Summary
The appropriate use of any test requires the clinician to appreciate that test’s limitations. By recognizing the potential confounders of the auscultatory assessment of blood pressure, the clinician minimizes the likelihood of enacting therapeutic decisions based on inaccurate data. When approaching the treatment of a hypertensive patient, several points should be kept in mind.
First, the measurement of persistent and severe hypertension in a patient receiving treatment who describes symptoms of orthostatic hypotension with apparently adequate standing blood pressure or who lacks corroborating retinal, echocardiographic, or electrocardiographic signs of hypertension should raise the concern of pseudohypertension or a white-coat response. Similarly, when one finds a normal or near-normal systolic blood pressure in a patient with a clinical picture consistent with severe hypertension, one should make a directed effort to look for an unrecognized auscultatory gap.
Second, marked discrepancies in measurements as obtained by different operators or in different settings should raise concern of the white-coat response or methodologic errors by one operator, such as undercuffing, excessive pressure on the head of the stethoscope, rapid deflation of the cuff, or use of different arms. In treating hypertension in even the minimally obese patient, a special point must be made that an adequate size cuff be used for all blood pressure determinations.
Third, when blood pressure is determined with the patient in any but the standardized back-and-arm-sup-ported seated position described above, the clinician should acknowledge the possibility that the position may alter the patient’s classification.
Fourth, the diagnosis and management of hypertension requires multiple measurements of blood pressure. To the extent possible, measurements on different days or at different times should be taken with conditions as identical as possible so that differences seen result from therapeutic interventions and not methodologic differences.
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References
Pirsig R. Zen and the Art of Motorcycle Maintenance. New York: Bantam Books. 1984:94.
U.S. Department of Health and Human Services. National Ambulatory Medical Care Survey: 1989 Summary. Hyattsville, MD: 1992:12–3.
Pickering GW. High Blood Pressure. London: J & A Churchill, 1955:10–6.
Cantwell JD, Nicolai S. Korotkoff. Clin Cardiol. 1989;12:233–5.
Sphygmomanometers: Principles and Precepts. Copiague, NY: W. A. Baum, 1969.
American Heart Association. Recommendations for human blood pressure determination by sphygmomanometry. Dallas: American Heart Association, 1988.
Pickering TG, Blank SG. Blood pressure measurement and ambulatory blood pressure monitoring: evaluation of available equipment. In: Laragh JH, Brenner BM (eds). Hypertension: Pathophysiology. Diagnosis, and Management. New York: Raven Press. 1990: 1429–41.
Nielsen PE. D IV or D V in measurement of arm blood pressure. Acta Med Scand Suppl. 1982;670:75–82.
Short D. The diastolic dilemma. BMJ. 1976;2:685–6.
Uhari M, Nuutinen M, Turtinen J, Pokka T. Pulse sounds and measurement of diastolic blood pressure in children. Lancet. 1991;338:158–61.
Manning DM, Kuchirka C, Kaminski J. Miscuffing: inappropriate blood pressure cuff application. Circulation. 1983;68:763–6.
King GE. Errors in clinical measurement of blood pressure in obesity. Clin Sci. 1967;32:223–37.
Trout KW, Bertrand CA, William MH. Measurement of blood pressure in obese persons. JAMA. 1956;162:970–1.
van Montfrans GA, van der Hoeven GMA, Karemaker JM, Wieling W, Dunning AJ. Accuracy of auscultatory blood pressure measurement with a long cuff. BMJ. 1987;295:354–5.
Maxwell MH, Waks AU, Schroth PC, Karam M, Dornfield LP. Error in blood-pressure measurement due to incorrect cuff size in obese patients. Lancet. 1982;2:33–6.
von Recklinghausen H. Ueber Blutdruckmessung Beim Menschen. Arch Exp Pathol Pharmakol. 1901;46:78–132.
Rastam L, Prineas RJ, Gomez-Marin O. Ratio of cuff width/arm circumference as a determinant of arterial blood pressure measurements in adults. J Intern Med. 1990;227:225–32.
Karvonen MJ, Telivou LJ, Javinen EJK. Sphygmomanometer cuff size and the accuracy of indirect measurement of blood pressure. Am J Cardiol. 1964;13:688–93.
Simpson JA, Jamieson G, Dickhaus DW, Grover RF. Effect of size of cuff bladder on accuracy of measurement of indirect blood pressure. Am Heart J. 1965;70:208–15.
Croft PR, Cruickshank, JK. Blood pressure measurement in adults: large cuffs for all? J Epidemiol Cummunity Health. 1990;44:170–3.
Nielsen PE, Janniche H. The accuracy of auscultatory measurement of arm blood pressure in very obese subjects. Acta Med Scand. 1974;195:403–9.
Burch GE, Shewey L. Sphygmomanometric cuff size and blood pressure recordings. JAMA. 1973;225:1215–8.
Geddes LA, Whistler SJ. The error in indirect blood pressure measurement with the incorrect size of cuff. Am Heart J. 1978;96: 4–8.
King GE. Taking the blood pressure. JAMA. 1969;209:1902–4.
Linfors EW, Feussner, JR, Blessing CL, Starmer F, Neelson FA, McKee PA. Spurious hypertension in the obese: effect of sphygmomanometer cuff size on prevalence of hypertension. Arch Intern Med. 1984;144:1482–5.
Prineas RJ, Jacobs D. Quality of Korotkoff sounds: bell vs diaphragm, cubital fossa vs brachial artery. Prev. Med. 1983;12:715–9.
Mauro AMP. Effects of the bell versus diaphragm on indirect blood pressure measurement. Heart Lung. 1988;17:489–94.
Cushman WC, Cooper KM, Home RA, Meydrech EF. Effect of back support and stethoscope head on seated blood pressure determinations. Am J Hypertens. 1990;3:240–1.
Zachariah PK, Sheps SG, Moore AG. Office blood pressures in supine, sitting, and standing positions: correlation with ambulatory blood pressures. Int J Cardiol. 1990;28:353–60.
Pickering TG. Posture and the measurement of blood pressure [editorial). Int J Cardiol. 1990;29:109–11.
Webster J, Newnham D, Petrie JC, Lovell HG. Influence of arm position on measurement of blood pressure, BMJ. 1984;288:1574–5.
Waal-Manning HJ, Paulin JM. Effects of arm position and support on blood-pressure readings. J Clin Hypertens. 1987;3:624–30.
Parr GD, Poole PH. Effects of sphygmomanometer type and position of the arm on blood pressure measurement. J Hum Hypertens. 1988;2: 153–6.
Mariotti G, Alli C, Avanzini F, et al. Arm position as a source of error in blood pressure measurement. Clin Cardiol. 1987;10:591–3.
Mitchell PL, Parlin RW, Blackburn H. Effect of vertical displacement of the arm on indirect blood-pressure measurement. N Engl J Med. 1964;271:72–4.
Viol GW, Goebel M, Lorenz GH, Ing TS. Seating as a variable in clinical blood pressure measurement. Am Heart J. 1979;98:813–4.
Hashimoto F, Hunt WC, Hardy L. Differences between right and left arm blood pressures in the elderly. West J Med. 1984;141:189–92.
Goldhill DR. Bilateral simultaneous indirect systolic blood pressure measurements. Cardiovasc Res. 1986;20:774–7.
Sapira JD. The vital signs. In: Sapira JD. The Art and Science of Bedside Diagnosis. Baltimore: Urban & Schwarzenberg. 1990:85–104.
Londe S, Klitzner TS. Auscultatory blood pressure measurement—effect of pressure on the head of the stethoscope. West J Med. 1984;141:193–5.
Whelton PK. Personal communication. Welch Center for Prevention, Epidemiology & Clinical Research: John Hopkins Health Institutions, Baltimore, MD, 1993.
Rodbard S, Margolis J. The auscultatory gap in arteriosclerotic heart disease. Circulation. 1957;15:850–4.
Mancia G, Betinieri G, Grassi G, et al. Effects of blood-pressure measurement by the doctor on patient’s blood pressure and heart rate. Lancet. 1983;2:695–8.
Pickering TG, James GD, Boddie C, Harshfield GA, Blank S, Laragh JH. How common is white coat hypertension? JAMA. 1988;259:225–8.
Lerman CE, Brody DS, Hui T, Lazaro C, Smith DG, Blum MJ. The white-coat hypertension response: prevalence and predictors. J Gen Intern Med. 1989;4:226–31.
van Loo JM, Peer PG, Thien TA. Twenty-five minutes between blood pressure readings: the influence on prevalence rate of isolated systolic hypertension. J Hypertens. 1986;4:631–5.
Korner PI, Bauer GE, Doyle AE, et al. Untreated mild hypertension: a report by the management committee of the Australian therapeutics trial in mild hypertension. Lancet. 1982;1:185–91.
White WB. Assessment of patients with office hypertension by 24-hour noninvasive ambulatory blood pressure monitoring. Arch Intern Med. 1986;146:2196–9.
Julius S, Mejia A, Jones K, et al. “White coat” versus “sustained” borderline hypertension in Techumseh, Michigan. Hypertension. 1990;16:617–23.
Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. The fifth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med. 1993;2:154–83.
American College of Physicians. Automated ambulatory blood pressure devices and self-measured blood pressure monitoring devices: their role in the diagnosis and management of hypertension. Ann Intern Med. 1993;118:889–92.
Appel LJ, Stason WB. Ambulatory blood pressure monitoring and blood pressure self-measurement in the diagnosis and management of hypertension. Ann Intern Med. 1993;118:867–82.
Taguchi JT, Suwangool P. “Pipe-stem” brachial arteries: a cause of pseudohypertension [ease report]. JAMA. 1974;228:733.
Littenberg B, Wolfberg C. Pseudohypertension masquerading as malignant hypertension: case report and review of the literature. Am J Med. 1988;84:539–42.
Spence JD, Sibbald WJ, Cape RD. Pseudohypertension in the elderly. Clin Sci Mol Med Suppl. 1978;55:399S-402S.
Finnegan TP, Spence JD, Wong DG, Wells GA. Blood pressure measurement in the elderly: correlation of arterial stiffness with difference between intraarterial and cuff pressures. J Hypertens. 1985;3: 231–5.
Messerli FH, Ventura HO, Amodeo C. Osier’s maneuver and pseudohypertension. N Eng J. Med. 1985;312:1548–51.
Messerli FH. Osier’s maneuver, pseudohypertension, and true hypertension in the elderly. Am J Med. 1986;80:906–10.
Tsapatsaris NP, Napolitana GT, Rothchild J. Osiers maneuver in an outpatient setting. Arch Intern Med. 1991;151:2209–11.
Prochazka AV, Martel R. Osier’s maneuver in outpatient veterans. J Clin Hypertens. 1987;3:554–8.
Hla KM, Stoneking. HT, Samsa GP, Feussner, JR. Observer variability and utility of the Osier’s maneuver for detection of pseudo-hypertension [abstract], Clin Res. 1989;37:776A.
Oster JR, Materson BJ. Pseudohypertension: a diagnostic dilemma. J Clin Hypertens. 1986;4:307–13.
Hla KM, Feussner JR. Screening for pseudohypertension. A quantitative non-invasive approach. Arch Intern Med. 1988;148:673–6.
Mejia AD, Egan BM, Schork NJ, Zweifler AJ. Artefacts in measurement of blood pressure and lack of target organ involvement in the assessment of patients with treatment-resistant hypertension. Ann Intern Med. 1990;112:270–7.
Sykes D, Dewar R, Mohanaruban K. et al. Measuring blood pressure in the elderly: does atrial fibrillation increase observer variability? BMJ. 1990;300:162–3.
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Baker, R.H., Ende, J. Confounders of auscultatory blood pressure measurement. J Gen Intern Med 10, 223–231 (1995). https://doi.org/10.1007/BF02600259
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DOI: https://doi.org/10.1007/BF02600259