Blood pressure and its variability: classic and novel measurement techniques

Abstract

Current hypertension guidelines recommend using the average values of several blood pressure (BP) readings obtained both in and out of the office for the diagnosis and management of hypertension. In-office BP measurement using an upper-arm cuff constitutes the evidence-based reference method for current BP classification and treatment targets. However, out-of-office BP evaluation using 24 h ambulatory or home BP monitoring is recommended by all major medical associations for obtaining further insights into the BP profile of an individual and how it relates to their daily activities. Importantly, the highly variable nature of office and out-of-office BP readings has been widely acknowledged, including the association of BP variability with cardiovascular outcomes. However, to date, the implications of BP variability on cardiovascular outcomes have largely been ignored, with limited application in clinical practice. Novel cuffless wearable technologies might provide a detailed assessment of the 24 h BP profile and behaviour over weeks or months. These devices offer many advantages for researchers and patients compared with traditional BP monitors, but their accuracy and utility remain uncertain. In this Review, we outline and compare conventional and novel methods and techniques for assessing average BP levels and BP variability, and reflect on the utility and potential of these methods for improving the treatment and management of patients with hypertension.

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“…Recent attention in the medical field to the concept of BP variability [ 325 ] rather than clinical spot checks highlights the need for ambulatory BP monitors that are both ergonomic for the patient to increase compliance and comfort, as well as reliable and well validated. A common pitfall in the use of calibrated techniques is that subsequent test data points do not differ significantly from the calibration value and thus yield small errors in prediction, whereas the data are presented as an aggregate pooled correlation plot or Bland-Altman plot with a correlation value that simply reflects the range of BPs across the population rather than patient-specific BP variation [ 326 , 327 ].…”

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“…The coefficient of variation (CV) was calculated as the ratio of the standard deviation (SD) to the mean (µ). The CV is one of the most popular indices that estimate the variability in repeatedly measured values (e.g., dayto-day blood pressure levels, visit-to-visit glucose levels) during a certain period (23)(24)(25). The SD and variability independent of the mean (VIM) are also commonly used to estimate variability.…”

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“…It is axiomatic that BP is not a single snapshot but a dynamic measure with instant-to-seasonal variations. Office and diurnal BP variability is a well-known risk factor in hypertensive patients [8] , and it is also true for home BP fluctuations [9,10] . Thus, it seems reasonable to investigate BP ranges rather than specific targets.…”