For more than half a century measurement of blood pressure in the doctor's office using a mercury sphygmomanometer and the auscultatory method has been the cornerstone for hypertension management. However, due to the environmental and service issues mercury devices will not be available in the near future. As the mercury sphygmomanometer is being progressively eliminated from clinical use, it is being replaced by a variety of devices, which may not have been validated. This change in the practice of measurement may have an unpredictable impact on the threshold levels used for the diagnosis of hypertension and may also influence the management of hypertension. This expert document provides (i) information on the current availability of technologies and devices with potential for professional use (oscillometric, hybrid, aneroid and mercury devices) and the advantages and limitations of each one of them, and (ii) guidance on the requirements and selection of mercury-free blood pressure monitors for professional use. With the increasing use of automated oscillometric devices it is likely that the auscultatory technique will soon become redundant. However, consideration will be given to some of the technical aspects of the oscillometric technique and to the educational aspects of auscultation that may make it premature to abandon the technique altogether.

Ambulatory blood pressure (ABP) monitoring is recommended as a standard method for the evaluation of resistant hypertension (RH). This study assessed the diagnostic value of home blood pressure (HBP) monitoring in RH. Subjects on stable treatment with ≥3 antihypertensive drugs were included. Clinic RH (CRH) was defined as elevated clinic blood pressure and true RH (TRH) as elevated ABP. The diagnosis of CRH was verified by ABP and HBP monitoring. The diagnostic value of HBP was assessed by taking ABP as reference method. Threshold for hypertension diagnosis was ≥135/85 mm Hg (systolic and/or diastolic) for HBP and awake ABP and ≥140/90 mm Hg for clinic blood pressure. Among 73 subjects on ≥3 antihypertensive drugs, 44 (60%) had CRH and 40 (55%) TRH. There was agreement between ABP and HBP in diagnosing CRH in 82% of the cases (26 subjects (59%) with CRH and 10 (23%) without CRH; kappa 0.59). Regarding the diagnosis of TRH, there was agreement between ABP and HBP in 74% of the cases (36 subjects (49%) with TRH and 18 (25%) without TRH; kappa 0.46). The sensitivity, specificity, and positive and negative predictive values of HBP in detecting CRH were 93%, 63%, and 81% and 83%, respectively, and TRH were 90%, 55%, and 71%, and 82%, respectively (ABP taken as reference method). These data suggest that HBP is a reliable alternative to ABP in the evaluation of RH. These methods are necessary in both uncontrolled and controlled subjects on triple therapy to detect the white coat phenomenon and also masked RH.

This study validated a hybrid mercury-free device as a replacement of the mercury sphygmomanometer for professional use, and also as a standard for future validations. A validation study was performed according to the European Society of Hypertension International Protocol 2010 (ESH-IP) in 33 subjects using simultaneous blood pressure (BP) measurements. A total of six BP measurements were taken per participant simultaneously by a supervisor (S; hybrid auscultatory device Nissei DM3000) and two observers (A and B; mercury sphygmomanometers). ESH-IP analysis (99 BP readings): mean device-observer systolic/diastolic BP difference 0.2±2.0/0.1±2.0 mm Hg; systolic BP differences ≤5/10/15 mm Hg in 97/99/99 readings, respectively (diastolic 98/99/99). All 33 subjects had 2 of 3 BP differences ≤5 mm Hg and none without a difference ≤5 mm Hg. Further analysis (198 BP readings): mean differences S-A 0.1±2.4/0.2±2.4 mm Hg (systolic/diastolic), S-B 0.3±2.1/0.2±2.2, A-B 0.2±2.4/0.0±2.3; differences ≤2 mm Hg S-A in 88/84% (systolic/diastolic), S-B 87/85%, A-B 87/86% and ≤4 mm Hg S-A 95/96%, S-B 95/96%, A-B 95/98%. In conclusion, a hybrid mercury-free auscultatory BP monitor comfortably passed the ESH-IP 2010 requirements and has the same level of accuracy as the mercury sphygmomanometer. This device appears to be a reliable alternative to the mercury sphygmomanometer for professional use and also as a standard for future validations.

The ankle-brachial index (ABI) is a method used widely for peripheral arterial disease (PAD) diagnosis and cardiovascular risk prediction. This study validated automated ABI measurements taken using an oscillometric blood pressure (BP) monitor allowing simultaneous arm-leg BP measurements. A total of 93 patients (hypertension 83%; dyslipidemia 72%; diabetes 45%; cardiovascular disease 23%; smoking 15%) were submitted to Doppler and automated ABI measurements, performed using a professional oscillometric BP monitor (Microlife WatchBP Office; triplicate simultaneous arm-leg BP measurements), in a randomized order. The mean difference between the Doppler reading (1.08 ± 0.17) and (1) the first oscillometric ABI reading was 0.03 ± 0.11, (2) the average of two oscillometric readings was 0.02 ± 0.10 and (3) the average of three oscillometric readings was 0.02 ± 0.09 (P < 0.01 for all). Strong correlations were found between oscillometric and Doppler ABI (r 0.80, 0.85 and 0.86 for single and average of two and three oscillometric readings, respectively; P < 0.001 for all). Agreement between oscillometric and Doppler ABI in diagnosing PAD (Doppler ABI < 0.9) was found in 95% of cases (κ 0.79; agreement in diabetics: 94%, κ 0.79). A receiver operating characteristic (ROC) curve revealed area under the curve at 0.98, with a 0.97 oscillometric ABI cutoff for optimal sensitivity (92%) and specificity (92%) in diagnosing PAD. Average time for automated ABI measurement was 5.8 vs. 9.3 min for Doppler (P < 0.001). Doppler and oscillometric ABI were associated and predicted (multivariate regression analysis) by the same cardiovascular risk factors (pulse pressure, smoking and cardiovascular disease history). Automated ABI measurement using a professional BP monitor allowing simultaneous arm-leg BP measurements appears to be a reliable and faster alternative to Doppler measurement.

The objective of this study was to compare home blood pressure (HBP) vs. ambulatory (ABP) and clinic (CBP) measurements in terms of their association with target-organ damage in children and adolescents. A total of 81 children and adolescents (mean age 13 ± 3 years, 53 boys) referred for elevated CBP had measurements of CBP (1 visit), HBP (6 days) and ABP (24-h). Seventy-six participants were also assessed with carotid-femoral pulse wave velocity (PWV) and 54 with echocardiography. Average CBP was 122.1 ± 15.1/71 ± 12.9 mm Hg (systolic/diastolic), HBP 121.3 ± 11.5/69.4 ± 6.6 mm Hg and 24-h ABP 118.9 ± 12/66.6 ± 6.1 mm Hg. Left ventricular mass (LVM) was correlated with systolic blood pressure (BP) (coefficient r = 0.55/0.54/0.45 for 24-h/daytime/nighttime ABP, 0.53 for HBP and 0.41 for CBP; all P< 0.01). No significant correlations were found for diastolic BP. PWV was also significantly correlated with systolic BP (r = 0.52/0.50/0.48 for 24-h/daytime/nighttime ABP, 0.50 for HBP and 0.47 for CBP; all P < 0.01). Only diastolic ABP and HBP were significantly correlated with PWV (r = 0.30 and 0.28, respectively, P<0.05). In multivariate stepwise regression analysis (with age, gender, body mass index [BMI], clinic, home and 24-h ambulatory systolic/diastolic BP and pulse pressure, clinic, home and 24-h heart rate as independent variables), PWV was best predicted by systolic HBP (R(2) = 0.22, beta ± s.e. = 0.06 ± 0.01), whereas LVM was determined (R(2) = 0.67) by 24-h pulse pressure (beta = 1.21 ± 0.41), age (beta = 2.93 ± 1.32), 24-h heart rate (beta = -1.27 ± 0.41) and BMI (beta = 1.78 ± 0.70). These data suggest that, in children and adolescents, ABP as well as HBP measurements appear to be superior to the conventional CBP measurements in predicting the presence of subclinical end-organ damage.

At present, clinic blood pressure (BP) evaluation is being increasingly complemented by ambulatory BP measurements for the evaluation of haemodynamic patterns during daily activities and sleep. Nondipping pattern, a measure of decreased attenuation of nighttime over daytime BP, has been correlated with enhanced target organ damage and adverse cardiovascular (CV) outcomes in different clinical settings beyond pure hypertensive cohorts. As the nondipping pattern is a derivative extract of both daytime and nighttime BP, it is yet questionable whether the crude estimate of nocturnal BP is superior to daytime BP and nondipping pattern in the prediction of subclinical damage and CV events. In this review, we aimed at comparing the CV predictive value of the nondipping pattern with that of nocturnal BP using cross-sectional and longitudinal data obtained from different cohort studies within the past 10 years. Our findings suggest that nocturnal BP including the phenotype of isolated nocturnal hypertension is better associated with CV target organ damage and 'hard end points' as compared with the nondipping pattern.

Oscillometric devices are being widely used for ambulatory, home and office blood pressure (BP) measurement, and several of them have been validated using established protocols. This cross-sectional study assessed the impact on antihypertensive treatment decisions of replacing the mercury sphygmomanometer by a validated oscillometric device. Consecutive subjects attending a hypertension clinic had triplicate simultaneous same-arm BP measurements using a mercury sphygmomanometer and a validated professional oscillometric device. For each device, uncontrolled hypertension was defined as average BP ≥140/90 mm Hg (systolic/diastolic). A total of 5108 simultaneous BP measurements were obtained from 763 subjects in 1717 clinic visits. In 24% of all visits, the mercury and the oscillometric BP measurements led to different conclusion regarding the diagnosis of uncontrolled hypertension. In 4.9% of the visits, the diagnostic disagreement was considered as 'clinically important' (BP exceeding the diagnostic threshold by >5 mm Hg). These data suggest that the replacement of the mercury sphygmomanometer by a validated professional oscillometric device will result into different treatment decisions in about 5% of the cases. Therefore, and because of the known problems when using mercury devices and the auscultatory technique in clinical practise, the oscillometric devices are regarded as reliable alternatives to the mercury sphygmomanometer for office use.