Med Biol Eng Comput (2011) 49:33–39
DOI 10.1007/s11517-010-0694-y
ORIGINAL ARTICLE
Estimation of mean arterial pressure from the oscillometric cuff
pressure: comparison of different techniques
Dingchang Zheng • John N. Amoore •
Stephan Mieke • Alan Murray
Received: 10 June 2010 / Accepted: 7 October 2010 / Published online: 2 November 2010
 International Federation for Medical and Biological Engineering 2010
Abstract Mean arterial pressure (MAP) is determined in
most automated oscillometric blood pressure devices, but
its derivation has been little studied. In this research, dif-
ferent techniques were studied and compared with the
auscultatory technique. Auscultatory systolic and diastolic
blood pressure (SBP and DBP) were obtained in 55 healthy
subjects by two trained observers, and auscultatory MAP
was estimated. Automated MAP was determined by six
techniques from oscillometric cuff pressures recorded
digitally and simultaneously during manual measurement.
MAPs were derived from the peak and foot of the largest
oscillometric pulse, and from time domain curves fitted to
the sequence of oscillometric pulse amplitudes (4th order
and three versions of the 6th order polynomial curve). The
agreement between automated and auscultatory MAPs was
assessed. Compared with the auscultatory MAP, the auto-
mated MAP from the baseline cuff pressure at the peak of
the 6th order polynomial curve had the smallest mean
paired difference (-1.0 mmHg), and smallest standard
D. Zheng
A. Murray
Regional Medical Physics Department, Freeman Hospital,
Newcastle University, Newcastle upon Tyne, UK
J. N. Amoore
Department of Medical Physics, Royal Infirmary of Edinburgh,
Edinburgh, UK
S. Mieke
Physikalisch-Technische Bundesanstalt, Abbestrasse 2-12,
10587 Berlin, Germany
D. Zheng (&)
Cardiovascular Physics and Engineering Research Group,
Regional Medical Physics Department, Freeman Hospital,
Newcastle University, Newcastle upon Tyne NE7 7DN, UK
e-mail: dingchang.zheng@ncl.ac.uk
deviation of paired differences (3.7 mmHg). These values
from the peak of the largest oscillometric pulse were -1.3
and 6.2 mmHg, respectively. Determining MAP from a
model of the oscillometric pulse waveform had the smallest
differences from the manual auscultatory technique.
Keywords Blood pressure
Cuff pressure
Mean arterial
pressure (MAP)
Non-invasive blood pressure (NIBP)

Oscillometric pulse
1 Introduction
Measurement of blood pressure is one of the most common
and important clinical and diagnostic measurements made
by family doctors and hospital physicians [3]. Accurate
blood pressure measurement is very important, with pub-
lished data estimating that with a 5 mmHg overestimation,
millions of people would receive an inaccurate diagnosis of
hypertension and take unnecessary anti-hypertension
medication, as well as increase unnecessary costs to
healthcare providers [13]. A systematic error of 5 mmHg is
also the absolute maximum systematic error allowed in
assessing blood pressure devices [12].
Systolic and diastolic blood pressures (SBP and DBP)
are important in assessing cardiovascular status, but there is
also clinical interest in mean arterial pressure (MAP),
defined as the average pressure throughout the cardiac
cycle. MAP is considered to be the driving pressure for
perfusion of most vital organs, which should be at least
60 mmHg [4]. MAP has physiological and clinical
importance, and can be used as a predictor of cardiovas-
cular risk [21]. For women in pregnancy, MAP has been
reported as a better predictor for pre-eclampsia than SBP
and DBP [7]. MAP is also useful in intensive care, where it
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can often be directly measured from invasive arterial changes in the oscillometric pulses in the cuff pressure, and
pressure, for assessing hemodynamic variables to guide hence destroy the smoothness of the oscillometric wave-
treatment [10]. form envelope, leading to difficulties in accurate BP
The true MAP is calculated from the invasive blood determination. Therefore, developing a technique which
pressure curve, but invasive measurements are generally can reliably determine MAP is important.
not clinically acceptable. Traditionally, non-invasive MAP The aim of this study was to develop different tech-
is calculated by using an empirical formula, in which MAP niques to estimate automated MAPs from oscillometric
approximately equals DBP plus 33% of the pressure dif- waveforms and to compare these estimations of MAP with
ference between SBP and DBP [11]. The value of ‘33%’ is the auscultatory derived method.
referred to here as the manual mean weight for calculating
MAP. The gold standard for non-invasive SBP and DBP
measurement has been readings taken by a trained observer 2 Methods
using a mercury sphygmomanometer and the Korotkoff
sound technique [17]. MAP derived from this classic 2.1 Subjects
manual technique is regarded as a useful measurement.
Mean arterial pressure is also determined in most auto- Fifty-five normal healthy subjects, with no known cardio-
matic, non-invasive blood pressure measurement devices vascular disease, were studied. There were 39 male and 16
(NIBP) using the oscillometric technique [8, 18], even female subjects, with ages in the range 20–74 years. The
where it is not displayed. Those automated devices are detailed subject information including age, sex, height,
used frequently in many health care institutions [3]. weight and arm circumference are summarized in Table 1.
Technically, automated oscillometric devices analyse the This study received ethical permission, and all subjects
pressure pulse changes (oscillometric pulses) induced in a gave their written informed consent.
pressurized cuff wrapped round the limb during deflation.
These changes are caused by the pulse radiating down the 2.2 Blood pressure measurement protocol
artery producing pressure changes in the cuff, which are
expected to be greatest at MAP [18]. This feature has been Blood pressure measurements were undertaken in a quiet
used to determine MAP in these oscillometric blood pres- room. The subject was seated in a chair with their feet on
sure devices. Manufacturers of automated devices then the floor and with their arm supported at heart level. There
devise their own algorithms by adding additional infor- was a 5-min rest period before formal recording to allow
mation, such as characteristic ratios of the pulse amplitude cardiovascular stabilization.
to the maximum pulse amplitude, to estimate SBP and Figure 1 shows the schematic representation of the
DBP after using MAP in the calculation [8, 24]. measurement protocol. Auscultatory SBP and DBP were
A characteristic of the oscillometric pulses (typically recorded under controlled conditions with a reliable, accu-
amplitude) is used to construct the oscillometric waveform rate and clinically validated electronic sphygmomanometer
envelope which characterizes the variation in oscillometric
pulse amplitude with cuff pressure. Ideally, the oscillo-
metric waveform envelope is a smooth curve with a distinct
peak from which the MAP can be determined. However, Table 1 General data information for the subjects studied
the oscillometric waveform envelope is constructed from Subject information
samples (at the pulse rate) of the changing cuff pressure. In
No. of subjects 55
the majority of oscillometric NIBP devices, often with fast
No. of male 39
deflation rates up to 10 mmHg/s, the number of detectable
No. of female 16
oscillations is reduced in comparison with that from the
No. of 148
recommended deflation rate of 2–3 mmHg/s. Interpolation
measurements
is then necessary to compensate for long periods between
oscillometric pulses. Furthermore, the oscillometric wave- Minimum Maximum Mean SD
form envelope is not always a neat bell-shaped curve with a Age (years) 20 74 39 16
distinct peak [2]. Rather than a distinct peak the oscillo- Height (cm) 152 188 172 9
metric waveform envelope may have a plateau. To further Weight (kg) 46 103 71 11
add to the challenge of determining the MAP, the oscil- Arm circumference (cm) 22 38 28 2
lometric measurement is compromised by movement and SBP (mmHg) 90 140 119 13
other forms of artefact, such as respiratory disturbance DBP (mmHg) 53 90 75 10
[1, 14, 19, 22]. These disturbances are associated with

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Med Biol Eng Comput (2011) 49:33–39 35

Oscillometric three recordings on 38 subjects and two recordings on 17

cuff pressure waveform Automated MAP
to computer
Observer1
(SBP, DBP)
Manual MAP
Observer2
(SBP, DBP)
Fig. 1 Overview of the blood pressure measurement protocol
(Accoson Greenlight 300) [9], simultaneously by two
trained observers using a dual-headed stethoscope. The
whole auscultatory measurement procedure followed the
guidelines recommended by the American Heart Associa-
tion [17]. All measurement pairs agreed within 4 mmHg
and their average values were used for further analysis. On
each subject, repeat recordings were performed after the
cuff pressure was released for 2 min. There was no signif-
icant difference on the auscultatory SBP and DBP between
repeat recordings (both P [ 0.15). The average value of
auscultatory SBP and DBP from the repeat recordings was
calculated as the reference SBP and DBP for that subject. In
total, 148 recordings were included from all subjects, with
subjects. The overall mean and standard deviation (SD) of
auscultatory SBP and DBP over all subjects are also given
in Table 1.
During each recording, the cuff pressure was deflated at
2–3 mmHg/s and recorded by a pressure sensor in a sep-
arate recording system. As the subject was asked to keep
still during the whole measurement procedure, movement
artefact and its effect to the cuff air system was minimized.
The cuff pressure was then digitally recorded to a data
capture computer at a sample rate of 2000 Hz for sub-
sequent off-line analysis. The oscillometric pulses were
then extracted from the cuff pressure after segmenting each
pulse and removing the baseline cuff pressure by using the
software previously developed by the PTB in Berlin,
Germany, and checking the pulse extraction manually [16].
The segmentation borders were at the feet of oscillometric
pulses. The peak of each oscillometric pulse was used for
further analysis. Figure 2 shows typical examples of
deflating cuff pressures and the corresponding oscillomet-
ric pulses as the cuff pressure was reduced. The oscillo-
metric waveform in Fig. 2a has a distinct peak, whilst there
is a plateau in Fig. 2b.

Fig. 2 Typical examples of

cuff pressure and extracted
oscillometric pulse waveforms
with a distinct peak (a) and with
a plateau (b). Oscillometric
pressure was measured from the
oscillometric pulses, which
were extracted from the cuff
pressure after the removal of the
cuff deflation pressure

Fig. 3 Illustration of the

calculation of MAP from six
different techniques. See text
for the detailed definition. In
this example, MAP 5 overlaps
MAP4

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2.3 Mean arterial blood pressure determination
Auscultatory MAP was estimated in each recording from
auscultatory DBP plus 33% of the pressure change from
DBP to SBP, with supplementary data for the use of 40% in
the formula [5]. Six different techniques were then devel-
oped using Matlab 7.1. (MathWorks Inc., USA) to deter-
mine the corresponding automated MAPs from the cuff
pressure at a specific time determined from oscillometric
pulse pressure. Details are illustrated in Fig. 3 and descri-
bed below:
• MAP1 and MAP2 were the cuff pressures at the peak
and foot, respectively of the largest oscillometric pulse
[25]. They are the traditional oscillometric techniques
for MAP estimation, but can be influenced by the
variation of oscillometric waveform caused by artefact
or noise.
• MAP3 and MAP4 were the cuff pressures at the peak of
the pulse which was closest to the peak of the 4th and
6th order fitted polynomial curve, respectively. The
polynomial curve fitting technique was used here
because it has the power to interpolate between
the sampled pulses and to smooth out noise in the
oscillometric waveform. Furthermore, because the
oscillometric waveform envelope is similar to a bell-
shaped curve, an even number of orders above 2 is
required to construct a curve with flat features at the
beginning and the end.
• MAP5 was obtained from MAP4 after correcting for
the amplitude difference between the 6th order poly-
nomial curve and the recorded oscillometric pulse, such
that when the polynomial curve lay above the oscillo-
metric pulse, the correction added was positive. This
amplitude difference can be caused by respiratory
effects.
• MAP6 was the baseline cuff pressure associated with
the peak of the 6th order fitted polynomial curve, where
the baseline was drawn through the foot of all pulses.
This technique may be able to correct the effect of fast
cuff deflation rate, with a limited number of detectable
oscillometric pulses.
2.4 Data analysis
For all the blood pressure recordings, SPSS software
package (SPSS Inc., USA) was employed to determine the
effect of different techniques on MAP estimation, and also
to perform regression analysis between the auscultatory
MAPs and automated MAPs from the six different oscil-
lometric techniques, obtaining the square of the correlation
coefficients (R2). Bland–Altman analysis (Systat Software
Inc., USA) was also performed to assess the agreement
between the automated MAPs and auscultatory MAPs,
with their paired differences and SD of differences calcu-
lated. A value of P \ 0.05 was considered statistically
significant. Finally, the automated mean weights calculated
from the automated MAPs were compared with the clas-
sical manual mean value of 33%.
3 Results
The overall mean MAPs from all the recordings for the
auscultatory and oscillometric techniques are given in
Table 2. ANOVA analysis showed that different tech-
niques resulted in significant differences in MAP estima-
tion (P \ 0.001). The mean paired differences between the
oscillometric techniques and the auscultatory technique
were significant (all P \ 0.01). Technique 6 with curve
fitting improved the paired differences from -1.3 and
-3.4 mmHg (classic technique, without curve fitting) to
-1.0 mmHg. These paired differences were associated
with differences between the manual and automated mean
weights of 4% (33–29%) and 9% (33–24%) for the classic
techniques to 2% (33–31%) for technique 6.
Figure 4 shows the comparison of MAPs obtained
from the auscultatory and different oscillometric tech-
niques. The linear regression analysis showed that the

Table 2 The mean MAP

Measurement technique Mean MAP Mean paired SD of paired Mean weight
calculated from the manual
(mmHg) difference to difference calculated from
auscultatory method and from
auscultatory (mmHg) the MAPs (%)
six different oscillometric
MAP (mmHg)
techniques. Their mean and SD
of paired differences, and the Auscultatory 89.3 – – 33
mean weights calculated from
the MAPs are also presented Automated oscillometric 1 88.0 -1.3 6.2 29
technique 2 85.9 -3.4 5.9 24
3 91.5 2.1 4.1 38
4 91.0 1.6 4.1 37
5 90.9 1.6 4.1 37
6 88.3 -1.0 3.7 31

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Fig. 4 Regression analysis
results of MAP from the
auscultatory and six
oscillometric techniques (top six
sub-figures). Bland–Altman plot
of MAP differences ±2SD
between the six oscillometric
techniques and the auscultatory
method (bottom six sub-figures)
correlations between the six calculated automated
MAPs and the auscultatory MAP were significant (all
P \ 0.001), with the R2 of 0.71, 0.73, 0.84, 0.84, 0.84
and 0.86, respectively, increasing from techniques 1 to 6.
Bland–Altman analysis showed that technique 6
improved the SD of paired differences best from 6.2 and
5.9 mmHg (classic technique, without curve fitting) to
3.7 mmHg.
When the mean weight of 40% rather than 33% was
used to calculate the auscultatory MAP, all mean paired
difference in comparison with the auscultatory MAP fell by
an identical 2.9 mmHg with no change to the differences
between oscillometric techniques. There were small dif-
ferences in the SD of paired differences, but not to the
order between oscillometric techniques, with MAP6 still
having the lowest variability.
4 Discussion
We have shown that the automated MAPs calculated from
the oscillometric waveform using different measurement
algorithms were different. The technique associated with
the peak of the 6th order polynomial model of the oscil-
lometric pulse waveform yielded the smallest mean paired
difference in comparison with the auscultatory technique.
Technique 1 yielded a higher mean than that from tech-
nique 2. This difference reflects the amplitude of the
37
oscillometric pulses (see Fig. 3) with technique 2 associ-
ated with the lower cuff pressure as it is the pressure at the
foot, rather than the peak of the oscillometric pulse. Sim-
ilarly, the MAPs from technique 3, 4 and 5 were higher
than from technique 6 although the polynomial curve fit-
ting technique was applied to all of them. This difference
again reflects the amplitude of oscillometric pulse with
technique 3–5, whilst technique 6 used the cuff pressure at
the baseline (see Fig. 3). Although the mean MAP differ-
ences compared with the auscultatory technique were less
than 5 mmHg, the systematic mean difference between
different oscillometric techniques was up to 5.5 mmHg.
The International Standard requires a maximum systemic
difference of 5 mmHg [12]. Furthermore, in a patient
population, the mean differences between the oscillometric
techniques and the auscultatory technique can be expected
to be much higher.
Next, the significant differences between MAPs from the
oscillometric techniques and the auscultatory technique
resulted in the automated mean weights calculated from
automated MAPs being different for all the six techniques
studied. Technique 6 produced the smallest mean difference
(-2%) against the classically assumed mean value of 33%.
It is generally accepted that the automated MAP from the
oscillometric waveform gives a fairly accurate estimation in
comparison with the intra-arterial MAP [24], our finding
allows us to question whether 33% is a useful mean weight
for achieving accurate MAP estimation. It has been reported
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that a weight of 41% is more accurate than the traditional
33% for the calculation of MAP from invasive SBP and
DBP after investigating the pulses measured invasively
from 150 patients during cardiac catheterization [15]. Bos
et al. [5] also found that, in comparison with the intra-
arterially measured MAP, using the mean weight of 40%
avoided the underestimation of MAP calculated from the
empirical formula. Razminia et al. [20] reported the use of
the traditional 33%, but with an added correction for heart
rate (HR), where MAP was expressed as: MAP = DBP ?
[0.33 ? (HR 9 0.0012)] 9 (SBP-DBP). It is accepted that
there is still uncertainty with calls for more invasive clinical
studies to evaluate the mean weight for MAP estimation
[6, 23], and whether the mean weight changes with different
clinical conditions, such as the age and blood pressure
range, which could influence the shape of the oscillometric
waveform [2]. These values would provide useful infor-
mation for validating automated blood pressure devices for
clinical use.
More interestingly, we have also shown that the vari-
ability of MAP measurement differences from different
oscillometric techniques in comparison with the ausculta-
tory technique can be improved with curve fitting algo-
rithms. The technique, associated with the peak of the 6th
order polynomial model of the oscillometric pulse wave-
form, was shown to result in the lowest variability. It
yielded the smallest SD of paired differences (3.7 mmHg)
when referenced to those calculated from the classic
empirical formula. The smoothing of the polynomial curve
fitting of the peaks accounted for its reduced SD. The fitted
curve smoothes out random and noisy variations in the
oscillometric waveform. Having a good quality extracted
oscillometric waveform is important for improving the
estimation of automated MAP. In addition, although it is
recognized that the interpolation errors would be greater
with fewer oscillometric peaks detected in a single mea-
surement, this model-based technique with interpolation
takes account of the peak of the fitted curve lying between
two oscillometric pulses, hence correcting for the effect of
cuff deflation (or inflation) between heartbeats. This is
increasingly important because clinical demands lead to
reduced determination time and hence increased cuff
deflation rate, with a reduced number of detectable oscil-
lometric pulses.
In conclusion, different techniques for automated MAP
estimation from the oscillometric waveform produced dif-
ferent results, and the technique associated with the peak of
the 6th order polynomial curve was shown to have the
smallest differences in comparison with the manual au-
scultatory technique.
Acknowledgments Dr Dingchang Zheng is funded by the Engi-
neering and Physical Sciences Research Council (EPSRC).
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Med Biol Eng Comput (2011) 49:33–39
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