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Automated-auscultatory (Hybrid) sphygmomanometers for clinic blood pressure measurement: a suitable substitute to mercury sphygmomanometer as reference standard?

Journal of Human Hypertension volume 26, pages 211–213 (2012)Cite this article

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An accurate measurement of blood pressure (BP) has important implications for clinical decision making, as it is the basis for a reliable diagnosis of hypertension and allows assessing whether and how much the goals of antihypertensive treatment are being achieved. Mercury sphygmomanometer, using the auscultatory method, has long been regarded as the reference standard for this purpose, because most evidence on the cardiovascular risk associated with elevated BP levels, as well as on the benefits of BP lowering, comes from studies using this method.1, 2 Indeed, in spite of the mercury sphygmomanometer having practical and technical limitations, and requiring specific training and regular maintenance, when BP is measured by a trained observer using the auscultatory technique, the mercury sphygmomanometer is still regarded as an accurate device for indirect BP measurement. In recent years, however, growing awareness on the detrimental consequences of mercury for human health and for the environment has led to progressively ban its use in measuring devices in many countries, promoting at the same time the search for viable alternatives.3 In such a context, recent recommendations from regulatory authorities (Scientific Committee on Emerging and Newly Identified Health Risks, SCENIHR, Mercury Sphygmomanometers in Healthcare and the Feasibility of Alternatives, 2009)4 have proposed to confine the use of mercury sphygmomanometers to ongoing epidemiological studies and to validation studies of new devices for BP measurement, where it is still currently employed as a reference standard. Indeed, the SCENIHR group was not only worried about the risk associated with use of mercury devices, but also concerned that the replacement of mercury-containing sphygmomanometers by alternative mercury-free devices might be responsible for problems in the clinical management of high BP conditions, either by endangering proper health care in specific groups of patients, and/or by undermining long-term epidemiological studies for public health, where a sudden change in the BP measuring method in the course of these studies might introduce possible biases and errors in the final outcome. The SCENIHR experts were also concerned about the need to consider both availability and quality of alternative devices for BP measurement. Among mercury free alternatives for conventional BP measurement, the most commonly available ones are those based on use of an aneroid manometer or of an electronic pressure transducer. These alternative sphygmomanometers use the auscultatory approach for BP determination, and therefore have the advantages and limitations, characteristic of the auscultatory technique and related to the observer's performance, which also apply to the mercury sphygmomanometer. It has to be emphasized, however, that aneroid manometers would require frequent calibration, every 6 months, in absence of which their accuracy becomes questionable.5

Additional solutions for mercury-free BP measurements are provided by use of non-auscultatory devices based on the oscillometric technique. Oscillometric instruments, however, operate under a completely different principle and are thus not considered as true ‘alternatives’ to mercury sphygmomanometers. Moreover, even validated oscillometric devices may have accuracy limitations in special patient groups, including patients with arrhythmias, diabetes, pre-eclampsia and the elderly,5 in whom, conversely, validated non-mercury auscultatory alternatives can be more appropriate.4

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  1. Department Cardiology, Istituto Auxologico Italiano, IRCCS, Milano, Italy

    G Parati & J E Ochoa

  2. Department Clinical Medicine and Prevention, University Milano-Bicocca, Milan, Italy

    G Parati & J E Ochoa

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  1. G Parati
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Correspondence to G Parati.

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Parati, G., Ochoa, J. Automated-auscultatory (Hybrid) sphygmomanometers for clinic blood pressure measurement: a suitable substitute to mercury sphygmomanometer as reference standard?. J Hum Hypertens 26, 211–213 (2012). https://doi.org/10.1038/jhh.2011.119

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