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Cited by 96Blood Pressure and Hypertension StudiesClinical practice guidelines implementationCardiovascular Health and Disease Prevention

International Consensus on Standardized Clinic Blood Pressure Measurement – A Call to Action

Open access
Cheung, Alfred K., Whelton, Paul K., Muntner, Paul, Schutte, Aletta E., Moran, Andrew E., Williams, Bryan, Sarafidis, Pantelis, Chang, Tara I. +17 more·2023·The American Journal of Medicine
DOI 10.1016/j.amjmed.2022.12.015PMC PMC10159895
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Integrity signals

Registry

Crossref · 10.1016/j.amjmed.2022.12.015

Cites

39 of 39 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

29 of 47 cited sources checked · 15 supported · 0 flagged · accuracy not yet measured

  • Premisecitation

    After a brief curriculum in standardized hypertension screening and management, 33 health care professionals staffing 18 primary care clinics in Tanzania substantially improved their blood pressure measurement knowledge and technique.

    “after receiving instructions in a brief curriculum in standardized hypertension screening and management, 33 health care professionals staffing 18 primary care clinics in Tanzania substantially improved BP measurement knowledge and BP measurement techniques.38”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [38] Edward, 2022, Effectiveness of instructional videos for enhancing healthcare provider competencies for hypertension management - a pre-post study in primary healthcare settings, Tanzania, BMC Health Serv Res source
  • Premisecitation

    Lowering blood pressure substantially reduces cardiovascular disease risk.

    “and lowering BP substantially reduces that risk.5–7”
    Quote in the paperSubstantial claim2 of 3 sources checked
    • cites [5] 2021, Pharmacological blood pressure lowering for primary and secondary prevention of cardiovascular disease across different levels of blood pressure: an individual participant-level data meta-analysis, Lancet source
      Experimental — accuracy not yet measured
    • cites [6] Bundy, 2017, Systolic blood pressure reduction and risk of cardiovascular disease and mortality: a systematic review and network meta-analysis, JAMA Cardiol source
      Experimental — accuracy not yet measured
    • cites [7] Ettehad, 2016, Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis, Lancet source
  • Premisecitation

    Countries in which physicians currently carry out all blood pressure measurement and management tasks may be ill-equipped to support implementation of standardized blood pressure measurement.

    “Countries where physicians currently execute all tasks related to BP measurement and management may be ill-equipped to support the implementation of standardized BP measurements;39”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [39] Giraldo, 2021, Mapping stages, barriers and facilitators to the implementation of HEARTS in the Americas initiative in 12 countries: a qualitative study, J Clin Hypertens (Greenwich) source

      The Results section (‘Common main barriers and solutions’; page unavailable) identifies physician-centered responsibility for most hypertension-control tasks as a barrier to task-sharing. It does not say physicians perform all blood-pressure measurement and management tasks or specifically link that arrangement to difficulty implementing standardized BP measurement. (LLM, conf=0.84)

      Experimental — accuracy not yet measured
  • Premisecitation

    Approximately 1 in 5 US adults could have their hypertension diagnosis or control status misclassified if blood pressure were measured in a nonstandardized manner.

    “It has been estimated that approximately 1 in 5 US adults could have their hypertension diagnosis or control status misclassified if BP were measured in a nonstandardized manner.27”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [27] Sakhuja, 2022, Potential impact of systematic and random errors in blood pressure measurement on the prevalence of high office blood pressure in the United States, J Clin Hypertens (Greenwich) source
  • Premisecitation

    A systematic review of 328 articles identified 29 components of the blood pressure measurement procedure that can affect systolic and diastolic blood pressure levels.

    “A systematic review of 328 articles found 29 components of the BP measurement procedure that can affect systolic BP (SBP) and diastolic BP (DBP) levels.27”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [27] Sakhuja, 2022, Potential impact of systematic and random errors in blood pressure measurement on the prevalence of high office blood pressure in the United States, J Clin Hypertens (Greenwich) source

      The Discussion says that patient-, technician-, and device-related factors can affect blood pressure readings, and the References list a systematic review on measurement inaccuracy. Our copy does not state that the review examined 328 articles or identified 29 components, so it does not support those specific figures. (LLM, conf=0.84)

      Experimental — accuracy not yet measured
  • Classified as probably not a substantial claim. 10
  • May combine two claims. 10

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    High blood pressure is the single leading risk factor for cardiovascular disease worldwide.

    “High blood pressure (BP) is the single leading risk factor for cardiovascular disease worldwide,1–4”
    Quote in the paperNot a substantial claim2 of 4 sources checked
    • cites [1] Flint, 2019, Effect of systolic and diastolic blood pressure on cardiovascular outcomes, N Engl J Med source
    • cites [2] Fuchs, 2020, High blood pressure and cardiovascular disease, Hypertension source
    • cites [3] He, 1999, Elevated systolic blood pressure and risk of cardiovascular and renal disease: overview of evidence from observational epidemiologic studies and randomized controlled trials, Am Heart J source
    • cites [4] Rapsomaniki, 2014, Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1.25 million people, Lancet source

      The Introduction says high blood pressure was the leading risk factor for the overall global burden of disease in 2010, and the Results link hypertension to higher cardiovascular disease risk. The paper does not establish the narrower ranking that it is the single leading risk factor for cardiovascular disease worldwide. (LLM, conf=0.82)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    The MAP protocol moved 16 South Carolina primary care clinics and more than 16,000 patients from usual care blood pressure measurement to standardized measurement, and the transition was successful and favored by participating health care workers.

    “The “Measure accurately, Act rapidly and Partner with patients” (MAP) protocol used a practice facilitation model to transition 16 South Carolina primary care clinics and more than16,000 patients from usual care BP measurement practices to standardized BP measurement.42”
    • Also stated in: § Standardized BP Measurements in Clinics Are Feasible · plain
      “Transition to higher BP measurement standards was successful and, in fact, favored by participating health care workers.42”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [42] Egan, 2018, Improving hypertension control in primary care with the measure accurately, act rapidly, and partner with patients protocol, Hypertension source

  • May combine two claims.

    Premisecitation

    Standardization of blood pressure measurement is not implemented in most clinical practices, because its importance is underappreciated and the required steps are seen as time-consuming and impractical.

    “Despite these efforts, standardization is not implemented in most clinical practices18 because its importance is often underappreciated, and the necessary steps are considered time-consuming and impractical.23”
    • Also stated in: § CALL TO ACTION · plain
      “The importance of clinic BP measurement has been recognized for many decades but adherence to guidelines on proper, standardized BP measurement remains uncommon in clinical practice.”
    Quote in the paperSubstantial claim2 of 2 sources checked
    • cites [18] Stergiou, 2018, Office blood pressure measurement: the weak cornerstone of hypertension diagnosis, Hypertension source

      In “Types and Fallacies of OBP” (page unavailable), the paper says standardization has been ignored for too long and describes general-practice measurements as unstandardized. It also says one automated approach requires additional resources and may not suit all settings, but it does not say that clinicians regard the necessary steps as time-consuming or impractical, or establish the reasons for nonimplementation across most practices. (LLM, conf=0.79)

      Experimental — accuracy not yet measured
    • cites [23] Hwang, 2018, Barriers to accurate blood pressure measurement in the medical office, J Prim Care Community Health source

      The Results (Workflow; Staff Knowledge and Behavior, page unavailable) report that staff lacked time for recommended steps and found them difficult to apply in a busy clinic. The paper does not establish that the importance of standardized measurement was underappreciated. The separate claim about most clinical practices is attached to citation 18, not this source. (LLM, conf=0.84)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    For some people, routine clinic blood pressure readings are lower than those obtained with a standardized protocol, resulting in missed detection of high blood pressure or a missed need to intensify antihypertensive treatment.

    “In contrast, for some people, routine clinic BP readings are lower than those obtained following a standardized protocol,29,30 resulting in a missed opportunity to detect high BP or the need to intensify antihypertensive treatment.”
    Quote in the paperSubstantial claim2 of 2 sources checked
    • cites [29] Agarwal, 2017, Implications of blood pressure measurement technique for implementation of systolic blood pressure intervention trial (SPRINT), J Am Heart Assoc source

      The Results and Discussion (page unavailable) report wide limits of agreement: for some patients, routine clinic systolic readings were lower than research-grade readings, although the average routine reading was higher. The paper does not report missed detection of high blood pressure or missed treatment intensification; those are inferred consequences, not findings it establishes. (LLM, conf=0.84)

      Experimental — accuracy not yet measured
    • cites [30] Drawz, 2020, Concordance between blood pressure in the systolic blood pressure intervention trial and in routine clinical practice, JAMA Intern Med source

      The Discussion reports that 657 of 3032 participants (21.7%) had routine outpatient systolic readings that averaged lower than their SPRINT trial readings. The paper does not show that these lower readings caused missed detection of high blood pressure or missed treatment intensification; it generally describes routine readings as higher than trial readings. No page numbers are available in our copy. (LLM, conf=0.87)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Standardization is essential because many aspects of blood pressure measurement, including the patient's physical condition, the clinic environment and the equipment, can readily produce inaccurate and unreliable values.

    “Standardization is essential because there are many aspects of BP measurement, including the patient’s physical condition, clinic environment, and equipment that can readily result in inaccurate and unreliable values.23,25,26”
    Quote in the paperSubstantial claim3 of 3 sources checked
    • cites [23] Hwang, 2018, Barriers to accurate blood pressure measurement in the medical office, J Prim Care Community Health source
    • cites [25] Kallioinen, 2017, Sources of inaccuracy in the measurement of adult patients' resting blood pressure in clinical settings: a systematic review, J Hypertens source
    • cites [26] Picone, 2020, How to check whether a blood pressure monitor has been properly validated for accuracy, J Clin Hypertens (Greenwich) source

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationcitation

    The evidence base for blood pressure targets using ambulatory or home monitoring is uncertain, so their role should be considered complementary to standardized clinic blood pressure measurement unless clinic measurements are unavailable.

    “As such, the evidence base to support BP targets using ABPM or HBPM is uncertain and their role at present should be considered complementary to standardized clinic BP measurements, unless clinic BP measurements are unavailable.23”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [23] Hwang, 2018, Barriers to accurate blood pressure measurement in the medical office, J Prim Care Community Health source

      The Introduction (page unavailable) says office BP measurement remains the de facto method in routine care and that major hypertension trials used office BP to guide treatment. It does not assess whether evidence for ABPM or HBPM targets is uncertain or recommend using those methods only as complements to standardized clinic measurements unless clinic measurements are unavailable. (LLM, conf=0.84)

      Experimental — accuracy not yet measured
    • Rests on an assumption: No large randomized controlled outcome trial of blood pressure targets or antihypertensive drugs has used ambulatory or home blood pressure monitoring to guide management.

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductreasoning

    The report's recommendations were derived from an examination of procedures recommended in clinical practice guidelines and from a compilation of elements supported by consensus among the authors.

    “Our report is based on a careful examination of the procedures recommended in clinical practice guidelines and a compilation of the most essential elements that are supported by consensus among the authors of this document.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based).

    Interpretationnone given

    Any change to clinic workflow, especially one involving multiple stakeholders such as patients, providers, institutions and administrators, is likely to encounter resistance.

    “any change to clinic workflow, particularly when it involves multiple stakeholders such as patients, health care providers, institutions, and administrators, is likely to be met with resistance.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation

    Implementing standardized blood pressure measurement is feasible in primary health care settings, although the supporting examples come mostly from high-income countries.

    “Several examples support the premise that implementing standardized BP measurement is feasible in primary health care settings, admittedly mostly in high-income countries.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given

    Low- and middle-resource health care systems may struggle to implement standardized clinic blood pressure measurement because of scarce monitors, suboptimal clinic environments, limited personnel training and other barriers.

    “Low- and middle-resource health care systems may struggle to implement standardized clinic BP measurements due to scarcity of BP monitors, optimal clinic environment, personnel training, and other barriers.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Routine retraining, for example annually, helps maintain proficiency in blood pressure measurement.

    “Retraining on a routine basis (eg, annually) is helpful to ensure proficiency.24”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [24] Bruce, 1988, Observer bias in blood pressure studies, J Hypertens source

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationnone given

    It is feasible to streamline the clinic workflow and adopt strategies that reduce the time needed to perform standardized blood pressure measurement.

    “We posit that it is feasible to streamline the clinic workflow and adopt other strategies that minimize the amount of time required to perform standardized BP measurements.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation

    Clinic blood pressure measurements that do not follow a standardized protocol are likely to yield inaccurate and highly variable readings from one visit to the next, making it difficult to target a specified blood pressure goal.

    “Clinic BP measurements that do not follow a standardized protocol are likely to result in inaccurate and highly variable readings from one clinic visit to the next, making targeting a specified BP goal very challenging.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    An automated upper-arm cuff monitor reduces interactions between the patient and health care professionals and therefore distractions during preparation and measurement.

    “It minimizes interactions between the patient and health care professionals and, therefore, distractions during the preparatory and BP measurement phases.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Interpretationnone given

    An automated upper-arm cuff monitor removes human error associated with manual devices, such as errors from hearing impairment and digit preference, and requires less training.

    “It eliminates human error associated with manual devices (eg, those due to hearing impairment and digit preference) and requires less training.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationreasoning

    Practising evidence-based medicine and achieving outcome results similar to those of randomized controlled trials require adherence to these measurement recommendations.

    “The practice of evidence-based medicine and the likelihood of achieving outcome results similar to those shown in randomized controlled trials require adherence to these recommendations.”
    Quote in the paperSubstantial claim
16 of 16

  • The authors state this as an assumption.

    A simplified standardized blood pressure measurement protocol will be widely adopted in daily practice with minimal loss of measurement accuracy and reliability.

    “Our presumption is that a simplified standardized BP measurement protocol will lead to its wide adoption in daily practice, with minimal compromise in measurement accuracy and reliability.”

  • The paper relies on this without support.

    In most settings worldwide, a patient's usual blood pressure level is estimated from clinic measurements, often the only method available.

    “In most settings worldwide, estimation of a patient’s usual level of BP is based on clinic measurements, often as the only method available.”

  • The paper relies on this without support.

    Almost all cohort studies of blood-pressure-related cardiovascular risk and the randomized controlled trials underpinning antihypertensive treatment recommendations and blood pressure goals used standardized clinic blood pressure measurements.

    “Almost all of the cohort studies that estimated BP-related cardiovascular disease risks and the randomized controlled trials that underpin the recommendations for antihypertensive treatment and BP treatment goals for adults with high BP have employed standardized BP measurements in the clinic.”

  • The paper relies on this without support.

    No large randomized controlled outcome trial of blood pressure targets or antihypertensive drugs has used ambulatory or home blood pressure monitoring to guide management.

    “However, no large randomized controlled outcome trial addressing BP targets or anti-hypertensive drugs has used ABPM or HBPM to guide management.”
4 of 4

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Authors
Cheung, A. K., Whelton, P. K., Muntner, P., Schutte, A. E., Moran, A. E., Williams, B., Sarafidis, P., Chang, T. I., Daskalopoulou, S. S., Flack, J. M., Jennings, G., Juraschek, S. P., Kreutz, R., Mancia, G., Nesbitt, S., Ordunez, P., Padwal, R., Persu, A., Rabi, D., Schlaich, M. P., Stergiou, G. S., Tobe, S. W., Tomaszewski, M., Williams, K. A., & Mann, J. F. E.
Affiliations
  • University of Utah (US)
  • Tulane University (US)
  • University of Alabama at Birmingham (US)
  • UNSW Sydney (AU)
  • Columbia University Irving Medical Center (US)
  • University College London (GB)
  • Aristotle University of Thessaloniki (GR)
  • Stanford Medicine (US)
  • McGill University Health Centre (CA)
  • SIU Medicine (US)
  • The University of Sydney (AU)
  • Beth Israel Deaconess Medical Center (US)
  • Charité – Universitätsmedizin Berlin (DE)
  • University of Milano-Bicocca (IT)
  • The University of Texas Southwestern Medical Center (US)
  • University of Alberta (CA)
  • Cliniques Universitaires Saint-Luc (BE)
  • University of Calgary (CA)
  • The University of Western Australia (AU)
  • National and Kapodistrian University of Athens (GR)
  • University of Toronto (CA)
  • Manchester Academic Health Science Centre (GB)
  • Friedrich-Alexander-Universität Erlangen-Nürnberg (DE)
Corresponding author
Mann, Johannes F.E.
ORCID
Venue
The American Journal of Medicine
Publisher
Elsevier BV
Published
2023-05
Volume
136
Issue
5
Pages
438-445.e1
ISSN
0002-9343 (ISSN-L)
DOI
10.1016/j.amjmed.2022.12.015
PMC
PMC10159895
OpenAlex
W4313547265
Semantic Scholar
9371ae303bad71a2aad9f5941a85a235bbead2fd
Cited by
96
References
40
Citations by year
2026: 24 · 2025: 33 · 2024: 27 · 2023: 12
FWCI
18.86
Type
journal article
Language
en
Open access
Licence
Locations
  • The American Journal of Medicine (publishedVersion)
  • UWA Profiles and Research Repository (UWA) (publishedVersion, other-oa)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
  • UCL Discovery (University College London) (submittedVersion)
  • BOA (University of Milano-Bicocca) (submittedVersion)
  • Digital Access to Libraries (submittedVersion)
  • Research Explorer (The University of Manchester) (submittedVersion)
Funders
  • Amgen
  • Pfizer
  • AstraZeneca
  • GlaxoSmithKline
  • Sanofi
  • Gilead Sciences
  • Teva Pharmaceutical Industries
  • FibroGen
  • ReCor Medical
  • Omron Healthcare
  • Daiichi-Sankyo
  • Gedeon Richter
  • Novo Nordisk
  • Servier
  • Idorsia Pharmaceuticals
  • Pan American Health Organization
  • National Heart, Lung, and Blood Institute (K23HL135273, R01HL153191, R01HL158622)
Topics
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Blood Pressure and Hypertension Studies
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Clinical practice guidelines implementation
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Health and Disease Prevention
Keywords
blood pressure measurement, hypertension, blood pressure control, cardiovascular risk, measurement accuracy
MeSH terms
Blood Pressure, Blood Pressure Determination, Humans, Hypertension, Blood Pressure Monitoring, Ambulatory, Consensus

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