm circumference, it is likely that the BP reading will higher than it actually should be. That could lead to an extra blood pressure medicine and that could lead to additional adverse drug reactions.
The SPRINT Trial vs. Office Readings:
Research published in JAMA Internal Medicine (Oct. 12, 2020) compared office blood pressure measurements to the careful readings obtained in the SPRINT research trial. There were over 3,000 patients whose data in these two different settings were compared.
To be clear, these patients were participating in this very carefully supervised research program. The investigators followed techniques for taking blood pressure that followed strict guidelines established by professional societies. The same patients had their blood pressure measured during routine doctor visits.
There was surprising variability between the numbers obtained in the office and those in the study. Many of the participants had higher blood pressure readings in the routine office visits compared to the research setting. The range of discrepancy was substantial. These higher BP readings could lead to the misdiagnosis of hypertension and the prescribing of unnecessary drugs.
Blood Pressure Measurement Mistakes:
The authors of the study offer this explanation for the differences in readings:
“Our results are generally consistent with prior studies that have demonstrated that BPs measured using proper technique are typically 5 to 15 mm Hg [mercury] lower than the corresponding BPs measured in the routine clinical practice settings. Improper BP measurement technique is likely the underlying cause of higher BPs in routine clinical practice compared with trial measurements. Nearly all of the protocol deviations in routine practice (eg, lack of rest period prior to readings, talking during measurement, and arm not supported) are associated with overestimation of BP.”
A Commentary on Blood Pressure Measurement Mistakes:
A commentary in the same issue of the JAMA Internal Medicine (October 12, 2020) noted that routine blood pressure measurements in the office setting don’t often follow established guidelines. People are rarely given 5 minutes of quiet time before their blood pressure is measured three different times.
The cuff size is almost never matched to the size of the patient’s arm and people may not be positioned with their feet on the floor, their back supported, and their arms supported at heart level.
The researchers suggest that blood pressure measurement mistakes might have contributed to the problem. The authors emphasize that proper blood pressure measurement technique is crucial.
The authors note:
“Blood pressure measurement in the office setting has been the primary method used for managing hypertension. These data underscore what has been reported in the literature for decades—routine office BP and research-quality office BP are different measures—and highlight the major gap between clinical practice and research studies in the management of hypertension.”
We now know that there are lots of blood pressure measurement mistakes made in the doctor’s office or clinic.
Readers Share Their Stories About Blood Pressure Measurement Mistakes:
We have heard from many readers who complain about pain when the BP cuff is inflated. Here is Gigi’s story:
“I have so much pain in my arm from a tight cuff when they check blood pressure. The nurse tells me to lower my arm, and rest my hand in my lap. This is wrong. If I try to place it at heart level, I am reprimanded.
“I can go in perfectly normal, and my BP will go up to 190 because they continually keep taking it the wrong way. Last week, the nurse took it 8 times in a row until I refused to let her touch me. My BP goes up as soon a the cuff begins to tighten. It’s like a panic attack, and nothing helps.”
Gayle has also had problems with automated blood pressure equipment:
“The new auto BP cuffs at the doctor’s office hurt like a *#*, and suddenly I have high blood pressure and am put on a medication to treat it. The drug makes me cough– not acceptable!
“I quit that med, and when next at the doctor’s office months later, insisted on manual reading. Big surprise, my BP was back to its usual 116/70. Gee I guess pain does raise your BP!”
Here is why waiting several minutes prior to BP reading is essential! Mary shares this story:
“My husband was at the doctor’s office and his first BP reading was 158. The doctor was very concerned but my husband said wait. After they had talked, my husband asked her to do another reading. It was 101, this was 15 minutes later! He dropped 57 points in 15 minutes.”
Preventing Blood Pressure Measurement Mistakes:
We have written extensively about how blood pressure measurements should be taken. Here is a link to an article with practical tips:
Seven Mistakes to Avoid When Measuring Blood Pressure!
Do you avoid mistakes when measuring blood pressure? We are constantly amazed at how many technicians incorrectly take blood pressure readings. Here are tips to help you eliminate errors.
You may also find this article of value:
What’s the Best Way to Measure Blood Pressure?
What’s better, blood pressure readings at the doctor’s office or at home? A new study will surprise many health professionals. The results should change attitudes!
Our eGuide to Blood Pressure Treatment provides additional insights on how to avoid blood pressure measurement mistakes. It also offers nondrug options for helping to control high blood pressure. Here is a link.
Final Words and Choosing the Right Size BP Cuff:
Before you let someone measure your blood pressure at a clinic or doctor’s office, ask that person to measure the circumference of your arm. That is especially important if you are either under or overweight! If they look at you with a blank stare, ask them if they have a cuff to accommodate your arm size.
Here are some guidelines to help you make sure you get the right size blood pressure cuff (American Journal of Hypertension, Nov. 2022):
Mid-arm circumference:
- Less than 26 cm (1o.2 inches) = Small Adult Size Cuff
- 26-34 cm (10.2 to 13.4 inches) = Regular Adult Size Cuff
- 34-44 cm (13.4 to 17.3 inches) = Large Adult Size Cuff
- More than 44 cm (17.3 inches) = Extra Large Adult Size Cuff
Please share your own experience with blood pressure measurement in the comment section below. If you think this article could help a friend or family member, please send it along.
Grace
I’d say my BP is taken incorrectly at least 40% of the time by the Medical Assistants and nurses at my PCP resulting in readings that are too high. When I ask for it to be retaken, it’s always lower. They use a manual extra large cuff on everyone every time but never wait and don’t always have my arm at heart level. My readings taken at home are always significantly lower.
Edward
I use a wrist cuff. It reads near my old arm cuff, which failed after several years of use. Disappointed that wrist cuffs were not addressed in the article.
Cindy
I’m surprised you guys didn’t emphasize (though it was mentioned indirectly) about the “white coat syndrome” problem, in which a person’s BP rises simply because he or she (a grammar nazi, I REFUSE to say “they” for one person) is in a doctor’s office! Added to that, battling traffic, trying desperately to make it there on time, and then searching for parking…! This can raise the BP significantly. Although my BP is low, it’s often measured 50 points higher because of these factors. Yes, I’m excitable plus I’m always running late.
Joy
I don’t think my BP has ever been taken correctly in a Dr’s office, and I am 76 years old! Pathetic!! Thankfully, my cardiologist takes my home readings, plus my white coat syndrome into consideration. At home I sit calmly for 5 min. (at random times of day) with my feet flat on floor, my arm level on arm of sofa. BP is mostly 110’s-120’s over 60’s-70’s. In Dr’s (and Dentist) it run 160’s-180’s over 80’s. None of the above rules are followed! Sad!
Anne
I need a larger cuff, and I do much better with manual blood pressure readings. When the medical assistant slaps my arm into a standard cuff on an automated machine, the process becomes very painful for me and my fingers start to get numb, and I become ready to howl. Many times when I ask for a larger cuff, they say they don’t have one. And often they don’t have a manual cuff, or someone who knows how to use it correctly.
Linda
The persons taking my blood pressure always holds my arm and/or tucks my hand in their armpit! This is very offputting and raises my blood pressure. I keep a weekly record of my readings at home and my blood pressure is very good.
Cate
In a building designated for cardiology there are many treatment rooms, and not a single one is set up to take blood pressure in a responsible way. I have had one dopey self-important paraprofessional in her high heels insist on taking my blood pressure while I was standing up, having just entered the room, on the way to the little chair against the wall, with no desk next to it on which to place the arm….Sometimes they want me to sit up on the exam table — I decline—and sometimes they pull my arm out straight while “supporting” it with one of their hands. This is par for the course in the St. Luke’s medical system, which places full page ads in the paper about how its cardio program has been named as wonderful beyond compare. People are sick and tired of corporate medicine. My husband of course has the same sort of half-baked negligent treatment, a large arm, and huge amounts of poisonous drugs prescribed to treat blood pressure. Any attempt to discuss is ignored. I guess the blood pressure measurement scam is one way to gin up business, after patients are damaged by it.
Lulu
Our doctor’s office use a wrist cuff, as we do at home. Hopefully that will help get an accurate reading as I don’t believe there is as much difference in wrist measurements as in upper arm.
My husband and I have “white coat syndrome” and the readings go back down when BP is re checked at the END of the appointment.
Julie R
I no longer allow my PCP to take my blood pressure for all the reasons listed in your article. I have a quality BP machine at home with which I take readings. Even my Cardiologist’s nurses don’t take it correct at least 50% of the time. (Seems there is a new nurses every time I visit.) I also agree with the pain and bad readings from those rolling BP machines. My Cardiologist accepts my home readings without concern. Thank you for your fine investigative work on this and many other issues.
Joe
It always seems like a race to get through the intake process. It is often that my BP is taken within 30 seconds of getting to the exam room. All the while the “nurse” is asking me questions. They squirm when I ask how long it has been since the BP machine has been recalibrated.
Theresa
I am an RN of over 50 years who taught correct BP measurement techniques to new nursing assistants.
I am constantly appalled at the lack of training/understanding of correct procedures, poorly calibrated electronic equipment, and apathy at the importance of accuracy in this vital sign.
When I give advice or make corrective statements, even very graciously, I’ve been labeled as “trouble,” even having one physician come in and chastise me for upsetting her technician (I told her she was using the wrong size cuff). No long using that medical practice, but lack of knowledge and undersanding is rampant.
Marilyn
Interesting comments!!
Another important factor in accurate blood pressure readings is correctly identifying the pulse point for placement of the cuff or stethoscope.
CHARLES
Where is “mid-arm”? Thanks
Kenneth
My wife recently had a 150/84 reading in our new doctor’s office, the doctor prescribed Amlodipine, which made her feel dizzy. The doctor agreed to stop the medication.
We took some readings at home on an Omron BP machine, my wife’s numbers were in the 90/60s. We sent those numbers to the doctor, who then understood that my wife’s blood pressure was normally not high.
Reading this article, I now think she needs the small adult cuff to get more accurate readings, her BP measurements in her former doctor’s office were were more in the 110s for the upper number.
It may be that our new doctor’s BP cuff isn’t the right size for her either.
R
I am going to type this up and print it out as an instruction card to hand to the technologist when I go, with the references at the bottom.
Linda
“Systolic blood pressure increases at a constant rate with age[7]. In sharp contrast to the current paradigm, we find that this increase does not incur additional risk.”
There is a non-linear relationship between mortality and blood pressure/European Heart Journal (2000) 21, 1635–1638 doi:10.1053/euhj.2000.2227
I’ve read several medical journal articles stating that the Framingham Study that resulted in the current medical thinking was wrong. I haven’t revisited the subject for several years so maybe it’s different now but it seems that no matter how many studies are done to disprove current practices, they are all disregarded by what passes for medical care now.
Among my elderly friends and I, our conclusion is that we need to stay as healthy as possible and avoid “medical care” if we can because it’s pretty much a contradiction in terms with corporate “health care” and big pharma. They’re killing us more than curing us, keeping us barely alive to keep the insurance money rolling in.
Lars
I have white coat hypertension and measure my blood pressure at home.
I had an interesting experience at the dentist recently. Usually I follow all the guidelines you have mentioned here like remaining silent.
But since it was only the dentist, this time I answered a question and spoke during the measurement to continue the conversation with the hygienist.
Well guess what! Evidently by thinking about the conversation instead of worrying about the measurement, it helped me relax and my blood pressure was 117 / 73.
I think I worry so much about “relaxing” and everything being correct that it is making things worse.
So next time I’m going to try making small talk during the next measurement to see if it was a fluke, or if that gives my brain something else to think about and lets me relax to my normal BP.
Lillian
The condition of the blood vessels in your retina can indicate if you really have high blood pressure and the optometrist can check when you have your next eye exam.
Jackie
I understood you should have both feet flat on the ground, arm raised and rested to heart level. You should not eat or drink prior to having the BP taken, (especially caffeinated drinks or dark chocolate), and should remain silent (not talking), during the duration of the test. My husband,( who had heart failure for many years), was put on a high seat at his cardiologists office, feet dangling in the air and arm barely raised from his body. I helped a neighbour recently who was taking their own BP with the pulse meter not in the crook of the elbow, but behind the arm. I’ve seen that on TV too where they should be more aware surely? Take care everybody.
Sandy
Read all the comments so far. They are all spot on! My BP is fine at home. I have white coat syndrome and finally told docs about that up front so they take several readings, and see that it comes down. Once I even refused to let a doc take it because he kept insisting that I go on BP meds even though it was never high except in his office. Ended up changing docs. People absolutely HAVE to stick up for themselves and not be put on meds that can damage other organs, etc. Insist on wearing a monitor for 24+ hours before allowing meds if you fall into these categories.
Gerry
After waiting in the reception area for nearly an hour was grabbed and put in a chair, arm hanging, blood pressure cuff slapped on, bp taken twice. Assistant says “Oh, that’s not good.” Later, sitting in chair in another office waiting for doctor, same thing, arm hanging, not good result. Doc said “You may need diabetes meds.”
I changed doctors, haven’t tried this new one but if no good will change again. BIG problem. They aren’t trained correctly; they are rushed; I feel like they see me as just an old person who needs to die and get out of their way. Drugs are their answer to everything.
I refuse to take them as I have a lot of life-threatening allergies to many of the ingredients.
Carol
I’ve had similar struggles to get my PCP to properly take my BP. After struggling over readings taking without proper setup, compared to mine at home (slightly elevated but normal for my age), I finally gave in. After 1 day on meds, I suffered a medical event where my BP dropped dangerously low. I was terrified!
Only then was I told I probably don’t need medications! My BP is still elevated in office, but since they won’t employ proper techniques, I just continue monitoring at home where it’s normal. I don’t understand why BP isn’t taken properly in a clinical setting when the same staff would be more meticulous about any other testing that’s necessary for over all health evaluations?
Marilyn
My blood pressure is almost always high at the doctor’s office and much lower at home. At home it is lower than 120 over 80. I haven’t been to a doctor’s office that took my blood pressure correctly, ever! When I tell the nurse all the things you state in this article, they always say that doesn’t matter. How can we get the medical staff to take our blood pressure correctly?
Cate
Local hospital corporation, one of two that has been buying up every private practice in town for a decade or more, has a whole building devoted to cardiology. We have been seen by two cardiologists, one an electrophysiologist and one a specialist in heart failure, and been examined in at least half a dozen different rooms. Not one of those exam rooms was set up for the proper way of taking blood pressure. They ask you to sit on an exam table, with legs dangling, or they have actually taken my blood pressure the minute I entered the room, while I am standing up, with my arm extended out in front of me. Never done more than once, even when some nurse practitioner got a really weird reading (an artifact of atrial fibrillation). She simply changed my medication dose for one day….of course, I ignored her nonsense.
Even when I sit in a chair with side arm rests, they do not allow me to rest my arm, but pull my arm straight out in front of me. And I am swallowing four different drugs that lower blood pressure. It is disgusting what passes for medicine these days.
Mary A
While out of town, I had emergency gallbladder surgery on Labor Day. I had been up all Saturday night in severe pain (left side, referred pain according to ER doctor). I didn’t sleep much on Sunday night either, had surgery Monday morning, spent Monday night in the hospital. The day nurse got a high BP reading, told the floor doctor, and they ordered BP Meds. Small cuff, no sleep, surgery, age 65, over weight. I refused to take the medicine until they got a larger cuff. When they got the larger cuff I no longer had high BP. The nurse actually expressed surprise that I had low to medium normal BP. I am a large, 65 year old woman (BMI 36). I said there were probably at lot of women like me who were on meds unnecessarily. She had no comment but I have always wondered if the automatic assumption of age and weight stops medical professionals from re-checking.
Brian
Seeing is believing. I see myself as my own heart health patient. These times are filled with healthy heart substitutes. Fresh Air has no Sub. Now that I do not smoke my heart is healthier too. Give less substitutes, and watch me live better. I do not like all these fakes. Thanks for the watch dog article.
Neville
I have “white coat syndrome” although these days many doctors do not wear white coats. My BP was regularly in the region of 150/90 and put on a statin. After being unable to get out of my chair at home because of its side effect, I was sent to hospital outpatients and fitted with a 24 hour monitor. The result came back with an average reading of 118/78. I then purchased a DIY home monitor from a pharmacy. My most recent BP reading was 114/76.
Out of interest. I eat a Mediterranean/Scandinavian diet, Oily fish, fruits and vegetables. No red or processed meats. Always been a teetotaller and never smoked.
Marie
Not to mention to aggravation of waiting forever in the reception area to see a doctor. By then I’m so annoyed that I’m sure it’s higher than usual. I have a good cuff at home, and monitor my BP that way.
Mary
I agree with Rebecca. The nurse rushes you in, asks questions the whole time, and never uses the right size cuff. I have a large arm and the standard cuff pops off during inflation.
One of my doctors has a “high chair” that makes it more convenient for the nurses (they don’t have to bend over to get to you) but leaves your feet dangling and has no back support.
I have NEVER had my arm supported, never given any rest time and you can’t talk them into taking a second let alone a third reading.
My home readings average 110/70, but have been as high as 120/80. At the doctor’s I have gotten as high as 150/90.
My doctor wanted to put me on BP meds but after I took my blood pressure machine to him so he could see the readings he said he was glad he didn’t start meds because I probably would have passed out.
Chris
Normally have slightly elevated BP. At the dr office, an aide took my BP with a very large cuff (I weigh 120). I told her the cuff was too large, and she said it was ok. When she got the reading, both systolic and diastolic were under 100. I said it’s wrong, that’s way too low. She says, well I guess this is your lucky day. I reported that one, but it was not taken again.
Mags
Thank you for this important and informative article. Raising awareness of these mistakes are very important to so many conditions for which we need consistent and ongoing care.
Mary
I agree. I have one doctor who uses a manual BP device, and my BP is always lower than with the automated ones. How often do the BP machines get checked for accuracy? I realize that how well a person hears could effect the manually-done readings
One PCP actually told me that I would have a stroke if I didn’t start medication. My response was that I would consider medication IF and only IF my BP was taken properly. They had me on the exam table with feet dangling… no support for my back, my arm, and they told me to rest my arm on the table – so basically let it just hang there. When I asked if she would take it again with me sitting on a chair, feet on the floor, back supported on the chair and arm supported on the desk. Her response? The cord won’t reach that far for me to plug it in by the chair. I found another PCP.
Tim
So I was at the doctor 3 days ago. After driving there and waiting outside for 10 minutes in 80 degree sunshine (because of covid 19), I’m finally escorted inside, stop to weigh in, then go into the exam room and immediately have my BP taken. It’s 136/90. What would it have been if I could have cooled off and rested a few minutes?
Donna
I have an auto immune disease that, among other things, has caused lung disease and also asthma and allergies. I have a chronic cough from these things. Walking into the doctor’s office often leaves me coughing and short of breath. I’m short, so the chairs never fit me well, i.e. my feet are never flat on the floor, and my back not supported. My blood pressure always runs high in the doctor’s office. If they take it again 10 -15 min later, it’s gone down. When I take it at home, I make sure my feet are flat on the floor, my back is supported, my arm is resting at heart level, and I rest that way 10 – 15 min. It’s still not quite as low as the recommended level, but not bad. I should note that I am on some blood pressure meds, too.
Jane
At my last doctor visit my bp was incorrectly taken, ie virtually immediately, my arm hanging down and the nurse chatting away with questions. I also would submit that most people will have a bit of elevation at a medical office. It is at least a little stressful to most I imagine.
I have become so cynical, I don’t think there is any such thing as “unnecessary” medication as far as the medical community is concerned. The prevailing view seems to be that the entire population suffers from a lack of pharmaceuticals. To me there is something fundamentally wrong with the entire approach if half of the adult population, or more, has “pre-existing conditions.”
Perhaps if the same amount of TV time was spent on public service announcements regarding healthy life style as on drug advertising we could make some actual progress with health.
CC
My father in-law, now deceased, was an internist for NFL football team, who said they took BP with a thigh cuff on arms of players in order to get correct reading. Arm cuff was inaccurate due to size of arms.
Alison
I started speaking up at the doctor’s office. I ask for rest time after walking in. I complain if the cuff is not on correctly. I don’t speak when asked questions during my BP. I always ask out loud, “Why doesn’t this chair have an armrest.” If the cuff is too high or too low I speak up and have it adjusted. It makes a difference. If the reading is too high for me I ask for my BP to be taken again before I leave the doctor’s office.
Rebecca
I would have never guessed the correct way to measure BP, based on my experience with doctors. At least 95% of the time at least one of the rules are broken – sometimes over half of them are.
The biggest mistakes
No rest time
Talking – nurse keeps asking questions
Arm dangling – not at heart level
One reading only
Cuff wrong size
Most of these mistakes are made most of the time.