Accuracy of Cuff-Measured Blood Pressure
Open accessAbstract
Background Hypertension (HTN) is the single greatest cardiovascular risk factor worldwide. HTN management is usually guided by brachial cuff blood pressure (BP), but questions have been raised regarding accuracy.Objectives This comprehensive analysis determined the accuracy of cuff BP and the consequent effect on BP classification compared with intra-arterial BP reference standards.Methods Three individual participant data meta-analyses were conducted among studies (from the 1950s to 2016) that measured intra-arterial aortic BP, intra-arterial brachial BP, and cuff BP.Results A total of 74 studies with 3,073 participants were included. Intra-arterial brachial systolic blood pressure (SBP) was higher than aortic values (8.0 mm Hg; 95% confidence interval [CI]: 5.9 to 10.1 mm Hg; p < 0.0001) and intra-arterial brachial diastolic BP was lower than aortic values (-1.0 mm Hg; 95% CI: -2.0 to -0.1 mm Hg; p = 0.038). Cuff BP underestimated intra-arterial brachial SBP (-5.7 mm Hg; 95% CI: -8.0 to -3.5 mm Hg; p < 0.0001) but overestimated intra-arterial diastolic BP (5.5 mm Hg; 95% CI: 3.5 to 7.5 mm Hg; p < 0.0001). Cuff and intra-arterial aortic SBP showed a small mean difference (0.3 mm Hg; 95% CI: -1.5 to 2.1 mm Hg; p = 0.77) but poor agreement (mean absolute difference 8.0 mm Hg; 95% CI: 7.1 to 8.9 mm Hg). Concordance between BP classification using the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure cuff BP (normal, pre-HTN, and HTN stages 1 and 2) compared with intra-arterial brachial BP was 60%, 50%, 53%, and 80%, and using intra-arterial aortic BP was 79%, 57%, 52%, and 76%, respectively. Using revised intra-arterial thresholds based on cuff BP percentile rank, concordance between BP classification using cuff BP compared with intra-arterial brachial BP was 71%, 66%, 52%, and 76%, and using intra-arterial aortic BP was 74%, 61%, 56%, and 65%, respectively.Conclusions Cuff BP has variable accuracy for measuring either brachial or aortic intra-arterial BP, and this adversely influences correct BP classification. These findings indicate that stronger accuracy standards for BP devices may improve cardiovascular risk management.
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On average, brachial artery systolic BP is 8.0 mmHg higher than proximal aortic systolic BP, while diastolic BP is slightly lower at the brachial artery (−1.0 mmHg).
“On average, brachial artery systolic BP is 8.0 mmHg (95% confidence interval: 5.9 to 10.1 mmHg) higher than that in the proximal aorta, whereas the diastolic BP varies minimally and is only slightly lower at the brachial artery (−1.0 mmHg; 95% confidence interval: −2.0 to −0.1 mmHg) [38].”
From Automated 'oscillometric' blood pressure measuring devices: how they work and what they measure (2022) · cites this paper as [38]
The Discussion confirms that intra-arterial brachial systolic BP was higher than aortic systolic BP and that diastolic BP differed little between the two sites. The available non-abstract passages do not establish the claimed 8.0 and −1.0 mmHg estimates or their confidence intervals. (LLM, conf=0.72)
Experimental — accuracy not yet measuredPulse pressure measured by sphygmomanometer underestimates intra-arterial pulse pressure by an average of 11 mmHg, with a mean absolute difference of 11.8 mmHg.
“The consequent results for pulse pressure measured by sphygmomanometer were underestimation by an average of 11 mmHg, and with a mean absolute difference of 11.8 mmHg (95% confidence interval 9.1 to 14.7) indicating wide scatter from intra-arterial measures [38].”
From Automated 'oscillometric' blood pressure measuring devices: how they work and what they measure (2022) · cites this paper as [38]
The “META-ANALYSES ON BP DIFFERENCES” section reports that brachial cuff pulse pressure underestimated intra-arterial brachial pulse pressure, but gives a pooled mean difference of −12.0 mmHg (95% CI −14.7 to −9.3), not the cited 11 mmHg. The passages found do not report a mean absolute pulse-pressure difference of 11.8 mmHg or its stated confidence interval. Page numbers were not available in our copy. (LLM, conf=0.88)
Experimental — accuracy not yet measuredA meta-analysis comparing intra-arterial and brachial cuff BP found that cuff measurement underestimated systolic BP and overestimated intra-arterial diastolic BP by 5-6 mmHg, causing considerable underestimation of pulse pressure.
“A meta-analysis of studies that compared intra-arterial BP readings with brachial cuff BP readings showed that the latter underestimated systolic BP levels and overestimated intra-arterial diastolic BP levels (by 5–6 mmHg for each measurement), resulting in considerable underestimation of pulse pressure34.”
From Blood pressure and its variability: classic and novel measurement techniques (2022) · cites this paper as [34]
The underestimation of intra-arterial brachial systolic BP by automated BPMDs means that estimated systolic BP may be similar to intra-arterial central aortic systolic BP, but this is device-specific and may vary between individuals.
“The underestimation of intra-arterial brachial systolic BP by automated BPMDs means that the estimated systolic BP may be similar to intra-arterial central aortic systolic BP, but this is a device-specific performance characteristic that may vary between individuals [38].”
From Automated 'oscillometric' blood pressure measuring devices: how they work and what they measure (2022) · cites this paper as [38]
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Self-citation
- Authors
- Picone, D. S., Schultz, M. G., Otahal, P., Aakhus, S., Al-Jumaily, A. M., Black, J. A., Bos, W. J., Chambers, J. B., Chen, C.-H., Cheng, H.-M., Cremer, A., Davies, J. E., Dwyer, N., Gould, B. A., Hughes, A. D., Lacy, P. S., Laugesen, E., Liang, F., Melamed, R., Muecke, S., Ohte, N., Okada, S., Omboni, S., Ott, C., Peng, X., Pereira, T., Pucci, G., Rajani, R., Roberts-Thomson, P., Rossen, N. B., Sueta, D., Sinha, M. D., Schmieder, R. E., Smulyan, H., Srikanth, V. K., Stewart, R., Stouffer, G. A., Takazawa, K., Wang, J., Westerhof, B. E., Weber, F., Weber, T., Williams, B., Yamada, H., Yamamoto, E., & Sharman, J. E.
- Affiliations
- University of Tasmania (AU)
- Norwegian University of Science and Technology (NO)
- St. Antonius Ziekenhuis (NL)
- St Thomas' Hospital (GB)
- Taipei Veterans General Hospital (TW)
- Imperial College London (GB)
- BMI The London Independent Hospital (GB)
- University College London (GB)
- National Institute for Health and Care Research (GB)
- Aarhus University Hospital (DK)
- Shanghai Jiao Tong University (CN)
- Abbott Northwestern Hospital (US)
- Flinders University (AU)
- Nagoya City University (JP)
- Chiba University (JP)
- Italian Institute of Telemedicine (IT)
- Friedrich-Alexander-Universität Erlangen-Nürnberg (DE)
- Universidade Politécnica de Coimbra (PT)
- University of Perugia (IT)
- Kumamoto University (JP)
- King's College London (GB)
- SUNY Upstate Medical University (US)
- University of Auckland (NZ)
- University of North Carolina at Chapel Hill (US)
- Tokyo Medical University Hospital (JP)
- Amsterdam UMC Location Vrije Universiteit Amsterdam (NL)
- University of Duisburg-Essen (DE)
- Klinikum Wels-Grieskirchen (AT)
- Tokushima University Hospital (JP)
- Corresponding author
- Sharman, James E.
- ORCID
- Picone, Dean S.
- Schultz, Martin G.
- Aakhus, Svend
- Black, J. Andrew
- Bos, Willem J.
- Chambers, John B.
- Cheng, Hao-Min
- Davies, Justin E.
- Dwyer, Nathan
- Hughes, Alun D.
- Lacy, Peter S.
- Laugesen, Esben
- Liang, Fuyou
- Melamed, Roman
- Ohte, Nobuyuki
- Okada, Sho
- Omboni, Stefano
- Peng, Xiaoqing
- Pereira, Telmo
- Pucci, Giacomo
- Rajani, Ronak
- Sueta, Daisuke
- Sinha, Manish D.
- Schmieder, Roland E.
- Srikanth, Velandai K.
- Stewart, Ralph
- Stouffer, George A.
- Takazawa, Kenji
- Westerhof, Berend E.
- Weber, Thomas
- Williams, Bryan
- Yamada, Hirotsugu
- Yamamoto, Eiichiro
- Sharman, James E.
- Venue
- Journal of the American College of Cardiology
- Publisher
- Elsevier BV
- Published
- 2017-08
- Volume
- 70
- Issue
- 5
- Pages
- 572-586
- ISSN
- 0735-1097 (ISSN-L)
- OpenAlex
- W2736824509
- Semantic Scholar
- afab55c7cae160a408db3a5f37160d5d263cf6c6
- Cited by
- 277
- References
- 48
- Citations by year
- 2026: 20 · 2025: 42 · 2024: 31 · 2023: 36 · 2022: 35 · 2021: 31 · 2020: 28 · 2019: 29 · 2018: 20 · 2017: 5
- FWCI
- 3.16
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of the American College of Cardiology (publishedVersion)
- PubMed (publishedVersion)
- Amsterdam UMC (VU Amsterdam) - Institutional Repository (publishedVersion)
- eCite Digital Repository (University of Tasmania) (submittedVersion)
- UTAS Research Repository (submittedVersion)
- Universitätsbibliographie, Universität Duisburg-Essen (submittedVersion)
- Pure Amsterdam UMC (submittedVersion)
- Data Archiving and Networked Services (DANS) (submittedVersion)
- Funders
- Bristol-Myers Squibb
- Pfizer
- AstraZeneca
- Bayer
- National Institute for Health and Care Research (NF-SI-0509-10222, NF-SI-0514-10011)
- Medical Research Council (MC_PC_13090)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Blood Pressure and Hypertension Studies
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Health and Disease Prevention
- Physical Sciences › Engineering › Biomedical Engineering › Non-Invasive Vital Sign Monitoring
- Keywords
- cuff blood pressure, blood pressure measurement accuracy, intra-arterial blood pressure, brachial blood pressure, aortic pressure, hypertension classification, hypertension diagnosis, measurement agreement, systolic and diastolic blood pressure, cardiovascular risk factors, antihypertensive treatment response, blood pressure variability
- MeSH terms
- Blood Pressure, Blood Pressure Determination, Cardiovascular Diseases, Equipment Design, Reproducibility of Results
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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