Editor ial

Comments on the New AHA Recommendations

for Blood Pressure Measurement
Marvin Moser, MD
Editor in Chief

n this issue of The Journal of Clinical Hypertension, Pickering et al.1 summarize the American
Heart Association (AHA) Recommendations from
the Council of High Blood Pressure Research for
blood pressure (BP) measurements in humans. This
is an expanded and excellent update of the 1985
National High Blood Pressure Education Program
recommendations for medical devices for measuring BP and the AHA recommendations in 1993.2,3
The report is a must-read for anyone involved in
screening, treatment programs, or research that
involve BP measurements. There are, however, certain questions that practitioners may have about
its content.
For years, concerns have been expressed about
problems with the usual methods of recording
casual BPsproblems that may result in misdiagnoses and occasional inappropriate treatment.
The report appropriately notes that physicians
(and other health care providers) traditionally
round out the mm Hg numbers favoring a 5
and 0 rather than recording more exact readings. The AHA recommendations state that the
number should be more carefully determined and
recorded to the nearest 2 mm Hg. It is important
to note, however, that while scientifically this is an
important and correct recommendation, especially
in research studies, this is difficult to do in the real
world of practice. Determining specific numbers,
i.e., 2, 4, 6, 8, etc. on the BP monitor is difficult
and involves very careful attention with the current method of using a stethoscope and mercury
sphygmomanometer.
The recommendations note that the bell portion
of the stethoscope, rather than the diaphragm, be
used in taking BP. This is to be desired since there

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are fewer outside noises with the bell. Again, in

the real world, many physicians do not even have
a bell attachment and use the diaphragm. They
will probably continue to use what they are accustomed to when measuring BP. However, it may not
make that much difference in most clinical settings
if careful attention is paid to the procedure.
The discussion in this report of the various methods of taking BP should be helpful. Recognition of
the increasing use of digital readout instruments
that do not require a stethoscope is also important.
Convenience is greater with these instruments.
Although there is always some question about careful calibration of the electronic digital machines, in
general, these are acceptable for use not only in
offices or clinics but as home BP measuring devices.
There may come a time when we may not be able
to test them against a mercury manometer if these
are eventually restricted or eliminated, but other
standard pressure devices will be available for the
necessary calibration. As noted, these devices do
not require the use of a stethoscope and eliminate
digit preference. They are easier to use for home
BP follow-up; many machines on the market have
been carefully calibrated.
Despite many problems appropriately pointed
out in the AHA recommendations about clinic or
office casual BPs, it should be remembered that the
casual pressures taken in an office or clinic have
proved predictive of risk in epidemiologic studies
as well as predictive of outcome in long-term clinical trials. A lower BP in the clinic is indicative of a
better prognosis; a lower BP in a long-term clinical
study indicates a better outcome (BPs are often
taken only three to four times a year). White coat
hypertension is real and not uncommon and the
report stresses the use of the ambulatory BP monitoring to rule this out. This syndrome, however,
THE JOURNAL OF CLINICAL HYPERTENSION

71

The Journal of Clinical Hypertension (ISSN 1524-6175) is published monthly by Le Jacq Ltd., Three Parklands Drive, Darien, CT 06820-3652. Copyright 2005 by Le Jacq Ltd., All rights reserved. No part of this publication may be
reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publishers. The opinions
and ideas expressed in this publication are those of the authors and do not necessarily reflect those of the Editors or Publisher. For copies in excess of 25 or for commercial purposes, please contact Sarah Howell at
showell@lejacq.com or 203.656.1711 x106.

can also be ruled out with less expense and effort

with home BP recordings, which do not involve
one or two office visits for attachment and removable of the automated BP machine and the cost
of the procedure. Home readings will often give a
better picture of BP over time than one 24-hour or
even two 24-hour measurements of BP levels. In
some situations, ambulatory BP monitoring may
be useful to determine the status of BP changes
during the night, but, for example, physicians may
use available data on nondipping that is common
in many black or diabetic patients to determine a
treatment plan without doing the procedure.
It should be emphasized that clinic levels are
predictive. While these may not be as accurate as
an ambulatory BP monitoring in predicting some
target organ involvement, such as left ventricular
hypertrophy, this may not be of great importance
in management. Individuals with office BPs consistently >140/90 mm Hg should be treated whether or
not they have left ventricular hypertrophy. Although
there is some disagreement regarding this issue, it is
probably reasonable at present to use the office BP
to determine treatment decisions, except in unusual
situations (unexplained dizziness or headaches, etc.).
In these cases, home BPs are useful.
The report notes that individuals with white
coat hypertension can progress to sustained hypertension. In addition, some studies have reported
that people with normal BPs at home and in the

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THE JOURNAL OF CLINICAL HYPERTENSION

office or clinic are different physiologically from

those patients with higher BPs in the clinic and
normal pressures at home. Vascular resistance may
be increased and there may be evidence of left ventricular diastolic dysfunction. White coat hypertension is an important entity, but these patients
should not be ignored; if the white coat syndrome
persists, some treatment should be instituted.
The AHA report reviews data on systolic and
diastolic BP and pulse pressure differences. It concludes that, although pulse pressures are predictors
of outcome, the use of systolic BP and diastolic BP
readings should be used in making diagnostic and
treatment decisions.
While some practicing physicians may question
some of the recommendations for BP measurement
of this expert panel regarding a procedure that is
probably performed more often in medical care than
almost any other, the report is an excellent update.

REFERENCES
1 Pickering TG, Hall JE, Appel LJ, et al. Recommendations
for blood pressure management in humans: an AHA scientific statement from the Council on High Blood Pressure
Research Professional and Public Education Subcommittee.
J Clin Hypertens (Greenwich). 2005;7:102109.
2 Hunt J, Frohlich E, Moser M, et al. Devices used for selfmeasurement of blood pressure: revised statement of the
National High Blood Pressure Education Program. Arch
Intern Med. 1985;145:22312234.
3 Perloff D, Grim C, Flack J, et al. Human blood pressure determination by sphygmomanometry. Circulation.
1993;88:24602470.

VOL. 7 NO. 2 FEBRUARY 2005

The Journal of Clinical Hypertension (ISSN 1524-6175) is published monthly by Le Jacq Ltd., Three Parklands Drive, Darien, CT 06820-3652. Copyright 2005 by Le Jacq Ltd., All rights reserved. No part of this publication may be
reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publishers. The opinions
and ideas expressed in this publication are those of the authors and do not necessarily reflect those of the Editors or Publisher. For copies in excess of 25 or for commercial purposes, please contact Sarah Howell at
showell@lejacq.com or 203.656.1711 x106.