Recommendations for Blood Pressure Measurement in Humans: An AHA Scientific Statement From the Council on High Blood Pressure Research Professional and Public Education Subcommittee

Thomas G. Pickering, MD, DPhil; John E. Hall, PhD; Lawrence J. Appel, MD; Bonita E. Falkner, MD; John W. Graves, MD; Martha N. Hill, PhD; Daniel W. Jones, MD; Theodore Kurtz, MD; Sheldon G. Sheps, MD; Edward J. Roccella, PhD, MPH

Disclosures
In This Article

Introduction

Ten years have passed since the last version of the American Heart Association (AHA) blood pressure (BP) measurement recommendations,[1] during which time there have been major changes in the ways in which BP is measured in clinical practice and research; hence this document represents a major revision of previous versions.[2] BP determination continues to be one of the most important measurements in clinical medicine, and still one of the most inaccurately performed. The gold standard for clinical BP measurement has always been readings taken by a trained health care provider using a mercury sphygmomanometer and the Korotkoff sound technique. There is increasing evidence, however, that this procedure may lead to the misclassification of large numbers of individuals as hypertensive, and fail to diagnose other individuals whose BP may be normal in the clinic setting but elevated at other times. There are three reasons for this: 1) inaccuracies in the methods, some of which are avoidable; 2) the inherent variability of BP; and 3) the tendency for BP to increase in the presence of a physician (the so-called "white coat effect").

Numerous surveys have shown that physicians and other health care providers rarely follow established guidelines for BP measurement, but when they do, the readings they get correlate more closely with more objective measures of BP than the usual clinic readings. It is generally agreed that conventional clinic readings, when made correctly, are a surrogate marker for a patient's true BP, which is conceived as the average level over prolonged periods of time, and which is thought to be the most important component of BP in determining its adverse effects. Usual clinic readings give a poor estimate of this, not only because of poor technique, but also because they typically consist only of one or two individual measurements, and the beat-to-beat BP variability is such that a small number of readings may only give a crude estimate of the average level.

The recognition of these limitations of traditional clinic readings has led to two parallel developments: first, increasing use of measurements out of the clinic, which avoids the unrepresentative nature of the clinic setting and also allows for an increased number of readings; and second, the increased use of automated devices, which are being used both in and out of the office setting. This decreased reliance on traditional readings has been accelerated by the fact that mercury is being banned in many countries, although there is still uncertainty as to what will replace it.

Several dimensions of BP are associated with an increased risk of vascular disease. Clinic-based measurements that predict vascular disease include systolic and diastolic BP as well as mean arterial pressure and pulse pressure. Several studies have attempted to tease apart the relative importance of these measure-ments.[3,4] Despite evolving interest in pulse pressure, the best available evidence still supports the use of systolic and diastolic BPs to classify individuals.

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