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Improving the Measurement of Blood Pressure: Is It Time for Regulated Standards?

Lawrence J. Appel, MD, MPH; Edgar R. Miller III, MD, PhD; and Jeanne Charleston, BSN, RN
[+] Article, Author, and Disclosure Information

From Johns Hopkins University, Baltimore, MD 21205.

Acknowledgment: The authors thank Drs. William Cushman and Jackson Wright Jr. for their insightful reviews of this editorial.

Potential Conflicts of Interest: None disclosed. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-1042.

Requests for Single Reprints: Lawrence J. Appel, MD, MPH, Johns Hopkins University, 2024 East Monument Street, Suite 2-618, Baltimore, MD 21205-2223; e-mail, lappel@jhmi.edu.

Current Author Addresses: Drs. Appel and Miller: Welch Center for Prevention, Epidemiology and Clinical Research, Division of General Internal Medicine, Department of Epidemiology, Johns Hopkins University, 2024 East Monument Street, Suite 2-618, Baltimore, MD 21205-2223.

Ms. Charleston: Department of Epidemiology, Johns Hopkins University, 2024 East Monument Street, Suite 2-618, Baltimore, MD 21205-2223.

Ann Intern Med. 2011;154(12):838-839. doi:10.7326/0003-4819-154-12-201106210-00014
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In this issue, Powers and colleagues' analysis examined the effects of measuring blood pressure by 3 methods: during routine outpatient visits, during research study visits, and recorded at home. The editorial discusses the implications of the findings regarding the need to base decisions on average blood pressure measurements rather than on a single measurement.

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Improving the measurement of blood pressure.
Posted on July 21, 2011
David Nunan
University of Oxford
Conflict of Interest: None Declared

TO THE EDITOR: I read with interest Powers and colleagues' retrospective analysis of home versus clinic BP measurement and the accompanying editorial.[1, 2]

It is not possible to ascertain if clinic and research measurements were taken at the same visit or on separate occasions and whether the order in which clinic and research measurements was randomized. We cannot therefore be clear if research BP measurements suffer from a familiarization bias.

An explanation of such a large range in the mean number of home BP measures per patient (1-83 for the first 30 days and 1-1454 over the 18 months) was not provided and raises the question why was the number of weekly home measures not standardized?

A key concern is the fact that patients entered into the study were those with a diagnosis of hypertension and poor BP control based on previous clinic measurements of BP. Moreover, diagnosis was made from a clinic BP that may have used a different method to measure clinic BP compared to that used prospectively in the study itself. It is highly likely many patients enrolled on the study were presenting with WCH and could explain why home BP measures performed better. A new diagnosis could have been made from clinic BP measures using the study protocols.

The accompanying editorial sites poor conformance with recommended standards for discrepant clinic measurements.[2] However, the use of standardized protocol and an automated device to obtain clinic measures makes this an unlikely explanation. What is important to highlight is the fact that the Powers et al. did not include a measure of office BP (taken by the physician in their office), instead opting for clinic BP taken by a trained nurse. In many cases this would not represent BP measurement in clinical practice, particularly for hypertension management.[3]

I also disagree with Appel, Miller and Charleston that "the importance of accurate and precise BP measurement has largely been ignored". One need only read the recent UK clinical guidelines for the management of hypertension for evidence that this is not the case.[4] I think many of us already are "serious about BP measurement".[5]


1. Powers, BJ, Olsen MK, Smith VA, Woolson RF, Bosworth HB, Oddone EZ; Measuring blood pressure for decision making and quality reporting: Where and how many measures. Ann Intern Med. 2011;154:781-8.

2. Appel LJ, Miller ER, Charleston J; Improving the measurement of blood pressure: Is it time for regulated standards? Ann Intern Med. 2011;154:838 -839.

3. Williams B, Poulter NR, Brown MJ, Davis M, McInnes GT, Potter JF, Sever PS, McG Thom S. BRITISH HYPERTENSION SOCIETY GUIDELINES; Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004-BHS IV. J Hum Hypertens. 2004;18:139- 85.

4. Hypertension: clinical management of primary hypertension in adults. Nice guideline. Draft for consultation, February 2011. Available from: URL:http://www.nice.org.uk/nicemedia/live/12167/53225/53225.pdf

5. Padfield PL. The case for home monitoring in hypertension. BMC Medicine. 2010;8:55-9.

Conflict of Interest:

None declared

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