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JH-D-21-00169

Consensus Document

2021European Society of Hypertension practice

guidelines for office and out-of-office blood
pressure measurement
George S. Stergiou a, Paolo Palatini b, Gianfranco Parati c,d, Eoin O’Brien e, Andrzej Januszewicz f,
Empar Lurbe g,h, Alexandre Persu i, Giuseppe Mancia j, Reinhold Kreutz k, on behalf of the European
Society of Hypertension Council and the European Society of Hypertension Working Group on
Blood Pressure Monitoring and Cardiovascular Variability
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monitoring (ABPM), or home BP monitoring (HBPM),

Collaborators: Lucas Aparicio (Argentina), Kei Asayama along with measurements in other settings (pharmacies,
(Japan), Roland Asmar (France), Grzegorz Bilo (Italy), Jean- public spaces). With lower BP targets currently recom-
Marc Boivin (France), Alejandro de la Sierra (Spain), Eamon mended by hypertension guidelines, the accuracy in BP
Dolan (Ireland), Jan Filipovsky (Czech Republic), Geoffrey measurement has become even more important to achieve
Head (Australia), Yutaka Imai (Japan), Kazuomi Kario optimal control and prevent adverse effects of over-treat-
(Japan), Anastasios Kollias (Greece), Efstathios Manios ment. Current guidelines recommend widespread use of
(Greece), Klaus Matthias (Germany), Richard McManus ABPM and HBPM for detecting white-coat hypertension
(UK), Anastasia Mihailidou (Australia), Paul Muntner (USA), (WCH), masked hypertension (MH), resistant hypertension
Martin Myers (Canada), Teemu Niiranen (Finland), Angeliki and other clinically important conditions. However, to date
Ntineri (Greece), Takayoshi Ohkubo (Japan), Aleksander the classification of BP, as well as the threshold and
Prejbisz (Poland), Athanase Protogerou (Greece), Menno target for treatment, are still based on conventional OBP
Pruijm (Switzerland), Aletta Schutte (Australia), Daichi measurements.
Shimbo (USA), Joseph Schwartz (USA), James Sharman This European Society of Hypertension (ESH) statement
(Australia), Andrew Shennan (UK), Jan Staessen (Belgium), aims to summarise essential recommendations for BP meas-
Markus van der Giet (Germany), Liffert Vogt (The urements for clinical practice in and out of the office.
Netherlands), Jiguang Wang (China), Paul Whelton (USA), Members of the ESH Working Group on Blood Pressure
William White (USA). Monitoring and Cardiovascular Variability prepared the first
Keywords: ambulatory, clinic, diagnosis, home, draft, which was reviewed by ESH Council members to
hypertension, kiosk, monitoring, office, pharmacy, self- formulate a draft statement. This document was then
measurement reviewed by external international experts, including gen-
eral practitioners, and a final statement was developed.
Abbreviations: ABPM, ambulatory blood pressure
monitoring; BP, blood pressure; CVD, cardiovascular
disease; HBPM, home blood pressure monitoring; MH; Journal of Hypertension 2021, 39:000–000
a
masked hypertension; OBP, office blood pressure; WCH, Hypertension Center STRIDE-7, National and Kapodistrian University of Athens,
School of Medicine, Third Department of Medicine, Sotiria Hospital, Athens, Greece,
white-coat hypertension b
Department of Medicine, University of Padova, Padova, Italy, cDepartment of
Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, IRCCS, Istituto
Auxologico Italiano, dDepartment of Medicine and Surgery, University of Milano-
Bicocca, Milan, Italy, eThe Conway Institute, University College Dublin, Dublin, Ireland,
SECTION 1: INTRODUCTION [1^4] f
Department of Hypertension, National Institute of Cardiology, Warsaw, Poland,
g
Pediatric Department, Consorcio Hospital General, University of Valencia, Valencia,

H
igh blood pressure (BP) is the leading modifiable h
CIBER Fisiopatologı́a Obesidad y Nutrición (CB06/03), Instituto de Salud Carlos III,
risk factor for morbidity and mortality worldwide. Madrid, Spain, iDivision of Cardiology, Cliniques Universitaires Saint-Luc and Pole of
Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université
The basis for diagnosing and managing hyperten- Catholique de Louvain, Brussels, Belgium, jPoliclinico di Monza, University of Milano-
sion is the measurement of BP, which is routinely used to Bicocca, Milan, Italy and kCharité - Universitätsmedizin Berlin, corporate member of
initiate or rule out costly investigations and long-term Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health,
Department of Clinical Pharmacology and Toxicology, Charité University Medicine,
therapeutic interventions. Inadequate measurement meth- Berlin, Germany
odology or use of inaccurate BP measuring devices can lead Correspondence to Professor George S. Stergiou, MD, FRCP, Hypertension Center
to overdiagnosis and unnecessary treatment, or underdiag- STRIDE-7, National and Kapodistrian University of Athens, School of Medicine, Third
nosis and exposure to preventable cardiovascular disease Department of Medicine, Sotiria Hospital, 152 Mesogion Avenue, Athens 11527,
Greece. Tel: +30 2107763117, fax: +30 2107719981; e-mail: [email protected]
(CVD). Received 13 February 2021 Accepted 14 February 2021
Office BP (OBP) is measured using different methods J Hypertens 38:000–000 Copyright ß 2021 Wolters Kluwer Health, Inc. All rights
(auscultatory, automated, unattended with patient alone in reserved.
the office), and out-of-office using ambulatory BP DOI:10.1097/HJH.0000000000002843

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SECTION 2: ASPECTS COMMON TO ALL 2.2. Cuffs for BP measuring devices [3,4,7]
BP MEASUREMENT TECHNIQUES
Cuff characteristics
2.1. Accuracy of BP measuring devices [5,6]  Electronic devices have their own cuffs, which are not
interchangeable with those of other monitors even of
Background the same brand.
 Reliable devices are essential for proper BP measure-  The selection of an appropriate cuff size is crucial for
ment. If inaccurate devices are used, measurements accurate BP measurement and depends on the arm
may be misleading. Automated electronic devices are circumference of each individual. A smaller than
now used almost exclusively for HBPM and ABPM and required cuff overestimates BP and a larger under-
increasingly for OBP measurement. estimates BP. A single cuff cannot fit the range of arm
 For the clinical validation of electronic BP monitors, sizes of all adults.
several protocols developed by scientific organiza-  Manual auscultatory devices: use a cuff with inflatable
tions have been used in the past. In 2018, a Universal bladder length which is 75–100% of the individual’s
Standard was developed by the American Association middle upper-arm circumference and width 37–50%
for the Advancement of Medical Instrumentation, the of the arm circumference.
ESH and the International Organization for Standardi-  Automated electronic devices: select cuff size accord-
zation (AAMI/ESH/ISO) for global use. ing to the device’s instructions. Some devices have
 Only BP measuring devices, which have been suc- ‘wide-range’ cuffs, which fit the arm of most adults,
cessfully validated by using an established protocol but require proper validation.
should be used (Table 1). Unfortunately, most of the  People with large arms (mid-arm circumference
devices available on the market have not been sub- >42 cm): prefer a conic-shape cuff as rectangular cuff
jected to independent evaluation using an established may overestimate BP. When BP cannot be measured
protocol. using an upper-arm cuff device, a validated electronic
 An electronic BP monitor, which has been success- wrist-cuff device may be used.
fully validated in adults may not be accurate in other
special populations, including children, pregnant Procedure
women, individuals with very large arms (circumfer-  Place the centre of the bladder over the brachial artery
ence >42 cm) and patients with arrhythmias (particu- pulsation in the antecubital fossa.
larly atrial fibrillation). In these populations, separate  The lower end of the cuff should be 2–3 cm above the
validation is necessary. antecubital fossa.
 The cuff should exert comparable tightness at the top
Selecting reliable devices and bottom edges. One finger should easily fit under
 Updated lists of validated devices can be downloaded the cuff at its top and bottom.
from several websites; those associated with scientific
organisations are listed in Table 1.
2.3. White-coat hypertension and masked
 At the present time, of the over 4000 devices available
on the market worldwide, fewer than 10% have hypertension [1,2,8–10]
passed established validation protocols.  When BP is evaluated using both office and out-of-
 BP measuring devices with additional features (e.g. office measurements (HBPM or ABPM), patients are
measurement of pulse wave velocity or central BP, classified into four categories (Fig. 1): normotension
atrial fibrillation detection, actigraphy), need to be (OBP and out-of-office BP not elevated); sustained
validated for these functions, with evidence being hypertension (elevated OBP and out-of-office BP);
provided to support their use in clinical practice. WCH (elevated OBP but not out-of-office BP); MH
(elevated out-of-office but not OBP).

TABLE 1. Organisations with scientific association providing online lists of validated BP monitors
Organisation Device lists Scientific associationa Website
(language)
STRIDE BP International European Society of Hypertension – International Society www.stridebp.org
(English, Chinese, Spanish) of Hypertension – World Hypertension League
BIHS UK/Ireland British and Irish Hypertension Society www.bihsoc.org/bp-monitors
(English)
VDL USA American Medical Association www.validatebp.org
(English)
Hypertension Canada Canada Hypertension Canada www.hypertension.ca/bpdevices
(English)
Deutsche Hochdruckliga Germany German High Pressure League www.hochdruckliga.de/betroffene/
(German) blutdruckmessgeraete-mit-pruefsiegel
JSH Japan Japanese Society of Hypertension www.jpnsh.jp/com_ac_wg1.html
(Japanese)
a
Two websites are not associated with a scientific organisation (www.dableducational.org, www.medaval.ie).

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ESH blood pressure measurement guidelines

TABLE 2. Diagnosis and management of white-coat and masked

hypertension phenomena (in untreated or treated
individuals)
White-coat Masked
hypertensiona hypertensiona
Diagnosis Elevated OBP, but not 24 h Elevated 24 h ambulatory
ambulatory and/or home BPb and/or home BP, but
not OBPb
Management Lifestyle changes and annual Lifestyle changes and
follow-up. consider drug
Consider drug treatment in treatment
patients with high or
very-high CVD risk
a
These diagnoses require confirmation with repeat OBP and out-of-office BP
measurements.
b
‘Elevated’ based on OBP threshold 140/90 mmHg, 24 h ambulatory BP 130/
80 mmHg, home BP 135/85 mmHg.

present, BP variability remains a research topic without

FIGURE 1 Classification of patients attending BP clinics according to their office
and out-of-office BP measurements. application in daily practice.

 WCH and MH are common in both untreated individ- SECTION 3: OFFICE BP MEASUREMENT
uals and those with treated hypertension. Even with
carefully taken OBP measurements, about 15–25% of [1^4,13]
individuals attending hypertension clinics have WCH (Poster with key recommendations in Supplement), http://
and 10–20% MH. links.lww.com/HJH/B621
 The diagnoses of WCH and MH require confirmation
with a second set of out-of-office BP measurements, Background (Table 3)
as their reproducibility is limited (Table 2).  OBP remains the most used and often the only
 When OBP is close to the 140/90 mmHg threshold, the method used for hypertension detection and manage-
probability of misdiagnosis is increased. Thus, in ment. It is the most well studied method with the
individuals with OBP levels within the grade 1 hyper- strongest evidence, on which the BP classification of
tension range (140–159/90–99 mmHg), the probabil- hypertension and the recommended thresholds for
ity of WCH is increased compared with those with treatment initiation and treatment targets are based.
higher OBP. Likewise, the probability of MH is  When used alone, OBP may be misleading in diag-
increased in individuals with OBP within the high- nosing hypertension in several untreated and
normal BP range (130–139/85–89 mmHg) than those treated individuals.
with lower levels. Thus, when OBP is 130–159/  Whenever possible, diagnostic and treatment deci-
85–99 mmHg, out-of-office BP evaluation is strongly sions should be made with confirmatory out-of-office
recommended. BP measurement (HBPM or ABPM). If this is not
 In some special cases, such as pregnant women, possible, repeated OBP measurements should be
children and chronic kidney disease patients, out- taken at additional visits.
of-office BP monitoring is particularly important for
both diagnosis and follow-up. Special recommenda-
tions must be followed in these cases, which are not OBP device requirements
discussed in this statement.  Use an automated electronic (oscillometric), upper-
arm cuff device, which is validated according to an
established protocol (Table 1). A device that takes
2.4. BP variability [11,12] triplicate readings automatically is preferred.
The adverse cardiovascular consequences of hypertension,  If validated automated devices are not available, then
including events and mortality, largely depend on use a manual electronic auscultatory device (hybrid)
increased average BP values. Thus, decision-making in
hypertension is based on average values of several BP
TABLE 3. Advantages and limitations of OBP measurements
readings obtained in and out of the office. However, BP
is characterized by short-term (24 h ABPM), mid-term (day- Advantages Limitations
to-day HBPM) and long-term (visit-to-visit OBP) fluctua-  Readily available in  Often poorly standardised leading to
tions, which are the result of complex interactions between most healthcare overestimation of BP.
intrinsic cardiovascular regulatory mechanisms and extrin- settings.  Inadequate reproducibility, with single-visit
 Strong data linking OBP OBP having low diagnostic precision in an
sic environmental and behavioural factors. Observational with CVD. Used in individual.
studies and non-randomized secondary analyses of ran- most observational and  Subject to WCH (reduced but still present
domised controlled trials suggest that adverse outcomes are interventional outcome with standardised measurements taken in
trials in hypertension repeated visits).
also independently associated with increased BP variability,  Will not detect MH.
yet its additional predictive value is unclear. Thus, at

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with LCD or LED mercury column-like display, or

Box 1 OBP MEASUREMENT PROCEDURE (Fig. 2)
digital countdown (mercury sphygmomanometers
are banned in most countries). Good quality shock- Conditions
resistant aneroid devices might be used, but require  Quiet room with comfortable temperature.
calibration at least once per year. Deflate at 2-  No smoking, caffeine, food or exercise for 30 min before measurement.
 Remain seated and relaxed for 3–5 min.
3 mmHg/s rate and use Korotkoff sound 1 for SBP  No talking by patient or staff during or between measurements.
and sound 5 for DBP in adults and children (use
Posture
Korotkoff sound 4 if sounds are present at full defla-
tion or at <40 mmHg point.  Sitting with back supported by chair.
 Legs uncrossed, feet flat on floor.
 Electronic devices for children and pregnant women  Bare arm resting on table; mid-arm at heart level.
must be validated specifically in these populations.
Measurements
 Select cuff size to fit the individual’s arm circumference
according to the device’s instructions (section 2.2).  Take 3 OBP readings (2 if they are normal) with 1 min interval
between readings.
 Ensure good working order with annual maintenance  Use the average of the last 2 readings.
of device.

FIGURE 2 Poster of OBP measurement methodology.

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TABLE 4. Interpretation of average OBP (at least 2-3 visits with 2-3 measurements per visit)
Normal-optimal BP High-normal BP Hypertension Grade 1 Hypertension Grade 2 and 3
(<130/85 mmHg) (130–139/85–89 mmHg) (140–159/90–99 mmHg) (160/100 mmHg)
Diagnosis Normotension Consider MH Consider WCH Sustained hypertension
highly probable highly probable
Action Remeasure after 1 year Perform HBPM and/or ABPM. Confirm within a few days or weeksa.
(6 months in those with If not available confirm with repeated office visits Ideally use HBPM or ABPM
other risk factors)
a
Treat immediately if OBP is very high (e.g. 180/110 mmHg) and there is evidence of target organ damage or CVD.

 Orthostatic hypotension is present when there is a

Diagnosis of hypertension based on OBP reduction in SBP of 20 mmHg within 3 min standing.
 At least 2-3 office visits at 1–4-week intervals (depend-
ing on the BP level and CVD risk) are usually required
for the evaluation of OBP. Unattended automated OBP measurement
 A diagnosis should not be made on a single office visit,  OBP measured automatically (3 or more readings)
unless OBP is very high (e.g. 180/110 mmHg) and without any medical staff in the examination room
there is evidence of target organ damage or CVD. (patient alone, i.e. ‘unattended’) provides a standard-
 In most cases, the diagnosis of hypertension should be ized OBP evaluation by ensuring quiet environment,
confirmed by HBPM or ABPM. Particularly in automated device, multiple BP readings, no talking.
untreated or treated individuals with OBP levels  Unattended automated OBP reduces but does not
within the grade 1 hypertension range (140–159/ eliminate the WCH phenomenon, and the MH phe-
90–99 mmHg), HBPM or ABPM is strongly recom- nomenon is also present as with usual OBP measure-
mended because of increased probability of WCH; ments. Thus, again out-of-office BP evaluation (HBPM
likewise, in those with high-normal OBP levels (130– or ABPM) is often needed for accurate diagnosis.
139/85–89 mmHg), as they have increased probability  Unattended OBP measurements typically give lower
of MH (Table 4). values than usual OBP measurements, which appear
 If it is not possible to perform HBPM or ABPM, then to be similar to daytime ABPM. Thus, the threshold for
confirm diagnosis by taking more OBP measurements diagnosing hypertension using unattended OBP is
in repeated visits. lower than with usual OBP measurements, yet not
clearly defined and with insufficient outcome data.
Interarm BP difference  Unattended OBP measurement may not be feasible in
 At the initial visit, measure BP in both arms (some several settings in clinical practice.
professional electronic devices can measure BP simul-
taneously). SECTION 4: 24 H AMBULATORY BP
 Interarm SBP difference >10 mmHg must be con-
firmed with repeated measurements. In this case,
MONITORING (ABPM) [1^4,14]
the arm with the higher BP should be used. (Poster with key recommendations in Supplement), http://
 Consistent interarm SBP difference >20 mmHg links.lww.com/HJH/B621
requires investigation for arterial disease.
Background (Tables 5-6)
Standing BP  Provides multiple BP readings away from the office, in
 Further to sitting BP, standing BP should be measured the usual environment of each individual.
in patients with treated hypertension, when there are  Provides BP readings during routine daytime activities
symptoms suggesting postural hypotension, particu- and night-time sleep.
larly in the elderly and in patients with neurodegen-  Identifies WCH and MH.
erative disease (e.g. Parkinson’s, dementia) or  Provides an evaluation of the 24 h BP control with
diabetes. antihypertensive drug treatment.
 Measure standing BP after 1 min and again after 3 min  Recommended in several guidelines as the best
standing. method for diagnosing hypertension.

TABLE 5. Advantages and limitations of ABPM

Advantages Limitations
 Objective results over 24 h.  Not widely available in primary care settings.
 Detects WCH and MH.  Rather expensive and time-consuming for healthcare provider.
 Confirms uncontrolled and resistant hypertension.  May cause discomfort particularly during sleep.
 Assesses BP during usual daily activities.  Reluctance of some patients to use, especially when repeated.
 Detects nocturnal hypertension and non-dippers.  Imperfect reproducibility for diagnosis within 24 h (superior to OBP).
 Detects excessive BP lowering by drug treatment.  Asleep BP often not calculated using the individuals’ sleeping times.

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TABLE 6. Clinical indications for ABPM

Initial diagnosis Treated hypertension When to repeata
 To diagnose hypertension.  To identify WCH and MH. To ensure adequate BP control, particularly in patients
 To detect WCH and MH.  To confirm the diagnosis of uncontrolled and with increased CVD risk. Depends on availability,
 To identify nocturnal hypertension resistant hypertension. individual’s risk and preferences.
and non-dippers.  To ensure 24 h BP control (particularly in high-risk  Uncontrolled hypertension: might perform every 2–3
 To assess BP changes due to patients, pregnancy). months until a normal 24 h profile.
autonomic failure.  To confirm symptomatic hypotension due to  Controlled hypertension: might perform annually.
excessive treatment.
 To assess nocturnal hypertension and non-dipping.
 Disagreement in diagnosis between OBP and HBPM.
a
Repeat on like days (preferably routine workdays)

TABLE 7. ABPM implementation

Basic requirements Fitting the monitor Removing the monitor
 Perform ABPM preferably on  Frequency of measurement 20–30 min during day  Remove the monitor after 24 h.
a routine working day. and night.  Determine day and night-time periods only according
 10–15 min needed to initialise  Cuff size according to the individual’s arm to patient’s report.
and fit the device. circumference.  Repeat ABPM if <20 valid awake or <7 asleep BP
 Fit cuff on bare non-dominant arm. Centre bladder readings.
over the brachial artery.  Interpretation of ABPM results in Box 3.
 Take a test measurement.
 Provide instructions to patient (Box 2).

ABPM device requirements and use

 Electronic (oscillometric) upper-arm cuff device vali-
dated according to an established protocol (Table 1).
 Select cuff size to fit the individual’s arm circumference
according to the device’s instructions (section 2.2).
 Devices for children or pregnant women must be
validated specifically in these populations.
 Ensure good working order with annual maintenance
of device.
 Recommendations on ABPM implementation in Table 7.

Box 2 ABPM INSTRUCTIONS TO PATIENT

 Explain the device function and procedure.
 Advise to follow usual daily activities.
 Advise to remain still with arm relaxed at each measurement.
 Advise not to drive. If this is necessary, to stop if possible or ignore
measurement.
 Advise to avoid taking a shower or bath during ABPM.
 Provide a form to record sleeping times, drug intake, any symptoms or
problems during the recording.
 Mark the brachial artery so that if the cuff becomes loose the patient can
refit it.
 Explain how to switch off the monitor in case of malfunctioning.

Box 3 ABPM INTERPRETATION (Fig. 3)

ABPM thresholds of hypertension

24 h average: 130/80 mmHg Primary criterion

Daytime (awake) average: 135/85 mmHg Daytime hypertensiona
Night-time (asleep) average: 120/70 mmHg Night-time hypertensionb

Asleep BP dip compared with awake BP (systolic and/or diastolic)

Asleep BP fall 10%: Dippera,b

Asleep BP fall <10%: Non-dippera,b
a
Apply only if day/night BP is calculated using the individuals’ sleeping times.
b
The diagnosis must be confirmed with repeat ABPM.
FIGURE 3 24 h ABPM recordings: (a) normal; (b) hypertensive dipper; (c) hyperten-
sive non-dipper.

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SECTION 5: HOME BP MONITORING Box 4 HBPM PROCEDURE (Fig. 2)

(HBPM) [1^4,15,16] Conditions

(Poster with key recommendations in Supplement), http://  Quiet room with comfortable temperature.
links.lww.com/HJH/B621.  No smoking, caffeine, food or exercise for 30 min before measurement.
 Remain seated and relaxed for 3–5 min.
 No talking during or between measurements.
Background (Tables 8-9)
 Widely used in many countries. Posture
 Provides multiple BP readings away from the office, in
the usual environment of each individual.  Sitting with back supported by chair.
 Legs uncrossed, feet flat on floor.
 Identifies WCH and MH.  Bare arm resting on table; mid-arm at heart level
 Recommended as the best method for long-term
follow-up of treated hypertension. Cuff

 Select cuff size that fits the arm circumference according to the
device’s instructions.
TABLE 8. Advantages and limitations of HBPM  Wrap the cuff around bare arm according to the device’s instructions (usually
left arm).
Advantages Limitations
 Widely available at relatively low  Requires medical supervision.
cost.  Inaccurate devices and
 Preferred method for long-term inappropriate cuff size often
monitoring of treated hypertensive used.
Box 5 PATIENT TRAINING
patients.  Monitoring may be too
 Acceptable to patients for long- frequent, in the presence of  Use a reliable device (lists in Table 1).
term use. symptoms, and under  Conditions and posture for measurement.
 Detects WCH and MH. inappropriate position.  Measurement schedule before office visit.
 Confirms uncontrolled and resistant  May induce anxiety to some  Measurement schedule between visits.
hypertension. patients.  Interpretation of measurements. Inform patients about usual BP variability.
 Detects excessive BP lowering from  Risk of unsupervised treatment  Action if BP is too high or too low.
drug treatment. changes by patients.
 Improves adherence with treatment  Possible selective reporting of
and thereby hypertension control BP readings by patients (usually
rates. omitting higher BP values).
 Can be used with telemonitoring  Doctors may estimate instead
and connection to electronic of calculating average home
patient files. BP.
Box 6 HBPM SCHEDULE (Fig. 4)
 Can reduce healthcare costs.  No information on BP at work
or during sleep (novel HBPM For diagnosis and before each office visit
devices under testing measure
BP during sleep).
 Measurements for 7 days (at least 3 days).
 Morning and evening measurements.
 Before drug intake if treated and before meals.
 Two measurements on each occasion with 1 min between them.
TABLE 9. Clinical indications for HBPM
Long-term follow-up of treated hypertension
Initial diagnosis Treated hypertension
 Make duplicate measurements once or twice per week (most frequent), or
 To confirm diagnosis  Use in all treated hypertensive patients, per month (minimum requirement).
of hypertension. unless incapable or unwilling to perform
 To detect WCH and MH. in good quality, or anxious with self-
monitoring.
 To identify WCH and MH.
 For titration of BP-lowering medication.
 For monitoring long-term BP control. upper-arm devices and issues with incorrect use.
 To ensure strict BP control where
mandatory (high-risk patients,
Validated wrist devices might be used in people with
pregnancy). very large arms when upper-arm cuff measurement is
 To improve patients’ long-term not possible or reliable.
compliance with treatment.
 Auscultatory devices are generally not recommended
for HBPM. Also, finger-cuff devices, wristband wear-
ables and other cuffless devices should not be used
HBPM device requirements and use for HBPM.
 Electronic (oscillometric) upper-arm cuff device vali-  Devices for children or pregnant women must be
dated according to an established protocol (Table 1). validated specifically in these populations.
 Prefer devices with automated storage and averaging  Select cuff size to fit the individual’s arm circumfer-
of multiple readings, or with mobile phone, PC or ence according to the device’s instructions (section
internet link connectivity enabling data transfer. 2.2).
 Wrist devices are generally not recommended  Recommendations on HBPM implementation and
because of their inferior accuracy compared with patient training in Boxes 4-7.

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FIGURE 4 Form for reporting 7-day HBPM.

Box 7 HBPM INTERPRETATION Box 8 CLINICAL IMPLEMENTATION OF BP MEASUREMENT IN PHARMACIES

 Prefer automated report and averaging of readings stored in device memory
Device Validated electronic upper-arm cuff device (Table
(or mobile). Otherwise, review readings reported in a logbook (Fig. 4).
1). Prefer a device that takes triplicate readings
 Assess HBPM of 7 days (at least 3 days with at least 12 readings).
automatically. Ensure good working order and
 Discard the first day and calculate the average of all the other readings.
annual maintenance. Cuff size to fit the
Individual readings have little diagnostic accuracy.
individual’s arm circumference according to the
 Average home BP 135/85 mmHg indicates hypertension.
device’s instructions (section 2.2).
Conditions As for OBP (Box 1, Fig. 2). Quiet area with
comfortable temperature and no talking during
or between measurements.
SECTION 6: BP MEASUREMENT IN Interpretation Average of 2-3 readings 135/85 mmHg suggests
PHARMACIES [17] uncontrolled hypertension. Diagnosis and
treatment decisions should not be based solely
on such measurements.
Background (Table 10)
 Widely used in several countries.
 Its validity and applicability for management have not
been adequately investigated.
 24 h ABPM may be performed in pharmacies.

TABLE 10. Advantages and limitations of BP measurement in

pharmacies
Advantages Limitations SECTION 7: BP MEASUREMENT IN
 Easily accessible and convenient for patients  Possible use of non-validated PUBLIC SPACES (KIOSKS) [4]
as no appointment is generally required. devices, inappropriate cuff
 Useful for screening untreated individuals size and conditions (posture, Background (Table 11)
and for following treated hypertensive rest, talking, etc.).
patients.  Weak evidence on BP
 Kiosks are stations in public spaces where BP is
 Could save both general practitioner time threshold for diagnosis and measured with an automatic device triggered by the
and healthcare costs. interpretation. user.
 May not induce a pronounced white-coat  Possible impact of inadequate
effect. measurement and interpreta-  Very little studied, but useful for screening in the
 Possible alternative to ABPM or HBPM if tion on increased referrals to general population.
they are not feasible. general practitioners.

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ESH blood pressure measurement guidelines

TABLE 11. Advantages and limitations of BP measurement in and maintenance costs. Digital health is a promising
public spaces
approach and has the potential to significantly improve
Advantages Limitations management of patients with hypertension. However, there
 Useful for screening in the  Possible use of non-validated devices,
is high heterogeneity of proposed interventions, and more
general population. inappropriate cuff size and conditions adequately powered randomized controlled trials are
 Accessible to the public and (posture, rest, talking, etc.). needed to clarify feasibility, efficacy and cost-effectiveness
convenient to patients as no  Single standard size or wide-range cuff
appointment is required. generally available, which may not fit
of these new strategies, before they can be recommended
 Could save both general too small or large arms. for clinical practice.
practitioner time and  Unknown hypertension thresholds.
healthcare costs.  Frequent lack of follow-up by medical
professionals. SECTION 10: COMBINED USE OF BP
MEASUREMENT METHODS
(Table 12) [1^4]
Box 9 CLINICAL IMPLEMENTATION OF BP MEASUREMENT IN PUBLIC
OBP
SPACES  OBP is the most used and often the only method
available for hypertension management, on which the
Device Validated electronic upper-arm cuff device BP classification and thresholds for treatment initia-
(Table 1). Preferably the device should have a tion and targets are based.
wide-range cuff to fit arm size of most adults
and should take 2-3 readings automatically. It  Out-of-office BP evaluation (ABPM or HBPM) is nec-
should display instructions to user for posture essary for the accurate evaluation of many untreated
and procedure.
Conditions As for OBP (Box 1, Fig. 2), plus follow specific
and treated individuals. If this is not possible, repeated
device’s instructions. Quiet area with OBP measurements should be taken in additional
comfortable temperature and no talking during visits.
or between measurements.
Interpretation Threshold for hypertension unknown and probably
variable according to conditions. Use only for
screening. Diagnosis or treatment decisions ABPM–HBPM
should not be based on such measurements.  Both methods are appropriate for hypertension diag-
nosis, treatment titration and long-term follow-up.
ABPM may be more suitable for the initial evaluation
and HBPM for long-term follow-up.
 ABPM is better studied and gives results for awake and
asleep BP in an unbiased way within 24 h. However, it
SECTION 8: CUFFLESS WEARABLE BP is relatively expensive, not widely available, inade-
MONITORS [18] quately reimbursed in many countries, and not
A large number of cuffless wearable (wrist-band) devices acceptable for repeated use by some patients.
are available on the market claiming that they accurately  HBPM is widely available at relatively low cost in most
measure BP. These devices have a sensor, which evaluates countries, it is well accepted by most patients for long-
the pulsation of arterioles and estimate BP based on pulse term use and improves treatment adherence. How-
wave velocity, or other technologies. Cuffless wearable ever, often it is not standardised, non-validated devi-
devices have great potential as they can obtain multiple ces are often used, and appropriate patient education
or even continuous BP measurements for days or weeks and counselling are necessary.
without the disturbance of cuff-induced limb compression.  In general, any two of the three methods (office,
The assessment of the accuracy of cuffless devices requires home, ambulatory), which agree are necessary for
the use of a validation protocol, which is specific for these reliable diagnosis. In most patients, BP should be
devices and includes procedures additional to those used evaluated in the office and with ABPM or HBPM.
for conventional cuff-devices. At present, the accuracy and When office and out-of-office measurements agree
usefulness of cuffless devices are uncertain. Therefore, they on the hypertension classification (Fig. 1), a diagnosis
should not be used for diagnostic or treatment decisions. can be safely made. When they disagree (WCH, MH)
then confirmation with repeated office and out-of-
office BP measurements is necessary and decisions
SECTION 9: MOBILE TECHNOLOGIES^ should be based on ABPM or HBPM. Ideally, both
APPS [19] ABPM and HBPM should be used, as they occasionally
provide different and complementary information.
Recently, impressive expansion of mobile devices has led to
the development of mobile health (mHealth) technologies,
identified by the WHO as a potential promoter of better BP measurement in pharmacies and public
health conditions even in low-income countries, through spaces
strategies based on mobile apps. However, despite good  There is inadequate evidence regarding diagnostic
results in clinical studies, BP telemonitoring based on thresholds or clinical utility for hypertension diagnosis
services by professional providers is not regularly imple- and management. Therefore, they are useful for
mented in daily practice, mainly because of high installation screening and not for decision-making.

Journal of Hypertension www.jhypertension.com 9

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Stergiou et al.

TABLE 12. Clinical utility of office and out-of-office BP measurement methods

Clinical use Office Home 24 h ambulatory Pharmacy Public space
Screening þþþ þ – þþ þ
Initial diagnosis þ þþ þþþ – –
Treatment titration þ þþ þþ – –
Follow-up þþ þþþ þ þ –
Main indication Screening of untreated Long-term follow-up Initial diagnosis Screening of untreated Opportunistic
individuals. Follow-up of treated patients (preferred method) individuals. Follow-up screening
of treated patients (preferred method) of treated patients
Hypertension (mmHg) 140/90 135/85 130/80 135/85 (?) ?

8. Mancia G, Facchetti R, Bombelli M, Grassi G, Sega R. Long-term risk of

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