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Out-of-office blood pressure measurement: Ambulatory and self-measured blood pressure monitoring

Out-of-office blood pressure measurement: Ambulatory and self-measured blood pressure monitoring
Authors:
Raymond R Townsend, MD
Jordana Cohen, MD, MSCE
Section Editors:
George L Bakris, MD
Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
Deputy Editors:
Karen Law, MD, FACP
John P Forman, MD, MSc
Literature review current through: Jan 2024.
This topic last updated: Jan 30, 2024.

INTRODUCTION — Screening for hypertension and monitoring of treated hypertension are typically performed by obtaining blood pressure measurements in a clinician's office. However, office-based blood pressure readings may not always accurately represent an individual's blood pressure; many individuals with elevated office-based blood pressure will not have hypertension upon further testing (ie, they have white coat hypertension), and some individuals who are being treated for hypertension may have elevated office-based readings, despite having controlled blood pressure when not in the clinician's office (ie, white coat effect) (figure 1). Consequently, the use of out-of-office blood pressure measurement is appropriate to confirm the diagnosis of hypertension and to monitor patients on therapy. (See "White coat and masked hypertension".)

The technique, interpretation, and indications to obtain out-of-office blood pressure measurements are presented in this topic. The appropriate technique for office-based blood pressure measurement is discussed elsewhere. (See "Blood pressure measurement in the diagnosis and management of hypertension in adults", section on 'Office-based blood pressure measurement'.)

Other relevant discussions pertaining to hypertension can be found in separate topics:

●Overview and diagnosis of hypertension (see "Overview of hypertension in adults")

●Evaluation of the hypertensive adult (see "Initial evaluation of adults with hypertension")

●Choice of drug therapy to treat hypertension (see "Choice of drug therapy in primary (essential) hypertension")

●Goal blood pressure in adults (see "Goal blood pressure in adults with hypertension")

●Evaluation and treatment of resistant hypertension (see "Definition, risk factors, and evaluation of resistant hypertension" and "Treatment of resistant hypertension")

TYPES OF OUT-OF-OFFICE BLOOD PRESSURE MEASUREMENTS

Ambulatory blood pressure monitoring (ABPM) — ABPM is performed using a device worn by the patient that takes blood pressure measurements over a 24- to 48-hour period, usually every 15 to 30 minutes during the daytime and every 30 to 60 minutes during sleep [1]. These blood pressures are recorded on the device, and the average day (diurnal) or night (nocturnal) pressures are calculated by a computer. The percentage of blood pressure readings exceeding the upper limit of normal can also be determined.

Measuring blood pressure outside the office setting with ABPM captures the effects of normal daily activities on blood pressure, provides information on the behavior of blood pressure during sleep, and provides a greater number of readings than can be obtained during a typical office encounter.

However, ABPM is unavailable in most clinicians' offices. This is due to a combination of factors, including lack of knowledge regarding its utility, the expense, and lack of reimbursement by third-party payers.

In addition, ABPM is a one-time evaluation, and blood pressure must be followed serially over time.

Self-measured blood pressure (SMBP) — As information accumulates on discrepancies between office-based and out-of-office blood pressure measurements, attention has shifted to asking patients to self-measure their blood pressure at home or at work. Although home blood pressure measurement devices have been available for many years, the exclusion of mercury from these devices and the development of oscillometric devices has made self-measured blood pressure more practical and convenient.

The technique of SMBP is similar to that of blood pressure measured by a clinician in the office. Proper positioning and choice of cuff size, rest prior to measurement, and care taken to empty the bladder and avoid influences such as caffeine and cigarette usage are critical to obtaining reliable data (table 1) [2]. Patients are typically asked to obtain multiple SMBP readings over a limited time period, which are then shared with the clinician. (See 'Performance and interpretation of self-measured blood pressure (SMBP)' below.)

Many blood pressure devices are available for purchase directly by patients (online or in stores). However, device manufacturers are not required to perform validation studies (ie, careful testing for accuracy) before marketing a blood pressure monitor to consumers. As a result, various professional societies, such as the International Society of Hypertension, Hypertension Canada, and the American Medical Association, provide websites to inform consumers about which monitors have been validated.

Comparison of ABPM and SMBP — ABPM and SMBP are acceptable methods for confirming the diagnosis of hypertension and monitoring patients being treated for hypertension (although SMBP is more practical for longitudinal monitoring). (See "Blood pressure measurement in the diagnosis and management of hypertension in adults", section on 'Selecting a measurement strategy'.)

Properly done office-based blood pressure measurements and home-based SMBP use the same basic techniques (table 1), the only difference being the environment. ABPM, on the other hand, does not require restrictions on the patient's activity level, or exposures such as diet, exercise, and cigarette use.

Both ABPM and SMBP provide greater prognostic value than office-based blood pressure measurements (see 'Superior prognostic value of ABPM' below). However, this is better established for ABPM [3,4], and, in addition, ABPM records nighttime blood pressure, which has independent prognostic value [5]. In one meta-analysis that compared SMBP with ABPM in the same populations, ABPM predicted the development of cardiovascular outcomes even after adjusting for SMBP (although the reverse was not true) [6].

Home blood pressure has the advantage of easy repeatability, greater patient acceptance, and lower patient cost (eg, USD $40 to $60 for a semiautomatic device). Depending upon insurance coverage and diagnosis, partial or full reimbursement for the cost of the device may even be available.

The cost of ABPM includes the clinician's initial investment in purchasing the monitors and computer software, minor costs for training staff, and the clinician's charges to patients for test interpretation. In 2018, the average cost for equipment was USD $2000 to $5000 for each monitor, and computer software was free up to USD $4000 [7]. Clinician charges are variable. In the United States, insurance coverage for ABPM differs widely depending upon insurance carrier and diagnosis although increasingly it is a covered service for suspected white coat and masked hypertension. If no or limited insurance reimbursement is available, the out-of-pocket-cost for patients may be prohibitive.

Although ABPM and SMBP increase the costs of blood pressure measurement compared with office-based measurement, they reduce the overall costs of antihypertensive medication treatment by detecting white coat hypertension and white coat effect, and therefore may be cost effective for these patients [8-10]. (See "White coat and masked hypertension".)

SMBP and ABPM can be used as complementary methods for out-of-office assessment. ABPM provides blood pressure data while patients are "on the go" and during the nighttime, although typically for only 24 hours. Conversely, SMBP, while only providing daytime readings, can be used as a more frequent assessment of blood pressure over the long-term.

DEFINITION OF HYPERTENSION BASED UPON OUT-OF-OFFICE MEASUREMENTS — The definition of hypertension based upon data from ambulatory blood pressure monitoring (ABPM) and home (self-measured) blood pressure (SMBP) is discussed in detail elsewhere (table 2):

●(See "Overview of hypertension in adults", section on 'Definitions based upon ambulatory and home readings'.)

●(See "Blood pressure measurement in the diagnosis and management of hypertension in adults", section on 'Interpretation of blood pressure measurements'.)

REASONS FOR MEASURING OUT-OF-OFFICE BLOOD PRESSURE

Identification of white coat and masked hypertension — Both ambulatory blood pressure monitoring (ABPM) and home or work (self-measured) blood pressure (SMBP) have value in clinical practice (table 3) [11-15].

There are four possible scenarios when comparing the results of office-based and out-of-office blood pressure measurements (table 4 and figure 1):

When office-based and out-of-office readings concur:

●Blood pressures are below the threshold of hypertension in a patient who is normotensive or has controlled hypertension.

●Blood pressures are above the threshold of hypertension in a patient with sustained hypertension or uncontrolled hypertension.

When office-based and out-of-office readings are discordant:

●If office-based measurements are above the threshold of hypertension but out-of-office measurements are normal (see "White coat and masked hypertension", section on 'Definitions'):

•White coat hypertension is present in a patient who is not being treated for hypertension.

•White coat effect is present in a patient who is already being treated with antihypertensive medication.

●If office-based measurements are normal but out-of-office measurements demonstrate elevated blood pressures, then masked hypertension is present. (See "White coat and masked hypertension", section on 'Definitions'.)

Most expert panels, including the American College of Cardiology/American Heart Association (ACC/AHA), European Society of Cardiology/European Society of Hypertension (ESC/ESH), United States Preventive Services Task Force (USPSTF), and Canadian Hypertension Education Program (CHEP) recommend that ABPM or SMBP should be used, if possible, to confirm a new diagnosis of hypertension in most outpatients who have elevated office-based blood pressure [16-19]. However, mostly due to issues of cost and inconvenience, confirmation of office-based readings using out-of-office measurements is not always feasible.

Patients with white coat hypertension have a higher risk of transitioning to sustained hypertension than patients without white coat hypertension. Those with confirmed white coat hypertension should have out-of-office blood pressure measurements repeated at one-year intervals for older patients and at two-year intervals for younger patients.

Other indications — There are a number of other potential indications for out-of-office measurement advocated by some experts, which include [20-22]:

●To determine the effectiveness of antihypertensive therapy. Usually, SMBP is performed for this purpose, although repeated ABPM can be effective. Therapeutic decisions can be made according to the out-of-office blood pressure findings. One report, for example, found that antihypertensive therapy was adjusted in nearly one-half of patients as a consequence of ABPM, and office-based blood pressure control was improved in most patients within three months [23]. (See "Blood pressure measurement in the diagnosis and management of hypertension in adults", section on 'Selecting a measurement strategy'.)

●To confirm that blood pressure is uncontrolled in a patient with apparent resistant hypertension. (See "Definition, risk factors, and evaluation of resistant hypertension", section on 'White coat effect'.)

●To confirm (by SMBP using a validated device) [24], elevated office blood pressure in pregnant women, when gestational hypertension or preeclampsia are suspected. (See "Gestational hypertension", section on 'Diagnostic evaluation'.)

In addition to these clinical indications, ABPM or SMBP can be used to establish nondipper status or nocturnal hypertension (using ABPM), evaluate whether antihypertensive therapy is affecting the early morning blood pressure surge (using ABPM), or assess substantial longitudinal blood pressure variability (using SMBP).

Superior prognostic value of ABPM — Multiple studies suggest that all-cause mortality and cardiovascular events correlate more closely with 24-hour, daytime, and particularly nighttime ABPM than with the office-based blood pressure measurement and that an elevated 24-hour blood pressure predicts these outcomes even after adjusting for office-based blood pressure [3,5,25-32]. As an example, in a cohort study of 59,124 patients referred for hypertension management, 24-hour ambulatory systolic blood pressure was associated with both all-cause mortality (hazard ratio [HR] 1.43, 95% CI 1.37-1.49) and cardiovascular mortality (HR 1.51, 95% CI 1.41-1.62) after adjustment for office-based blood pressure [32]. ABPM is also a superior prognostic indicator of future cardiovascular disease in patients with resistant hypertension [33-35].

In addition to cardiovascular risk prediction, ambulatory blood pressure, and particularly nighttime blood pressure, may be a stronger marker of kidney disease progression and development of end-stage kidney disease (ESKD) than office-based blood pressure [36-38].

SMBP readings obtained at home or work, which correlate more closely with the results of 24-hour or daytime ABPM than with office-based blood pressure [1,39-41], may also be more predictive of adverse outcomes (eg, stroke, ESKD) than blood pressure obtained in the clinic [37,42-45]. However, there are fewer data supporting the prognostic value of SMBP than ABPM.

The difference in prognostic accuracy between ABPM and office-based readings might be diminished by obtaining repeated blood pressure measurements in the office during the same visit and with appropriate technique (table 1) or by measuring office blood pressure with an automated office blood pressure (AOBP) device that can automatically take and average multiple measurements [46-50]. (See "Blood pressure measurement in the diagnosis and management of hypertension in adults", section on 'Automated office blood pressure measurement'.)

Nocturnal dipping (ie, the proportional decrease in nighttime compared with daytime blood pressure) can also be evaluated with ABPM. Dipping has independent value as a prognostic marker; the association of dipping with cardiovascular events is presented below. (See 'Dipping' below.)

Possible improvement in blood pressure control with SMBP — Patient SMBP can improve blood pressure control, especially if combined with other supportive interventions [14,42,51-65], such as automated telemonitoring with support from a pharmacist [52,60] and education with a tailored medication self-titration plan [59,62,64,66]. A 2013 meta-analysis of 52 trials that randomly allocated patients to SMBP monitoring or standard clinic-based monitoring found the following significant benefits associated with home-based monitoring [55]:

●A greater decrease in blood pressure by 3.9/2.4 mmHg at six months when SMBP monitoring was compared with usual care.

●A greater decrease in blood pressure by as much as 8.3/4.4 mmHg at 12 months when SMBP monitoring combined with additional supportive interventions was compared with usual care.

Proposed mechanisms for the observed improvement in control with SMBP include better patient adherence and decreased therapeutic inertia.

However, the efficacy of SMBP on blood pressure reduction and control is less clear in patients with socioeconomic health barriers. As an example, in a trial of 900 patients from community health centers in New York City, most of whom were Black patients and Hispanic patients, provision of a home blood pressure monitor along with training on its use did not improve systolic blood pressure (which fell by 15 compared with 14 mmHg in the control group) or the proportion of patients achieving goal blood pressure (39 percent in both groups) [67]. Thus, additional interventions, such as nurse-led disease management [68], may be required in combination with SMBP monitoring to achieve better control in populations with barriers to health care.

PERFORMANCE AND INTERPRETATION OF AMBULATORY BLOOD PRESSURE MONITORING (ABPM)

Performing ABPM — Ambulatory blood pressure monitoring (ABPM) can be arranged in the clinician's office or by mail (through a third party). Appropriate devices for performance of ABPM have been summarized in the literature [7] and are identified by online validated-device listings such as Hypertension Canada and STRIDE BP.

The process of performing ABPM is summarized as follows:

●Patient preparation and instructions – We instruct patients in advance that they should arrive ready to have the monitor applied, wearing a short-sleeved shirt or blouse (a bare arm is the best surface for obtaining accurate blood pressures). Patients should be made aware in advance that they will be wearing the monitor for 24 hours, and it is preferable not to remove it.

We require that the monitor be returned the next day. If they wish to take home a copy of the ABPM report, patients are advised that it can take up to 30 minutes to remove the monitor, download the data, and print a copy of the report.

All patients are counseled that there may be some discomfort associated with cuff inflation, particularly for overweight or obese patients, even with the use of an appropriately sized cuff.

Ambulatory blood pressure monitors register blood pressure by detecting small oscillations during deflation; therefore, it is critical that the patient keep their arm relaxed, still, and at their side when a measurement commences.

Patients should be instructed on how to stop an individual measurement if it commences at an inconvenient time (this is an option available on most monitors). If a reading is skipped, the internal timer will reset the device to take the next blood pressure reading as scheduled.

If the device is unable to assess the blood pressure accurately, it will try to measure a second time. If the second attempt is unsuccessful, the monitor will not attempt a third cuff inflation but will instead try again after the preset time interval. Patients who observe that the monitor is often, or always, requiring a second inflation to obtain a reading, should contact the provider's office for advice. The cuff may have slipped or there may be a problem with a kink or a leak in the tubing.

We provide patients with a diary to record the time at which they go to bed, the time they wake, timing of naps, and times that antihypertensive medications are taken. We also ask patients to record in the diary if and when they exercise, experience stressful situations (eg, worksite presentations), or experience symptoms potentially attributable to their blood pressure, like headaches or lightheadedness.

●Configuring the monitor before use – Monitor configuration is usually not standardized, and clinicians need to manually enter measurement settings though these can be saved in the software. Most clinical centers set the monitor to acquire a blood pressure every 15 to 30 minutes during the day and every 60 minutes during the night. Most monitors have a default setting for the nighttime hours from 10:00 PM to 6:00 AM; however, the nighttime hours can often be reconfigured before the monitor is applied, based upon the patient's report of their usual bedtime and wake time. Some monitors allow the patient to manually enter the nighttime hours.

Many programs configure the monitor to obscure the blood pressure readings (after the first few done in the office), to reduce anxiety in some patients who focus on their blood pressure while wearing the device. There is also an option to set an alert sound issued by the monitor approximately five seconds prior to inflation, which prompts the patient to relax their arm by their side to facilitate accurate readings. This warning sound is helpful during the day but can be disabled at night to minimize sleep disruption.

●Applying the monitor – The cuff should ideally be applied to the nondominant arm, with the attached inflation/recording unit worn on the opposite hip using either a belt or an over-the-shoulder strap. For those patients who have a reason to avoid blood pressure measurements on their nondominant arm (eg, lymphedema, prior axillary lymph node dissection), the contralateral arm should be used. (See "Breast cancer-associated lymphedema".)

At least two inflations of the ABPM unit should be obtained in the office so that the patient becomes comfortable with how the device works and feels and to ensure that the readings obtained correlate to those obtained by an office-based reading. Preferably, the office-based blood pressure should be taken between two ABPM readings. ABPM readings can be triggered manually (in addition to the preprogramed timed readings) by pressing the unit's "manual blood pressure" button.

Interpreting ABPM — Each ABPM manufacturer provides the ability to customize ABPM reports. In addition to patient identifiers and demographic information, the report should include the indication for the ABPM study; the number of daytime, nighttime, and total readings obtained; summaries of daytime, nighttime, and 24-hour blood pressures; and heart rates. Patient-related observations including medications taken, the time to bed and the time arising, time of naps (if any), and any symptoms are recorded in a diary; most ABPM software allows the addition of such notes.

Minimum required number of readings — There is no clear consensus regarding the minimal number of readings required for a valid 24-hour ABPM assessment. Several guidelines require a minimum of 70 percent of successful programmed measurements, corresponding to a minimum of 20 daytime readings and seven nighttime readings [17,69]. If the number of measurements obtained is slightly fewer than this, it may still be reasonable to accept the ABPM study as valid, understanding that the results are not optimal. If the number of measurements obtained is substantially less than this, we would repeat the ABPM study.

The ABPM report — The major data provided by the ABPM report include (figure 2):

●Average 24-hour blood pressure

●Average daytime (awake) blood pressure

●Average nighttime (asleep) blood pressure

The average 24-hour blood pressure and the average daytime blood pressure can be used to confirm or exclude the presence of hypertension, using the definitions described elsewhere (table 2). The prognostic value of 24-hour, daytime, and nighttime blood pressure are discussed above. (See "Overview of hypertension in adults", section on 'Definitions based upon ambulatory and home readings' and "Blood pressure measurement in the diagnosis and management of hypertension in adults", section on 'Interpretation of blood pressure measurements' and 'Superior prognostic value of ABPM' above.)

Most experts agree that an average 24-hour blood pressure <115/75 mmHg is probably normal and that an average 24-hour blood pressure ≥125/≥75 mmHg is probably abnormal [1,16,21].

Other data that are provided by ABPM include:

●Nocturnal dipping of blood pressure – Dipping is the proportional decrease in nighttime compared with daytime blood pressure (reported as the percentage decline). The normal "dip" in systolic pressure is 10 to 20 percent. The prognostic implications of dipping are discussed below. (See 'Dipping' below.)

●Morning surge – Morning surge is defined as the difference between the nighttime blood pressure and the average of early morning blood pressures (figure 3). Although there is no standardized method of calculating morning surge, the average blood pressure from the first two hours after awakening minus the average nighttime blood pressure may be the most reproducible [70]. Patients who have a larger surge from nighttime to early morning blood pressure may have a greater risk of future cardiovascular events [71-74].

●Systolic blood pressure load – Systolic blood pressure load is the proportion of time during the day in which the systolic blood pressure is above the threshold for elevated daytime blood pressure. This value provides insight into the duration and lability of elevated blood pressure. A patient whose systolic pressure is above the threshold for ≥40 percent of daytime measurements is generally considered to have an excessively high systolic blood pressure load. Systolic blood pressure load has not been demonstrated to provide additional prognostic information beyond the mean systolic blood pressure [75]. Nonetheless, this metric is analogous to time-in-target range (the proportion of time that an individual's blood pressure is within the goal range), which is linked to longitudinal cardiovascular and kidney outcomes [76,77].

●Diastolic blood pressure load – Similarly, diastolic blood pressure load is the proportion of time during the day in which the diastolic blood pressure is above the threshold for elevated daytime blood pressure. Like the systolic blood pressure load, this value provides insight into the duration and lability of elevated blood pressure but does not provide independent prognostic information.

●Ambulatory arterial stiffness index (AASI) – The AASI is determined by plotting a regression of all the diastolic blood pressure values with the simultaneous systolic blood pressure values and subtracting the slope of this line from 1. Higher values generally correspond to stiffer blood vessels and a higher risk of cardiovascular disease [78-81].

Dipping — Dipping is the proportional decrease in nighttime compared with the daytime blood pressure (reported as the percentage decline). The average nighttime systolic and diastolic blood pressure is approximately 15 percent lower than the daytime value in both normotensive and hypertensive patients (figure 2) [82]. Failure of the blood pressure to fall by at least 10 percent during sleep is called "nondipping" (figure 4). The underlying mechanisms of nondipping are unknown, but intrinsic kidney defects may contribute [39,83,84]. Melatonin deficiency and sleep apnea may also have a role. (See "Obstructive sleep apnea and cardiovascular disease in adults", section on 'Hypertension'.)

Independent of the degree of hypertension, nondipping is a risk factor for the development of heart failure and other cardiovascular complications [25,30,85-88]. In one large cohort, for example, the risk of heart failure among nondippers was more than twice that of dippers (HR 2.21, 95% CI 1.12-4.36), even after controlling for office-based blood pressure and other factors [88].

In addition, nondipping is associated with progression of nephropathy among diabetic patients and more rapid decline in kidney function and risk for end-stage kidney disease (ESKD) among patients with chronic kidney disease [37,89-91].

However, "extreme dipping" (eg, >20 percent nocturnal decline in blood pressure) may also be potentially deleterious [72,87].

Whether reversal of nondipping is possible or beneficial is uncertain. There are conflicting data about whether nocturnal dosing of antihypertensive medications can restore a dipping pattern. This issue is discussed in detail elsewhere. (See "Choice of drug therapy in primary (essential) hypertension".)

Previously, the only way to obtain nocturnal blood pressure readings was through wearing an ABPM. However, several devices designed for home use, such as watch-type wearable blood pressure monitors, may facilitate nocturnal measurements [92-94].

PERFORMANCE AND INTERPRETATION OF SELF-MEASURED BLOOD PRESSURE (SMBP) — There are many blood pressure measurement devices that can be purchased by the patient (online or in stores). The US Food and Drug Administration (FDA) does not require formal validation studies for a manufacturer to sell a blood pressure device; it is enough for the manufacturer to claim "substantial equivalence" with other devices already on the market [95]. Similarly, most other countries do not require formal validation in order for devices to be marketed. Less than 15 percent of commercially available blood pressure devices worldwide have published information on device accuracy [96], and only about 20 percent of the most commonly purchased devices have been validated [97]. Concerns about this have led to the development of websites to help patients and clinicians know which blood pressure devices have undergone actual validation studies. Sites hosted by the International Society of Hypertension, the American Medical Association, and Hypertension Canada provide listings of validated monitors.

There are no established protocols for self-measured blood pressure (SMBP) monitoring [42,66,98-100]. How frequently such blood pressures are obtained will depend upon the reason:

●Establishing the diagnosis of hypertension – To establish a diagnosis of hypertension using SMBP, it is useful to measure blood pressure twice daily (once between 7:00 to 10:00 AM and once between 1:00 to 10:00 PM) for up to one week (table 5) [1,16,39,82,83,101-106]. (See "Blood pressure measurement in the diagnosis and management of hypertension in adults", section on 'Home blood pressure monitoring'.)

As with ambulatory monitoring, SMBP readings can vary widely during the day, being influenced by factors such as stress (particularly at work), smoking, caffeine intake, natural circadian variation, and exercise [107]. Thus, multiple readings are required to determine the average level.

●Monitoring the effect of therapeutic changes – SMBP should be performed beginning seven days after the initiation or dosing change of antihypertensive drugs; this allows the change in therapy to reach its full effect. After this seven-day period, the effect can be assessed with two to three consecutive measurements twice daily (eg, two morning measurements and two evening measurements) for a minimum of three, and ideally five to seven, consecutive days.

●Monitoring of well-controlled hypertension – For surveillance of seemingly well-controlled hypertension, SMBP can be performed as infrequently as two consecutive measurements twice daily (ie, two measurements in the morning and two measurements in the evening), once monthly or once weekly. However, some experts advocate collecting 12 to 28 readings (ie, two consecutive SMBP readings twice daily for three to seven consecutive days) every three months [1].

●Confirming resistant hypertension – When therapeutic resistance is suspected, two to three consecutive measurements should be performed twice daily for a minimum of three, and ideally five to seven, consecutive days every month.

Accurate SMBP is predicated on the patient following the same set of instructions that are recommended for office-based blood pressure measurement (table 1) [108]. The patient should have an empty bladder and have refrained from exercise, caffeine, and cigarette usage for at least 30 minutes prior to obtaining a reading. Being seated comfortably with both feet on the floor, legs uncrossed, back supported, and the elbow at the heart level are necessary prerequisites [2]. In addition, the timing of antihypertensive medication can confound the interpretation of SMBP, particularly if the patient is prescribed short-acting drugs that are taken a few hours before measuring the blood pressure. This problem can be minimized by having the patient self-measure their blood pressure 30 to 60 minutes before taking their antihypertensive medications.

No matter which type of device is used (aneroid or oscillometric), the device should be validated [109], the patient should be provided with adequate training in its use, and the machine should be checked for accuracy approximately once yearly [1,110,111]. Accuracy can be tested by having the patient take the blood pressure in the office with their personal device, while the clinician measures the blood pressure in the other arm simultaneously; readings that correspond within 5 mmHg are considered acceptable.

There are multiple ways for clinicians to obtain their patient's out-of-office SMBP readings:

●Patients can record their SMBP readings (table 5) and share these records with their clinicians (electronically or in person).

●Some electronic health records (EHRs) permit patients to directly enter their own health data, including their blood pressures.

●Some devices designed for home blood pressure measurement can automatically download data into the EHR via a smartphone or other mobile application.

Once enough SMBP readings are obtained over the specified time period, they should be averaged. Using the average out-of-office SMBP, most experts agree that a blood pressure ≥130/≥80 mmHg signifies hypertension. The interpretation of SMBP to determine if a patient with hypertension has achieved their goal blood pressure is presented separately (table 6). (See "Goal blood pressure in adults with hypertension", section on 'Overview of our approach'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Hypertension in adults".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Checking your blood pressure at home (The Basics)" and "Patient education: High blood pressure in adults (The Basics)")

●Beyond the Basics topics (see "Patient education: High blood pressure in adults (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Office-based blood pressure readings may not always accurately represent an individual's blood pressure; many individuals with elevated office-based blood pressure will not have hypertension upon further testing (ie, they have white coat hypertension), and some individuals who are being treated for hypertension may have elevated office-based readings, despite having controlled blood pressure when not in the clinician's office (ie, white coat effect) (table 4 and figure 1). Consequently, the use of out-of-office blood pressure measurement is appropriate to confirm the diagnosis of hypertension and to monitor patients on therapy. (See 'Introduction' above.)

●Out-of-office blood pressure evaluation includes ambulatory blood pressure monitoring (ABPM) or self-measured blood pressure (SMBP). ABPM is performed using a device worn by the patient that takes blood pressure measurements over a 24- to 48-hour period during the daytime and during sleep. SMBP is similar to blood pressure measured by a clinician (table 1); patients are typically asked to obtain multiple SMBP readings over a limited time period, which are then shared with the clinician (table 5). (See 'Types of out-of-office blood pressure measurements' above.)

●There are four possible scenarios when comparing the results of office-based and out-of-office blood pressure measurements (table 4 and figure 1). (See 'Identification of white coat and masked hypertension' above.)

When office-based and out-of-office readings concur:

•Blood pressures are below the threshold of hypertension in a patient who is normotensive or has controlled hypertension.

•Blood pressures are above the threshold of hypertension in a patient with sustained hypertension or uncontrolled hypertension.

When office-based and out-of-office readings are discordant:

•If office based-measurements are above the threshold of hypertension but out-of-office measurements are normal, then white coat hypertension or white coat effect is present.

•If office-based measurements are normal but out-of-office measurements demonstrate elevated blood pressures, then masked hypertension is present.

●In addition to diagnosing white coat and masked hypertension, other indications for obtaining out-of-office blood pressure measurements include (table 3) (see 'Other indications' above):

•Confirming a new diagnosis of hypertension in most outpatients who have elevated office-based blood pressure

•Determining the effectiveness of antihypertensive therapy

•Confirming that blood pressure is uncontrolled in a patient with apparent resistant hypertension

•Confirming (by SMBP) elevated office blood pressure in pregnant women, when gestational hypertension or preeclampsia are suspected

●All-cause mortality and the risk of cardiovascular events correlate more closely with 24-hour, daytime, or nighttime ABPM than with the office-based blood pressure measurement. In patients with resistant hypertension, ABPM is also a superior prognostic indicator of future cardiovascular disease. (See 'Superior prognostic value of ABPM' above.)

●ABPM can be arranged in the clinician's office or by mail (through a third party). The major data provided by the ABPM report include (figure 5) (see 'Performance and interpretation of ambulatory blood pressure monitoring (ABPM)' above):

•Average 24-hour blood pressure

•Average daytime (awake) blood pressure

•Average nighttime (asleep) blood pressure

Most experts agree that an average 24-hour blood pressure <115/75 mmHg is probably normal and that an average 24-hour blood pressure ≥125/≥75 mmHg is probably abnormal (table 2 and table 6). The ABPM may also report nocturnal blood pressure dipping (figure 6).

●For SMBP, there are many blood pressure measurement devices available for purchase by the patient, although these devices are not required to be validated for accuracy. There are, however, resources available to patients and clinicians, including online websites, that provide information on which devices are validated. The patient should be provided with adequate training in the machine's use, and the device should be checked for accuracy approximately once yearly. (See 'Performance and interpretation of self-measured blood pressure (SMBP)' above.)

There are no established protocols for SMBP monitoring; how frequently blood pressure measurements are obtained will depend upon the reason (eg, establishing the diagnosis of hypertension, monitoring the effect of therapeutic changes, monitoring of well controlled hypertension, confirming resistant hypertension). Once enough SMBP readings are obtained over the specified time period, they should be averaged. Using the average out-of-office SMBP, most experts agree that a blood pressure ≥130/≥80 mmHg signifies hypertension (table 2 and table 6).

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Norman M Kaplan, MD (deceased), who contributed to earlier versions of this topic review.

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Topic 3820 Version 68.0

References

1 : Call to action on use and reimbursement for home blood pressure monitoring: executive summary: a joint scientific statement from the American Heart Association, American Society Of Hypertension, and Preventive Cardiovascular Nurses Association.

2 : Blood Pressure Assessment in Adults in Clinical Practice and Clinic-Based Research: JACC Scientific Expert Panel.

3 : Diagnostic and predictive accuracy of blood pressure screening methods with consideration of rescreening intervals: a systematic review for the U.S. Preventive Services Task Force.

4 : Out-of-Office Blood Pressure Monitoring: A Comparison of Ambulatory Blood Pressure Monitoring and Home (Self) Monitoring Of Blood Pressure.

5 : Superiority of ambulatory over clinic blood pressure measurement in predicting mortality: the Dublin outcome study.

6 : Studies comparing ambulatory blood pressure and home blood pressure on cardiovascular disease and mortality outcomes: a systematic review.

7 : Out-of-Office Blood Pressure Monitoring in 2018.

8 : Antihypertensive treatment based on conventional or ambulatory blood pressure measurement. A randomized controlled trial. Ambulatory Blood Pressure Monitoring and Treatment of Hypertension Investigators.

9 : Effect of ambulatory blood pressure monitoring on the diagnosis and cost of treatment for mild hypertension.

10 : Cost-effectiveness of ambulatory blood pressure: a reanalysis.

11 : The 2005 Canadian Hypertension Education Program recommendations for the management of hypertension: part 1- blood pressure measurement, diagnosis and assessment of risk.

12 : Clinical practice guidelines for the management of hypertension in the community a statement by the American Society of Hypertension and the International Society of Hypertension.

13 : 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).

14 : Self-Measured Blood Pressure Monitoring at Home: A Joint Policy Statement From the American Heart Association and American Medical Association.

15 : 2021 European Society of Hypertension practice guidelines for office and out-of-office blood pressure measurement.

16 : 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.

17 : 2023 ESH Guidelines for the management of arterial hypertension The Task Force for the management of arterial hypertension of the European Society of Hypertension: Endorsed by the International Society of Hypertension (ISH) and the European Renal Association (ERA).

18 : Screening for high blood pressure in adults: U.S. Preventive Services Task Force recommendation statement.

19 : Hypertension Canada's 2018 Guidelines for Diagnosis, Risk Assessment, Prevention, and Treatment of Hypertension in Adults and Children.

20 : Practice guidelines of the European Society of Hypertension for clinic, ambulatory and self blood pressure measurement.

21 : 2007 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).

22 : Ambulatory blood-pressure monitoring.

23 : Management of hypertension after ambulatory blood pressure monitoring.

24 : Accuracy of Blood Pressure Measurement Devices in Pregnancy: A Systematic Review of Validation Studies.

25 : Prognostic value of isolated nocturnal hypertension on ambulatory measurement in 8711 individuals from 10 populations.

26 : Ambulatory blood pressure and mortality: a population-based study.

27 : Relating cardiovascular risk to out-of-office blood pressure and the importance of controlling blood pressure 24 hours a day.

28 : Prognostic impact of clinic and ambulatory blood pressure components in high-risk type 2 diabetic patients: the Rio de Janeiro Type 2 Diabetes Cohort Study.

29 : Prognostic value of ambulatory blood-pressure recordings in patients with treated hypertension.

30 : Prognostic accuracy of day versus night ambulatory blood pressure: a cohort study.

31 : Predictors of all-cause mortality in clinical ambulatory monitoring: unique aspects of blood pressure during sleep.

32 : Relationship between clinic and ambulatory blood pressure and mortality: an observational cohort study in 59 124 patients.

33 : Prognostic value of ambulatory blood pressure monitoring in refractory hypertension: a prospective study.

34 : Prognostic influence of office and ambulatory blood pressures in resistant hypertension.

35 : Prognostic value of nocturnal blood pressure reduction in resistant hypertension.

36 : Prognostic Significance of Ambulatory BP Monitoring in CKD: A Report from the Chronic Renal Insufficiency Cohort (CRIC) Study.

37 : Prognostic importance of ambulatory blood pressure recordings in patients with chronic kidney disease.

38 : Prognostic role of ambulatory blood pressure measurement in patients with nondialysis chronic kidney disease.

39 : Home blood pressure monitoring in CKD.

40 : What is the value of home blood pressure measurement in patients with mild hypertension?

41 : Home blood pressure measurement: a systematic review.

42 : Home blood pressure monitoring: methodology, clinical relevance and practical application: a 2021 position paper by the Working Group on Blood Pressure Monitoring and Cardiovascular Variability of the European Society of Hypertension.

43 : Prognostic Impact of Home Blood Pressures for Adverse Cardiovascular Outcomes and Mortality in Patients With Resistant Hypertension: A Prospective Cohort Study.

44 : Prediction of stroke by self-measurement of blood pressure at home versus casual screening blood pressure measurement in relation to the Joint National Committee 7 classification: the Ohasama study.

45 : Home-measured blood pressure is a stronger predictor of cardiovascular risk than office blood pressure: the Finn-Home study.

46 : Prediction of cardiac structure and function by repeated clinic and ambulatory blood pressure.

47 : Misclassification of blood pressure by usual measurement in ambulatory physician practices.

48 : Are there really differences between home and daytime ambulatory blood pressure? Comparison using a novel dual-mode ambulatory and home monitor.

49 : Measurement of blood pressure in the office: recognizing the problem and proposing the solution.

50 : Comparison of Automated Office Blood Pressure With Office and Out-Off-Office Measurement Techniques.

51 : Blood pressure management through application-based telehealth platforms: a systematic review and meta-analysis.

52 : Comparative Effectiveness of Implementation Strategies for Blood Pressure Control in Hypertensive Patients: A Systematic Review and Meta-analysis.

53 : Effectiveness of home blood pressure telemonitoring: a systematic review and meta-analysis of randomised controlled studies.

54 : Self-monitoring of blood pressure in hypertension: A systematic review and individual patient data meta-analysis.

55 : Self-measured blood pressure monitoring in the management of hypertension: a systematic review and meta-analysis.

56 : Role of home blood pressure monitoring in overcoming therapeutic inertia and improving hypertension control: a systematic review and meta-analysis.

57 : Blood pressure control by home monitoring: meta-analysis of randomised trials.

58 : Two self-management interventions to improve hypertension control: a randomized trial.

59 : Effect of self-monitoring and medication self-titration on systolic blood pressure in hypertensive patients at high risk of cardiovascular disease: the TASMIN-SR randomized clinical trial.

60 : Effect of home blood pressure telemonitoring and pharmacist management on blood pressure control: a cluster randomized clinical trial.

61 : Impact of home blood pressure monitoring on blood pressure control in older individuals: a French randomized study.

62 : Efficacy of self-monitored blood pressure, with or without telemonitoring, for titration of antihypertensive medication (TASMINH4): an unmasked randomised controlled trial.

63 : Home and Online Management and Evaluation of Blood Pressure (HOME BP) using a digital intervention in poorly controlled hypertension: randomised controlled trial.

64 : Home Blood Pressure Self-monitoring plus Self-titration of Antihypertensive Medication for Poorly Controlled Hypertension in Primary Care: the ADAMPA Randomized Clinical Trial.

65 : PERson-centredness in Hypertension management using Information Technology: a randomized controlled trial in primary care.

66 : Telemonitoring and self-management in the control of hypertension (TASMINH2): a randomised controlled trial.

67 : Self-blood pressure monitoring in an urban, ethnically diverse population: a randomized clinical trial utilizing the electronic health record.

68 : Nurse-led disease management for hypertension control in a diverse urban community: a randomized trial.

69 : Hypertension Canada's 2017 Guidelines for Diagnosis, Risk Assessment, Prevention, and Treatment of Hypertension in Adults.

70 : Morning blood pressure surge: the reliability of different definitions.

71 : New Insight of Morning Blood Pressure Surge Into the Triggers of Cardiovascular Disease-Synergistic Resonance of Blood Pressure Variability.

72 : Morning surge in blood pressure as a predictor of silent and clinical cerebrovascular disease in elderly hypertensives: a prospective study.

73 : Triggers, acute risk factors and vulnerable plaques: the lexicon of a new frontier.

74 : Prognostic value of the morning blood pressure surge in 5645 subjects from 8 populations.

75 : Blood pressure load does not add to ambulatory blood pressure level for cardiovascular risk stratification.

76 : Systolic Blood Pressure Time in Target Range and Cardiovascular Outcomes in Patients With Hypertension.

77 : Systolic Blood Pressure Time in Target Range and Major Adverse Kidney and Cardiovascular Events.

78 : Aortic pulse wave velocity improves cardiovascular event prediction: an individual participant meta-analysis of prospective observational data from 17,635 subjects.

79 : Ambulatory arterial stiffness index derived from 24-hour ambulatory blood pressure monitoring.

80 : Ambulatory arterial stiffness index as a predictor of cardiovascular mortality in the Dublin Outcome Study.

81 : Ambulatory arterial stiffness index and 24-hour ambulatory pulse pressure as predictors of mortality in Ohasama, Japan.

82 : Nocturnal blood pressure fall on ambulatory monitoring in a large international database. The "Ad Hoc' Working Group.

83 : Circadian rhythm of natriuresis is disturbed in nondipper type of essential hypertension.

84 : Normalization of circadian blood pressure profiles after renal transplantation.

85 : Blunted nocturnal fall in blood pressure in hypertensive women with future cardiovascular morbid events.

86 : Association of blunted nocturnal blood pressure dip with intracerebral hemorrhage.

87 : Prognostic significance for stroke of a morning pressor surge and a nocturnal blood pressure decline: the Ohasama study.

88 : Diurnal blood pressure pattern and risk of congestive heart failure.

89 : Increase in nocturnal blood pressure and progression to microalbuminuria in type 1 diabetes.

90 : Diurnal blood pressure variation and albuminuria in normotensive patients with insulin-dependent diabetes mellitus.

91 : Association of impaired diurnal blood pressure variation with a subsequent decline in glomerular filtration rate.

92 : Management of Hypertension in the Digital Era: Small Wearable Monitoring Devices for Remote Blood Pressure Monitoring.

93 : Validation of two watch-type wearable blood pressure monitors according to the ANSI/AAMI/ISO81060-2:2013 guidelines: Omron HEM-6410T-ZM and HEM-6410T-ZL.

94 : Validation of the Microlife WatchBP Home device for self home blood pressure measurement according to the International Protocol.

95 : The evolution of substantial equivalence in FDA's premarket review of medical devices.

96 : Lancet Commission on Hypertension group position statement on the global improvement of accuracy standards for devices that measure blood pressure.

97 : Availability, Cost, and Consumer Ratings of Popular Nonvalidated vs Validated Blood Pressure-Measuring Devices Sold Online in 10 Countries.

98 : Electronic communications and home blood pressure monitoring (e-BP) study: design, delivery, and evaluation framework.

99 : Usability and Acceptability of a Home Blood Pressure Telemonitoring Device Among Community-Dwelling Senior Citizens With Hypertension: Qualitative Study.

100 : Incorporating self-blood pressure measurements at home in the guideline from the Ohasama study.

101 : Home blood-pressure monitoring: US and European consensus.

102 : Diagnosis of hypertension using home or ambulatory blood pressure monitoring: comparison with the conventional strategy based on repeated clinic blood pressure measurements.

103 : European Society of Hypertension guidelines for blood pressure monitoring at home: a summary report of the Second International Consensus Conference on Home Blood Pressure Monitoring.

104 : European Society of Hypertension practice guidelines for home blood pressure monitoring.

105 : Optimal schedule for home blood pressure measurement based on prognostic data: the Finn-Home Study.

106 : Home blood pressure monitoring in the 21st century.

107 : The influence of daily activity on ambulatory blood pressure.

108 : Measurement of Blood Pressure in Humans: A Scientific Statement From the American Heart Association.

109 : History and Justification of a National Blood Pressure Measurement Validated Device Listing.

110 : Guidelines for the use of self-blood pressure monitoring: a summary report of the First International Consensus Conference. Groupe Evaluation&Measure of the French Society of Hypertension.

111 : ABC of hypertension: Blood pressure measurement. Part II-conventional sphygmomanometry: technique of auscultatory blood pressure measurement.

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