1992 - Kaplan - Blood Pressure Measurement and Monitoring

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Blood pressure measurement and monitoring
Updated 2018 Jan 23 03:31:00 PM: home blood pressure monitoring may reduce blood
pressure in adults with hypertension (Ann Intern Med 2017 Dec 26 early online) view update Show
more updates
Related Summaries:
Hypertension (list of topics)
Hypertension
Masked hypertension
High blood pressure - differential diagnosis
Definitions:
commonly used abbreviations for blood pressure measurement
HBPM - home blood pressure monitoring
ABPM - ambulatory blood pressure monitoring
AOBP - automated office blood pressure
References - Hypertension 2017 Nov 13 early online, BMJ 2011 Feb 7;342:d286 full-text
Overview:
blood pressure (BP) may be measured using auscultatory method (manual measurement) or
oscillometric technique (automated device)
in clinical settings, automated BP measurement may reduce white coat effect (may reduce blood
pressure reading that is elevated in clinical setting but not in other settings)
manual BP measurement technique
patient seated and relaxed for > 5 minutes with arm rested on support at level of heart, with
back supported, and with feet flat on the floor
patient should avoid caffeine, exercise, and smoking for ≥ 30 minutes before measurement
ensure patient has emptied their bladder, and neither patient nor observer should talk during rest
period or during measurement
inflatable bladder of cuff should encircle 80% of patients' arm circumference; clothing should be
removed from location of cuff placement
systolic and diastolic blood pressure recorded as onset of first Korotkoff sound and disappearance
of all Korotkoff sounds, respectively (use nearest even number)
use validated blood pressure measurement device and ensure device is calibrated periodically
separate repeated measurements by 1-2 minutes
use average of ≥ 2 readings obtained on ≥ 2 occasions to estimate blood pressure
out-of-office BP measurement
home blood pressure monitoring (HBPM)
use out-of-office BP measurements to confirm diagnosis of hypertension and for titration of
BP-lowering medication, in conjunction with telehealth counseling or clinical interventions
(ACC/AHA Class I, Level A)
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consider screening for white coat hypertension using HBPM before diagnosis of hypertension
in adults with untreated systolic blood pressure (SBP) > 130 mm Hg but < 160 mm Hg or
diastolic blood pressure (DBP) > 80 mm Hg but < 100 mm Hg (ACC/AHA Class IIa, Level B-
NR)
consider periodic monitoring using HBPM to detect transition to sustained hypertension in
adults with white coat hypertension (ACC/AHA Class IIa, Level C-LD)
consider screening for masked hypertension using HBPM in adults with untreated office blood
pressures consistently between 120-129 mm Hg for SBP or between 75-79 mm Hg for DBP
(ACC/AHA Class IIa, Level B-NR)
consider screening for white coat effect using HBPM in adults on multiple drug therapies for
hypertension and office blood pressures within 10 mm Hg above goal (ACC/AHA Class IIb,
Level C-LD)
consider screening for masked uncontrolled hypertension using HBPM in adults being treated
for hypertension with office readings at goal, and in presence of target organ damage or
increased overall cardiovascular disease risk (ACC/AHA Class IIb, Level C-EO)
ambulatory blood pressure monitoring (ABPM)
consider screening for white coat hypertension using daytime ABPM before diagnosis of
hypertension in adults with untreated systolic blood pressure (SBP) > 130 mm Hg but < 160
mm Hg or diastolic blood pressure (DBP) > 80 mm Hg but < 100 mm Hg (ACC/AHA Class IIa,
Level B-NR)
consider periodic monitoring using ABPM to detect transition to sustained hypertension in
adults with white coat hypertension (ACC/AHA Class IIa, Level C-LD)
consider confirming blood pressure measurement using ABPM in adults being treated for
hypertension with office blood pressure readings not at goal and HBPM readings suggestive of
significant white coat effect (ACC/AHA Class IIa, Level C-LD)
consider screening for masked hypertension using ABPM in adults with untreated office blood
pressures consistently between 120-129 mm Hg for SBP or between 75-79 mm Hg for DBP
consider screening for white coat effect using ABPM in adults on multiple drug therapies for
hypertension and office blood pressures within 10 mm Hg above goal (ACC/AHA Class IIb,
Level C-LD)
consider confirmation of diagnosis using ABPM before intensification of antihypertensive drug
treatment in adults being treated for hypertension with elevated HBPM readings suggestive of
masked uncontrolled hypertension (ACC/AHA Class IIb, Level C-EO)
ABPM may result in less overdiagnosis of hypertension compared to clinic or home blood pressure
monitoring for diagnosis of hypertension in adults (level 2 [mid-level] evidence)
elevated home systolic blood pressure and elevated 24-hour ambulatory systolic blood pressure
each associated with increased risk of cardiovascular mortality and cardiovascular events
independent of office blood pressure
self-monitoring
self-monitoring may be associated with modest reduction in systolic and diastolic blood pressure
and possibly increased likelihood of achieving target blood pressure (level 3 [lacking direct]
evidence)
self-management interventions associated with reductions in systolic blood pressure (level 3
[lacking direct] evidence)
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Devices for Blood Pressure (BP) Measurement
Overview of types:
sphygmomanometers for manual use - auscultatory method
auscultatory devices (mercury, aneroid, or other) not generally useful for home blood pressure
monitoring because patients rarely master technique required for accurate measurement(4)
mercury sphygmomanometers are considered to be standard for accuracy(3)
aneroid (dial-type) sphygmomanometers, especially mobile versions, require frequent
calibration and may introduce error due to misreading of the small dial(3)
hybrid devices use an electronic pressure gauge instead of a mercury column and may be as
accurate as mercury sphygmomanometers; may be displayed as digital readout, simulated
mercury column, or simulated aneroid display(3)
automated sphygmomanometers - oscillometric technique
oscillations of pressure in sphygmomanometer cuff estimate systolic and diastolic blood
pressures indirectly using device-specific algorithms(3)
amplitude of oscillations vary with factors other than blood pressure, including arterial stiffness
(may underestimate mean arterial pressure in patients with stiff arteries and wide pulse
pressures)(3)
automated devices have been used successfully in clinic, home monitors, and ambulatory blood
pressure monitors and may reduce "white coat effect"(2, 3)
oscillometric method may not be reliable in patients with certain arrhythmias (for example,
atrial fibrillation or frequent ectopic beats); such devices should be validated before use (for
example, compared to auscultatory method in clinic)(1, 2, 3)
automated devices in public places may not be calibrated or use appropriate cuff size(3)
blood pressure measurement approaches that are less commonly used(3)
finger monitors not recommended; available monitors outside of research settings are
inaccurate
ultrasound using Doppler probe over brachial artery can be used in patients with very faint
Korotkoff sounds
tonometry can be used where artery lies over bone, but position-dependent and requires
patient-specific calibration
list of specific sphygmomanometers tested for accuracy can be found at Dabl Educational Trust
Sphygmomanometers for manual use:
use of auscultatory devices (mercury, aneroid, or other) not generally useful for home blood
pressure monitoring because patients rarely master technique required for accurate
measurement(4)
high prevalence of inaccurate sphygmomanometers in primary care, attributed to lack
of regular maintenance and calibration
based on cohort study
279 sphygmomanometers from 45 general practices in United Kingdom calibrated with
electronic reference pressure sensor
17.9% had errors exceeding +/- 3 mm Hg threshold
such error rates found in 33 of 62 (53%) aneroid devices and 16 of 217 (7.8%) mercury and
automated devices
Reference - Blood Press Monit 2005 Aug;10(4):18
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aneroid sphygmomanometers provide accurate pressure measurements when maintenance

protocol is followed (Arch Intern Med 2001 Mar 12;161(5):729 EBSCOhost Full Text)
list of specific manual sphygmomanometers tested for accuracy can be found at Dabl Educational
Trust
Automated BP measuring devices:
Clinical settings:
list of specific automated sphygmomanometers for clinical use tested for accuracy can be found at
Dabl Educational Trust
automated office blood pressure measurement may significantly reduce white coat
response in patients with systolic hypertension (level 3 [lacking direct] evidence)
based on cluster randomized trial without clinical outcomes
67 primary care practices with 88 physicians randomized to automated office BP measurement
(BpTRU device) vs. manual office BP measurement for patients
555 patients with systolic hypertension were assessed with awake ambulatory blood pressure
monitoring
comparing automated vs. manual office BP measurement
mean manual office BP measurement before enrollment 149.5/81.4 mm Hg vs. 149.9/81.8
mm Hg
mean office BP measurement after enrollment 135.6/77.7 mm Hg vs. 141.4/80.2 mm Hg
automated office BP measurement better correlated with awake ambulatory BP measurement
Reference - CAMBO trial (BMJ 2011 Feb 7;342:d286 full-text)
results persisted at 2 years in follow-up of 461 patients with continued elimination of white
coat effect (office-induced hypertension) with switch from manual to automated BP
measurement (Fam Pract 2012 Aug;29(4):376 full-text)
practice-based self-monitoring using electronic BP machine associated with
improvement in blood pressure at 6 months but not 1 year (level 3 [lacking direct]
evidence)
based on randomized trial without clinical outcomes
441 primary care patients with hypertension not controlled below 140/85 mm Hg were
randomized to practice-based self-monitoring using electronic BP machine vs. usual care (BP
monitored by practice)
practice-based self-monitoring reduced SBP by 4.3 mm Hg at 6 months (95% CI 0.8-7.9 mm
Hg) and 2.7 mm Hg at 1 year (not statistically significant)
Reference - BMJ 2005 Sep 3;331(7515):493 full-text, editorial can be found in BMJ 2005 Sep
3;331(7515):466
continuous noninvasive blood pressure monitoring associated with improved
detection of rapid blood pressure changes in sedated patients
based on small cohort study
40 patients having interventional endoscopy had continuous noninvasive BP monitoring based
on vascular unloading technique (CNAP) in addition to standard monitoring with discontinuous
non-invasive blood pressure measurement (NIBP)
due to the continuous nature of CNAP, CNAP blood pressure readings detected changes in
blood pressure (maximum increase of 30.8% and a maximum decrease of 22.4%) between 2
separate NIBP measurements
Reference - Int J Med Sci 2009;6(1):37 full-text
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Community settings:
list of specific automated sphygmomanometers for home or community use tested for accuracy
can be found at Dabl Educational Trust
automatic blood pressure machines in community pharmacies
in-pharmacy automated BP kiosk BP readings may be similar to in-office automated
BP readings and ambulatory BP readings
100 adults with hypertension had blood pressure monitored using
baseline in-office readings using automated device (3 readings spaced 1 minute apart)
24-hour ambulatory BP monitoring between in-pharmacy visits (between second and
third visit)
in-pharmacy automated BP kiosk (PharmaSmart PS-2000) (4 visits total with 3 readings
on each visit)
mean systolic BP
135.7 mm Hg with in-office readings using automated device
135.5 mm Hg 24 hour daytime ambulatory blood pressure
137.8 mm Hg with in-pharmacy automated BP kiosk (p < 0.05 vs. 24 hour daytime BP,
but differences not clinically meaningful)
mean diastolic BP
79.4 mm Hg with in-office readings using automated device
79.7 mm Hg with 24 hour daytime ambulatory blood pressure
81.9 mm Hg with in-pharmacy automated BP kiosk blood pressure (p < 0.05 vs. 24 hour
daytime BP, but differences not clinically meaningful)
Reference - J Am Soc Hypertens 2015 Feb;9(2):123
self-monitoring BP readings using automated devices may correlate better with
ambulatory BP readings than BP readings from general practitioner or nurse
based on prospective cohort study
99 patients aged 20-75 years with elevated initial BP had BP measurements taken by general
practitioner, practice nurse, and by themselves over 7 months
BP measurements taken by patients at home with an automated device were closer to
ambulatory BP measurements than those taken by either general practitioner or practice nurse
Reference - Br J Gen Pract 1998 Sep;48(434):1585 PDF
automated finger blood pressure devices appear to be inaccurate and imprecise
100 patients had BP measured with standard arm BP cuff and 3 different automated finger BP
devices in quick succession
no statistically significant correlation found between standard arm BP cuff readings and with
automated finger BP device readings
Reference - Fam Med 1996 Mar;28(3):189
Blood Pressure Values Using Different Methods
Corresponding Values of Blood Pressure for Clinic, Home, Daytime ABPM, Nighttime
ABPM, and 24-Hour ABPM Measurements:
Office/Clinic HBPM Daytime ABPM Nighttime 24-Hour ABPM

ABPM
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Office/Clinic HBPM Daytime ABPM Nighttime 24-Hour ABPM

ABPM
120/80 120/80 120/80 100/65 115/75
130/80 130/80 130/80 110/65 125/75
140/90 135/85 135/85 120/70 130/80
160/100 145/90 145/90 140/85 145/90
Abbreviations: ABPM, ambulatory blood pressure monitoring; DBP, diastolic blood pressure; HBPM,
home blood pressure monitoring; SBP, systolic blood pressure.
Reference - (4)
manual office/clinic blood pressure measurements generally higher than automated office blood
pressure measurements
automated office blood pressure measurement of 131/85 mm Hg appears to
correspond to manual office blood pressure measurement of 140/90 mm Hg by
trained nurse
2,145 adults aged 25-64 years in Czech Republic were randomly selected for blood pressure
measurement using automated office BpTRU device and manual mercury
sphygmomanometer operated by trained nurse
patients having automated office blood pressure (AOBP) measurement rested for about
20 minutes in sitting position in quiet room before 6 readings were taken at 1-minute
intervals; nurse present only for initial reading which was discarded (subsequent 5
readings were averaged)
patients having manual measurement rested for 5 minutes with patient in sitting position
before nurse took 3 consecutive measurements at 1-minute intervals (last 2
measurements were averaged)
automated systolic blood pressure (SBP)/diastolic blood pressure (DBP) readings were lower
than manual SBP/DBP readings (mean difference for SBP/DBP 6.39/2.5 mm Hg)
automated SBP/DBP 131/85 mm Hg corresponded to manual SBP/DBP 140/90 mm Hg
based on regression analysis
using automated SBP 131 mm Hg or SBP/DBP 135/85 mm Hg as cutoff
24% had white coat hypertension (defined as automated SBP < 131 or SBP/DBP <
135/85 mm Hg and manual SBP/DBP ≥ 140/90 mm Hg)
10% had masked hypertension (defined as automated SBP ≥ 131 or SBP/DBP ≥ 135/85
mm Hg and manual SBP/DBP < 140/90 mm Hg in those not treated with
antihypertensive medications)
11% had masked uncontrolled hypertension (defined as automated SBP ≥ 131 or
SBP/DBP ≥ 135/85 mm Hg and manual SBP/DBP < 140/90 mm Hg in those treated with
antihypertensive medications)
Reference - J Hypertens 2016 Nov;34(11):2180
automated office blood pressure measurement in patients resting quietly
associated with lower blood pressure and reduced white coat response compared
to manual office blood pressure measurement by physician
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309 patients (mean age 63 years) referred for 24-hour ambulatory blood pressure
monitoring (ABPM) had blood pressure measured using 4 methods
patients having automated office blood pressure (AOBP) measurement with BpTRU
device rested for 5-10 minutes in sitting position in quiet room before 6 readings were
taken at 1 or 2-minute intervals; nurse present only for initial reading which was
discarded (subsequent 5 readings were averaged)
manual office measurement by family physician (number of measurements not reported)
manual office measurement by technician (mean of 2 measurements taken)
mean awake ambulatory measurement calculated from 24-hour ABPM unit that recorded
blood pressure at 15-minute intervals between 6 AM and 10 PM and at 30-minute
intervals at night
mean systolic blood pressure (SBP)/diastolic blood pressure (DBP) readings were
132/75 mm Hg with AOBP measurement (p < 0.05 vs. mean awake ambulatory
measurement)
152/87 mm Hg with manual office measurement by family physician (p < 0.001 vs. mean
awake ambulatory measurement)
140/80 mm Hg with manual office measurement by technician (p < 0.001 vs. mean
awake ambulatory measurement)
134/77 mm Hg with mean awake ambulatory measurement
among 163 patients (53%) receiving antihypertensive medication, white coat response
(office SBP ≥ 20 mm Hg and/or DBP ≥ 10 mm Hg than mean awake ambulatory
measurement) in
12% with AOBP measurement
65% manual measurement by family physician (p < 0.001 vs. AOBP measurement)
26% with manual measurement by technician (p < 0.001 vs. AOBP measurement)
among 146 patients (47%) who were untreated, white coat response (SBP/DBP < 140/90
mm Hg for manual office measurement and < 135/85 mm Hg for awake ambulatory
measurement or automated measurement) in
16% with AOBP measurement
55% with manual measurement by family physician (p < 0.001 vs. AOBP measurement)
18% with manual measurement by technician (no p value reported)
Reference - J Hypertens 2009 Feb;27(2):280
simultaneous blood pressure measurements by automated office device and
hypertension nurse specialist in patients resting quietly appear to have 92%
agreement for diagnosing hypertension
106 adults aged 18-85 years with elevated casual blood pressure (BP) who were referred for
6-hour ambulatory blood pressure monitoring had blood pressure measured using 2
methods simultaneously
automated BpTRU device recorded 6 measurements after 5 minutes of rest in quiet room
at 3-minute intervals with initial measurement being discarded
hypertension nurse specialist who followed American Heart Association/Joint National
Committee VII guideline technique auscultated 3 blood pressures beginning with second
BpTRU measurement
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mean SBP was 135.9 mm Hg with automated BpTRU device vs. 137.7 mm Hg with nurse
specialist (p < 0.01)
mean DBP was 78.9 mm Hg with automated BpTRU device vs. 74.1 mm Hg with nurse
specialist (p < 0.001)
automated BpTRU device and hypertension nurse specialist had 92% agreement for
diagnosing hypertension
Reference - J Hum Hypertens 2003 Dec;17(12):823 EBSCOhost Full Text
DynaMed commentary -- This study employed the use of "Y" tubing which connected the
BpTRU device and the aneroid sphygmomanometer, allowing measurements by the 2
methods to be taken simultaneously; this method of measurement may not be reflective of
usual routine office/clinic measurement since the BpTRU device controlled automated cuff
inflation and deflation.
Manual BP Measurement
Basic technique:
accurate blood pressure measurement involves(3)
use of equipment that is regularly inspected and validated
trained personnel using standardized technique
use appropriately sized cuff
patient seated quietly for at least 5 minutes in a chair with feet on floor with back supported
arm supported at heart level
legs should not be crossed
no talking during measurement
use average of at least 2 measurements
take blood pressure in both arms and use the arm that has the consistently higher pressure
step-by-step approach(4)
step 1 - prepare patient
have patient relax, sitting in a chair (feet on floor, back supported) for > 5 minutes
patient should avoid caffeine, exercise, and smoking for ≥ 30 minutes before measurement
ensure patient has emptied their bladder
neither patient nor observer should talk during rest period or during measurement
remove all clothing covering the location of cuff placement
these criteria are NOT fulfilled if measurements made while patient is sitting or lying on
examining table
step 2 - use proper measurement techniques
use validated blood pressure measurement device and ensure device is calibrated
periodically
support patient’s arm
position middle of cuff on patient’s upper arm at level of right atrium (midpoint of sternum)
use correct cuff size; bladder should encircle 80% of arm (note if a larger- or smaller-than-
normal cuff size is used)
either stethoscope diaphragm or bell may be used for auscultatory readings
step 3 - take proper measurements required for diagnosis/treatment of elevated blood
pressure/hypertension
at first visit, record blood pressure in both arms; use arm that gives higher reading for
subsequent readings
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separate repeated measurements by 1-2 minutes

for auscultatory determinations
use palpated estimate of radial pulse obliteration pressure to estimate systolic blood
pressure (SBP); inflate cuff 20-30 mm Hg above this level for auscultatory determination
of blood pressure
deflate cuff pressure 2 mm Hg per second, and listen for Korotkoff sounds
step 4 - properly document accurate blood pressure readings
record SBP and diastolic blood pressure (DBP)
if using auscultatory technique, record SBP and DBP as onset of first Korotkoff sound and
disappearance of all Korotkoff sounds, respectively (use nearest even number)
note time of most recent blood pressure medication taken before measurements
step 5 - average the readings - use average of ≥ 2 readings obtained on ≥ 2 occasions to
estimate blood pressure
step 6 - provide readings to patient - provide patients with SBP/DBP readings both verbally and
in writing
interpretation of sounds(3)
Korotkoff phase I - appearance of clear tapping sounds, corresponds to appearance of palpable
pulse, recorded as systolic blood pressure
Korotkoff phase II - sounds become softer and longer
Korotkoff phase III - sounds become crisper and louder
Korotkoff phase IV - sounds become muffled and softer
Korotkoff phase V - sounds disappear completely, recorded as diastolic blood pressure
noted that many practitioners use Korotkoff sound phase IV instead of phase V (which is used in
trials), and this may falsely suggest diagnosis of hypertension (letter in BMJ 1996 Nov
9;313(7066):1203)
Cuff selection:
inflatable cuff bladder
should cover 80%-100% of patients' arm circumference(2)
should encircle 80% of arm(4)
cuff size(4)
arm circumference 22-26 cm (8.7-10.2 inches) - small adult cuff size
arm circumference 27-34 cm (10.6-13.4 inches) - adult cuff size
arm circumference 35-44 cm (13.7-17.3 inches) - large adult cuff size
arm circumference 45-52 cm (17.7-20.5 inches) - adult thigh cuff size
cuffs that are too small may give falsely high BP readings(2)
cuffs that are too large may underestimate BP(2)
if regular-sized cuff used in obese patient, BP can be measured as 10-40 mm Hg higher than
accurate reading (Arch Intern Med 1988 May;148(5):1023 in Cortlandt Forum 1996
Dec;9(12):77,106-9)
discussion of proper size selection of interchangeable bladders for BP cuffs (BMJ 2008 Jul
31;337:a431)
Position:
arm position parallel to torso associated with increased BP readings compared to arm
position perpendicular to torso
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100 adults without hypertension seen in emergency department had BP measured in standing,
sitting, and supine positions
arm position parallel to torso associated with 8.8-14.4 mm Hg higher mean systolic and
diastolic BP readings than arm position perpendicular to torso
Reference - Ann Intern Med 2004 Jan 6;140(1):74 EBSCOhost Full Text
BP measurement in positions other than chair-seated position (bed-seated, supine,
standing) associated with higher readings
540 patients with essential hypertension had BP measured in chair after being seated for ≥ 5
minutes, in supine position, seated on bed, and after standing for a few minutes
compared to BP measurement after being seated for ≥ 5 minutes, all other positions
associated with significantly higher blood pressure measurements
Reference - Am J Hypertens 2005 Feb;18(2):244, commentary can be found in Am J Hypertens
2006 Jul;19(7):659
DynaMed commentary -- study did not account for order of measurement as all patients had
chair-seated measurements before other measurements
Shirt sleeves:
BP measurement recorded over bare arm and over sleeved arm appear to provide
similar results
based on randomized trial with allocation concealment not stated
376 patients (mean age 61.6 years) had BP measured using automated device once on bare
skin then randomized to second BP reading on bare arm vs. over sleeved arm
comparing mean differences between first and second readings with bare arm vs. sleeved arm
4.1 mm Hg vs. 3.4 mm Hg for systolic blood pressure (not significant)
0.1 mm Hg vs. 0.4 mm Hg for diastolic blood pressure (not significant)
no significant differences due to sleeve thickness
Reference - CMAJ 2008 Feb 26;178(5):585 EBSCOhost Full Text full-text
shirt sleeve under cuff does not appear to significantly affect normotensive readings
but may significantly alter hypertensive readings
201 patients (mean age 46 years) had 3 BP recordings with digital device in random order with
cuff on bare arm, cuff over sleeve, and cuff below rolled-up sleeve
differences between mean BP readings between clothed and bare arm were 0.5/1 mm Hg and
not statistically significant
mean difference in SBP 2 mm Hg in hypertensive subjects, but difference ranged from -32 mm
Hg to +22 mm Hg
Reference - Fam Pract 2003 Dec;20(6):730 PDF
Timing of measurement:
waiting 10 minutes after sitting in chair associated with lower blood pressure
readings
55 patients with untreated essential hypertension had blood pressure measured manually
every 2 minutes for 16-minute period
group 1 had 27 patients who went from standing position to sitting position, with BP
measured while sitting for 16 minutes, followed by resting supine for 60 minutes (the last
16 minutes of which, BP was again measured)
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group 2 had 28 patients who had 60-minute supine rest (the last 16 minutes of which, BP
was measured) before a 16-minute chair-seated rest (BP measured during 16-minute
period)
pooled results among all 55 patients
decrease in blood pressure from minute 2 to minute 16 of the chair-seated rest was (p <
0.01)
10.7 mm Hg for systolic blood pressure (SBP)
3.4 mm Hg for diastolic blood pressure (DBP)
decrease in blood pressure from minute 44 to 60 of the supine rest interval was (p < 0.05)
1.8 mm Hg for SBP
0.9 mm Hg for DBP
about 75% of the spontaneous fall in BP occurred within 10 minutes of chair-seated rest
Reference - Am J Hypertens 2006 Jul;19(7):713
waiting 30 minutes after caffeine ingestion prior to blood pressure monitoring
reported to be inadequate to avoid potential effects of caffeine
based on literature review of acute effects of caffeine on BP
reported caffeine pharmacokinetics
peak level 3-120 minutes after oral intake
half-life 3-6 hours
acute effects of caffeine on BP may be diminished by caffeine tolerance
hypertensive patients may be more susceptible to BP changes
caffeine reported to increase systolic BP 3-15 mm Hg and increase diastolic BP 4-13 mm Hg
BP changes reported to occur within 30 minutes, peak in 1-2 hours, and persist > 4 hours
authors recommend asking patients about caffeine consumption and interpreting BP on this
information rather than asking them to abstain for 30 minutes
Reference - Ann Pharmacother 2008 Jan;42(1):105
Other factors affecting BP measurement:
different methods of blood pressure measurement might produce different results
during single office visit
223 patients with type 2 diabetes in 5 family practices were evaluated
BP measured ≥ 4 times with 4 different interpretations for determining BP
use of first reading
mean of first 2 readings
mean of last 3 readings with < 15% coefficient of variation difference
mean of first 2 consecutive readings with maximum 5 mm Hg difference
most pairwise comparisons showed significant differences ranging with differences up to
7.9/3.3 mm Hg
Reference - Fam Pract 2006 Feb;23(1):20
different settings of blood pressure measurement associated with variable results
444 veterans with hypertension had repeated BP measurements using 3 methods for 18
months
111,181 SBP measurements obtained
SBP control rates at baseline classified as in-control in
28% by clinic measurement during outpatient visit
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47% by home measurement transmitted electronically

68% by research measurement at 6-month intervals
patients could not be classified as having BP in or out of control with 80% certainty on the
basis of single clinic systolic BP measurement from 120-157 mm Hg
Reference - Ann Intern Med 2011 Jun 21;154(12):781 EBSCOhost Full Text, editorial can
be found in Ann Intern Med 2011 Jun 21;154(12):838 EBSCOhost Full Text
BP difference between arms:
difference of ≥ 10 mm Hg in systolic blood pressure between arms may suggest
higher likelihood of peripheral vascular disease (level 2 [mid-level] evidence)
based on systematic review limited by heterogeneity
systematic review of 28 cohort and cross-sectional studies evaluating association between
difference in systolic blood pressure (SBP) between arms of ≥ 10 mm Hg or ≥ 15 mm Hg and
vascular disease or mortality
for diagnosing peripheral vascular disease
difference of ≥ 10 mm Hg in SBP between arms had
sensitivity 32% (95% CI 23%-41%)
specificity 91% (95% CI 86%-94%)
difference of ≥ 15 mm Hg in SBP between arms had
for diagnosing cerebrovascular disease, difference of ≥ 15 mm Hg SBP between arms had
Reference - Lancet 2012 Mar 10;379(9819):905, correction can be found in Lancet 2012 Jul
21;380(9838):218, editorial can be found in Lancet 2012 Mar 10;379(9819):872
blood pressure difference between arms appears uncommon unless obstructive
arterial disease
147 consecutive patients from hypertension clinic had 3 sets of 3 BP readings using different
devices, protocol repeated at second visit for 91 patients
2 patients had consistent large inter-arm SBP differences, both had obstructive arterial disease
right arm BP readings were slightly higher than left arm by 2-3/1 mm Hg for all 3 sets
11 patients (7.5%) had mean inter-arm difference > 5 mm Hg for SBP across all 3 sets of
readings
4 patients (2.7%) had mean inter-arm difference > 5 mm Hg for DBP across all 3 sets of
readings
no patient with inter-arm BP difference > 5 mm Hg who completed the test had consistent
differences across 2 visits
Reference - Arch Intern Med 2007 Feb 26;167(4):388 EBSCOhost Full Text
inter-arm blood pressure difference may exist in hemiparetic patients
based on literature review finding 4 studies
measurement should be taken in unaffected arm
Reference - Fam Med 2008 Sep;40(8):540 PDF
Home BP Monitoring (HBPM)
Recommendations from professional organizations:

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American College of Cardiology/American Heart Association Guideline for the Prevention,

Detection, Evaluation, and Management of High Blood Pressure in Adults(4)
HBPM general information
helpful for confirmation and management of hypertension
may be more practical alternative to ambulatory blood pressure monitoring in clinical
practice
precise relationship between office readings, HBPM readings, and ambulatory blood
pressure readings not completely clear, but general agreement that office blood pressures
higher than ABPM or HBPM (particularly at higher blood pressures)
recommendations
use out-of-office BP measurements to confirm diagnosis of hypertension and for titration of
BP-lowering medication, in conjunction with telehealth counseling or clinical interventions
(ACC/AHA Class I, Level A)
consider screening for white coat hypertension by using either home blood pressure
monitoring (HBPM) or daytime ambulatory blood pressure monitoring (ABPM) before
diagnosis of hypertension in adults with untreated systolic blood pressure (SBP) > 130 mm
Hg but < 160 mm Hg or diastolic blood pressure (DBP) > 80 mm Hg but < 100 mm Hg
consider periodic monitoring (using either HBPM or ABPM) to detect transition to sustained
hypertension in adults with white coat hypertension (ACC/AHA Class IIa, Level C-LD)
consider screening for masked hypertension (using HBPM or ABPM) in adults with untreated
office blood pressures consistently between 120-129 mm Hg for SBP or between 75-79 mm
Hg for DBP (ACC/AHA Class IIa, Level B-NR)
consider screening for white coat effect (using HBPM or ABPM) in adults on multiple drug
therapies for hypertension and office blood pressures within 10 mm Hg above goal
(ACC/AHA Class IIb, Level C-LD)
consider screening for masked uncontrolled hypertension (using HBPM) in adults being
treated for hypertension with office readings at goal, and in presence of target organ
damage or increased overall cardiovascular disease risk (ACC/AHA Class IIb, Level C-EO)
American Heart Association, American Society of Hypertension, Preventive Cardiovascular Nurses
Association (AHA/ASH/PCNA) joint scientific statement on HBPM(1)
HBPM should be routine in blood pressure (BP) measurement in most patients with known or
suspected hypertension
HBPM may also be useful for
patients with high-normal BP (some normal and some high BP readings)
detection of masked hypertension in patients with prehypertension
patients with diabetes or kidney disease with clinic BP ≥ 130/80 mm Hg
monitoring response to treatment, especially in patients with target organ damage
patients in whom decision to start treatment is unclear
children
pregnant women
elderly (due to increased BP variability and white-coat effect)
European Society of Hypertension (ESH) practice guideline on HBPM - indications for self
measurement(2)
all patients taking antihypertensive medication
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patients for whom strict BP control is mandatory (high-risk patients such as those with
diabetes, chronic kidney disease, or pregnancy)
to evaluate white coat, false uncontrolled, masked, or resistant hypertension
to improve patient's compliance to treatment regimen
to improve control rates
Diagnostic thresholds and targets:
precise relationship between office readings, home blood pressure readings, and ambulatory
blood pressure readings not completely clear, but general agreement that office blood pressures
higher than ABPM or HBPM (particularly at higher blood pressures)(4)
European Society of Hypertension (ESH) practice guideline on HBPM(2)
suggested normal values for home BP 130/80 mm Hg
mean SBP ≥ 135/85 mm Hg and/or DBP > 85 mm Hg considered elevated
home BP targets may need to be lower in high-risk patients
borderline or abnormal home BP measures should be confirmed by ABPM
self-reported blood pressure readings reported to differ from objective blood pressure readings
and may be biased (Br J Gen Pract 2003 Mar;53(488):221 PDF, Blood Pressure Monitoring
1998;3(Suppl 1):S19, Am J Hypertens 1998 Dec;11(12):1413)
see Hypertension medication selection and management for additional information on target
blood pressure
Technique and procedure:
Detection, Evaluation, and Management of High Blood Pressure in Adults - procedures for use of
home blood pressure monitoring(4)
train patient under medical supervision, including
information about hypertension and equipment selection
acknowledgment that individual blood pressure readings may vary substantially
interpretation of results
devices
verify use of validated automated devices
use of auscultatory devices (mercury, aneroid, or other) not generally useful for home blood
pressure monitoring since patients rarely master technique needed for accurate blood
pressure measurement
monitors which can store readings in memory preferred
verify use of appropriate cuff size to fit arm
verify that left/right inter-arm differences are insignificant; if differences are significant,
instruct patient to measure blood pressure in arm with higher readings
instructions for home blood pressure monitoring technique
remain still
avoid smoking, caffeinated beverages, or exercise within 30 min before blood pressure
measurements
ensure ≥ 5 min of quiet rest before blood pressure measurements
sit properly
sit with back straight and supported (for example, on straight-backed dining chair rather
than sofa)
sit with feet flat on floor with legs uncrossed
keep arm supported on a flat surface (such as table), with upper arm at heart level
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place bottom of cuff directly above antecubital fossa (bend of the elbow)
take multiple readings
take ≥ 2 readings, 1 minute apart in morning before taking medications and in evening
before supper
measure and record blood pressure daily; obtain weekly blood pressure readings beginning
2 weeks after change in treatment regimen and during week before a clinic visit
record all readings accurately
bring monitors with built-in memory to all clinic appointments
base blood pressure on average of readings on ≥ 2 occasions for clinical decision making
information may be reinforced with video instruction
Reference - Hypertension 2017 Nov 13 early online
American Heart Association, American Society Of Hypertension, and Preventive Cardiovascular
Nurses Association (AHA/ASH/PCNA) joint scientific statement on HBPM - testing technique(1)
use validated monitors (see Dabl Educational Trust for list of devices tested for accuracy)
fully automated device with upper arm cuff, wrist monitors not clinically useful
monitors with measurement storage preferred
no tobacco or caffeine for 30 minutes preceding measurement
measure BP on nondominant arm (or arm with the highest BP)
after 5 minutes of rest
with arm at heart level
back supported and feet flat on the ground
check patient technique and monitor accuracy annually
take 2-3 measurements (in seated position) each morning and 2-3 measurements each
evening for 7 days (before taking medication if on treatment)
use mean of 12 morning and evening measurements
European Society of Hypertension (ESH) practice guideline on HBPM(2)
use validated devices with appropriately sized arm cuff (see Dabl Educational Trust for list of
devices tested for accuracy)
semi-automated or automated oscillometric arm cuff devices recommended
devices with memory preferred
monitoring schedule
measure BP for 3-7 days before next medical appointment
less frequent measurements might be acceptable for long-term follow-up aimed at
reinforcing compliance
isolated readings should not be used for diagnostic purposes
measure BP twice 1-2 minutes apart in morning (before taking antihypertensive medication)
and evening (before eating)
record measurements
in sitting position with feet flat on ground and arm supported
after 5 minutes rest
no smoking, eating, caffeine, or physical exercise 30 minutes preceding measurement
cuff placement at heart level
if significant consistent difference in BP between arms, patient should use arm with higher
BP
maintain recorded results in BP log and diary or in device memory
instruct patient to avoid self-modification of treatment
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patients should be trained under medical supervision

Prognostic ability of HBPM:
increasing home systolic BP associated with increasing risk of cardiovascular
mortality and cardiovascular events, independent of office BP
based on systematic review
systematic review of 8 prospective longitudinal studies evaluating association between home
BP and adverse outcomes (cardiovascular events and mortality) in 17,698 patients
follow-up ranged from 3.2 to 10.9 years
increasing home systolic blood pressure (SBP) associated with increasing risk of
all-cause mortality (hazard ratio [HR] 1.14, 95% CI 1.01-1.29 per 10 mm Hg increase) in
analysis of 5 studies
cardiovascular mortality (HR 1.29, 95% CI 1.02-1.64 per 10 mm Hg increase) in analysis of
3 studies
cardiovascular events (HR 1.14, 95% CI 1.09-1.2 per 10 mm Hg increase) in analysis of 5
studies
increased office SBP
not associated with risk of all-cause mortality in analysis of 4 studies
not associated with risk of cardiovascular mortality in analysis of 3 studies
associated with increased risk of cardiovascular events (HR 1.1, 95% CI 1.06-1.15 per 10
mm Hg increase) in analysis of 5 studies
after adjusting for home and office BP, in analyses of 3 studies
home SBP remained significantly associated with cardiovascular mortality and cardiovascular
events
office SBP not associated with cardiovascular mortality or cardiovascular events
Reference - J Hypertens 2012 Mar;30(3):449
10 mm Hg increase in home BP measurement associated with increased risk of
cardiovascular events in normotensive or mildly hypertensive patients
pooled analysis of individual patient data from 5 population-based cohort studies evaluating
the efficacy of home blood pressure monitoring with oscillometric device for cardiovascular risk
stratification in 5,008 participants not being treated with antihypertensive drugs
all cohorts were enrolled in the International Database of Home Blood Pressure in Relation
to Cardiovascular Outcome (IDHOCO)
all participants had baseline conventional blood pressure measurement
follow-up duration ranged from 5.5 to 11.9 years (median 8.3 years)
during follow-up, 522 participants died and 414 participants had fatal or nonfatal
cardiovascular events
conventional blood pressure defined as average of 2 consecutive measurements made at a
clinic
10-mm Hg increase in home systolic blood pressure associated with increased risk of
cardiovascular events in patients with
optimal conventional blood pressure (< 120/80) (hazard ratio [HR] 1.28, 95% CI 1.01-1.62)
normal conventional blood pressure (120–129/80–84) (HR 1.22, 95% CI 1-1.49)
high-normal conventional blood pressure (130–139/85–89) (HR 1.24, 95% CI 1.03-1.49)
mild hypertension (140–159/90–99) (HR 1.2, 95% CI 1.06-1.37)
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no significant differences in cardiovascular risk with 10-mm Hg increase in home systolic blood
pressure in patients with severe hypertension by conventional blood pressure
masked hypertension (≥ 130/85 at home but < 140/90 conventional blood pressure) occurred
in
5% of participants with optimal conventional blood pressure
18.4% of participants with normal conventional blood pressure
30.3% of participants with high-normal conventional blood pressure
masked hypertension associated with increased risk of cardiovascular events (HR 2.29, 95% CI
1.52-3.45)
Reference - PLoS Med 2014 Jan;11(1):e1001591 EBSCOhost Full Text full-text
home BP measurements and ambulatory BP measurements may have higher
correlation with preclinical increases in left ventricular mass than office BP
measurements
systematic review of 23 studies evaluating association between BP measurement methods and
preclinical target organ damage in adults
BP measurement methods included home, ambulatory, or office BP measurements
comparing home BP measurements to ambulatory BP measurements, no significant difference
in correlations with left ventricular hypertrophy as assessed by echocardiographic left
ventricular mass index in analysis of 9 studies with 1,000 adults
comparing home BP measurements to office BP measurements
home BP measurements had significantly higher correlation with cardiac enlargement
assessed by echocardiographic left ventricular mass index (p < 0.001) in analysis of 10
studies with 1,832 adults
no significant differences in correlations between BP measurements and other damage
assessments
Reference - J Hypertens 2012 Jul;30(7):1289
Ambulatory BP Monitoring (ABPM)
Recommendations from professional organizations:

Detection, Evaluation, and Management of High Blood Pressure in Adults(4)
ABPM general information
may be used to supplement blood pressure readings measured in office settings
may provide estimate of mean blood pressure over entire monitoring period as well as
during nighttime and daytime periods
may be used to determine daytime to nighttime blood pressure ratio to identify extent of
nocturnal “dipping”
may help identify early-morning blood pressure surge pattern, estimate blood pressure
variability, and identify symptomatic hypotension
precise relationship between office readings, ABPM readings, and home blood pressure
measurements not completely clear, but general agreement that office blood pressures
higher than ABPM or home blood pressure measurements (particularly at higher blood
pressures)
United States Centers for Medicaid and Medicare Services provide reimbursement for ABPM
in patients with suspected white coat hypertension
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recommendations
consider screening for white coat hypertension by using either daytime ABPM or home blood
pressure monitoring (HBPM) before diagnosis of hypertension in adults with untreated
systolic blood pressure (SBP) > 130 mm Hg but < 160 mm Hg or diastolic blood pressure
(DBP) > 80 mm Hg but < 100 mm Hg (ACC/AHA Class IIa, Level B-NR)
consider periodic monitoring (using either ABPM or HBPM) to detect transition to sustained
hypertension in adults with white coat hypertension (ACC/AHA Class IIa, Level C-LD)
consider confirming blood pressure measurement (using ABPM) in adults being treated for
hypertension with office blood pressure readings not at goal and HBPM readings suggestive
of significant white coat effect (ACC/AHA Class IIa, Level C-LD)
consider screening for masked hypertension (using HBPM or ABPM) in adults with untreated
office blood pressures consistently between 120-129 mm Hg for SBP or between 75-79 mm
Hg for DBP (ACC/AHA Class IIa, Level B-NR)
consider screening for white coat effect (using HBPM or ABPM) in adults on multiple drug
therapies for hypertension and office blood pressures within 10 mm Hg above goal
(ACC/AHA Class IIb, Level C-LD)
consider confirmation of diagnosis (using ABPM) before intensification of antihypertensive
drug treatment in adults being treated for hypertension with elevated HBPM readings
suggestive of masked uncontrolled hypertension (ACC/AHA Class IIb, Level C-EO)
European Society of Hypertension/European Society of Cardiology (ESH/ESC)
guideline
ABPM suggested as alternative to in-office BP measurement for diagnosis or monitoring
ABPM may improve prediction of cardiovascular risk in untreated and treated patients
indications for 24-hour ABPM
suspicion of white coat hypertension
grade 1 hypertension in office
high office BP in persons without asymptomatic organ damage and at low total
cardiovascular risk
suspicion of masked hypertension
high normal BP in office
normal office BP in persons with asymptomatic organ damage or at high total
cardiovascular risk
identification of white coat effect in hypertensive patients
substantial variability of office BP over same or different visits
autonomic, postural, postprandial, siesta- or drug-induced hypotension
elevated office BP or suspected preeclampsia in pregnant women
identification of true and false resistant hypertension
significant difference between office BP and home BP
assessment of dipping status (decrease in nighttime BP compared to daytime BP)
suspicion of nocturnal hypertension or absence of dipping, such as in patients with sleep
apnea, chronic kidney disease, or diabetes
assessment of BP variability
when measuring 24-hour ABPM
use validated devices by international standardized protocols (see Dabl Educational Trust for
list of devices tested for accuracy)
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use cuff of appropriate size and ensure initial values are within 5 mm Hg of
sphygmomanometer
set readings at 15-minute intervals during day and 30-minute intervals at night, or every 20
minutes throughout 24 hour period
refrain from strenuous exercise, keep arm extended, still, and at level of heart during cuff
inflation
maintain diary of unusual events, drug ingestion, meals, and duration and quality of night
sleep
repeat ABPM if < 70% valid values during initial study
if sufficient measurements are obtained, editing is not necessary and only grossly incorrect
readings should be deleted
readings may not be accurate when markedly irregular cardiac rhythm
Reference - Eur Heart J 2013 Jul;34(28):2159 PDF
American Heart Association (AHA) consensus statement on ABPM in children and
adolescents
indications for use
for primary hypertension, to
confirm diagnosis of hypertension
detect
masked hypertension
white coat hypertension
evaluate effectiveness of antihypertensive therapy
conditions that may merit ABPM use
secondary hypertension
diabetes (type 1 and type 2)
chronic kidney disease
obesity
sleep apnea
Williams syndrome
Turner syndrome
Neurofibromatosis 1
hypertension research
discard values falling outside of following range
systolic BP 60-220 mm Hg
diastolic BP 35-120 mm Hg
heart rate 40-180 beats/minute
pulse pressure 40-120 mm Hg
Reference - Hypertension 2014 May;63(5):1116 full-text
list of specific sphygmomanometers for ambulatory blood pressure measurement tested for
accuracy can be found at Dabl Educational Trust
Diagnostic thresholds:
precise relationship between office readings, home blood pressure readings, and ambulatory
blood pressure readings not completely clear, but general agreement that office blood pressures
higher than ABPM or HBPM (particularly at higher blood pressures)(4)
European Society of Hypertension/European Society of Cardiology (ESH/ESC)
guideline
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definitions of hypertension based on ambulatory BP and home BP are lower than measurement
in-office
home SBP > 135 mm Hg and/or DBP > 85 mm Hg
ambulatory BP
daytime (or awake) SBP > 135 mm Hg and/or DBP > 85 mm Hg
nighttime (or asleep) SBP > 120 mm Hg and/or DBP > 70 mm Hg
24-hour SBP > 130 mm Hg and/or DBP > 85 mm Hg
Reference - Eur Heart J 2013 Jul;34(28):2159 PDF
ambulatory blood pressure monitoring may result in less overdiagnosis of
hypertension compared to clinic or home blood pressure monitoring for diagnosis of
hypertension in adults (level 2 [mid-level] evidence)
based on systematic review of diagnostic studies with methodologic limitations
systematic review of 20 studies comparing accuracy of clinic and home blood pressure (BP)
monitoring to ABPM (reference standard) for diagnosis of hypertension in 5,863 adults
methodologic limitations included lack of or unclear blinding or use of validated devices
diagnostic thresholds used for hypertension
clinic BP > 140/90 mm Hg
home BP > 135/85 mm Hg
ambulatory BP > 135/85 mm Hg
using ambulatory BP as reference standard
clinic BP monitoring associated with
mean sensitivity of 74.6% (95% CI 60.7%-84.8%) in pooled analysis of 7 studies
mean specificity of 74.6% (95% CI 47.9%-90.4%) in pooled analysis of 7 studies
home BP monitoring associated with
mean sensitivity of 85.7% (95% CI 78%-91%) in pooled analysis of 3 studies
mean specificity of 62.4% (95% CI 48%-75%) in pooled analysis of 3 studies
Reference - BMJ 2011 Jun 24;342:d3621 full-text
optimal ambulatory blood pressure thresholds for diagnosis and treatment of
hypertension may be lower compared with clinic blood pressure
8,575 patients (mean age 56 years) had 24-hour ambulatory BP recorded
1,693 patients had BP measured by physicians
mean clinic measurements by trained staff were
6/3 mm Hg higher than daytime ambulatory BP
10/5 mm Hg higher than 24-hour BP
9/7 mm Hg lower than clinic values measured by physicians
Diagnostic and Treatment Thresholds for ABPM Measured by Trained Staff or

Physician:
ABPM Optimal Blood Target Blood Pressure Hypertension

Pressure Plus 1 Condition
Measured Staff Physician Staff Physician Staff Physician
by
Abbreviation: ABPM, ambulatory blood pressure monitoring.

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ABPM Optimal Blood Target Blood Pressure Hypertension

Pressure Plus 1 Condition
Daytime < 120/78 < 117/70 < 128/78 < 123/73 ≥ 136/87 ≥ 129/81
blood mm Hg mm Hg mm Hg mm Hg mm Hg mm Hg
pressure
Nighttime < 102/67 < 99/61 < 112/67 < 106/61 ≥ 121/76 ≥ 113/69
pressure
24-hour < 117/76 < 113/70 < 125/76 < 119/70 ≥ 133/84 ≥ 126/78
pressure
Abbreviation: ABPM, ambulatory blood pressure monitoring.

Reference - BMJ 2010 Apr 14;340:c1104 full-text, editorial can be found in BMJ 2010 Apr
14;340:c1782
ABPM can be used as early as age 3-6 years (Pediatr Nephrol 1997 Dec;11(6):707
EBSCOhost Full Text)
see Hypertension medication selection and management for additional information on target
blood pressure
Prognostic ability of ABPM:
elevated 24-hour ambulatory systolic blood pressure associated with increased risk of
cardiovascular events and mortality independent of office BP
systematic review of 15 cohort studies evaluating association between noninvasive 24-hour
ambulatory systolic blood pressure (SBP) and incident cardiovascular events in 19,771 patients
mean follow-up ranged from 1.9 to 11.1 years
in analyses adjusted for office BP, increased 24-hour SBP associated with increased risk of
cardiovascular events (hazard ratio [HR] 1.21, 95% CI 1.1-1.33 per 10 mm Hg increase) in
analysis of 4 cohort studies
cardiovascular mortality (HR 1.19, 95% CI 1.13-1.26 per 10 mm Hg increase) in analysis of
3 studies
all-cause mortality (HR 1.12, 95% 1.07-1.17 per 10 mm Hg increase) in analysis of 3 studies
stroke (HR 1.33, 95% CI 1.22-1.44 per 10 mm Hg increase) in analysis of 3 studies
cardiac events (HR 1.17, 95% CI 1.09-1.25 per 10 mm Hg increase) in analysis of 3 studies
Reference - J Hypertens 2008 Jul;26(7):1290
similar results can be found in Ann Intern Med 2015 Feb 3;162(3):192 EBSCOhost Full
Text, editorial can be found in Ann Intern Med 2015 Feb 3;162(3):233 EBSCOhost Full
Text
ambulatory BP is better correlated with future risk of cardiovascular events than
office BP
based on 5 cohort studies
7,030 persons (mean age 56 years) in Belgium, Denmark, Japan, and Sweden followed for
median 9.5 years (J Hypertens 2007 Aug;25(8):1554)
1,700 Danish men and women aged 41-72 years followed for mean 9.5 years (Hypertension
2005 Apr;45(4):499)
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1,332 persons > 40 years old in Japan followed for mean 10 years (J Am Coll Cardiol 2005 Aug
2;46(3):508), commentary can be found in J Fam Pract 2005 Dec;54(12):1031 EBSCOhost
Full Text
808 patients aged ≥ 60 years with isolated systolic hypertension with median 4.4 year follow-
up (JAMA 1999 Aug 11;282(6):539 EBSCOhost Full Text)
556 patients with resistant hypertension followed for median 4.8 years (Arch Intern Med 2008
Nov 24;168(21):2340 EBSCOhost Full Text)
higher ambulatory systolic blood pressure predicts cardiovascular events in patients
with treated hypertension
1,963 patients with treated hypertension had 24-hour ABPM then followed for median 5 years
(range 1-66 months)
157 patients (8%) had new cardiovascular events
comparing 810 patients with mean 24-hour ambulatory SBP ≥ 135 mm Hg vs. 1,153 with
ambulatory SBP < 135 mm Hg
cardiovascular events in 12.5% vs. 4.9% (p < 0.001)
death from any cause in 5.3% vs. 3% (p = 0.01)
Reference - N Engl J Med 2003 Jun 12;348(24):2407, editorial can be found in N Engl J Med
2003 Jun 12;348(24):2377
nighttime ambulatory blood pressure appears better than daytime ambulatory blood
pressure for predicting cardiovascular events and mortality
based on prospective cohort studies
meta-analysis of individual patient data from 4 European prospective cohort studies including
3,468 patients with hypertension but without major cardiovascular disease at baseline
61% were receiving antihypertensive treatment at time of ABPM
during median follow-up of 6.6 years
324 patients (9.3%) died (including 145 cardiovascular-related deaths)
72 patients (2.1%) had nonfatal myocardial infarctions
93 patients (2.7%) had nonfatal strokes
in analyses including adjustment for office BP, daytime and nighttime SBP significantly and
independently predicted all-cause mortality, cardiovascular mortality, coronary heart
disease, and stroke
in analyses including adjustment for daytime BP, nighttime SBP significantly predicted all-
cause mortality, noncardiovascular mortality, cardiovascular mortality, coronary heart
disease, and stroke
in analyses including adjustment for nighttime BP, daytime SBP was not predictive of
mortality or adverse cardiovascular outcomes
Reference - Hypertension 2008 Jan;51(1):55
prospective cohort study in 3 continents
7,458 patients (mean age 56.8 years) randomly recruited in studies in Europe, Asia, and
South America had 24-hour BP monitoring
during median follow-up 9.6 years
993 patients (13.3%) died, including 387 patients (5.2%) with cardiovascular mortality
and 560 patients (7.5%) with noncardiovascular mortality
943 patients (12.6%) had cardiovascular events, including 525 (7%) cardiac events and
420 (5.6%) stroke events
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adjusted for daytime BP, nighttime BP significantly predicted mortality (total, cardiovascular,
and noncardiovascular)
adjusted for nighttime BP, daytime BP significantly predicted only noncardiovascular
mortality; lower BP associated with associated with increased risk
daytime and nighttime BP significantly predicted cardiovascular events and stroke events;
only nighttime BP significantly predicted cardiac events
antihypertensive drug treatment removed significant association between cardiovascular
events and daytime BP
Reference - Lancet 2007 Oct 6;370(9594):1219, commentary can be found in Lancet 2007
Oct 6;370(9594):1192, Lancet 2008 Jan 12;371(9607):113
"office-hour" BP monitoring (that is, 8 AM to 6 PM) predicted 24-hour ABPM in 84 patients (J Hum
Hypertens 2006 Jun;20(6):440 EBSCOhost Full Text)
elevated ambulatory systolic-diastolic pressure regression index associated with
increased risk of all-cause and cardiovascular mortality and stroke
based on systematic review without assessment of study quality and clinical heterogeneity
systematic review of 7 cohort studies evaluating ambulatory systolic-diastolic pressure
regression index (ASDPRI) in 20,505 patients followed for mean 7.8 years
ASDPRI (commonly referred as ambulatory arterial stiffness index) calculated as 1 minus slope
of regression line for diastolic pressure vs. systolic pressure from 24-hour ambulatory blood
pressure recording
mean follow-up 7.8 years
threshold for stratification to high vs. low ASDPRI groups varied across studies
compared to low ASDPRI, high ASDPRI associated with increase in
all-cause mortality (relative risk [RR] 1.25, 95% CI 1.1-1.41) in analysis of 4 studies
cardiovascular mortality (RR 1.51, 95% CI 1.18-1.93) in analysis of 5 studies
stroke (RR 2.01, 95% CI 1.6-2.52) in analysis of 4 studies
Reference - Stroke 2012 Mar;43(3):733 full-text
Central BP Measurement
higher central blood pressure indexes associated with increased risk for
cardiovascular events in varied populations
systematic review of 11 longitudinal studies evaluating central hemodynamics in 5,648 persons
mean follow-up 45 months
populations included patients with coronary artery disease or having coronary angiography (5
studies), patients with end stage renal disease (3 studies), elderly patients (2 studies), and
American Indians free of cardiovascular disease (1 study)
higher central systolic BP associated with increased risk of cardiovascular events (adjusted
relative risk [RR] 1.09, 95% CI 1.02-1.18 per 10 mm Hg increase) in analysis of 3 studies
higher central pulse pressure associated with increased risk of cardiovascular events (adjusted
RR 1.14, 95% CI 1.06-1.22 per 10 mm Hg increase) in analysis of 6 studies, results limited by
significant heterogeneity
higher central augmentation index
associated with increased risk of cardiovascular events (adjusted RR 1.32, 95% CI 1.09-1.59
per 10% increase) in analysis of 5 studies, results limited by significant heterogeneity
associated with increased risk of all-cause mortality (adjusted RR 1.4, 95% CI 1.11-1.76 per
10% increase) in analysis of 3 studies
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Reference - Eur Heart J 2010 Aug;31(15):1865 full-text

higher central pulse pressure and disappearance of pulse pressure amplification
associated with increased all-cause mortality in patients with end stage renal disease
180 patients (mean age 52 years) with end stage renal disease and receiving hemodialysis
were followed for mean 52 months
all patients had carotid pulse pressure measurements (pulse wave analysis), echocardiography,
and aortic pulse wave velocity measurements (Doppler ultrasonography) at baseline
70 deaths occurred during follow-up
increased risk of all-cause mortality associated with
higher carotid pulse pressure (adjusted hazard ratio [HR] 1.4, 95% CI 1.1-1.8 per 1
standard deviation increment)
higher aortic pulse wave velocity (adjusted HR 1.3, 95% CI 1-1.7 per 1 standard deviation
increment)
disappearance of pulse pressure amplification also independently predicted all-cause mortality
in adjusted analysis
brachial BP not associated with risk of mortality in adjusted analyses
Reference - Hypertension 2002 Mar 1;39(3):735 full-text
Self-Monitoring
Self-monitoring alone:
home blood pressure monitoring may reduce blood pressure in adults with
hypertension (level 3 [lacking direct] evidence)
based on systematic review without clinical outcomes
systematic review of 100 randomized trials comparing implementation strategies for blood
pressure control vs. usual care in 55,920 adults with hypertension
29 trials evaluated home blood pressure monitoring
follow-up ranged from 6 months to 2 years
home blood pressure monitoring associated with reduced
systolic blood pressure (adjusted mean difference -2.7 mm Hg, 95% CI -3.6 to -1.7 mm Hg)
in analysis of 26 trials, results limited by significant heterogeneity
diastolic blood pressure (adjusted mean difference -1.5 mm Hg, 95% CI -2.3 to -0.8 mm
Hg) in analysis of 27 trials
Reference - Ann Intern Med 2017 Dec 26 early online EBSCOhost Full Text
home blood pressure monitoring (self-monitoring) may be associated with lower
blood pressure and possibly increased likelihood of achieving target blood pressure
(level 3 [lacking direct] evidence)
based on 2 systematic reviews without clinical outcomes, and with small effect sizes and
heterogeneity
systematic review of 25 randomized trials limited by heterogeneity
self-monitoring associated with reduced office systolic BP (weighted mean difference -3.82
mm Hg [95% CI -5.61 to -2.03 mm Hg]) in analysis of 20 trials with 5,898 patients
self-monitoring associated with reduced office diastolic BP (weighted mean difference -1.45
mm Hg [95% CI -1.95 to -0.94 mm Hg]) in analysis of 23 trials with 6,038 patients
self-monitoring associated with increased likelihood of reaching target office BP (relative risk
1.09, 95% CI 1.02-1.6) in analysis of 12 trials with 2,260 patients
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all 3 analyses limited by significant heterogeneity

Reference - Ann Med 2010 Jul;42(5):371 EBSCOhost Full Text
systematic review of 52 prospective comparative studies evaluating self-monitoring of blood
pressure (SMBP) at home (with or without additional support) with ≥ 8 weeks' follow-up in
adults with hypertension
compared with usual care
SMBP alone associated with moderate-strength evidence for lower BP at 6 months
(summary net difference 3.9 mm Hg and 2.4 mm Hg for systolic and diastolic BP), but
not at 12 months, in analysis of 26 studies
SMBP plus additional support associated with high-strength evidence for lower BP at 12
months (range 3.4-8.9 mm Hg and 1.9-4.4 mm Hg for systolic and diastolic blood
pressure) in 25 studies
low-strength evidence demonstrating no significant difference in BP comparing SMBP
monitoring plus additional support vs. SMBP monitoring alone or with less intense additional
support in 13 studies
very few trials evaluated objective clinical outcomes
Reference - Ann Intern Med 2013 Aug 6;159(3):185 EBSCOhost Full Text, AHRQ
Comparative Effectiveness Review 2012 Jan:45 PDF
interactive digital interventions may decrease blood pressure in patients with
hypertension (level 3 [lacking direct] evidence)
based on nonclinical outcome in systematic review
systematic review of 7 randomized trials comparing interactive digital interventions vs. usual
care in 1,259 adults with hypertension
interactive digital interventions defined as interventions accessed through computer or smart
phone to deliver tailored self-management support for blood pressure control
follow-up ranged from 6 weeks to 24 months
interactive digital interventions associated with decreases in
systolic blood pressure (mean difference [MD] -3.74 mm Hg, 95% CI -5.28 to -2.19 mm Hg)
in analysis of 6 trials
diastolic blood pressure (MD - 2.37 mm Hg, 95% CI -4.35 to -0.4 mm Hg) in analysis of 5
trials, results limited by significant heterogeneity
Reference - J Hypertens 2016 Apr;34(4):600
practice-based self-monitoring associated with improvement in systolic BP at 6
months but not 1 year (level 3 [lacking direct] evidence)
441 primary care patients with hypertension not controlled below 140/85 mm Hg were
randomized to practice-based self-monitoring vs. usual care (BP monitored by practice)
practice based self-monitoring involved coming to the medical office to use a validated
electronic BP machine once a month
practice-based self-monitoring reduced SBP by 4.3 mm Hg at 6 months (95% CI 0.8-7.9 mm
Hg)
results at 1 year not statistically significant
Reference - BMJ 2005 Sep 3;331(7515):493 full-text, editorial can be found in BMJ 2005 Sep
3;331(7515):466 full-text
home blood pressure monitoring may lower blood pressure at 60 days in patients with
uncontrolled hypertension while on medication (level 3 [lacking direct] evidence)
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136 patients with uncontrolled hypertension while on medication randomized to HBPM vs.
usual care, without medication modification during trial, and assessed by 24-hour ambulatory
blood pressure monitoring at 60 days
BP < 130/80 mm Hg in 32.4% with HBPM vs. 16.2% with usual care (p = 0.03, NNT 7)
Reference - MONITOR trial (J Hypertens 2012 Jan;30(1):75)
self-measurement of blood pressure may slightly increase medication adherence in
patients with hypertension (level 3 [lacking direct] evidence)
228 patients with mild-to-moderate hypertension randomized to perform self-measurement of
BP at home in addition to office BP checks vs. office BP checks only and followed for 1 year
comparing home measurement with office-only measurement, medication adherence 92.3%
vs. 90.9% (p = 0.04) as assessed by medication event monitoring system
Reference - J Hypertens 2010 Mar;28(3):622
Self-monitoring with self-management:
self-management program for hypertension associated with improvements in blood
pressure (level 3 [lacking direct] evidence)
systematic review of 13 randomized trials comparing self-management programs vs. usual care
in patients with hypertension
compared to usual care alone, self-management programs associated with pooled effect size
reduction in
systolic blood pressure 0.39 (95% CI 0.28-0.51), equivalent to change in BP of about 5 mm
Hg in analysis of 13 trials
diastolic blood pressure 0.51 (95% CI 0.3-0.73), equivalent to change in BP of about 4.3
mm Hg in analysis of 13 trials
Reference - Ann Intern Med 2005 Sep 20;143(6):427 EBSCOhost Full Text, editorial can
be found in Ann Intern Med 2005 Sep 20;143(6):458 EBSCOhost Full Text, commentary
can be found in Am Fam Physician 2006 Apr 1;73(7):1260, Ann Intern Med 2006 Apr
18;144(8):617 EBSCOhost Full Text
self-management education program might be associated with reduction in systolic
BP in patients with diabetes (level 3 [lacking direct] evidence)
systematic review of 7 randomized trials comparing self-management education program
compared to control in 1,606 patients with diabetes
compared to control, self-management education program associated with significant reduction
in systolic blood pressure in analysis of 7 trials with 1,606 patients
Reference - Arch Intern Med 2004 Aug 9-23;164(15):1641 EBSCOhost Full Text
self-monitoring plus medication self-titration may reduce blood pressure in patients
with high cardiovascular risk (level 3 [lacking direct] evidence)
552 patients ≥ 35 years old with blood pressure ≥ 130/80 mm Hg randomized to blood
pressure self-monitoring plus individualized medication self-titration algorithm vs. usual care for
1 year
all patients had high risk of cardiovascular disease (history of stroke, coronary heart disease,
diabetes, or chronic kidney disease)
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blood pressure target was 130/80 mm Hg at office and 120/75 mm Hg at home

self-monitoring and self-titration associated with decreased
systolic blood pressure (mean difference 8.8 mm Hg, 95% CI 4.9 to 12.7 mm Hg)
diastolic blood pressure (mean difference 3.1 mm Hg, 95% CI 0.7 to 5.5 mm Hg)
Reference - TASMIN-SR trial (JAMA 2014 Aug 27;312(8):799 EBSCOhost Full Text),
correction can be found in JAMA 2014 Nov 26;312(20):2169, editorial can be found in JAMA
2014 Aug 27;312(8):795 EBSCOhost Full Text
self-management of hypertension plus telemonitoring of measurements associated
with decreased systolic BP (level 3 [lacking direct] evidence)
527 patients aged 35-85 years with BP > 140/90 mm Hg receiving antihypertensive therapy
randomized to self-management vs. usual care
self-management included self-titration of antihypertensive drugs, self-monitoring of BP, plus
telemonitoring of BP measurements
reduction in mean systolic BP (SBP) comparing self-management vs. usual care
12.9 mm Hg vs. 9.2 mm Hg at 6 months (p = 0.013)
17.6 mm Hg vs. 12.2 mm Hg at 12 months (p = 0.0004)
Reference - TASMINH2 trial (Lancet 2010 Jul 17;376(9736):163), editorial can be found in
Lancet 2010 Jul 17;376(9736):144
compared to no home-based titration of medications, home-based titration of
medications may not decrease systolic BP in minority patients with low income (level
3 [lacking direct] evidence)
237 patients (mean age 60 years) with poorly controlled hypertension (SBP ≥ 145 mm Hg or
diastolic BP [DBP] ≥ 90 mm Hg) randomized to home titration of BP medications vs. no
titration for 6 months
all were low income and 80% were of Latino or Asian descent
all received BP monitoring plus health coaching
SBP decreased by 23.9 mm Hg with home titration vs. 19.3 mm Hg with no titration (not
significant)
Reference - Ann Fam Med 2012 May;10(3):199 EBSCOhost Full Text full-text
HBPM with additional support:
home blood pressure monitoring plus tailored behavioral intervention may improve
long-term blood pressure control compared to usual care (level 3 [lacking direct]
evidence)
based on randomized trial with high dropout rate and without clinical outcomes
636 patients (mean age 61 years) with hypertension randomized to 1 of 4 groups
home BP monitoring 3 times weekly
bimonthly tailored behavioral intervention with nurse-administered telephone call targeting
hypertension-related behaviors
monitoring plus behavioral intervention
usual care
25% lost to follow-up
monitoring plus behavioral intervention compared to usual care associated with significant
reduction in estimated
systolic blood pressure of
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3.3 mm Hg (95% CI 0.8-5.7 mm Hg) at 12 months

diastolic blood pressure of
Reference - Ann Intern Med 2009 Nov 17;151(10):687 EBSCOhost Full Text PDF
home blood pressure monitoring offered through workplace with personalized web-
based management may reduce blood pressure in employees with hypertension or
prehypertension (level 3 [lacking direct] evidence)
based on cluster-randomized trial without clinical outcomes
6 computer industry work sites randomized 404 employees aged 35-65 years to 1 of 2 BP
monitoring programs for 6 months for employees with hypertension or prehypertension
home BP monitor with device to upload readings (encouraged to upload ≥ twice weekly)
plus access to website (encouraged to access ≥ once weekly) to view BP trends, educational
material, and automated rules-based messages plus training
access to BP monitor at work and training in use
comparing intervention vs. control
≥ 10 mm Hg reduction in SBP in 21.3% vs. 16.4% (p = 0.044, NNT 21)
≥ 5 mm Hg reduction in DBP in 27.4% vs. 15.9% (p = 0.03, NNT 9)
Reference - Am Heart J 2012 Oct;164(4):625
home blood pressure telemonitoring with pharmacist management may improve
blood pressure control in patients with uncontrolled hypertension (level 3 [lacking
direct] evidence)
based on nonclinical outcome from cluster-randomized trial
16 primary care clinics randomized to telemonitoring intervention vs. usual care for 12 months
for adults with uncontrolled BP
in telemonitoring group, patients transmitted BP data to pharmacists who could adjust
antihypertensive therapy as needed
450 patients (mean age 61 years) were enrolled
BP control was defined as < 140/90 mm Hg or < 130/80 mm Hg in patients with diabetes or
chronic kidney disease
comparing telemonitoring intervention vs. usual care
BP control at both 6 and 12 months in 57.2% vs. 30% (p = 0.001, NNT 4)
BP control at 18 months in 71.8% vs. 57.1% (p = 0.003, NNT 7)
telemonitoring intervention associated with (at 18 months)
decreased SBP (mean difference -6.6 mm Hg, p = 0.004)
nonsignificant decrease in DBP (mean difference -3 mm Hg, p = 0.07)
Reference - JAMA 2013 Jul 3;310(1):46 EBSCOhost Full Text, editorial can be found in
JAMA 2013 Jul 3;310(1):40 EBSCOhost Full Text
home blood pressure telemonitoring with optional patient support may reduce blood
pressure in patients with uncontrolled hypertension (level 3 [lacking direct] evidence)
based on nonclinical outcome from randomized trial without intention-to-treat analysis
401 patients (mean age 61 years) with uncontrolled hypertension (mean daytime ambulatory
BP 135/85-210/135 mm Hg) were randomized to home BP telemonitoring with optional patient
support vs. usual care for 6 months
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home BP telemonitoring included transmission of patient-recorded home BP by mobile phone,

plus optional online access to BP records and consultation for patients and healthcare providers
90% were included in analyses for change in BP
home BP telemonitoring associated with
decreased daytime systolic ambulatory blood pressure (mean difference -4.1 mm Hg, p =
0.0006)
decreased daytime diastolic ambulatory blood pressure (mean difference -2.2 mm Hg, p =
0.0022)
increased hypertensive drug use (p < 0.0001)
no significant differences in anxiety, health related quality of life, exercise tolerance, body
mass index, cholesterol, or HbA1c
Reference - BMJ 2013 May 24;346:f3030 full-text
addition of self-care support to home blood pressure telemonitoring lowers blood
pressure in patients with diabetes and uncontrolled systolic hypertension (level 3
[lacking direct] evidence)
based on randomized trial without blinding of clinical outcome
110 patients (mean age 63 years) with uncontrolled systolic hypertension (mean daytime SBP
≥ 130 mm Hg) and diabetes were randomized to home BP telemonitoring system with self-
care support vs. BP monitoring alone for 1 year
home BP telemonitoring system consisted of smartphone plus Bluetooth-enabled BP
monitoring device that sent self-care messages to patient following each BP reading
advising additional physician visit or continued self-monitoring (messages based on running
30-day BP average)
control group had identical-appearing monitoring device but did not receive self-care
messages
all patients measured BP twice in morning and twice in evening on 2 days per week
comparing home self-care support vs. no self-care support
target BP < 130/80 mm Hg reached in 51% vs. 31% (p < 0.05, NNT 5)
mean decrease in daytime ambulatory SBP 9.1 mm Hg vs. 1.5 mm Hg (p = 0.003)
mean decrease in daytime ambulatory DBP 4.6 mm Hg vs. 1.3 mm Hg (p = 0.003)
no significant difference in antihypertensive medication use, physician visits
Reference - Hypertension 2012 Jul;60(1):51 PDF
Quality Improvement
Quality and Outcomes Framework Indicators:

BP2 (NM61). Percentage of patients ≥ 45 years old who have record of blood pressure in
preceding 5 years
see Quality and Outcomes Framework Indicators for additional information
Guidelines and Resources
Guidelines:
United States guidelines:
American College of Cardiology/American Heart Association/American Academy of Physician
Assistants/Association of Black Cardiologists/American College of Preventive Medicine/American
Geriatrics Society/American Pharmacists Association/American Society of Hypertension/American
Society for Preventive Cardiology/National Medical Association/Preventive Cardiovascular Nurses
3/21/2018 DynaMed
Association (ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA) guideline on

prevention, detection, evaluation, and management of high blood pressure in adults can be found
in J Am Coll Cardiol 2017 Nov 7 early online
American Heart Association (AHA) recommendations on blood pressure measurement can be
found in Circulation 2005 Feb 8;111(5):697 full-text or in Hypertension 2005 Jan;45(1):142 full-
text, summary can be found in Am Fam Physician 2005 Oct 1;72(7):1391
Emergency Nurses Association (ENA)
ENA clinical practice guideline on non-invasive blood pressure measurement with automated
devices can be found at ENS 2012 Dec PDF or at National Guideline Clearinghouse 2014 Apr
21:47352
ENA emergency nursing resource on orthostatic vital signs can be found at ENA 2011 PDF or at
National Guideline Clearinghouse 2012 Sep 10:36843
American Heart Association, American Society of Hypertension, and Preventive Cardiovascular
Nurses Association (AHA/ASH/PCNA) joint scientific statement on call to action on use and
reimbursement for home blood pressure monitoring can be found in Hypertension 2008
Jul;52(1):10 full-text, executive summary can be found in Hypertension. 2008 Jul;52(1):1 full-text
American Heart Association (AHA) scientific statement on ambulatory blood pressure monitoring
in children and adolescents can be found in Hypertension 2008 Sep;52(3):433 full-text,
commentary can be found in Hypertension 2008 Dec;52(6):e145
2014 update can be found in Hypertension 2014 May;63(5):1116 full-text
United Kingdom guidelines:
Association of Anaesthetists of Great Britain and Ireland/British Hypertension Society
(AAGBI/BHS) guideline on measurement of adult blood pressure and management of
hypertension before elective surgery can be found at AAGB/BHS 2016 Mar PDF
Canadian guidelines:
Hypertension Canada 2017 guideline update for pharmacists can be found in Can Pharm J (Ott)
2018 Jan-Feb;151(1):33 full-text
Hypertension Canada guideline on diagnosis, risk assessment, prevention, and treatment of
hypertension in adults can be found in Can J Cardiol 2017 May;33(5):557 PDF, correction can be
found in Can J Cardiol 2017 Dec;33(12):1733
European guidelines:
European Society of Hypertension/European Society of Cardiology (ESH/ESC) guideline on
management of arterial hypertension can be found in Eur Heart J 2013 Jul;34(28):2159 full-text
European Society of Hypertension (ESH) practice guideline on home blood pressure measurement
can be found in J Hum Hypertens 2010 Dec;24(12):779 EBSCOhost Full Text and Rev Med
Suisse 2010 Sep 15;6(262):1696 [French]
European Society of Hypertension recommendations for conventional, ambulatory and home
blood pressure measurement can be found in J Hypertens 2003 May;21(5):821, summary can be
found in BMJ 2004 Oct 16;329(7471):870 full-text, commentary can be found in BMJ 2005 Jan
15;330(7483):148 and BMJ 2005 Jan 15;330(7483):148
French Society of Hypertension (Société française d’hypertension artérielle [SFHTA]) guideline on
blood pressure measurements in diagnosis and monitoring of hypertensive patients can be found
in Presse Med 2012 Mar;41(3 Pt 1):221 [French]
Asian guidelines:
3/21/2018 DynaMed
Japanese Society of Hypertension (JSH) guidelines on self-monitoring of blood pressure at home

can be found in Hypertens Res 2012 Aug;35(8):777 EBSCOhost Full Text
Japanese Circulation Society (JCS) guideline on clinical use of 24 hour ambulatory blood pressure
monitoring (ABPM) can be found in Circ J 2012;76(2):508 PDF
Central and South American guidelines:
Grupo de Trabalho Monitorização Ambulatorial da Pressão Arterial/Grupo de Trabalho
Monitorização Residencial da Pressão Arterial (MAPA/MRPA) guidelines on ambulatory monitoring
of arterial pressure and home monitoring of blood pressure can be found in J Bras Nefrol 2011
Jul-Sep;33(3):365 full-text [Portuguese]
Sociedade Brasileira de Cardiologia/Sociedade Brasileira de Hipertensão/Sociedade Brasileira de
Nefrologia (SBC/SBH/SBN) guidelines on
ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM)
can be found be in Arq Bras Cardiol 2011 Sep;97(3 Suppl 3):1 full-text [Portuguese]
clinical and laboratory assessment and cardiovascular risk stratification can be found in J Bras
Nefrol 2010 Sep;32 Suppl 1:14 full-text [Portuguese]
Chilean Hypertension Society recommendations on ambulatory blood pressure monitoring can be
found in Rev Med Chil 2009 Sep;137(9):1235 [Spanish]
Review articles:
AHRQ Comparative Effectiveness Review 2012 Jan:45 PDF
review of blood pressure measurement can be found in Am J Kidney Dis 2012 Sep;60(3):449
AHRQ Evidence Report 2002 Nov:63 PDF (archived), commentary can be found in Evidence-Based
Medicine 2003 Jul-Aug;8(4):120
evidence-based review of measurement of blood pressure can be found in BMJ 2001 Apr
14;322(7291):908 full-text, correction can be found in BMJ 2001 Jul 21;323(7305):141,
commentary can be found in BMJ 2001 Aug 18;323(7309):399
review of blood pressure measurement (part 2) can be found in BMJ 2001 Apr
28;322(7293):1043 full-text
review of blood pressure measuring devices and recommendations of the European Society of
Hypertension can be found in BMJ 2001 Mar 3;322(7285):531 full-text, commentary can be found
in BMJ 2001 Aug 18;323(7309):398
review of blood pressure measurement can be found in BMJ 2001 Apr 21;322(7292):981 full-text,
correction can be found in BMJ 2001 Jun 2;322(7298):1349, correction can be found in BMJ 2001
Jul 21;323(7305):141, commentary can be found in BMJ 2001 Oct 6;323(7316):805
discussion of blood pressure measurement and devices can be found in JAMA 2003 Feb
26;289(8):1027 EBSCOhost Full Text, commentary can be found in JAMA 2003 Jun
4;289(21):2792 EBSCOhost Full Text
review of detecting white-coat hypertension can be found in J Fam Pract 2005 Jun;54(6):549
EBSCOhost Full Text
reviews of home blood pressure monitoring can be found in
Ann Intern Med 2015 Nov 3;163(9):691 EBSCOhost Full Text
Am J Med 2009 Sep;122(9):803
Am Fam Physician 2007 Jul 15;76(2):255 EBSCOhost Full Text full-text
Arch Intern Med 2000 May 8;160(9):1251 EBSCOhost Full Text, commentary can be
found in Arch Intern Med 2001 Jan 22;161(2):294 EBSCOhost Full Text
reviews of ambulatory blood pressure measurement can be found in
Ann Intern Med 2015 Nov 3;163(9):691 EBSCOhost Full Text
3/21/2018 DynaMed
N Engl J Med 2006 Jun 1;354(22):2368, commentary can be found in N Engl J Med 2006 Aug
24;355(8):850
Am Fam Physician 2003 Jun 1;67(11):2343 EBSCOhost Full Text full-text, editorial can be
found in Am Fam Physician 2003 Jun 1;67(11):2262 EBSCOhost Full Text
BMJ 2001 May 5;322(7294):1110 full-text
review of automated sphygmomanometry (self blood pressure measurement) can be found in
BMJ 2001 May 12;322(7295):1167 full-text
review of blood pressure self-monitoring (questions and answers from national conference) can
be found in BMJ 2008 Dec 22;337:a2732
Patient Information
handout on home blood pressure monitoring from American Academy of Family Physicians or in
Spanish
handout on using an ambulatory blood pressure monitor from American Academy of Family
Physicians or in Spanish
handout on home blood pressure monitoring from Mayo Clinic
handout on home and ambulatory blood pressure monitoring from Patient UK
References
General references used:

1. Pickering TG, Miller NH, Ogedegbe G, Krakoff LR, Artinian NT, Goff D, American Heart
Association, American Society of Hypertension, Preventive Cardiovascular Nurses Association. Call
to action on use and reimbursement for home blood pressure monitoring: executive summary: a
joint scientific statement from the American Heart Association, American Society Of Hypertension,
and Preventive Cardiovascular Nurses Association. Hypertension. 2008 Jul;52(1):1-9 full-text, joint
scientific statement can be found in Hypertension 2008 Jul;52(1):10 full-text, commentary can be
found in J Clin Hypertens (Greenwich) 2008 Oct;10(10):741
2. Parati G, Stergiou GS, Asmar R, et al, ESH Working Group on Blood Pressure Monitoring.
European Society of Hypertension practice guidelines for home blood pressure monitoring. J Hum
Hypertens. 2010 Dec;24(12):779-85 EBSCOhost Full Text, also published in Rev Med Suisse
2010 Sep 15;6(262):1696 [French]
3. Pickering TG, Hall JE, Appel LJ, et al. Subcommittee of Professional and Public Education of the
American Heart Association Council on High Blood Pressure Research. Recommendations for
blood pressure measurement in humans and experimental animals: Part 1: blood pressure
measurement in humans: a statement for professionals from the Subcommittee of Professional
and Public Education of the American Heart Association Council on High Blood Pressure Research.
Hypertension. 2005 Jan;45(1):142-61 full-text
4. Whelton PK, Carey RM, Aronow WS, et al. 2017
ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention,
Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the
American College of Cardiology/American Heart Association Task Force on Clinical Practice
Guidelines. J Am Coll Cardiol. 2017 Nov 7 early online
DynaMed editorial process:
DynaMed topics are created and maintained by the DynaMed Editorial Team and Process.
All editorial team members and reviewers have declared that they have no financial or other
competing interests related to this topic, unless otherwise indicated.
3/21/2018 DynaMed
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1992 - Kaplan - Blood Pressure Measurement and Monitoring

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1992 - Kaplan - Blood Pressure Measurement and Monitoring

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Blood pressure measurement and monitoring

Devices for Blood Pressure (BP) Measurement

aneroid sphygmomanometers provide accurate pressure measurements when maintenance

Office/Clinic HBPM Daytime ABPM Nighttime 24-Hour ABPM

Office/Clinic HBPM Daytime ABPM Nighttime 24-Hour ABPM

130/80 130/80 130/80 110/65 125/75

140/90 135/85 135/85 120/70 130/80

160/100 145/90 145/90 140/85 145/90

based on cohort study

separate repeated measurements by 1-2 minutes

47% by home measurement transmitted electronically

Recommendations from professional organizations:

American College of Cardiology/American Heart Association Guideline for the Prevention,

patients should be trained under medical supervision

Recommendations from professional organizations:

Diagnostic and Treatment Thresholds for ABPM Measured by Trained Staff or

ABPM Optimal Blood Target Blood Pressure Hypertension

Abbreviation: ABPM, ambulatory blood pressure monitoring.

ABPM Optimal Blood Target Blood Pressure Hypertension

Abbreviation: ABPM, ambulatory blood pressure monitoring.

Reference - Eur Heart J 2010 Aug;31(15):1865 full-text

all 3 analyses limited by significant heterogeneity

based on randomized trial without clinical outcomes

blood pressure target was 130/80 mm Hg at office and 120/75 mm Hg at home

3.3 mm Hg (95% CI 0.8-5.7 mm Hg) at 12 months

home BP telemonitoring included transmission of patient-recorded home BP by mobile phone,

Quality and Outcomes Framework Indicators:

Association (ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA) guideline on

Japanese Society of Hypertension (JSH) guidelines on self-monitoring of blood pressure at home

General references used:

Please give us your feedback by e-mailing DynaMed at: DynaMedEditor@ebscohost.com

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