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Cardiol Clin. Author manuscript; available in PMC 2013 30 April.

Published at the end o the edited as!

Cardiol Clin . 2010 November ; 2"#$%! &'1(&"). doi!10.101)*+.ccl.2010.0'.dollars.

The principles and techniques of blood pressure measurement

Ogedegbe Gbenga, MD AAnd Thomas Pickering, MD, DPhil ,

Associate Proessor o medicine and -irector o the Center or chanes in behavior healthu

-ivision

A

eneral Internal Medicine N chool o Medicine/ Ne4 or5

Proessor o medicine/ Cardiovascular Health Center behavior/ Columbia niversit6/ Ne4,

or5 #died%

AbstractAlthouh mercur6 sph6momanometer is 4idel6 rearded as 7old standard7 or oice

8he measurement o the blood pressure/ the ban on the use o mercur6 devices continue to

their role in9ice and hospital settins. At this time/ mercur6 device has been on a lare scale in th

raduall68he hospital. 8his has led to the prolieration o 6our non(mercur6 and has chaned #per

:ver% should modalit6 rom the measurement o the blood pressure in the clinic and hos

settins. In this caseArticle/ basic techniue o measurin the blood pressure and technical problems associ


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9edebe and Pic5erin/

sin this techniue is less accurate and oten reuire reuent calibration.

Bno4n as the 7-evice7 sph6momanometers h6brid/ has been developed as

replacementour mercur6. ,asicall6/ these devices combine the eatures o both and elec

8he auscultator6 device so that mercur6 column is replaced b6 the electronic p

Measure similar to the oscillometric devices/ but the blood pressure is ta5en

same 4a6As mercur6 or aneroid devices/ b6 an observer usin a stethoscope and listenBorot5o sound. '2

$n the oscillometric technique

8his 4as irst sho4n b6 Mare6 in 1$11/ 3"And he 4as subseuentl6 sho4s th

In oscillations o pressure in a sph6momanometer cu o recorded durin s

-elation/ oscillatin point in accordance 4ith the maimum mean intra(arte

8he pressure.32/3D/D' In oscillations start around the s6stolic blood pressure and c

nder the diastolic blood pressure #i. 1%/ so that the s6stolic blood pressur

diastolic blood pressure can onl6 be estimatedNot directl6 accordin to several alorithms derived empiricall6. this method i

inNo transducer needs to be placed in the brachial arteries/ and it is not vulnera

:ternal sound #but not or lo4 reuenc6 mechanical vibrations%/ and that the

can-eleted and replaced b6 the patients durin ambulator6 monitorin/ or eam

ta5e aho4er. 8he main deicienc6 o the recorder does not 4or5 4ith both ph6sical


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Technical problems with the arms of the measurement

8here is the potential or important sources o measurement 4ith the error o th

arms/


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The de(ice for measuring the clinic and hospital

Mercur! sph!gmomanometers'8he desin o the mercur6 sph6momanomete

Chaned little durin &0 6ears/ ecept that the modern versions o the less li5

shedMercur6 i dropped. As indicated earlier/ althouh usin mercur6 sph6moman

is old> or oice measurement o blood pressure/

4idespread8he implementation o the ban on the use o mercur6 devices continue to redu

role in9ice and hospital settins. At this time/ mercur6 device has been larel6 pha

in the 8he hospital.$38he reason is no loner accurate because the device has been develo

,ecause o concerns about the saet6 o mercur6. 8oda6/ t4o alternatives to

8he replacement o mercur6 is aneroid and electronic oscillometric

sph6momanometer #%8he device.

The de(ice Aneroid'8he ban on mercur6 sph6momanometer has placed ne4

An alternate method 4hich 6our aneroid main competitor. Interest :rror

@eport 4ith reard to the accurac6 o aneroid devices in hospital surve6 that

than the rane1 percent in the surve6 one/"8o $$ percent in another.$$8he validation stud6 conducted a dec

ho4 that the6 can be accurate. $.D) A recent stud6 that compared the u

Mercur6 versus aneroid device settins in the clinical trial on 20 clinical test

ites/ also proved accurate. 3)8his is the best evidence but the accurac6 o the proo

Aneroid devices.

*esources with error auscultator! method

ome o the main cause o the incompatibilit6 bet4een conventional clinical

measurement8he blood pressure and the pressure o the blood that is listed in the 8able 2.

8he Measurement,lood pressure usuall6 involves an interaction bet4een the patient and docto


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H6pertension is important because it appears clinicall6 to become relativel6 l

conditionsCompared to sustainable development o h6pertension #deined b6 the elevate

pressure in both the clinicAnd ambulator6 settins%.1DIt can onl6 be dianosed reliabl6 b6 ambulator6 monitor

Main Pae sel(monitorin as described later. observer error and observer bi

important8he sources o error 4hen sph6momanometers used. 8he dierences bet4e

strainin o the Fisual acuit6 eamination ever6 1(3 hearin8he 9bserver can cause an error/ consistent and preerence diits ver6 commomost8he observers record a disproportionate number the results ended in & or 0.or e

Is displa6ed in the i tree. & 8he result 4as ta5en b6 a specialist h6pertension

is clearl6 not immune8his error. values o the averae blood pressure is recorded b6 trained observer

individualHas been ound to var6 b6 as much as & to l0 mm H. 1'8he level o pressure

Noted also miht so aect the behavior b6 actors related to the eects o

8he 9bserver on the sub+ect o the most amous o the presence o a ph6sician.

Has been 5no4n or more than $0 6ears o blood pressure is recorded b6 the

ma6 asMan6 as 30 mm H pressure hiher than that ta5en b6 the patient in the hom

usin8he techniue and in the same position.38he doctor also notes the pressure is hiher than the nu

8he technicians.3'/'3 9ther actors that aect the pressure recorded ma6 include b8he race and ender observer. 12/$1

The cuff of the rate of inflation and deflation'8he inlation rate does not have a siniicant im

8he blood pressure/33,ut 4ith the ver6 slo4 delation internet #2 mm H*s or less% in

rom the voice o Borot5o has reduced/ resultin in diastolic pressure slih

hiher. 8his8he inluence is associated 4ith the densit6 o veins reduce blood lo4 rate du

ver6lo4 delation.2)In the usuall6 recommended delation rate is 2 to 3 mm H*s. 8he

Inlation and delation is ver6 important or sel(monitorin o blood pressur

,ecause isometric eercise involved in inlatin the cu o the produce o th

elevation o transit8he pressure on 10 mm H. ""Althouh this lasted onl6 about 20 seconds/ i the cu

8he ne4 ,M< ' eries 4ith run lat too ast the pressure ma6 not be restore

the baseline / and spuriousl6 hih6stolic pressure 4ill be recorded.

Auscultator! gap'8his can be deined as a loss and the re(emerence o the Borot5o

8hat happened bet4een s6stolic blood pressure and diastolic pressure durin t

o delation in the absence oHeart Arrh6thmias. 8hus/ i its presence is not 5no4n/ it ma6 lead to reistra

-iastolic puriousl6 hih or lo4 s6stolic pressure. It ma6 happen because o

phasicChanes in arterial pressure or in patients 4ho are 4ea5 Borot5o sound #i

Auscultator6 ap ma6 cause problems or automatic recorder/ operated b6

Borot5o sound techniue and cause ross error in the measurement o diastoli

pressure8he pressure.2) 9scillometric device is not vulnerable to this problem. 2)Its presen

Clinical siniicance because it has been associated 4ith increased prevalence o

oran8he damae.D

+rror technical resources' 8here are also technical resources 4ith an

Auscultator6 method/ althouh all this is usuall6 less 4hen a column mercur

rom


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The electronic monitor for self'monitoring of blood pressure


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No4 more than 30 cross(studies can increase relates to the etent to 4hich th

cardiovascular damae,oth the clinic and ambulator6 pressure.)" Almost all have sho4n that the rela

ome o the hiher coeicient or ambulator6/ althouh in man6 instances di

pressureA small. 8he Merit o ambulator6 pressure in this ma6 be caused b6 at least

In part to a reater number o readins and to them that more represents natu

The situation is different from the measurement

The measurement of the linic

8he recent interest in an alternative method to measure the pressure o the bl

been servin to:mphasi=e some potentiall6 can repair the lac5 o measurement o routine cl

,lood pressure.


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Ambulator! blood pressure monitoring

8here are si prospective stud6 to date sho4s that ambulator6 blood pressure i

8he ris5 o ener6 rom the pressure o the clinic and more on the 4a6 that t

published b6 Perlo:t al.)&/))sed noninvasive monitorin carried out durin the da6 and reported th

8he ambulator6 lo4 pressure in relation to the pressure o their clinic in lo4e

8he ris5 o morbidit6. 8he second/ b6 Ferdecchia et al.D0ollo4 the roup rom

And Normotensive individuals h6pertension durin 3 6ears; the sub+ect o

h6pertension 4ere classiiedAs have the 4hite robe or sustained h6pertension. In the event o morbid ain

per 100Patients 6ears in 4hite robes patients 4ith h6pertension #4hich is similar to an

o 0.$' in8he sub+ect o the normotensive%/ 4hereas it 4as 1.'D in dippers h6pertensio

orminMost/ and $.DD in nondippers. 8he third stud6 is the pilot results rom a popu

stud6 in9hasama/ Japan/&"


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)ariation of blood pressure in the diurnal computation'8here are diurnal computation called rh6thm o

8he pressure/ 4ith a drop o 10 to 20 mm H durin sleep and conirm the inc

the 4a5e up in the morninAnd risin in the mornin. 8he hihest blood pressure is usuall6 seen bet4een

and8he da6/ 4hich is also the time that the prevalence o Cardiovascular morbid

events8he hihest li5el6. $) 8he pattern o blood pressure durin the da6 is a reat

-ependin on the pattern o activit6/ pressure 4ith 5eep 4ill be hiher durinhours


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8he evidence that related to the blood pressure taret oran damae/ usuall6

reuired orComplete the clinic readins 4ith other t6pes o measurement beore reachin

8he decision o the therap6.


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@eular adult cu o #12K23 cm% ma6 seriousl6 overestimate blood pressure&8he e

8he arm circumerence on the cu o the method o measurin the blood pre

learnin6stematicall6 b6 Bin.32

The e/ercise

-urin d6namic eercise in the auscultator6 method ma6 underestimate the

pressure b6 rose8o l& mm H/ 4hile durin the period o the restoration ma6 be overestimate

mm H.-iastolic pressure are unli5el6 to be as reat/ ecept durin the recover6 perio

alseEo4 readin can be recorded. 2$8his is the reason 4h6 the American Heart Asso

@ecommends that too5 the ourth phase Borot5o sound ater the eercise.

Summar!

Althouh the use o mercur6 sph6momanometer is considered as a drat >o

8he measurement o the blood pressure oice prohibition etensivel6 in the

mercur6 devices have@educed their role in hospital settins. An alternative method such as automelectronic8he device has ained popularit6 increased the preerred location is measure

pper arms/ but an error ma6 have occurred because o chanes in the positio

arms. ,esides8echnical resources includin the cu o the error that does not match the si=e

ast delation o the cu o the sleeve.Clinical readin ma6 not be increasinl6 unrepresentative o patients blood pre

because8he 4hite robes/ securities is deined as the dierence bet4een the clinic readi

8he averae blood pressure in the da6time. Patients 4ith elevated clinic press

da6 normalIs said to have been the pressure o the 4hite robes o h6pertension/ 4hich is

described b6 the aniet6 state9r AC response. 8here are three commonl6 used methods to measure the blo

8he pressure or the purpose o clinical clinic! readins/ sel(monitorin b6 pat

the house/ and2$(hour ambulator6 readins. el(monitorin is usuall6 done usin electron8he device 4or5s on the oscillometric techniue. :ven thouh the protocol s

validation8here are man6 devices on the mar5et has not been tested or accurac6. such

can,lood pressure recordin o arms/ 4rists/ on 6our iner or/ but arm is

preerred. t4ent6(our hour ambulator6 monitorin is the best ener6 rom the cardiovascular ris

individualPatients and the techniue is the onl6 one 4ho can describe the rh6thm o bl

pressure diurnal computation


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$. ,aile6 @H/ Bnaus FE/ ,auer John Hancoc5. Aneroid sph6momanometers. assessm

accurac6 on a8he universit6 hospital and clinics. Arch Intern Med. 1DD1; 1&1!1$0D. PubMed! 20

&. Chatellier ,obrie / / :N: N/ et al. Pronosis or cardiovascular 7h6pertension

detected,6 blood pressure sel(measurement in elderl6 treated patients 4ith h6pertension. C

N8IE. 200$;2D1!1$1$. PubMed! 1&02)$01

). ,oro4 BM/ Ne4burer J


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2&. An Island/ -e Ea Fea / 8a6lor HE. imultaneousl6 blood pressure directl6 and in

8he measurement in man in the other and 4or5. J Ea4 Ph6siol. 1D&$; )!&0). Pu

1312D1"22). Imai / Abe B/ asa5i / et al. :valuation clinical semiautomatic and automatic dev

8he measurement o the blood pressure house! comparison bet4een the cu o the oscil

and microphone8his method. 8he Journal o h6pertension. 1D"D; '!2$30. PubMed! 2)2"$DD

2'. Imhol= ,P/ Eane4outers J/ van Montrans A/ et al. the easibilit6 o ambulator6continuousl6(Arterial pressure iner hours o recorded. H6pertension. 1DD3; 21!)&. PubMed! "

2". Inelsson :/ Eind ,+or5lund(,odeard B/ E/ et al. diurnal computation patterns o b

pressure and ris5Conestive heart ailure. Chennai until. 200); 2D&!2"&D. PubMed! 1)"0$1&2

2D. Jhalani J/ o6al 8/ Clemo4 E/ et al. aniet6 and epectations or the predict the 4h

8he inluence. Press Monit blood. 200&; 10!31'. PubMed! 1)$D)$$'

30. Bhattar @/ enior @/ Eahiri A. cardiovascular results in 4hite robes versus sustaina

H6pertension! 10 6ears o stud6 ollo4(up. Circulation. 1DD"; D"!1"D2. PubMed! D

31. Bi5u6a M/ Ho=a4a a/ 9ho5ubo 8/ et al. Pronostic iniicance o blood pressure a

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32. Bin :. An error in the measurement o the blood pressure in clinical obesit6. Clin 32!223.PubMed! )022"1'

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3$. H- Bleinert/ Harshield A/ Pic5erin 8/ et al. 4hat is meant b6 blood pressure h

values8he measurement in patients 4ith mild h6pertensionL H6pertension. 1D"$; )!&'$. P

)23&1D03&. Eenant C. 4or5in roup report on hih blood pressure in prenanc6. J Clin H6per

#reen4ich%. 2001; 3!'&. PubMed! 11$1))"D

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Clinical settins. I am J H6pertens. 200D; 22!2)3. PubMed! 1D0&'&1$

3'. ,ertinieri Mancia / / rassi / et al. the impact rom the measurement o the blood b6 the doctor,lood pressure and cardiac patients. Eancet. 1D"3; 2!)D&. PubMed! )13)"3'

3". Mare6/ :J. Ph6sioloie :perimentale. Paris! &)2. Pression et vitesse du sinin.

3D. Mauc5


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&0. Nielsen P:/ Janniche H. accurac6 o auscultator6 blood pressure measurement arm

8he sub+ect o obesit6. Acta Med cand. 1D'$; 1D&!$03. PubMed! $"300&'

&1. Hanninen Niiranen 8J/ Mr/ Johansson J/ et al. Main Pae to measure the pressure o t

is more po4erulCardiovascular ris5 ener6 rom the blood pressure 4or5! inn(Home tudies. H6pe

2010; &&!13$). PubMed! 203"&D'0

&2. 9>,rien :/ Petrie J/ Eittler ,rien :/ ,rien :8/ Eittler


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8he association Council on hih blood pressure @esearch. H6pertension. 200&; $&!1$2. P

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N8IE. 1D"";2&D!22&. PubMed! 333)1$0

'$. Pic5erin 8/ Miller NH/ 9edebe / et al. Call to Action on the use and replacem

unds to main pae,lood pressure monitorin! eecutive summar6! a +oint scientiic statement rom the A8he association o the heart o American societ6/ h6pertension/ and the prevention

Cardiovascular NursesAssociation. H6pertension. 200"; &2!1. PubMed! 1"$D'3'1

'&. Prinle :/ C/ Phillips 8hi+s E/ et al. variation o s6stolic blood pressure as ris5 acto

stro5eAnd cardiovascular mortalit6 in the elderl6 population o h6pertension. J H6perten

21!22&1.PubMed! 1$)&$'$$

'). @eder @/ -imich i/ Cohen ME/ et al. evaluate the measurement o blood pressure

directl6 techniues!A comparison o the three s6stems in inants and children. And Pediatrics. 1D'";

)2!32). PubMed! '0$20&''. @edon J/ Campos C/ Narciso ME/ et al. Pronostic Falue o ambulator6 blood pres

monitorinIn reractor6 h6pertension! prospective stud6. H6pertension. 1DD"; 31!'12. PubMed! D

'". ander -/ Bu5la C/ Blinelhoer J/ et al. the relationship bet4een the pattern o circblood pressure sleepAnd proression o earl6 carotid atherosclerosis! 3 6ear ollo4(up stud6. Circulatio

102!1&3). PubMed! 1100$1$&

'D. antucci / Cates :M/ James/ - et al. a comparison o t4o ambulator6 monitor bl

pressure/-el Mar Avionics Pressurometer IF and pacelabs D0202. I am J H6pertens. 1D"D

PubMed! 2"03)'3

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pressureCompared 4ith the blood pressure oice in the eneral population! ollo4 up resul

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111!1'''. PubMed! 1&"0D3''

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"2. pence J-/ ibbald


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D3. I Filleas Arias/ IC/ ,otero a/ et al. :valuation techniues used b6 health 4or5ers to

8a5e the blood pressure. H6pertension. 1DD&; 2)!120$. PubMed! '$D"DD'

D$.


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9edebe and Pic5erin

0ig1 21

Chanes occurrin distal to a sph6momanometer te cu delation. Uppe

Borot5o sounds. Second trace ! cu pressure. Third trace! oscillations in cu pressu

Maimum oscillation occurs at a pressure o 10" mm H/ the mean arterial p

Trace! radial pulse. FromPic5erin 8. ,lood pressure variabilit6 and ambu

Monitorin. Curr 9pin Nephrol H6pertens 1DD3a;2!3"0; 4ith its permissions

Cardiol Clin . Author manuscript; available in PMC 2013 April 30.


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9edebe and Pic5erin

0ig1 31

@ecordin o s6stolic pressure te laborator6 stress testin/ made simultaneousl6

Continuous beat(to(beat monitor #inapres% and an intermittent oscillometric

#Colin%.Cp cold pressor test; h handrip; ma mental arithmetic; ta tal5in.



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9edebe and Pic5erin

0ig1 418he eects o var6in arm positions on blood pressure recorded rom the bra

arter6.rom Pic5erin 8. ,lood pressure variabilit6 and ambulator6 monitorin. Cu

Nephrol H6pertens 1DD3a;2!3"0; 4ith its permissions.



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9edebe and Pic5erin

0ig1 51

el(rated headache score beore #pre% and ater #post% ,P #,P% chaired in di

Conditions. 9n da6 1/ the research assistant #@A% a measured ,P outside the m

:nvironment usin a mercur6 sph6momanometer #PH%. 9n da6 2/ the @a

measured ,P in8he absence o a ph6sician #M-% b6 manuall6 trierin a device or ambula

Chaired the #M8-% irst in the 4aitin room and net in the eamination be

ater8he M- a measured ,P usin headin PH. Headache scores 4ere obtainednormotensive sub+ects#N8% and in variabilit6 4ith 4hite coat h6pertension #89IE:8(H8%/ mas5e

h6pertension #M(H8%/And sustained h6pertension #(H8%.Reproduced with its permissions from Oged

Picering TG, Clemow !, et al" The misdiagnosis of h#pertension $ the role of

%eadache" &rch 'nternal (ed" )ec * +*- ./*0++1$ +2345+2/3"



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9edebe and Pic5erin

0ig1 61

8he percentae o terminal diits #chosen b6 our ph6sicians in a H6pertension

te@outine blood pressure chaired the. Note the mar5ed preerence or =eroes in

ph6sicians CAnd -.



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9edebe and Pic5erin

0ig1 71

8he phenomenon o the auscultator6 ap te cu delation. pper trace! :C.

8race! lo4 reuenc6 recordin o sounds under the sph6momanometer cu

trace!Borot5o sounds. ourth trace! auscultator6 mar5er pressed 4hen s6stolic a

diastolicounds 4ere heard arued. ith trace! cu pressure. ith trace! inapres recor

arterialPressure; note oscillations o pressure correspondin to the silent period o B

romPic5erin 8. ,lood pressure variabilit6 and ambulator6 monitorin. Curr 9

NephrolH6pertens 1DD3a;2!3"0; 4ith its permissions.



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9edebe and Pic5erin

0ig1 81

8he eects o chanes in the positions o the orearm on the blood pressure is re

b6 a


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9edebe and Pic5erin

0ig1 91cheme or combinin dierent measures o blood pressure in the evaluation

variabilit6


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