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Script writer
Cardiol Clin. Author manuscript; available in PMC 2013 30 April.
Published at the end of the edited as:
Cardiol Clin . 2010 November ; 28(4): 571-586. doi:10.1016/j.ccl.2010.07.dollars.

The principles and techniques of blood pressure measurement

Ogedegbe Gbenga, MD AAnd Thomas Pickering, MD, DPhil B
AAssociate Professor of medicine and Director of the Center for changes in behavior healthful sleep,
Division
General Internal Medicine NYU School of Medicine, New York
B Professor

of medicine, Cardiovascular Health Center behavior, Columbia University, New

York (died)

Abstract
Although mercury sphygmomanometer is widely regarded as "gold standard" for office
The measurement of the blood pressure, the ban on the use of mercury devices continue to reduce
their
role in
Office
and hospital settings. At this time, mercury device has been on a large scale in the us
gradually
The
hospital. This has led to the proliferation of your non-mercury and has changed (perhaps to
Ever) should modality from the measurement of the blood pressure in the clinic and hospital
settings.
In this
case
Article, basic
technique
of measuring the blood pressure and technical problems associated
With measurement in clinical practice discussed. The device that is currently available to the
And hospital
the measurement of the clinic and their important sources of this error is held. practical Advice
Given on how a different device and measurement techniques must be used. Blood Pressure
In different circumstances and measurement in special populations such as infants, children,
Pregnant women, elderly , and the subject of obesity discussed.

Key Words
The measurement of the blood pressure; self-monitoring, ambulatory blood pressure monitoring

The basic technique of measuring the blood pressure

Location Measurement
The location of the standard for the measurement of the blood pressure is brachial blood
Monitor
Measure thevessels.
pressure
on the that
wrist and the fingers have become popular but it is important to realize
Systolic blood pressure and diastolic pressure that vary substantially in different parts of the arterial
tree With systolic pressure increased more distal arteries, and diastolic blood pressure decreased.
In the auscultatory method
Although auscultatory method using mercury sphygmomanometer considered as
Draft ' gold' for office measurement of blood pressure, widespread implementation
The ban on the use of mercury sphygmomanometers continues to reduce the role of this
72 This situation worse by the fact that the aneroid manometers,
Engineering.

The
Writer
related
tothe
the
evidence
the disclaimer
mold: Ogedegbe
Gbenga,
MD,theCenter
foronly.
healthful sleep behavior change,
2010
Find
thatReed
can
affect
Elsevier
Inc.
content
All rights
andand
allreserved.
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journal

Ogedegbe and Pickering,

Page 2

72
Using this technique is less accurate and often require frequent calibration.
New
Known as the "Device" sphygmomanometers hybrid, has been developed as a
replacement
Your mercury. Basically, these devices combine the features of both and electronic
The auscultatory device so that mercury column is replaced by the electronic pressure
Measure similar to the oscillometric devices, but the blood pressure is taken in the
same
way or aneroid devices, by an observer using a stethoscope and listen during
As
mercury
Korotkoff sound. 72

In the oscillometric technique

This was first shown by Marey in 1411, And he38was subsequently shows that when
In oscillations of pressure in a sphygmomanometer cuff of recorded during slowly
Deflation, oscillating point in accordance with the maximum mean intra-arterial
32,39,97 In oscillations start around the systolic blood pressure and continue
The pressure.
Under the diastolic blood pressure (Fig. 1), so that the systolic blood pressure and
diastolic
pressure
can only
be estimated
Not
directlyblood
according
to several
algorithms
derived empirically. this method is useful
in No transducer needs to be placed in the brachial arteries, and it is not vulnerable to
External sound (but not for low frequency mechanical vibrations), and that the cuff of
can
Deleted and replaced by the patients during ambulatory monitoring, for example, to
take a The main deficiency of the recorder does not work with both physical during
Shower.
When there is a large movement activity artifact oscillometric technique that has.
Has been used successfully in ambulatory blood pressure monitor and home monitor.
He
must
Will
show that the brand that is different from the oscillometric recorder using a
different
algorithm,
and
There
is no
generic oscillometric
technique. Comparison of several different
commercial
The models intra-and arterial Korotkoff sound measurement, however, has shown
Generally good agreement.6,79
Ultrasound Techniques

This technique combines the device using the sender and the receiver ultrasound
placed onblood vessels under the cuff of the sphygmomanometer. As the cuff of the
-brachial
sleeve
is completely
movement,
From the
artery wall deflated
on systolic
blood pressure causing a phase Doppler changes in
reflected
Ultrasound and diastolic blood pressure is recorded as the point at which the
diminution
of the Another
artery variation of this method will detect the onset of the blood
In
Motion occurs.
flow
in the systolic
pressure
The pressure,
whichblood
has been
found to be a specific value to measure the pressure in
18
the
Andbaby
the
In patients
sons of. with very faint Korotkoff (for example the voice of the people with
Muscle atrophy) placing the Doppler probe through the brachial arteries that may help
to Systolic
detect pressure and the same technique can be used to measure the ankle-brachial
Index where the systolic pressure in the brachial and posterior tibial arteries are blood
vessels
Compared to get the index of peripheral arterial disease.
The finger cuff of Penaz method
63 work on the principle of
This first interesting method developed by Penaz
And
"the artery wall disassembled." acting as officers in a finger arteries detected by photoPlethysmograph under the pressure of the cuff of the sleeve. The output from the
plethysmograph
drive a on road-loop, which quickly change the cuff of
The role of servoused
assisttodepends
pressure
to keep opened
continuously
so In oscillations from the pressure in the cuff
Held
the arteries
some output,
countries.
Andinhave
been found to resemble
intra-arterial
blood pressure wave in most subjects
of measured
. Author manuscript; available in PMC 2013 30 April.

Ogedegbe and Pickering,

Page 3

Technical problems with the arms of the measurement

There is the potential for important sources of measurement with the error of the upper
arms,
Will be discussed in the following section.
The effects ofThere
posture
is no
andconsensus as to whether the pressure of the blood must be
67,72
Routinely measured while sitting or even though most supine guidelines recommend
sat.
In a survey of 245 subjects of different ages, Netea et al found that systolic pressure
The same position in both, but any discrepancy related to the age of the systematic to
diastolic
blood pressure
As the pressure
on the age of 30 sitting diastolic blood pressure is about 10 mm Hg
49
higherthe
than
Read
lie while at the age of 70 difference of only 2 mm Hg.
The position
The measurement
of the body- of the blood pressure was also influenced by the position
45,47,48,94
Arm).
As shown in the fig tree. 3, there is a progressive increase pressure around 5
To 6 mm Hg as the arm is moved to the bottom of the vertical position for horizontal. These changes exactly what would be expected from the change in pressure
hydrostatic
drive. He
is the return of patients supported during the measurement; if
It
is also important
that
patients
Sit bolt upright the diastolic pressure may be up to 6.5 mm Hg higher than if the sit
Back.14
The cuff of the hypertension inflationAlthough in most patients compressors actions a
The cuff of the Sphygmomanometer does not own change in blood pressure, as
62 And
indicated
by the
intra- 87where the effectiveness of patients there may be a while but
Bullets
Cassettes,
Finapres
42 condition
Large increase until 40 mm Hg coinciding with the cuff of inflation. This
Appear distinct from the white robes of hypertension, where increasing pressure in
both
Before the laws of inflation and outlasts it. He also must be distinguished from the
short
period
Increase
blood pressure that occur during the measurement themselves, because the
actions
The
cuffofofmuscles
the compressors.

The size of the

the cuff
cuffof
of-the related to the diameter of the arm is very important. Most
Common error is to use the cuff of too small, which will cause overestimation of
33,40,86
In general,
The pressure.
this error
can be reduced by using the scale of the large adult cuff sleeves to
All except the arms of the skinniest. Society of Hypertension English (Version)
recommends
that if exceeds 33 cm, most adult cuff of must be used width (12.5 to
The
arm circumference
13Cm long, 35 cm). 67 In the United States, protocol that most recommended to
The election of the cuff of the appropriate size is the one that is recommended by the
64 Shown in Table 1.
American
Heart
Association,

The device
Validation Monitor

The increased use of electronic monitor for both themselves and ambulatory
monitoring
been
Need
for thehas
development
of standard protocols to test them. Two most widely
52
Used has been developed by Version
The association
and to improve the medical services
2
Our Instrumentation (AAMI) in the United States.
Both require the taking of three blood
Pressure reading in 85 subjects (selected to have a variety of age and blood pressure)
Trained observers and the device is tested. Protocol Version that requires that the
by
deviceatmust
. Author
PMCand
2013
April. in 10 mm Hg with two
Provide
leastbe
50%
frommanuscript;
readings available
in 5 mmin Hg
7530percent

Ogedegbe and Pickering,

Page 4

The device for measuring the clinic and hospital

Mercury sphygmomanometersThe design of the mercury sphygmomanometers have
Changed little during 50 years, except that the modern versions of the less likely to
shed if dropped. As indicated earlier, although using mercury sphygmomanometer
Mercury
is Widely considered the draft 'gold' for office measurement of blood pressure,
widespread
The
implementation of the ban on the use of mercury devices continue to reduce their
role
in and hospital settings. At this time, mercury device has been largely phased out
Office
43 reason is no longer accurate because the device has been developed but
inThe
the hospital.
USThe
Because of concerns about the safety of mercury. Today, two alternatives to
The replacement of mercury is aneroid and electronic oscillometric
sphygmomanometer
()
The device.
The device AneroidThe ban on mercury sphygmomanometer has placed new interest
An alternate method which your aneroid main competitor. Interest Error
Report with regard to the accuracy of aneroid devices in hospital survey that is older
8 To 44
44 validation study conducted a decade ago
than
the range
1 percent
in the survey
one,
percent in another.
The
4.96 A recent study that compared the use of
Show that they can be accurate.
Mercury versus aneroid device settings in the clinical trial on 20 clinical test
Sites, also proved accurate.
This is the 36
best evidence but the accuracy of the proof of use
Aneroid devices.
Resources with error auscultatory method
Some of the main cause of the incompatibility between conventional clinical
measurement
The blood pressure and the pressure of the blood that is listed in the Table 2.
The Measurement
Blood
pressure usually involves an interaction between the patient and doctor (or
Who took the reading), and factors related to both can cause a tendency to good
Overestimate or underestimate the true blood pressure or to act as a source of two
directions
Error. As shown in table 2, there may be activities that precede or accompany
The measurements make it increasingly unrepresentative of pressure patients that
"true".
This includes
The
exercise
and smoking before the measurement and speaking during that time.
The white robe and a white robe effects of hypertensionOne of the main reasons for
Increased blood pressure emphasis on readings taken outside the office of the doctor or
Clinic is a white robe, Securities that contain as a rise in blood pressure that
Occurs at the time of a clinic visit and dissipating heat soon thereafter. recent study
shows
that
The
underlying
mechanism in white robes may include anxiety effects, a hyperactive
tells
Responses, or AC responseIn one of 29,55
these studies, we considered the blood of office
The pressure, ambulatory blood pressure and anxiety scores on three separate time one
In addition to the moon 238 patients. We find the largest white robes effects in
The presence of the doctor and record the white robes are conditioned response to
Securities
Medical
environment and the presence of doctors from a function of the nature of the
patient
The level of anxiety (see Figure 4). white robe this impression more big or small in
Most if not all patients with hypertension but smaller or absent in normotensive
The individuals. It is usually is defined as the difference between the clinic and the day
91 but an entity in its own right is a white robe hypertension,
Ambulatory
pressure.
related
Refers toAa closely
subset
of
patients
who according to their clinical hypertension blood

But
normotensive. Author
at other
times. Thus
theinwhite
robes30of
hypertension is the measure
pressure
manuscript;
available
PMC 2013
April.

Ogedegbe and Pickering,

5 Pages

Hypertension is important because it appears clinically to become relatively low-risk

conditionsto sustainable development of hypertension (defined by the elevated blood
Compared
pressure
in both thesettings).
clinic
And ambulatory
It can19
only be diagnosed reliably by ambulatory monitoring and
Main Page self-monitoring as described later. observer error and observer bias is
important
The sources of error when sphygmomanometers used. The differences between the
straining
of the
examination
1-3 hearing
The
Observer
canVisual
causeacuity
an error,
consistent every
and preference
digits very common, with
60
most
The observers record a disproportionate number the results ended in 5 or
For0.example,
Is displayed in the fig tree. 5 The result was taken by a specialist hypertension, which
is clearly
immune
This
error. not
values
of the average blood pressure is recorded by trained observers of the
17level of pressure from the
individual
Has been found to vary by as much as 5 to l0 mm Hg.The
Noted also might so affect the behavior by factors related to the effects of
The Observer on the subject of the most famous of the presence of a physician. He has
Has been known for more than 40 years of blood pressure is recorded by the doctor
may asas 30 mm Hg pressure higher than that taken by the patient in the home, with
Many
3 notes the pressure is higher than the nurses or
using
The technique and in the
Thesame
doctor
position.
also
37,73 Other factors that affect the pressure recorded may include both
The technicians.
The race and gender observer. 12,41
The cuff of the rate of inflation
The inflation
and deflationrate does not have a significant impact on
3
3
The blood pressure,
But with the very slow deflation internet (2 mm Hg/s or less) intensity
From the voice of Korotkoff has reduced, resulting in diastolic pressure slightly
higher.
This is associated with the density of veins reduce blood flow rate during the
The
influence
very
Slow deflation.
In the26usually recommended deflation rate is 2 to 3 mm Hg/s. The average
Inflation and deflation is very important for self-monitoring of blood pressure,
Because isometric exercise involved in inflating the cuff of the produce of the
88 this lasted only about 20 seconds, if the cuff of is
elevation
of transit
The
pressure
on 10 mm Hg.
Although
The new BMW 7 Series with run flat too fast the pressure may not be restored to
the
baseline
, and will
spuriously
high
Systolic
pressure
be recorded.
Auscultatory
This gapcan be defined as a loss and the re-emergence of the Korotkoff sound
That happened between systolic blood pressure and diastolic pressure during the cuff
ofHeart
deflation
in the absence
Arrhythmias.
Thus, of
if its presence is not known, it may lead to registration
Diastolic Spuriously high or low systolic pressure. It may happen because of the
phasic in arterial pressure or in patients who are weak Korotkoff sound (Fig. 6). In
Changes
Auscultatory gap may cause problems for automatic recorder, operated by
Korotkoff sound technique and cause gross error in the measurement of diastolic blood
26 Oscillometric device is not vulnerable to this problem. Its presence
26
pressure
The pressure.
from
Clinical significance because it has been associated with increased prevalence of target
9
organ
The damage.
Error technical resourcesThere are also technical resources with an error
Auscultatory method, although all this is usually less when a column mercury used
from
When
many semiautomatic method used (see later). The sources of this error including
The position of the column that should be approximately at the level of the heart. In
Mercury should read zero when no pressure is applied and it must be free fall when
Is reduced
(this column
may nottoapply
if mercury is
notbeclean
or if the
holes
of the pin
Connectpressure
the mercury
the atmosphere
will
blocked).
With
aneroid
meters, it is
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Ogedegbe and Pickering,

Page 6

The electronic monitor for self-monitoring of blood pressure

34
When the main page monitoring first used, most studies used aneroid
sphygmomanometers.
More
recently, but electronic devices automatically has become more popular. Gallup
Poll
The poll in 2005 indicated an increase in the number of patients they monitoring
The blood pressure in the house from 38% in 2000 to 55% in 2005. So too is the level
74 Types
ofPatients who have the monitor increased from 49% in 2000 to 64% inStandard
2005.
From the monitor for home use now a pressure oscillometric device that will record
from
Brachial blood vessels. All of this has the advantage of easy-to-use, because the
placement
the cuff ofbecause
not
As it is veryofimportant
with the device using Korotkoff sound microphone,
and
oscillometric
Has Been in the practice of the method has been found reliable as Korotkoff sound
85 those that are currently available are often
method.
In largely inaccurate
Early
version
But
Satisfactory.22,53
The Benefits of electronic monitor has been started to be respected by
Epidemiologists,13 That is always very concerned about the accuracy of clinical
The measurement of the blood pressure and have paid a lot of attention to the problem
of Digit
the problem
of theand
observer
preferences,
otherserror,
have been mentioned in the cause of the
inaccuracy.
Cooper
et
al
have
made
The case of ease of use electronic
devices and the lack of sensitivity of the relative
Actually took the reading can exceed any inherent inaccuracy compared with
13 should be advised to use only monitors
Traditional sphygmomanometer method.
Patients
That has been validated for accuracy and reliability according to international
standards
Testing protocol. Unfortunately, only a few of the device that is currently on the
market
Has
subjected to the appropriate validation test, such as AAMI and Version. To the list
From validated monitors is available on the Web site of Education DablHttp://
(
Www.dableducational.org ) and the British Hypertension Society Web Site ( Http://
Www.bhsoc.org/Default.stm).

The Monitor wrists-This Monitor has the advantages of smaller than the arm
The device and can be used in patients with obesity, such as on the wrist diameter
slightly affected
by obesity.
A monitor is the systematic error introduced by the
Potential
issues with
the wrist
hydrostatic
drive
As
a result of
differences in the position of the wrist relative
As shown
to the heart,
in 45
the fig tree. 7.
This can be avoided if the wrist is always at the level of the heart when readings taken,
but
There is no way to know whether held retrospectively upon 39 complied with when a
16,95
series
Readings are examined. Monitor wrists has potential but needs to be evaluated more
information.
Monitor
Although
yourthe
fingermonitor is is convenient to everything they have so far been found
74
Inaccurate and therefore cannot be used.
Ambulatory monitor

First developed almost 40 years ago, ambulatory blood pressure monitoring is only
now
Beginning to find acceptance as a useful technique in clinical latest technologic
Progress
Has
led to the introduction of the small monitor and relatively quiet and can take the
Up to 100 readings from the blood pressure more than 24 hours when patients go
about normal
Activities.
They quite accurately during the patients at rest but less so physical abuse
during When systematically deals surveyed (in 2001), only 24 has been validated in
Activity.
53
accordance
To AAMI criteria or Version that only 16 satisfied criteria for accuracy
Now
More monitor has been validated and updated list can be found on the Dabl
Information
about
the( three
main steps of the blood pressure:
thecan
level
of the average
Education Web
site
Http://www.dableducational.org
). They
in theory
provide
. Author manuscript; available in PMC 2013 30 April.
diurnal computation,

Ogedegbe and Pickering,

Page 7

Now more than 30 cross-studies can increase relates to the extent to which the
68 Almost all have shown that the relations
cardiovascular
Both the clinic damage
and ambulatory pressure.
Some of the higher coefficient for ambulatory, although in many instances differences
pressure
A small. The Merit of ambulatory pressure in this may be caused by at least
In part to a greater number of readings and to them that more represents nature.

The situation is different from the measurement

The measurement of the Clinic
The recent interest in an alternative method to measure the pressure of the blood has
been
servingsome
to potentially can repair the lack of measurement of routine clinic
Emphasize
Blood pressure. With increasing the number of readings taken per visit and the number
of Visits and by attempting to eliminate the error sources such as digit preferences,
The reliability of clinical pressure to estimate the correct blood pressure and the
consequences
canHowever, it must be remembered that there is a large number of
Will
proliferate.
The target with a white robe hypertension in the clinic will continue to provide
readings
The
values of the increasingly unrepresentative, no matter how many measurements
The survey
of the doctors and nurses in the practice actually make depressing
Thetaken.
techniques
used by
down
read.
Done
in aOne
teaching hospital found that not one of the workers 172 follow
The American Heart Association guidelines to measure the pressure of the blood in
clinical settings.
Although
68% is considered as the most accurate sphygmomanometer mercury, only
38% chose to use when given the option, and 60 percent judged must take the blood
pressure
It is not right.93
The measurement of the Self

Potential benefits have patients take their own blood pressure is twofold:
Corruption that is produced by the white robes will be eliminated, effects and some
readings
Taken
overcan
a prolonged. Self-measurement of blood pressure in the house has shown
74
To be useful for predicting target organ damage, cardiovascular events and death.
Five
Prospective studies have compared expected from morbid affinity events using the two
Conventional office and blood pressure house. Three were based on population
samples, patients
and
2 recruited
with hypertension. four study found that the main page BP is more
powerful
The risk of energy. The fifth find that both the steps BP predicted risk. 5,20,57,59,80
The most
The latest population-based study of prognosis self-comparison monitoring versus
office
BP
In predicting
cardiovascular events and death in between 2081 adults, are Finn51
Learning at home.
Even though the main page BP and office BP strongly associated with
Cardiovascular occurrence in separate Cox proportional hazard, when the two forms of
theHas
model
been included in the model, main page BP (the ratio of danger [HR], 1.22/1.15;
95% CI,to1.09
1.37/1.05
1.26) is still a strong energy from cardiovascular occurrence per 10/5 mm
Hg
Increase blood pressure, while office BP not (HR, predictive 1.01/1.06; 95% CI, 0.92
To 1.12/0.97 to 1.16). Similarly, systolic blood pressure of the house is the only one of
the
energy
the total
The
deathof(HR,
1.11, 95% CI, 1.01/1.23)). This study is the second population-based
study
to
Conclusively
confirm that higher prognostic value from the main page BP versus
office Bp
in totalabout the potential for observer error from the doctor reading
Death.
concerns
Can often be reduced by the use of the automatic device with memory chips. -Allows
Your
The
doctor
dependence
to remember
on self-monitored
the blood pressure
readings
readings
is not recommended,
taken by their patients.
they canWhile
provide
the
exclusive
useful additional. Author manuscript; available in PMC 2013 30 April.

Ogedegbe and Pickering,

Page 8

Ambulatory blood pressure monitoring

There are six prospective study to date shows that ambulatory blood pressure is better
The risk of energy from the pressure of the clinic and more on the way that the first
65,66 by
published
Perloff monitoring carried out during the day and reported that only
Et al.Used
noninvasive
The ambulatory low pressure in relation to the pressure of their clinic in lower
90 Follow the group from 1187
The risk of morbidity. The second, by Verdecchia et al.
And Normotensive individuals hypertension during 3 years; the subject of
were
classified
Ashypertension
have the white
robe
or sustained hypertension. In the event of morbid affinity 0.49
per
100
Patients years in white robes patients with hypertension (which is similar to an average
of 0.47
in
The subject
of the normotensive), whereas it was 1.79 in dippers hypertension,
forming
Most, and 4.99 in nondippers. The third study is the pilot results from a population
study in Japan, 58 Who reported that ambulatory pressure energy is better than
Ohasama,
The morbidity from screening pressure; no attempt was made to classify the individual
as having
The white robes of hypertension. Four
Is a77study of patients with hypertension refractory,
Is defined as a diastolic pressure above 100 mm Hg while on three or more as
Antihypertensives
Drugs. Patients classified in three groups according to the day they ambulatory
This pressure; the people in the lowest tertile (under 88 mm Hg) have significantly
lowermorbidity
level
The
for 4 years, despite the pressure of similar clinics. a fifth study, from
30
Northwick Park Hospital in London,
Followed
by 479 patients for almost ten years, all
Who is the reconstruction of the evaluated with intra-arterial ambulatory blood
pressure
monitoring technique. patients who are classified as having a white robe or
Using
the intra-arterial
covered
Hypertension, and he found that the diagnosis of the white robes of hypertension is
associated
With
one third of the risk of cardiovascular morbidity as sustainable hypertension. The
sixth
Learn in this series is Syst-Eur, a large number of placebo-controlled study of the
influence on pain to treat hypertension systolic pressure the old men with calcium
Cardiovascular
Channel blocker. A substudy from 1725 patients used ambulatory blood pressure
monitoring,
And
find that ambulatory blood pressure is far more powerful than the risk of energy
83
Blood pressure office.
The findings
from these studies that older this is confirmed by more
The latest data in other prospective studies. Thus, although this prognostic studies
distinct
Wide in their thoughts, start from a population study for one of the consequences of
hypertension
The
results ofrefractory
the subject, all point in the same direction, namely that ambulatory
pressure
gives a of prognosis after to control the pressure of the clinic, as a result of
Better
prediction
the
Patients with white coat hypertension has more than those with benign prognosis
Sustainable hypertension.

How should the measurement technique different blood pressure

can be used?

The steps that the blood pressure is important clinical?

There are three major steps that potential blood pressure that can contribute to the
Side Effects of hypertension. The first is the average or "true", the second level is
Diurnal computation variations and the third variation of short term.
The clinic an average of blood pressureThis time, and clinical data epidemiologic
Available only to the level of the average blood pressure. In clinical practice, a blood
patients.
Usually the pressure marked by a value of systolic blood pressure and diastolic
Extensive
evidence
patients
with
hypertension,
clinicalin
pressure
pressure,
tolevel ofinthe
Shows
the
average
taken
as usual Reading.
clinicalconsistently
settings, buthigher
no
than
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Ogedegbe and Pickering,

9 Pages

Variation of blood pressure in

There
the diurnal
are diurnal
computationcomputation called rhythm of blood
The pressure, with a drop of 10 to 20 mm Hg during sleep and confirm the increase in
the
wake
upininthe
themorning.
morning The highest blood pressure is usually seen between 6 a.m.
And
rising
and
The day, which is also the time that the prevalence of Cardiovascular morbid affinity
events
The highest likely. 46 The pattern of blood pressure during the day is a great extent
Depending on the pattern of activity, pressure with keep will be higher during the
11
hours
Work and while
In patients
in thewith
house.
hypertension,
diurnal computation blood pressure profile
A hard reset on a higher level of pressure, with maintenance of normal pattern in most.
Short-term variation of blood pressure is increased when expressed in absolute terms
(mm Hg), but the percentage of change is no different. Thus, hypertension can be
considered
As disturbances from the set point or tonic the level of blood pressure with normal
shortregulations.
term
The
Treatment as antihypertensives reverses these changes, again by
resetting toward
the set the normal, with little effect on short-term variations. the rhythm of
Pointing
normal
diurnal computation
Blood pressure
is disrupted in some individuals hypertension, with loss of normal
The giving of the fall of pressure. This was kept in various conditions including
Malignant hypertension, chronic renal failure, some types of secondary hypertension,
preEclampsia, conditions and associated with autonomic neuropathy.
There is71much evidence
Associate elevated blood pressure night to improve the morbidity and cardiovascular
Mortality compared with the blood pressure in the daytime. In population-based study
Ohasamma,
a
5 percent reduction
in night time BP lead up to 20 percent higher risk of heart disease
56
. Similarly
The deathwith
of 9 mm Hg increase in night BP has been associated with diastolic 25%
28
Increased risk of congestive heart failure in the middle of the elders of Sweden.
In Sys-Eur
83
The
A large
council,
number of placebo-controlled study of the influence on the cardiovascular
morbidity
of treatingis the old men with calcium channel blocker, a substudy from
Systolic
hypertension
1725
Patients used ambulatory blood pressure monitoring. Staessen et al found that night
Blood pressure is a better energy morbidity and cardiovascular mortality of the day
83 Although this discovery is not good enough to apply
The blood pressure.
For routine Clinical Practice, hypertension clinical interests in the night and
Nondipping status cannot be ignored for long, given the potential beneficial effects of
Treatment of hypertension nocturnal on reducing the risk of cardiovascular disease in
hypertension
Patients.10
The variations in blood
Thepressureinformation on the clinical significance of blood pressure
The variations to accumulate more than a decade with the latest data suggest that
increased blood pressure variations have been associated with the development of
Ambulatory
the
early carotid 78 And the high rate of cardiovascular morbidity.31More recently, in a
Arteriosclerosis,
Blood pressure ambulatory prospective study initially left untreated 2649 example
Patients with hypertension, Vedecchia and colleagues compared the value of
independent
prognostic
From
the night
and the day the variation of blood pressure for cardiovascular
events. They
found
Elevated
systolic
blood pressure night to become energy independent heart
89
The events.
Similarly, among elderly patients in the trial Syst-Eur, increased systolic blood
night in the entry into the council of Syst-Eur is independent risk
Variationpressure
of bloodand
pressure
factors
For stroke during the trial among the people in the placebo arm of the
trial. (refs
systolic
pressure
Pressure
variations
asblood
risk factors
for stroke and cardiovascular mortality in the elderly
75
The population of hypertension.
The measurement of the blood pressure clinics, both through the use of the device
The combined use of clinic, houses
ambulatory
. Authorand
manuscript;
availablemonitoring
in PMC 2013 30 April.

Ogedegbe and Pickering,

Page 10

The evidence that related to the blood pressure target organ damage, usually is not
required
Completefor
the clinic readings with other types of measurement before reaching a
The decision of the therapy. When the elevated blood pressure is the only detectable
abnormalities,
But
the possibility that the pressure of the clinic may be the correct pressure to assess
how
should This can be done by both the self-monitoring or by ambulatory
Considered.
monitoring.
A
To
use the scheme
of different procedures to measure the pressure of the blood when
evaluating
Patients with hypertension new diagnosed displayed in the fig tree. 8. If the selfmonitoring
and
The pressureselected
revealed
comparable with the value of the clinic, treatment may; but if
the appropriate
Main
Page readings are far lower than clinic readings, he did not rule out the
possibility
of
The
blood pressure
may be elevated in the workplace. This is the benefits of
ambulatory
Monitoring, which gives the best estimate of the full range of blood pressure
During the daily life.

The measurement of the blood pressure in special populations and

conditions

Infants and children

Korotkoff sound technique is recommended as the standard for children older than
Age 1 years; but he may give systematic error in baby, which is the voice of the
18 in
It was difficult to hear and the systolic pressure really be underestimated.
On the baby
6
The best direct measurement technique is an ultrasonic flow detector.7Specific
Issues
Associated with the measurement of blood pressure in children from various age is to
know
that of the to select the size. In Bhs recommends choose from three cuff of 4The cuff
15
size13
818
Cm,
andcm,
1235
cm (adult cuff of) and placed on the widest possible angle cuff of In
64
according
the arms.
The
American
Heart Association,
And the National High Blood Pressure Education Program
1
Has
(NHBPEP),
recommended that the cuff of size have been standardized to the circumference of
The arms.
Pregnant women
In pregnancy there is a drop in blood pressure, together with improving the Heart
The output and a big drop in peripheral resistance. As a result of this hyperkinetic
condition,
The
Korotkoff as sometimes can be heard the voice through the brachial blood vessels
without
The pressure applied to the cuff of the sleeve. The sounds that most probably because
the
flow
of the
in use of phase 4 have often recommended for
The
artery.
Asdistortion
a result, the
Register diastolic pressure on pregnant women, which may 12 mm Hg higher than
Phase 5.
In92the NHBPEP Working Group report recommends that record stage 4 and 5
35 In one study 85 pregnant women, but, phase 5 never
During pregnancy.
Near zero and phase 4 can be recognized in only half, led the authors to
Recommend Phase 5.81
Elderly patients
In some older people there is increasing systolic blood pressure without associating it
with
Increased diastolic blood pressure (systolic blood pressure and hypertension), which
has been arterial
associated
with
Decreased
distensibility
with increasing age. In extreme cases this may require
In a reduced compressibility arteries, and by sphygmomanometer cuff of, so false
82
High reading can be recorded, often called as pseudohypertension the elders.
These patients represent the exception rather than the rule, however, because studies
The subject of the elders healthy not show any difference between the greater and not
about
. Author manuscript; available in PMC 2013 30 April.

Ogedegbe and Pickering,

11 pages

50
Regular adult cuff of (1223 cm) may seriously overestimate blood pressure.
The effect
of
The arm circumference on the cuff of the method of measuring the blood pressure is
learning
Systematically by King. 32

The exercise
During dynamic exercise in the auscultatory method may underestimate the systolic
24,25
pressure
rose
To
l5 mmby
Hg,
while during the period of the restoration may be overestimated
Error
by
30
in
mm Hg. pressure are unlikely to be as great, except during the recovery period when
Diastolic
24 is the reason why the American Heart Association
false
Low reading can be recorded.This
Recommends that took the fourth phase Korotkoff sound after the exercise. 64

Summary
Although the use of mercury sphygmomanometer is considered as a draft 'gold' to
The measurement of the blood pressure office prohibition extensively in the use of
mercury devices
have
Reduced
their role
in hospital settings. An alternative method such as automatic
electronic
The device has gained popularity increased the preferred location is measurement
Upper arms, but an error may have occurred because of changes in the position of the
arms.
Besides
Technical
resources including the cuff of the error that does not match the size and so
fast
deflation
the cuff
of increasingly
the sleeve. unrepresentative of patients blood pressure is
Clinical readingofmay
not be
because
The
white robes, securities is defined as the difference between the clinic readings and
The average blood pressure in the daytime. Patients with elevated clinic pressure and
day
normal
Is said
to have been the pressure of the white robes of hypertension, which is often
described
by the anxiety
state
Or
AC response.
There are
three commonly used methods to measure the blood
The pressure for the purpose of clinical clinic: readings, self-monitoring by patients in
the24-hour
house, ambulatory
and
readings. Self-monitoring is usually done using electronic
The device works on the oscillometric technique. Even though the protocol standard
validation
There
are many devices on the market has not been tested for accuracy. such devices
can
Blood pressure recording of arms, wrists, on your finger or, but arm is
preferred.
twenty- monitoring is the best energy from the cardiovascular risk in the
Four
hour ambulatory
individual
Patients and the technique is the only one who can describe the rhythm of blood
pressure
diurnal
computation
With
the right.
Ambulatory
monitoring is mainly used to diagnose hypertension, while
Self-monitoring used to follow Response to treatment. different Techniques
The measurement of the blood pressure can be a choice in certain situations. On the
babytechnique,
in the ultrasound
This
while in pregnancy and best after working diastolic pressure may be
Tohard
measure using conventional auscultatory method. Obesity on subjects important to
Using the cuff of the correct size.

The statement
This work is supported by providing No. R01HL078566 from the National Institute of Health.

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94. Webster J, Newnham D, Petrie JC, et al. the influence of the position of the measuring arm on
the blood
The pressure. Br Med J (Clin Res Ed). 1984; 288:1574.
95. Wonka F, Thummler M, Schoppe A. clinical test of a blood pressure measuring devices with
The cuff of the wrist. Press Monit blood. 1996; 1:361. [PubMed: 10226260]
96. Yarows SA, Qian K. The accuracy of aneroid sphygmomanometers in clinical usage:
University
Michigan experience. Press Monit blood. 2001; 6:101. [PubMed: 11433131]
97. Yelderman M, Ream AK. The measurement is not directly from the blood pressure means in
anesthetized
The fieldpatients.
of Anesthesiology. 1979; 50:253. [PubMed: 434517]

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Page 17

Fig. 1.

Changes occurring distal to a sphygmomanometer te cuff deflation.

Upper trace:
Korotkoff sounds. Second trace : cuff pressure. Third
: oscillations
trace in cuff pressure. The
Maximum oscillation occurs at a pressure of 108 mm Hg, the mean arterial pressure.
Bottom
Trace: radial pulse. FromPickering TG. Blood pressure variability and ambulatory
Monitoring. Curr Opin Nephrol Hypertens 1993a;2:380; with its permissions

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

Ogedegbe and Pickering

Page 18

Fig. 2.

Recording of systolic pressure te laboratory stress testing, made simultaneously with a

Continuous beat-to-beat monitor (Finapres) and an intermittent oscillometric device
(Colin).
Cp = cold pressor test; hg = handgrip; ma = mental arithmetic; ta = talking.

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Ogedegbe and Pickering

Page 19

Fig. 3.

The effects of varying arm positions on blood pressure recorded from the brachial
artery.
From
Pickering TG. Blood pressure variability and ambulatory monitoring. Curr Opin
Nephrol Hypertens 1993a;2:380; with its permissions.

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

Ogedegbe and Pickering

Page 20

Fig. 4.

Self-rated headache score before (pre) and after (post) BP (BP) chaired in different
Conditions. On day 1, the research assistant (RA) a measured BP outside the medical
Environment using a mercury sphygmomanometer (SPH). On day 2, the Ra a
measured
The
absenceBP
ofina physician (MD) by manually triggering a device for ambulatory BP
Chaired the (MTD) first in the waiting room and next in the examination before and
after
The MD a measured BP using heading SPH. Headache scores were obtained in
normotensive
subjects with white coat hypertension (TOILETS-HT), masked
(NT) and in variability
hypertension
And
sustained(M-HT),
hypertension (S-HT).
Reproduced with its permissions from Ogedegbe G,
Pickering TG, Clemow L, et al. The misdiagnosis of hypertension : the role of patient
Headache. Arch Internal Med. Dec 8 2008; 168(22): 2459-2465.

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Page 21

Fig. 5.

The percentage of terminal digits (chosen by four physicians in a Hypertension Clinic

teRoutine blood pressure chaired the. Note the marked preference for zeroes in
physicians
And
D. C

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Ogedegbe and Pickering

Page 22

Fig. 6.

The phenomenon of the auscultatory gap te cuff deflation. Upper trace: ECG. Second
Trace: low frequency recording of sounds under the sphygmomanometer cuff. Third
trace:
Korotkoff sounds. Fourth trace: auscultatory marker pressed when systolic and
diastolic
Sounds
were heard argued. Fifth trace: cuff pressure. Sixth trace: Finapres recording of
arterial
Pressure; note oscillations of pressure corresponding to the silent period of K sounds.
From
Pickering TG. Blood pressure variability and ambulatory monitoring. Curr Opin
Nephrol
Hypertens 1993a;2:380; with its permissions.

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Ogedegbe and Pickering

Page 23

Fig. 7.

The effects of changes in the positions of the forearm on the blood pressure is recorded
byWrist
a
monitor. Unsurprisingly readings were taken in shipbuilders of three positions:
vertically down,
Horizontally
and vertically up. The average values are shown at the top of shipbuilders
bar.

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Ogedegbe and Pickering

Page 24

Fig. 8.

Scheme for combining different measures of blood pressure in the evaluation of

variability
With suspected hypertension.

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