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## Complete Summary

#### GUIDELINE TITLE

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.

#### BIBLIOGRAPHIC SOURCE(S)

Pickering TG, Hall JE, Appel LJ, Falkner BE, Graves J, Hill MN, Jones
DW, Kurtz T, Sheps SG, Roccella EJ. 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 AHA Council on
HBP. Circulation 2005 Feb 8;111(5):697-716. \[164 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15699287)

Pickering TG, Hall JE, Appel LJ, Falkner BE, Graves J, Hill MN, Jones
DW, Kurtz T, Sheps SG, Roccella EJ. 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 AHA Council on
HBP. Hypertension 2005 Jan;45(1):142-61.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15611362)

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Hypertension, including:

-   Isolated systolic hypertension

-   Isolated systolic hypertension of the young

-   Isolated diastolic hypertension

-   White-coat hypertension or isolated office hypertension

-   Masked hypertension of isolated ambulatory hypertension

-   Pseudohypertension

-   Orthostatic or postural hypotension

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation

#### CLINICAL SPECIALTY

Cardiology\
Family Practice\
Geriatrics\
Internal Medicine\
Nursing\
Obstetrics and Gynecology\
Pediatrics\
Preventive Medicine

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Nurses\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

To provide clinicians with a standardized set of recommendations for
blood pressure measurement in humans that, if followed, should lead to
accurate estimation of blood pressure

#### TARGET POPULATION

Patients in various settings at risk for hypertension including the
following special populations:

-   Elderly patients

-   Patients with pulseless syndromes

-   Patients with arrhythmias

-   Obese patients

-   Children

-   Pregnant women

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Blood pressure measurement methods

    -   Auscultatory method using:

        -   Mercury sphygmomanometer

        -   Aneroid sphygmomanometer

        -   Hybrid sphygmomanometer

    -   Oscillometric technique

    -   Finger cuff method of Penaz

    -   Ultrasound techniques

    -   Tonometry

    -   Location of measurement (arm, wrist, finger)

    -   Validation of monitors

2.  Blood pressure measurement in the clinic or office

    -   Subject preparation

    -   Choice of blood pressure measurement device

    -   Selection of proper cuff size

    -   Use of sitting or supine body position

    -   Positioning of arm; use of right or left arm

    -   Cuff placement and use of stethoscope

    -   Use of proper inflation/deflation techniques

    -   Limiting observer error

    -   Use of multiple blood pressure readings

    -   Use of automated devices

3.  Training, evaluation, and retraining of observers in required
    competencies

4.  Blood pressure measurement in other settings

    -   Measurement in acute care

    -   Measurement in public places

5.  Self-measurement

6.  Ambulatory blood pressure measurement

7.  Blood pressure recording in special situations

    -   Elderly patients

    -   Patients with pulseless syndromes

    -   Patients with arrhythmias

    -   Obese patients

    -   Children

    -   Pregnant patients

#### MAJOR OUTCOMES CONSIDERED

-   Accuracy of blood pressure measurement using various methods

-   Diagnostic and prognostic value of various methods of blood pressure
    measurement

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review\
Review of Published Meta-Analyses

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Expert peer review of American Heart Association (AHA) scientific
statements is conducted at the AHA National Center.

This statement was approved by the American Heart Association Science
Advisory and Coordinating Committee on October 13, 2004.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**[Blood Pressure Measurement Methods]{.underline}**

The auscultatory method has been the mainstay of clinical blood pressure
measurement for as long as blood pressure has been measured but is
gradually being supplanted by other techniques that are more suited to
automated measurement.

Please refer to the original guideline document for a full discussion of
blood pressure measurement methods, techniques, and devices.

**Validation of Monitors**

All monitors in clinical use should be tested for accuracy. This
involves 2 stages. First, all oscillometric automated monitors that
provide read-outs of systolic and diastolic pressure should be subjected
by independent investigators to formal validation protocols. The
original 2 protocols that gained the widest acceptance were developed by
the Association for the Advancement of Medical Instrumentation (AAMI) in
1987 and the British Hypertension Society (BHS) in 1990, with revisions
to both in 1993, and to AAMI in 2002. These required testing of a device
against 2 trained human observers in 85 subjects, which made validation
studies difficult to perform. One consequence of this has been that
there are still many devices on the market that have never been
adequately validated. More recently, an international group of experts
who are members of the European Society of Hypertension Working Group on
Blood Pressure Monitoring has produced an International Protocol that
could replace the 2 earlier versions and is easier to perform. Briefly,
it requires comparison of the device readings (4 in all) alternating
with 5 mercury readings taken by 2 trained observers. Devices are
recommended for approval if both systolic and diastolic readings taken
are at least within 5 mm Hg of each other for at least 50% of readings.

It is recommended that only those devices that have passed this or
similar tests should be used in practice. However, the fact that a
device passed a validation test does not mean that it will provide
accurate readings in all patients. There can be substantial numbers of
individual subjects in whom the error is consistently \>5 mm Hg with a
device that has achieved a passing grade. This may be more likely to
occur in elderly or diabetic patients. For this reason, it is
recommended that each oscillometric monitor should be validated on each
patient before the readings are accepted. No formal protocol has yet
been developed for doing this, but if sequential readings are taken with
a mercury sphygmomanometer and the device, then major inaccuracies can
be detected.

Another problem is that manufacturers may change the model number after
a device has been tested without indicating whether the measurement
algorithm has also been changed.

With nonautomatic devices, such as mercury and aneroid monitors, it is
recommended that the accuracy of the pressure registration mechanism be
checked. In the case of mercury sphygmomanometers, this involves
checking that the upper curve of the meniscus of the mercury column is
at 0 mm Hg, that the column is free of dirt, and that it rises and falls
freely during cuff inflation and deflation.

Aneroid devices or other nonmercury devices should be checked by
connecting the manometer to a mercury column or an electronic testing
device with a Y-tube. The needle should rest at the zero point before
the cuff is inflated and should register a reading that is within 4 mm
Hg of the mercury column when the cuff is inflated to pressures of 100
and 200 mm Hg. The needle should return to zero after deflation.

**[Blood Pressure (BP) Measurement in the Clinic or
Office]{.underline}**

Accurate auscultatory office blood pressure measurement is the bedrock
of the diagnosis and treatment of hypertension and has been the standard
method used in the major epidemiologic and treatment trials of the past
50 years. However, it is becoming increasingly clear that as it is used
in everyday practice, there are major shortcomings. Thus, surveys of
mercury devices in clinical practices have shown that there are
frequently mechanical defects, and physicians rarely follow official
guidelines for their use. Added to these is the phenomenon of the white
coat effect, whereby the recorded blood pressure may be unrepresentative
of the patient\'s true blood pressure.

**Subject Preparation**

A number of factors related to the subject can cause significant
deviations in measured blood pressure. These include room temperature,
exercise, alcohol or nicotine consumption, positioning of the arm,
muscle tension, bladder distension, talking, and background noise. The
patient should be asked to remove all clothing that covers the location
of cuff placement. The individual should be comfortably seated, with the
legs uncrossed, and the back and arm supported, such that the middle of
the cuff on the upper arm is at the level of the right atrium (the
mid-point of the sternum). Measurements made while the patient is on an
examining table do not fulfill these criteria and should preferably be
made while the patient is seated in a chair. At the initial visit, blood
pressure should be measured in both arms. The patient should be
instructed to relax as much as possible and to not talk during the
measurement procedure; ideally, 5 minutes should elapse before the first
reading is taken.

**Choice of Blood Pressure Measurement Devices**

The \"gold standard\" device for office blood pressure measurement has
been the mercury sphygmomanometer, but these are being removed from
clinical practice because of environmental concerns about mercury
contamination. Mercury sphygmomanometers are already banned in Veterans
Administration hospitals. There is a role for other types of device in
office use, both as a substitute for the traditional mercury readings
(e.g., aneroid and hybrid sphygmomanometers) and as supplements to them
(e.g., oscillometric automatic devices). However, because there is
currently no generally accepted replacement for mercury, it is
recommended that, if available, a properly maintained mercury
sphygmomanometer be used for routine office measurements. Mercury
sphygmomanometers are critical for evaluating the accuracy of any type
of nonmercury device. Nonmercury pressurometers that use electronic
pressure transducers with a digital read-out are available for
calibrating the pressure detection systems of aneroid or oscillometric
devices.

**Cuff Size**

Von Recklinghausen in 1901 recognized that Riva Rocci\'s device for
determination of accurate systolic blood pressure by palpation had a
significant flaw, its 5-cm-width cuff. Multiple authors have shown that
the error in blood pressure measurement is larger when the cuff is too
small relative to the patient\'s arm circumference than when it is too
large. Previous epidemiological data from Britain and Ireland had
suggested that arm circumferences of \>34 cm were uncommon. Data from
National Health And Nutrition Examination Survey (NHANES) III and NHANES
2000 have shown the opposite in the United States. In the United States
during the period from 1988 to 2000, there has been a significant
increase in mean arm circumference and an increase in the frequency of
arm circumferences of \>33 cm was found because of increasing weight in
the American population. This should not be surprising, because the
prevalence of obesity in the United States has increased from 22.9% in
NHANES III (1988 to 1994) to \>30% in 2000. Similar data regarding the
increased frequency of larger arm circumferences were also found in a
study of a referral practice of hypertensive subjects, in which a
striking 61% of 430 subjects had an arm circumference of
[\>]{.underline}33 cm. Recognition of the increasing need for the
\"large adult\" cuff, or even the thigh cuff, for accurate blood
pressure measurement is critical, because frequently in practice only
the standard adult size has been demonstrated to be available. More
importantly, it has been demonstrated that the most frequent error in
measuring blood pressure in the outpatient clinic is \"miscuffing,\"
with undercuffing large arms accounting for 84% of the \"miscuffings.\"

The \"ideal\" cuff should have a bladder length that is 80% and a width
that is at least 40% of arm circumference (a length-to-width ratio of
2:1). A recent study comparing intra-arterial and auscultatory blood
pressure concluded that the error is minimized with a cuff width of 46%
of the arm circumference. The recommended cuff sizes are:

-   For arm circumference of 22 to 26 cm, the cuff should be \"small
    adult\" size: 12X22 cm

-   For arm circumference of 27 to 34 cm, the cuff should be \"adult\"
    size: 16X30 cm

-   For arm circumference of 35 to 44 cm, the cuff should be \"large
    adult\" size: 16X36 cm

-   For arm circumference of 45 to 52 cm, the cuff should be \"adult
    thigh\" size: 16X42 cm

The optimum ratios of width and length to arm circumference are shown
for the small adult and standard adult cuffs. For the large adult and
thigh cuffs, the ideal width ratio of 46% of arm circumference is not
practical, because it would result in a width of 20 cm and 24 cm,
respectively. These widths would give a cuff that would not be
clinically usable for most patients, so for the larger cuffs, a less
than ideal ratio of width to arm circumference must be accepted. The
ideal ratio of length to arm circumference is maintained in all 4 cuffs.

In practice, bladder width is easily appreciated by the clinician but
bladder length often is not, because the bladder is enclosed in the
cuff. To further complicate the issue for clinicians, there are no
standards for manufacturers of different sizes of blood pressure cuff.
This has led to significant differences in which arm circumferences are
accurately measured by individual manufacturers\' standard adult and
large adult cuffs.

Individual cuffs should be labeled with the ranges of arm
circumferences, to which they can be correctly applied, preferably by
having lines that show whether the cuff size is appropriate when it is
wrapped around the arm. In patients with morbid obesity, one will
encounter very large arm circumferences with short upper arm length.
This geometry often cannot be correctly cuffed, even with the thigh
cuff. In this circumstance, the clinician may measure blood pressure
from a cuff placed on the forearm and listening for sounds over the
radial artery (although this may overestimate systolic blood pressure)
or use a validated wrist blood pressure monitor held at the level of the
heart.

**Effects of Body Position**

Blood pressure measurement is most commonly made in either the sitting
or the supine position, but the 2 positions give different measurements.
It is widely accepted that diastolic pressure measured while sitting is
higher than when measured supine (by approximately 5 mm Hg), although
there is less agreement about systolic pressure. When the arm position
is meticulously adjusted so that the cuff is at the level of the right
atrium in both positions, the systolic pressure has been reported to be
8 mm Hg higher in the supine than the upright position.

Other considerations include the position of the back and legs. If the
back is not supported (as when the patient is seated on an examination
table as opposed to a chair), the diastolic pressure may be increased by
6 mm Hg. Crossing the legs may raise systolic pressure by 2 to 8 mm Hg.

In the supine position, the right atrium is approximately halfway
between the bed and the level of the sternum; thus, if the arm is
resting on the bed, it will be below heart level. For this reason, when
measurements are taken in the supine position the arm should be
supported with a pillow. In the sitting position, the right atrium level
is the midpoint of the sternum or the fourth intercostal space.

**Effects of Arm Position**

The position of the arm can have a major influence when the blood
pressure is measured; if the upper arm is below the level of the right
atrium (when the arm is hanging down while in the sitting position), the
readings will be too high. Similarly, if the arm is above the heart
level, the readings will be too low. These differences can be attributed
to the effects of hydrostatic pressure and may be 10 mm Hg or more, or 2
mm Hg for every inch above or below the heart level.

Other physiological factors that may influence the blood pressure during
the measurement process include muscle tension. If the arm is held up by
the patient (as opposed to being supported by the observer), the
isometric exercise will raise the pressure.

**Differences Between the Two Arms**

Several studies have compared the blood pressure measured in both arms,
mostly using the auscultatory technique. Almost all have reported
finding differences, but there is no clear pattern; thus, the difference
does not appear to be determined by whether the subject is right- or
left-handed. One of the largest studies was conducted in 400 subjects
using simultaneous measurements with oscillometric devices, which found
no systematic differences between the 2 arms, but 20% of subjects had
differences of \>10 mm Hg. Although these findings are disturbing, it is
not clear to what extent the differences were consistent and
reproducible, as opposed to being the result of inherent blood pressure
variability. Nevertheless, it is recommended that blood pressure should
be checked in both arms at the first examination. This may be helpful in
detecting coarctation of the aorta and upper extremity arterial
obstruction. When there is a consistent interarm difference, the arm
with the higher pressure should be used. In women who have had a
mastectomy, blood pressure can be measured in both arms unless there is
lymphedema.

**Cuff Placement and Stethoscope**

Cuff placement must be preceded by selection of the appropriate cuff
size for the subject\'s arm circumference. The observer must first
palpate the brachial artery in the antecubital fossa and place the
midline of the bladder of the cuff (commonly marked on the cuff by the
manufacturer) so that it is over the arterial pulsation over the
patient\'s bare upper arm. The sleeve should not be rolled up such that
it has a tourniquet effect above the blood pressure cuff. The lower end
of the cuff should be 2 to 3 cm above the antecubital fossa to allow
room for placement of the stethoscope. However, if a cuff that leaves
such space has a bladder length that does not sufficiently encircle the
arm (at least 80%), a larger cuff should be used, recognizing that if
the cuff touches the stethoscope, artifactual noise will be generated.
The cuff is then pulled snugly around the bare upper arm. Neither the
observer nor the patient should talk during the measurement. Phase 1
(systolic) and phase 5 (diastolic) Korotkoff sounds are best heard using
the bell of the stethoscope over the palpated brachial artery in the
antecubital fossa, although some studies have shown that there is little
difference when using the bell or the diaphragm. The key to good
measurement is the use of a high-quality stethoscope with short tubing,
because inexpensive models may lack good tonal transmission properties
required for accurate auscultatory measurement.

**Inflation/Deflation System**

Indirect blood pressure measurement requires that occlusion of the
brachial artery is produced by gradual inflation and deflation of an
appropriately sized cuff. The tubing from the device to the cuff must be
of sufficient length (70 cm or more) to allow for its function in the
office setting. Successful inflation and deflation requires an airtight
system; ongoing inspection and maintenance of the tubing for
deterioration of the rubber (cracking) and the release valve are
required. The cuff should initially be inflated to at least 30 mm Hg
above the point at which the radial pulse disappears. The rate of
deflation has a significant effect on blood pressure determination.
Deflation rates \>2 mm per second can lead to a significant
underestimation of systolic and overestimation of diastolic blood
pressure. Automated devices with a linear deflation rate may have
improved accuracy over the more common circumstances in automated
devices that have stepwise deflation. It is recommended that a deflation
rate of 2 to 3 mm Hg per second (or per pulse when the heart rate is
very slow) be used.

*Important Points for Clinical Blood Pressure Measurement*

-   The patient should be seated comfortably with the back supported and
    the upper arm bared without constrictive clothing. The legs should
    not be crossed.

-   The arm should be supported at heart level, and the bladder of the
    cuff should encircle at least 80% of the arm circumference.

-   The mercury column should be deflated at 2 to 3 mm/s, and the first
    and last audible sounds should be taken as systolic and diastolic
    pressure. The column should be read to the nearest 2 mm Hg.

-   Neither the patient nor the observer should talk during the
    measurement.

**Observer**

The observer is the most critical component of accurate blood pressure
measurement. For accurate blood pressure measurement, the observer must:
(1) be properly trained in the techniques of blood pressure measurement;
(2) use an accurate and properly maintained device; (3) recognize
subject factors, such as anxiety and recent nicotine use, that would
adversely affect blood pressure measurements; (4) position the subject
appropriately; (5) select the correct cuff and position it correctly;
and (6) perform the measurement using the auscultatory or automated
oscillometric method and accurately record the values obtained.

Observer error is a major limitation of the auscultatory method.
Systematic errors lead to intra-observer and interobserver error.
Terminal digit preference is perhaps the most common manifestation of
suboptimal blood pressure determination. It is generally recommended
that the observer should read the blood pressure to the nearest 2 mm Hg,
but an inappropriate excess in the recording of \"zero\" as the last
digit in auscultatory blood pressure determinations has been reported by
multiple investigators in clinical and research settings. Digit bias or
digit prejudice is particularly common when the observer recognizes a
specific threshold value for blood pressure and, depending on the
circumstances, records a pressure just above or below that number. A
good example is the Syst-Eur Trial, which showed both increased zero
preference and a significant digit bias for 148 mm Hg systolic, the
threshold for successful treatment in that trial.

**Number of Measurements**

It is well recognized that the predictive power of multiple blood
pressure determinations is much greater than a single office reading.
One of the potential advantages of supplementing auscultatory readings
with readings taken by an automated device is the ability to obtain a
larger number of readings. When a series of readings is taken, the first
is typically the highest. A minimum of 2 readings should be taken at
intervals of at least 1 minute, and the average of those readings should
be used to represent the patient\'s blood pressure. If there is \>5 mm
Hg difference between the first and second readings, additional (1 or 2)
readings should be obtained, and then the average of these multiple
readings is used.

**Automated Methods**

Automated oscillometric blood pressure devices are increasingly being
used in office blood pressure measurement, as well as for home and
ambulatory monitoring. When they are used in the office, the readings
are typically lower than readings taken by a physician or nurse. The
potential advantages of automated measurement in the office are the
elimination of observer error, minimizing the white coat effect, and
increasing the number of readings. The main disadvantages are the error
inherent in the oscillometric method and the fact that epidemiologic
data are mostly based on auscultated blood pressure measures.

Automated devices may also offer the opportunity to avoid expensive and
repetitive training of health care professionals in auscultation, which
is necessary to reduce observer errors. Their use still requires careful
patient evaluation for caffeine or nicotine use, selection of the
correct cuff size, and proper patient positioning if accurate blood
pressures are to be obtained. Devices are now available that can take a
series of sequential readings and automatically average them.

**The White Coat Effect and the Differences Between Physician and Nurse
Blood Pressure Measurements**

The initial epidemiological studies of hypertension and the first major
hypertension treatment trial (Veterans Administration \[VA\] Cooperative
Study) were performed using physician blood pressure measurements. Since
that time, all the major hypertension treatment trials have used a
nurse, \"a trained observer,\" or automated blood pressure measurements.
In hypertensive patients (but not necessarily in normotensive patients),
the blood pressure recorded by a physician or nurse is typically higher
than the average daytime level, and this difference is commonly referred
to as the white coat effect.

In addition to these effects of the medical environment on blood
pressure measurement, there is a recognized difference between blood
pressure levels measured by a physician versus a nurse in the same
subjects. In the largest study of physician-nurse blood pressure
differences, it was found that a nurse recorded significantly lower mean
systolic and diastolic pressures than a physician (by 6.3/7.9 mm Hg).
This difference is not caused by any difference in technique, because
when a dual-headed stethoscope is used and the physician and nurse
simultaneously take the blood pressure, the physician-nurse difference
is insignificant. In addition, the nurse-recorded blood pressure is
usually closer to the patient\'s daytime average pressure than the
pressure recorded by the physician. Because all of the most recent
treatment trials of hypertension are based on blood pressure
measurements made by nurses or other professionals, but not by
physicians, the difference in office blood pressure measured by
physicians and nurses suggests that physician blood pressures should not
be used exclusively in the routine management of the hypertensive
subject.

**[Training of Observers]{.underline}**

As the number and type of blood pressure measurement devices and
direct-to-consumer advertising increase, more people are measuring blood
pressure more frequently. In medical settings, physicians, nurses,
nurses\' aids, students, and pharmacists all measure blood pressure and
record the values in a patient\'s records. Outside medical settings,
patients, family members, or lay persons also measure blood pressure.
The training given to lay observers should be as comprehensive and
similar to that recommended for health care professionals in ambulatory
and community settings. With careful training even unpaid volunteers in
large population surveys can measure blood pressure accurately. However,
even with the newer automated devices, the accuracy of the readings can
be optimal only if all observers are appropriately trained and retrained
and conscientious about using appropriate techniques.

**Required Competencies**

Before training begins, potential observers should be assessed for
physical and cognitive competencies required to perform the procedure.
The physical requirements include the following:

-   Vision. The observer must be able to see the dial of the manometer
    or the meniscus of the mercury column at eye level without straining
    or stretching, and must be able to read well enough to see the
    sphygmomanometer or digital display no further than 3 feet away.

-   Hearing. The observer must be able to hear the appearance and
    disappearance of Korotkoff sounds.

-   Eye/hand/ear coordination. This is required for the use of mercury
    and aneroid sphygmomanometers but not for the newer electronic
    technologies.

**Training**

Traditionally, health professionals are trained in blood pressure
measurement in introductory courses on physical assessment. They may
receive a classroom lecture with a video on how to measure blood
pressure, some laboratory skills training with demonstration and
practice on fellow trainees, and mentored experience measuring blood
pressure of patients, potential research subjects, or community
volunteers. In clinical trials, standardized programs with audiovisual
tapes that test and retest accuracy in measurement are extremely
effective in training and retraining. In contrast, such training and
retraining is not routinely required in nonresearch settings.

Some information is available on the Internet, and the British
Hypertension Society has a web-based video that can be used for the
training and evaluation of observers.

**Evaluation of Observers**

Pencil-and-paper questionnaires or interviews can be used to assess
knowledge of the correct methodology of blood pressure measurement. The
evaluation of observers should include an assessment of their knowledge
of the different types of observer bias, general technique, and the
interpretation of the measurements, including an understanding of the
normal variability of blood pressure by time of day, exercise, timing of
antihypertensive medications, etc. The observers should also know how
and when to communicate blood pressure readings gathered at home or
other settings to the health care professional responsible for the care
of the patient and management of hypertension.

Observers should be aware of the need to use only well-maintained and
calibrated equipment, choosing a quiet location with adequate room
temperature, correctly positioning the person having blood pressure
measured, and ensuring that the person does not talk or move during the
measurement.

The skills of the observer should be demonstrated by assessing items
such as positioning the patient, selecting the right size cuff,
obtaining a valid and reliable measurement, recording the measurement
accurately, and appropriate reporting of abnormal levels.

**Retraining**

Correct blood pressure measurement technique is difficult to maintain
without careful attention to all steps in the protocol and retraining.
The gold standard for retraining has been set by federally funded
multisite clinical trials of hypertension care and control, in which
retraining is required of all blood pressure observers every 6 months.
Retraining requires competency in cuff selection, patient positioning,
no talking, and accurate observation of the blood pressure level by
either auditory or visual assessment. Four methods of assessment are
used: audio-video test tapes; Y-tube-connected simultaneous readings by
2 trained observers; a written quiz; and direct observation. In the
National Heart, Lung, and Blood Institute (NLHBI)-sponsored multisite
clinical trials, a senior experienced person is assigned as the central
trial master trainer and a master trainer is designated for each site.
The central master trainer trains the site master trainers, and they in
turn train the observers at each site. This model could be replicated
within hospitals, ambulatory care settings, and community agencies.
Retraining of all health care professionals is strongly recommended.

**[Blood Pressure Measurement in Other Settings]{.underline}**

**Acute Care**

Blood pressure measurements in acute care settings, such as the
emergency department, dialysis unit, or operating suite, are usually
performed to judge vital signs and volume status of the patient rather
than the presence or absence of hypertension. Oscillometric devices are
widely used for this purpose and may give accurate assessment of mean
arterial pressure, but are often inaccurate for registering systolic and
diastolic pressure. Blood pressure values obtained in acute care
settings are unlikely to be useful for decisions on chronic hypertension
management, because of inadequate patient preparation, faulty equipment,
and the impact of the acute illness on blood pressure. Still, high
readings recorded in the emergency room do predict hypertension on
subsequent clinic visits, to some extent, and warrant follow-up.

Blood pressure measurement is also important in the prehospital setting.
Multiple techniques of blood pressure determination in the field and
ambulance and helicopter transportation environments, including
auscultatory, oscillometric, palpation, and use of obliteration of the
pulse wave on the pulse oximeter, have been used. All of these suffer
from a high degree of error that is worse with systolic blood pressures
of \<90 mm Hg. In addition, it has been shown that standard equipment
used by emergency medical services for blood pressure determination is
often highly unreliable. Determining blood pressures in prehospital
settings requires a high degree of clinical experience and repetitive
measurement. In this setting, establishment of trends in blood pressure
before arriving in the more controlled hospital environment is more
important than the absolute value of the blood pressure.

An elevated blood pressure in the acute care setting should raise the
suspicion that the patient has hypertension, and a referral to the
outpatient setting for further evaluation is warranted. Because of the
lack of precision of blood pressure measurement (and the impact of bed
rest, acute illness, medication administration, and alteration in the
patient\'s usual diet while in the hospital), blood pressures obtained
in the acute care setting should not be used to judge the adequacy of
blood pressure control.

**Public Places**

Automated blood pressure devices are commonly found in public places and
represent a potential mechanism for increased screening for
hypertension. In 1995, Whitcomb et al reported that since the
introduction of the VitaStat device in 1976, \>8000 devices were in use
in the United States, providing \>10 million measurements per year. The
initial version was the 8000 model, which was never tested by approved
protocols and which was found to give very inconsistent results,
particularly for systolic pressure. A later model (the 90550) has been
tested in a community setting and has also failed to meet the British
Hypertension Society (BHS) or Association for the Advancement of Medical
Instrumentation (AAMI) criteria for accuracy. Other potential problems
with these devices are that the cuff size (23X33 cm) is inadequate for
patients with large arms, and that they are not labeled to show when or
if there has been recent maintenance and revalidation of the device\'s
performance. Clear demonstration to the user of ongoing device servicing
and validation would be critical to acceptance of the devices for public
blood pressure screening.

**[Self-Measurement]{.underline}**

**Types of Monitor**

When self-monitoring or home-monitoring was first used, the majority of
studies used aneroid sphygmomanometers. In the past few years, automatic
electronic devices have become increasingly popular. The standard type
of monitor for home use is now an oscillometric device that records
pressure from the brachial artery. Unfortunately, only a few have been
subjected to proper validation tests such as the AAMI and BHS protocols,
and of 24 devices that have been tested by these, only 5 have passed. An
up-to-date list of validated monitors is available. The advantages of
electronic monitors have begun to be appreciated by epidemiologists, who
have always been greatly concerned about the accuracy of clinical blood
pressure measurement and have paid much attention to the problems of
observer error, digit preference, and the other causes of inaccuracy
described. It has been argued that the ease of use of the electronic
devices and the relative insensitivity to who is actually taking the
reading can outweigh any inherent inaccuracy compared with the
traditional sphygmomanometer method. This issue remains controversial,
however.

Electronic devices are now available that will take blood pressure from
the upper arm, wrist, or finger. Although the use of the more distal
sites may be more convenient, measurement of blood pressure from the arm
(brachial artery) has always been the standard method and is likely to
remain so for the foreseeable future. The fact that a device has passed
the validation criteria does not guarantee accuracy in the individual
patient, and it is essential that each device be checked on each patient
before the readings are accepted as being valid (see the previous
section on Validation of Monitors). Home-monitoring devices should be
checked for accuracy every 1 to 2 years.

**Clinical Applications**

Home- or self-monitoring has numerous advantages over ambulatory
monitoring, principal among which are that it is relatively cheap and
provides a convenient way for monitoring blood pressure over long
periods of time. There is some evidence that it improves both
therapeutic compliance and blood pressure control. However, technical,
economic, and behavioral barriers have until now inhibited the
widespread use of home-monitoring in clinical practice. Two
technological developments, low-cost monitors with memory and systems
for sending stored readings over the telephone, have the potential of
overcoming these barriers.

Unfortunately, accurate readings do not guarantee accurate reporting to
the physician. In 2 separate studies, patients were given home monitors,
but they were not told that the devices had memory. Patients were urged
to carefully record all readings, but in both studies, more than half
the subjects omitted or fabricated readings. Devices that have memory or
printouts of the readings are therefore recommended.

It is recommended that when readings are taken, the patient should not
have recently indulged in any activity such as exercise or eating that
is likely to affect the blood pressure, and the patient should be
resting quietly in a comfortable chair for 3 to 5 minutes with the upper
arm at heart level. Three readings should be taken in succession,
separated by at least 1 minute. The first is typically the highest, and
the average should be used as the blood pressure reading. It is helpful
to get readings in the early morning and the evening.

**What Is Normal Home Blood Pressure?**

Home blood pressures are consistently lower than clinic pressures in
most hypertensive patients. Several recent studies have addressed the
question of the level of home pressure that best corresponds to a normal
clinic pressure of 140/90 mm Hg. The largest, the Ohasama study,
proposed a level of 137/84 mm Hg as an acceptable upper limit for home
readings on the grounds that cardiovascular risk increases above this
level. An ad hoc committee of the American Society of Hypertension,
reviewing several studies, recommended 135/85 mm Hg as the upper limit
of normal for home and ambulatory blood pressure. As with office blood
pressure, a lower home blood pressure goal is advisable for certain
patients, including diabetic patients, pregnant women, and patients with
renal failure.

**Prognostic Significance**

One factor that has held back the wider use of self-monitoring in
clinical practice has been the lack of prognostic data. Two prospective
studies, 1 from Japan and 1 from France, have found that home blood
pressure predicts morbid events better than conventional clinic
measurements. There is an increasing body of evidence that home blood
pressure may also predict target organ damage better than clinic
pressure.

**Telemonitoring**

Devices are now available that have the capacity to store readings in
their memory and then transmit them via the telephone to a central
server computer, and then to the health care provider. They have the
potential to improve patient compliance and, hence, blood pressure
control. Readings taken with a telemonitoring system may correlate more
closely than clinic readings with ambulatory blood pressure.

Features of different methods of BP measurement are provided in Table 2
of the original guideline document.

**[Ambulatory Blood Pressure Measurement]{.underline}**

**Types of Monitor**

Ambulatory blood pressure (ABP) monitoring is a noninvasive, fully
automated technique in which blood pressure is recorded over an extended
period of time, typically 24 hours. It has been used for many years as a
research procedure and has recently been approved by Medicare for
reimbursement of a single recording in patients with suspected
white-coat hypertension (WCH). The standard equipment includes a cuff, a
small monitor attached to a belt, and a tube connecting the monitor to
the cuff. Most, but not all, ABP devices use an oscillometric technique.
Of the available ABP devices, most have undergone validation testing as
recommended by the AAMI or the BHS. An up-to-date list of validated
monitors is available.

During a typical ABP monitoring session, blood pressure is measured
every 15 to 30 minutes over a 24-hour period including both awake and
asleep hours, preferably on a workday. The total number of readings
usually varies between 50 and 100. Blood pressure data are stored in the
monitor and then downloaded into device-specific computer software. The
raw data can then be synthesized into a report that provides mean values
by hour and period: daytime (awake), nighttime (asleep), and 24-hour
blood pressure, both for systolic and diastolic blood pressure. The most
common output used in decision-making are absolute levels of blood
pressure, that is, mean daytime, nighttime, and 24-hour values.

The monitors can be attached by a trained technician, who should be
skilled in blood pressure measurement techniques (see the previous
section on Blood Pressure Measurement in Other Settings). The cuff is
attached to the nondominant upper arm, and a series of calibration
readings are taken with a mercury sphygmomanometer to ensure that the
device is giving accurate readings (within 5 mm Hg of the mercury
readings). It is important to instruct the patient to hold the arm still
by the side while the device is taking a reading. It may be helpful to
ask the patient to keep a diary of activities, particularly when going
to bed and getting up in the morning.

**Clinical Applications**

Although ABP could be used to monitor therapy, the most common
application is diagnostic, that is, to ascertain an individual\'s usual
level of blood pressure outside the clinic setting and thereby identify
individuals with WCH. Other potential applications of ABP include the
identification of individuals with a nondipping blood pressure pattern
(e.g., in diabetes), patients with apparently refractory hypertension
but relatively little target organ damage, suspected autonomic
neuropathy, and patients in whom there is a large discrepancy between
clinic and home measurements of blood pressure. The Centers for Medicare
and Medicaid Services has approved the use of ABP measurement for the
diagnosis of patients with suspected WCH (documented high clinic
pressures and normal pressures in other settings, and no evidence of
target organ damage).

A recent overview sponsored by Agency for Healthcare Research and
Quality summarized available evidence on cross-sectional associations of
ABP with subclinical outcomes and on prospective associations of ABP
with clinical outcomes. In cross-sectional studies of blood pressure
with left ventricular mass (22 studies) and albuminuria (6 studies), ABP
levels were directly associated with both measurements. Left ventricular
mass was less in individuals with WCH than in those with sustained
hypertension but was greater in WCH than in nonhypertensive subjects.
Such evidence suggests that WCH is an intermediate phenotype. In each of
10 prospective studies, at least one dimension of ABP predicted clinical
outcomes. In studies that compared the prognostic importance of ABP to
clinic measurements, ABP was usually superior to clinic measurements. In
some instances, including a recent study unavailable at the time of the
overview, mean ABP levels provided additional predictive information
beyond that of clinic measurements, confirming the seminal study by
Perloff et al. In a few prospective studies, WCH predicted a reduced
risk of cardiovascular disease events compared with sustained
hypertension. However, data were inadequate to compare the risk
associated with WCH to the risk associated with normotension. A
nondipping or inverse dipping pattern predicted an increased risk of
clinical outcomes. Just 2 ABP trials tested the usefulness of ABP to
guide blood pressure management. Overall, available studies indicate
that ABP monitoring can provide useful prognostic information.

**What Is Normal ABP?**

The normal range for ABP has been established in 2 ways: first, by
comparison of the ABP level that corresponds to a clinic pressure of
140/90 mm Hg and, second, by relating ABP to risk in prospective
studies. The suggested values for daytime, nighttime, and 24-hour
average levels are shown in the table below.

  -----------------------------------------------------------------------
  **Suggested Values                                  
  for the Upper Limit                                 
  of Normal                                           
  Ambulatory                                          
  Pressure**                                          
  ------------------- --------------- --------------- -------------------
  ** **               **Optimal**     **Normal**      **Abnormal**

  **Daytime**         \<130/80        \<135/85        \>140/90

  **Nighttime**       \<115/65        \<120/70        \>125/75

  **24-Hour**         \<125/75        \<130/80        \>135/85
  -----------------------------------------------------------------------

**Prognostic Significance**

Several prospective studies have documented that the average level of
ABP predicts risk of morbid events better than clinic blood pressure. In
addition to mean absolute levels of ABP, certain ABP patterns may
predict blood pressure-related complications. The patterns of greatest
interest are WCH and nondipping blood pressure. WCH is a pattern in
which clinic blood pressure is in the hypertensive range but ABP is
normal or low. Individuals with WCH are at lower risk for blood
pressure-related complications in comparison to individuals with
sustained hypertension. An important but unresolved issue is whether the
risk of cardiovascular disease in WCH exceeds that of nonhypertensive
subjects. Using both daytime and nocturnal ABP, one can identify
individuals, termed nondippers, who do not experience the decline in
blood pressure that occurs during sleep hours. Usually, nighttime
(asleep) blood pressure drops by 10% or more from daytime (awake) blood
pressure. Individuals with a nondipping pattern (\<10% blood pressure
reduction from night to day) appear to be at increased risk for blood
pressure-related complications compared with those with a normal dipping
pattern. Other evidence suggests that the nighttime blood pressure may
be the best predictor of risk.

**[Blood Pressure Recording in Special Situations]{.underline}**

**Elderly Patients**

Elderly patients are more likely to have WCH, isolated systolic
hypertension, and pseudohypertension (see the section on
Pseudohypertension in the original guideline document). Blood pressure
should be measured while seated, 2 or more times at each visit, and the
readings should be averaged. Blood pressure should also be taken in the
standing position routinely because the elderly may have postural
hypotension. Hypotension is more common in diabetic patients. It is
frequently noticed by patients on arising in the morning, after meals,
and when standing up quickly. Self-measurements can be quite helpful
when considering changes in dosage of antihypertensive medications.
Ambulatory blood pressure monitoring, sometimes coupled with Holter
recordings of electrocardiograms (ECGs), can help elucidate some
symptoms such as episodic faintness and nocturnal dyspnea.

**Pulseless Syndromes**

Rarely, patients present with occlusive arterial disease in the major
arteries to all 4 limbs (e.g., Takayasu arteritis, giant cell arteritis,
or atherosclerosis) so that a reliable blood pressure cannot be obtained
from any limb. In this situation, if a carotid artery is normal, it is
possible to obtain retinal artery systolic pressure and use the nomogram
in reverse to estimate the brachial pressure (oculoplethysmography), but
this procedure and the measurement of retinal artery pressures are not
generally available. If a central intra-arterial blood pressure can be
obtained, a differential in pressure from a noninvasive method can be
established and used as a correction factor.

**Arrhythmias**

When the cardiac rhythm is very irregular, the cardiac output and blood
pressure varies greatly from beat to beat. There is considerable
interobserver and intra-observer error. Estimating blood pressure from
Korotkoff sounds is a guess at best; there are no generally accepted
guidelines. The blood pressure should be measured several times and the
average value used. Automated devices frequently are inaccurate for
single observations in the presence of atrial fibrillation, for example,
and should be validated in each subject before use. However prolonged (2
to 24 hours) ambulatory observations do provide data similar to that in
subjects with normal cardiac rhythm. Sometimes, an intra-arterial blood
pressure is necessary to get a baseline for comparison. If severe
regular bradycardia is present (e.g., 40 to 50 bpm), deflation should be
slower than usual to prevent underestimation of systolic and
overestimation of diastolic blood pressure.

**Obese Patients**

A longer and wider cuff is needed for adequate compression of the
brachial artery in the obese patient with a very large upper arm (see
the previous section on Cuff Size). A large cuff may also be required
for a big, muscular arm with a prominent biceps over which a regular,
nontapered cuff might not fit smoothly. In both situations, it is
particularly important to place the center of the bladder over the
brachial artery pulse. If the upper arm is relatively short despite the
large circumference, it may be difficult to fit a standard large adult
cuff over the arm. The BHS\'s recommendation to use a very long cuff
(12X40 cm; BHS web site August 13, 2003,
[www.bhsoc.org/bp_monitors/BLOOD_PRESSURE_1784b.pdf](http://www.bhsoc.org/bp_monitors/BLOOD_PRESSURE_1784b.pdf))
could obviate this problem. In the rare patient with an arm
circumference \>50 cm, when even a thigh cuff cannot be fitted over the
arm, it is recommended that the health care practitioner wrap an
appropriately sized cuff around the patient\'s forearm, support it at
heart level, and feel for the appearance of the radial pulse at the
wrist. Other potential methods for measuring radial artery pressure
include listening for Korotkoff sounds over the radial artery, detecting
systolic pressure with a Doppler probe, or using an oscillometric device
to determine systolic blood pressure; diastolic blood pressure is
largely overestimated by both methods. The accuracy of these methods has
not been validated, but they provide at least a general estimate of the
systolic blood pressure. The error of overestimating the pressure when
measuring with a cuff that is too small for an obese arm can be
considerable and can lead to misclassification of an individual as
hypertensive and to unnecessary concern and therapy.

**Children**

Blood pressure is most conveniently measured in children by auscultation
with a standard mercury sphygmomanometer. As with adults, the
stethoscope is placed over the brachial artery pulse, proximal and
medial to the antecubital fossa, and below the bottom edge of the cuff.
The right arm is generally the preferred arm for blood pressure
measurement for consistency and comparison with the reference tables.

Correct blood pressure measurement in children requires the use of a
cuff that is appropriate for the size of the child\'s upper arm. A
technique that can be used to select a blood pressure cuff size of
appropriate size is to select a cuff that has a bladder width that is at
least 40% of the arm circumference midway between the olecranon and the
acromion. This will usually be a cuff bladder that will cover 80% to
100% of the circumference of the arm. The equipment necessary to measure
blood pressure in children 3 years of age through adolescence includes
pediatric cuffs of different sizes. For newborn-premature infants, a
cuff size of 4X8 cm is recommended; for infants, 6X12 cm; and for older
children, 9X18 cm. A standard adult cuff, a large adult cuff, and a
thigh cuff for leg blood pressure measurement and for use in children
with very large arms should also be available.

Blood pressure measurements in children should be conducted in a quiet
and comfortable environment after 3 to 5 minutes of rest. With the
exception of acute illness, the blood pressure should be measured with
the child in the seated position with the antecubital fossa supported at
heart level. It is preferable that the child has feet on the floor while
the blood pressure is measured, rather than feet dangling from an
examination table. Overinflation of the cuff should be avoided because
of discomfort, particularly in younger children. It is useful to
initially inflate the cuff while palpating the pulse to estimate the
approximate range for the systolic pressure and then inflate the cuff to
30 mm Hg above this estimate when the blood pressure is auscultated. The
blood pressure should be measured and recorded at least twice on each
measurement occasion, and the average of these 2 measurements is the
measurement for systolic and diastolic blood pressure.

Systolic blood pressure is determined by the onset of the auscultated
pulsation or first Korotkoff sound. The phase of the Korotkoff sounds
that defines diastolic blood pressure has been somewhat controversial.
The disappearance of Korotkoff sounds or fifth Korotkoff sound (K5, the
last sound heard) is the definition of diastolic pressure in adults. In
children, particularly preadolescents, a difference of several
millimeters of mercury is frequently present between the fourth and
fifth Korotkoff sounds. In some children, the Korotkoff sounds can be
heard to 0 mm Hg, which has limited physiological meaning.

Elevated blood pressure measurements in a child or adolescent must be
confirmed on repeated visits before characterizing a child as having
hypertension. Within individual children, blood pressure at high levels
tends to fall on subsequent measurement as a result of an accommodation
effect (reduction of anxiety as the circumstances become more familiar)
and regression to the mean, a nonbiological phenomenon that derives, in
part, from mathematical considerations. Therefore, a more precise
characterization of an individual\'s blood pressure level is an average
of multiple blood pressure measurements taken for weeks or months. A
notable exception to this general guideline for asymptomatic generally
well children would be situations in which the child is symptomatic or
has profoundly elevated blood pressure. Children who show elevated blood
pressure on repeated measurement should also have the blood pressure
measured in the leg as a screen for coarctation of the aorta. To measure
the blood pressure in the leg, a thigh cuff or an oversized cuff should
be placed on the thigh and the blood pressure measured by auscultation
over the popliteal fossa. If the systolic blood pressure measured in the
thigh is \>10 mm Hg lower than the systolic blood pressure measured in
the arm, additional studies for coarctation should be performed.

There continues to be an increase in the use of automated devices to
measure blood pressure in children. These devices are easier to use and
are becoming alternative instruments for blood pressure measurement when
use of mercury sphygmomanometers is not permitted for ecological
reasons. The most commonly used devices use oscillometric methods (see
the previous section on The Oscillometric Technique). Situations in
which the use of the automated devices is acceptable include blood
pressure measurement in newborn and young infants in whom auscultation
is difficult, as well as in an intensive care setting, where frequent
blood pressure measurement is necessary. The reliability of these
instruments in an ambulatory clinical setting is less clear, however.

The interpretation of the blood pressure measurement in children
requires consideration of the child\'s age, sex, and height.
Hypertension in children and adolescents is defined as systolic and/or
diastolic blood pressure that is consistently equal to or greater than
the 95th percentile of the blood pressure distribution. Tables are
available that provide the systolic and diastolic blood pressure level
at the 95th percentile according to age, sex, and height. These tables
should be consulted to determine if the blood pressure measurements are
normal or elevated. Children also demonstrate white coat effects, but
the role of ambulatory blood pressure monitoring is less clear in
children. Validated devices should be used, preferably in a center with
experience using ABPM. Large population-based normative data in children
using ABPM are limited.

**Pregnant Women**

Hypertension is the most common medical disorder of pregnancy and occurs
in 10 to 12% of all pregnancies. The detection of elevated blood
pressure during pregnancy is one of the major aspects of optimal
antenatal care; thus, accurate measurement of blood pressure is
essential. Mercury sphygmomanometry continues to be the recommended
method for blood pressure measurement during pregnancy. Blood pressure
should be obtained in the seated position. Measurement of blood pressure
in the left lateral recumbency, on the left arm, does not differ
substantially from blood pressure that is recorded in the sitting
position. Therefore, the left lateral recumbency position is a
reasonable alternative, particularly during labor. If the patient\'s
upper arm circumference is 33 cm or greater, a large blood pressure cuff
should be used. In the past, there had been some question as to whether
the fourth (K4) or fifth (K5) Korotkoff sound should be used to define
the diastolic blood pressure. The International Society for the Study of
Hypertension in Pregnancy currently recommends using K5 for the
measurement of diastolic blood pressure in pregnancy. When sounds are
audible with the cuff deflated, K4 should be used.

It is recognized that alternatives to mercury devices may be necessary
in the future, and a small number of automated blood pressure recorders
have been validated for use in pregnancy. Self-monitoring may be useful
in evaluating blood pressure changes during pregnancy.

**Summary and Recommendations**

Accurate measurement of blood pressure is essential to classify
individuals, to ascertain blood pressure-related risk, and to guide
management. The objective of this report is to provide clinicians with a
standardized set of recommendations that, if followed, should lead to
accurate estimation of blood pressure. The guideline developers
recognize that many committees and organizations have published
recommendations and that, in practice, blood pressure measurement
remains suboptimal. In view of the consequences of inaccurate
measurement, including both the risks of overtreatment and
undertreatment, it is the opinion of the committee that regulatory
agencies should establish standards to ensure the use of validated
devices, routine calibration of equipment, and the training and
retraining of manual observers. Because the use of automated devices
does not eliminate all major sources of human error, the training of
observers should be required even when automated devices are used.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is not specifically stated for each
recommendation.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Accurate estimation of blood pressure may help to classify individuals,
ascertain blood pressure-related risk, and guide management

#### POTENTIAL HARMS

-   Environmental concerns about mercury contamination exist with the
    mercury sphygmomanometer.

-   The consequences of inaccurate measurement include both the risks of
    overtreatment and undertreatment of hypertension.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness\
Staying Healthy

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Pickering TG, Hall JE, Appel LJ, Falkner BE, Graves J, Hill MN, Jones
DW, Kurtz T, Sheps SG, Roccella EJ. 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 AHA Council on
HBP. Circulation 2005 Feb 8;111(5):697-716. \[164 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15699287)

Pickering TG, Hall JE, Appel LJ, Falkner BE, Graves J, Hill MN, Jones
DW, Kurtz T, Sheps SG, Roccella EJ. 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 AHA Council on
HBP. Hypertension 2005 Jan;45(1):142-61.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15611362)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2005 Jan

#### GUIDELINE DEVELOPER(S)

American Heart Association - Professional Association

#### SOURCE(S) OF FUNDING

American Heart Association

#### GUIDELINE COMMITTEE

Subcommittee of Professional and Public Education of the American Heart
Association Council on High Blood Pressure Research

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

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

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

The American Heart Association makes every effort to avoid any actual or
potential conflicts of interest that may arise as a result of an outside
relationship or a personal, professional, or business interest of a
member of the writing panel. Specifically, all members of the writing
group are required to complete and submit a Disclosure Questionnaire
showing all such relationships that might be perceived as real or
potential conflicts of interest.

**Disclosure**

  -----------------------------------------------------------------------------------------------
  **Writing   **Research   **Speakers           **Stock       **Consultant/Advisory   **Other**
  Group       Grant**      Bureau/Honoraria**   Ownership**   Board**                 
  Member                                                                              
  Name**                                                                              
  ----------- ------------ -------------------- ------------- ----------------------- -----------
  Dr Thomas   None         None                 None          None                    Patent
  G.                                                                                  holder of
  Pickering                                                                           Accusphyg
                                                                                      blood
                                                                                      pressure
                                                                                      monitor

  Dr John E.  None         None                 None          None                    None
  Hall                                                                                

  Dr Lawrence None         None                 None          None                    None
  J. Appel                                                                            

  Dr Bonita   None         None                 None          None                    None
  E. Falkner                                                                          

  Dr John W.  None         None                 None          None                    None
  Graves                                                                              

  Dr Martha   None         None                 None          None                    None
  N. Hill                                                                             

  Dr Daniel   None         None                 None          None                    None
  W. Jones                                                                            

  Dr Theodore None         None                 None          None                    None
  Kurtz                                                                               

  Dr Sheldon  None         None                 None          None                    None
  G. Sheps                                                                            

  Dr Edward   None         None                 None          None                    None
  J. Roccella                                                                         
  -----------------------------------------------------------------------------------------------

This table represents the relationships of writing group members who may
be perceived as actual or reasonably perceived conflicts of interest as
reported on the Disclosure Questionnaire, which all members of the
writing group are required to complete and submit.

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the American Heart Association Web
site:

-   [HTML
    Format](http://circ.ahajournals.org/cgi/content/full/111/5/697)

-   [Portable Document Format
    (PDF)](http://circ.ahajournals.org/cgi/reprint/111/5/697)

Print copies: Available from the American Heart Association, Public
Information, 7272 Greenville Ave, Dallas, TX 75231-4596; Phone:
800-242-8721

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on April 27, 2005. The information
was verified by the guideline developer on May 6, 2005.

#### COPYRIGHT STATEMENT

Copyright to the original guideline is owned by the American Heart
Association, Inc. (AHA). Reproduction of the AHA Guideline without
permission is prohibited. Single reprint is available by calling
800-242-8721 (US only) or writing the American Heart Association, Public
Information, 7272 Greenville Ave., Dallas, TX 75231-4596. Ask for
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call 800-611-6083 (US only) or fax 413-665-2671; 1000 or more copies,
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### DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008