Assessment of Blood Pressure: Techniques and Implications From Clinical Trials

  • Dia R. Waguespack
    Address correspondence to Dia R. Waguespack, MD, Division of Renal Disease and Hypertension, McGovern Medical School at UTHealth, 6431 Fannin St, MSB 5.134, Houston, TX 77030.
    Division of Renal Disease and Hypertension, McGovern Medical School at UTHealth, Houston, TX
    Search for articles by this author
  • Jamie P. Dwyer
    Nephrology Clinical Trials Center, Division of Nephrology, Vanderbilt University Medical Center, Nashville, TN
    Search for articles by this author
      Hypertension is a global health problem and without adequate diagnosis and treatment is a risk factor for morbidity and mortality. Proper assessment of blood pressure is key to diagnosis and management of hypertension. Different methods of measurement are available for use and varying techniques are applied to patient care. Understanding the proper methods of blood pressure measurement both in and out of the physician's office is crucial for providing appropriate care to an individual patient. In addition, understanding the techniques used in research, on which current guidelines are based, is critical for proper application to daily practice. In this article, we review the types of blood pressure measurement techniques, discuss the benefits and limitations to each, explore future technological advances in measurement devices, and provide insight into research techniques, which ultimately guide our practice.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Advances in Chronic Kidney Disease
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Gakidou E.
        • Afshin A.
        • Abajobir A.A.
        • et al.
        Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016.
        Lancet. 2017; 390: 1345-1422
        • Forouzanfar M.H.
        • Liu P.
        • Roth G.A.
        • et al.
        Global burden of hypertension and systolic blood pressure of at least 110 to 115 mm Hg, 1990-2015.
        JAMA. 2017; 317: 165-182
        • Wright Jr., J.T.
        • Williamson J.D.
        • et al.
        • SPRINT Research Group
        A randomized trial of intensive versus standard blood-pressure control.
        N Engl J Med. 2015; 373: 2103-2116
        • Mallamaci F.
        • Minutolo R.
        • Leonardis D.
        • et al.
        Long-term visit-to-visit office blood pressure variability increases the risk of adverse cardiovascular outcomes in patients with chronic kidney disease.
        Kidney Int. 2013; 84: 381-389
        • McMullan C.J.
        • Lambers Heerspink H.J.
        • Parving H.-H.
        • Dwyer J.P.
        • Forman J.P.
        • de Zeeuw D.
        Visit-to-Visit variability in blood pressure and kidney and cardiovascular outcomes in patients with type 2 diabetes and nephropathy: a post hoc analysis from the RENAAL study and the Irbesartan Diabetic Nephropathy Trial.
        Am J Kidney Dis. 2014; 64: 714-722
        • Mezue K.
        • Goyal A.
        • Pressman G.S.
        • Horrow J.C.
        • Rangaswami J.
        Blood pressure variability predicts adverse events and cardiovascular outcomes in chronic kidney disease: a post-hoc analysis of the SPRINT trial.
        Am J Hypertens. 2017; 31: 48-52
        • Wang J.
        • Shi X.
        • Ma C.
        • et al.
        Visit-to-visit blood pressure variability is a risk factor for all-cause mortality and cardiovascular disease.
        J Hypertens. 2017; 35: 10-17
        • Leung A.A.
        • Nerenberg K.
        • Daskalopoulou S.S.
        • et al.
        Hypertension Canada's 2016 Canadian hypertension education program guidelines for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension.
        Can J Cardiol. 2016; 32: 569-588
        • Mancia G.
        • Fagard R.
        • Narkiewicz K.
        • et al.
        2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC).
        Eur Heart J. 2013; 34: 2159-2219
        • Staessen J.A.
        • Li Y.
        • Hara A.
        • Asayama K.
        • Dolan E.
        • O'Brien E.
        Blood pressure measurement Anno 2016.
        Am J Hypertens. 2017; 30: 453-463
        • Turner J.R.
        • Viera A.J.
        • Shimbo D.
        Ambulatory blood pressure monitoring in clinical practice: a review.
        Am J Med. 2015; 128: 14-20
        • Minutolo R.
        • Agarwal R.
        • Borrelli S.
        • et al.
        Prognostic role of ambulatory blood pressure measurement in patients with nondialysis chronic kidney disease.
        Arch Intern Med. 2011; 171: 1090-1098
        • Pogue V.
        • Rahman M.
        • Lipkowitz M.
        • et al.
        Disparate estimates of hypertension control from ambulatory and clinic blood pressure measurements in hypertensive kidney disease.
        Hypertension. 2009; 53: 20-27
        • Kallioinen N.
        • Hill A.
        • Horswill M.S.
        • Ward H.E.
        • Watson M.O.
        Sources of inaccuracy in the measurement of adult patients' resting blood pressure in clinical settings: a systematic review.
        J Hypertens. 2017; 35: 421-441
        • Pickering T.G.
        • James G.D.
        • Boddie C.
        • Harshfield G.A.
        • Blank S.
        • Laragh J.H.
        How common is white coat hypertension?.
        JAMA. 1988; 259: 225-228
        • O'Brien E.
        • Parati G.
        • Stergiou G.
        Ambulatory blood pressure measurement: what is the international consensus?.
        Hypertension. 2013; 62: 988-994
        • Franklin S.S.
        • Thijs L.
        • Hansen T.W.
        • O'Brien E.
        • Staessen J.A.
        White-coat hypertension: new insights from recent studies.
        Hypertension. 2013; 62: 982-987
        • Banegas J.R.
        • Ruilope L.M.
        • de la Sierra A.
        • et al.
        Relationship between clinic and ambulatory blood-pressure measurements and mortality.
        N Engl J Med. 2018; 378: 1509-1520
        • Minutolo R.
        • Gabbai F.B.
        • Agarwal R.
        • et al.
        Assessment of achieved clinic and ambulatory blood pressure recordings and outcomes during treatment in hypertensive patients with CKD: a multicenter prospective cohort study.
        Am J Kidney Dis. 2014; 64: 744-752
        • Rakotz M.K.
        • Townsend R.R.
        • Yang J.
        • et al.
        Medical students and measuring blood pressure: results from the American Medical Association Blood Pressure Check Challenge.
        J Clin Hypertens (Greenwich). 2017; 19: 614-619
        • Muldoon M.F.
        • Kronish I.M.
        • Shimbo D.
        Of signal and noise: overcoming challenges in blood pressure measurement to optimize hypertension care.
        Circ Cardiovasc Qual Outcomes. 2018; 11: e004543
        • Bakris G.L.
        • Williams M.
        • Dworkin L.
        • et al.
        Preserving renal function in adults with hypertension and diabetes: a consensus approach. National Kidney Foundation Hypertension and Diabetes Executive Committees Working Group.
        Am J Kidney Dis. 2000; 36: 646-661
        • Doane J.
        • Buu J.
        • Penrod M.J.
        • Bischoff M.
        • Conroy M.B.
        • Stults B.
        Measuring and managing blood pressure in a primary care setting: a pragmatic implementation study.
        J Am Board Fam Med. 2018; 31: 375-388
        • Siu A.L.
        • Force USPST
        Screening for high blood pressure in adults: U.S. Preventive Services Task Force recommendation statement.
        Ann Intern Med. 2015; 163: 778-786
        • O'Brien E.
        Has conventional sphygmomanometry ended with the banning of mercury?.
        Blood Press Monit. 2002; 7: 37-40
        • O'Brien E.
        • European Society of Hypertension Working Group on Blood Pressure M
        The Working Group on blood pressure monitoring of the European Society of Hypertension.
        Blood Press Monit. 2003; 8: 17-18
        • Nietert P.J.
        • Wessell A.M.
        • Feifer C.
        • Ornstein S.M.
        Effect of terminal digit preference on blood pressure measurement and treatment in primary care.
        Am J Hypertens. 2006; 19: 147-152
        • Stewart M.J.
        • Gough K.
        • Padfield P.L.
        The accuracy of automated blood pressure measuring devices in patients with controlled atrial fibrillation.
        J Hypertens. 1995; 13: 297-300
        • Myers M.G.
        The great myth of office blood pressure measurement.
        J Hypertens. 2012; 30: 1894-1898
        • Myers M.G.
        • Godwin M.
        • Dawes M.
        • et al.
        Conventional versus automated measurement of blood pressure in primary care patients with systolic hypertension: randomised parallel design controlled trial.
        BMJ. 2011; 342: d286
        • Myers M.G.
        Automated blood pressure measurement in routine clinical practice.
        Blood Press Monit. 2006; 11: 59-62
        • Myers M.G.
        • Valdivieso M.
        • Kiss A.
        Consistent relationship between automated office blood pressure recorded in different settings.
        Blood Press Monit. 2009; 14: 108-111
        • Kain H.K.
        • Hinman A.T.
        • Sokolow M.
        Arterial blood pressure measurements with a portable recorder in hypertensive patients. I. Variability and correlation with “casual” pressures.
        Circulation. 1964; 30: 882-892
        • Pickering T.G.
        • Shimbo D.
        • Haas D.
        Ambulatory blood-pressure monitoring.
        N Engl J Med. 2006; 354: 2368-2374
        • Steinhubl S.R.
        • Muse E.D.
        • Barrett P.M.
        • Topol E.J.
        Off the cuff: rebooting blood pressure treatment.
        Lancet. 2016; 388: 749
        • Lovibond K.
        • Jowett S.
        • Barton P.
        • et al.
        Cost-effectiveness of options for the diagnosis of high blood pressure in primary care: a modelling study.
        Lancet. 2011; 378: 1219-1230
        • Kronish I.M.
        • Kent S.
        • Moise N.
        • et al.
        Barriers to conducting ambulatory and home blood pressure monitoring during hypertension screening in the United States.
        J Am Soc Hypertens. 2017; 11: 573-580
        • Zullig L.L.
        • Melnyk S.D.
        • Goldstein K.
        • Shaw R.J.
        • Bosworth H.B.
        The role of home blood pressure telemonitoring in managing hypertensive populations.
        Curr Hypertens Rep. 2013; 15: 346-355
        • Agarwal R.
        • Bills J.E.
        • Hecht T.J.
        • Light R.P.
        Role of home blood pressure monitoring in overcoming therapeutic inertia and improving hypertension control: a systematic review and meta-analysis.
        Hypertension. 2011; 57: 29-38
        • Agarwal R.
        • Andersen M.J.
        Prognostic importance of clinic and home blood pressure recordings in patients with chronic kidney disease.
        Kidney Int. 2006; 69: 406-411
        • Carey R.M.
        • Whelton P.K.
        Prevention, detection, evaluation, and management of high blood pressure in adults: synopsis of the 2017 American College of Cardiology/American Heart Association Hypertension Guideline.
        Ann Intern Med. 2018; 168: 351-358
        • Kumar N.
        • Khunger M.
        • Gupta A.
        • Garg N.
        A content analysis of smartphone-based applications for hypertension management.
        J Am Soc Hypertens. 2015; 9: 130-136
        • Chandrasekaran V.
        • Dantu R.
        • Jonnada S.
        • Thiyagaraja S.
        • Subbu K.P.
        Cuffless differential blood pressure estimation using smart phones.
        IEEE Trans Biomed Eng. 2013; 60: 1080-1089
        • Chandrasekhar A.
        • Natarajan K.
        • Yavarimanesh M.
        • Mukkamala R.
        An iPhone application for blood pressure monitoring via the oscillometric finger pressing method.
        Sci Rep. 2018; 8: 13136
        • Persell S.D.
        • Karmali K.N.
        • Stein N.
        • et al.
        Design of a randomized controlled trial comparing a mobile phone-based hypertension health coaching application to home blood pressure monitoring alone: the Smart Hypertension Control Study.
        Contemp Clin Trials. 2018; 73: 92-97
        • Agarwal R.
        Implications of blood pressure measurement technique for implementation of Systolic Blood Pressure Intervention Trial (SPRINT).
        J Am Heart Assoc. 2017; 6: e004536