“My blood pressure is all over the place.” This is a common refrain from patients. What is a “good” blood pressure? Where is the best place to measure the blood pressure? How does getting a hair cut affect the blood pressure?

The blood pressure is never a single solitary number. It will fluctuate over the course of the day and is affected by many things, such as activity or drinking a cup of coffee. Think of the blood pressure as a wave on the ocean, it will have highs and it will have lows.  It is best to avoid tsunamis with wild swings between the peak and the trough. Large fluctuations in blood pressure are associated with an increased risk for heart disease. A controlled blood pressure will have gentle swings from high to low and be centered around an ideal number. That ideal number, or target blood pressure reading, has been a source of controversy. In late 2017 the American College of Cardiology published new guidelines declaring that patients with blood pressure greater than 130 systolic now have hypertension, supplanting the previous recommendation of 140. This reclassification means that there are 31 million people who now have hypertension and about 45 percent of Americans are considered to have hypertension, up from about 32 percent using the previous level. However, according to the new guideline, not all of the people with blood pressure > 130 should be treated with medication. Blood pressure lowering medications are recommended for patients with systolic pressure > 130 and who already have established heart disease or those whose estimated ten year cardiac risk is greater than 10 percent (based on the risk calculator cvriskcalculator.com).  Those with lower cardiac risk should continue with life style modification (exercise, weight loss, smoking cessation).  For patients with systolic blood pressure > 140, medication is recommended.

Where is the best place to measure the blood pressure? The doctor’s office is not the ideal location for blood pressure checks. Patients are often stressed about getting to the office on time and are often nervous. They are rushed into the exam room, not given time to relax, and a blood pressure cuff is slapped on their arm. None of this reflects a true reading of the pressure.  More and more these days doctors are relying on patients taking their blood pressure at home, where they are relaxed and comfortable. Another reliable method is an ambulatory blood pressure monitor, a blood pressure cuff worn for 24 hours, which gives an average blood pressure reading during the day and at night.  Both methods, home blood pressure readings and an ambulatory blood pressure monitor, can confirm hypertension in patients who have high readings in the office. Both can show if the patient has white coat hypertension (high readings in the office but normal at home) to avoid over diagnosis and over treatment.  Most importantly, ambulatory blood pressure monitoring is a stronger predictor of cardiac disease and mortality than office blood pressure values.  Given this data, the guidelines recommend the following for blood pressure targets: 140/90 in the office, 135/85 for home measurements and 130/80 for ambulatory monitors.  Lastly, the systolic blood pressure is a better predictor of mortality than the diastolic pressure. 

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What does having a haircut have to do with blood pressure? Black men have more hypertension, more hypertension resistant to treatment and a higher risk for cardiac death due to blood pressure than white men or black women. Until now, this population has been very difficult to treat.  A trial involving 15 black owned barbershops in Texas was able to reduce blood pressure by 27 points and was very successful at reaching blood pressure goals. How was this done? Blood pressure checks were done with the men in a relaxed environment while getting their haircut. A pharmacist was present in each barbershop and medication was prescribed and increased based on blood pressure readings each time the men came in.  These checks occurred every two to four weeks and the results were as dramatic as had ever been seen.

In general, the blood pressure should be lower than 140 systolic while avoiding wild swings. Ideally the blood pressure should be measured at rest and when comfortable, either at home or in your favorite hair salon.