Blood Pressure Measurement and Hypertension Diagnosis in the 2017 US Guidelines
First Things First
See related article, pp e13–e115
The 2017 US guidelines for hypertension have given a lot of attention to the accurate evaluation of blood pressure (BP) and the importance of out-of-office measurements for confirming diagnosis.1 This emphasis is to be welcomed, and at the time of writing, these guidelines provide the most comprehensive recommendations for both out-of-office and office BP measurement (OBPM). As such, the guidelines have provided to doctors clear BP measurement recommendations for managing the white-coat and masked hypertension phenomena in both untreated and treated subjects.
Inadequate evaluation of BP often leads to overdiagnosis, resulting in unnecessary investigation and long-term treatment, or to underdiagnosis with consequent undertreatment and increased risk of cardiovascular disease. Because the 2017 guidelines recommend a more aggressive strategy for treatment initiation and hypertension control, it is imperative that (1) OBPM becomes more standardized, yet feasible for clinical practice; and (2) BP levels are confirmed with out-of-office measurements.
We have critically reviewed the methodological issues of BP measurement and hypertension diagnosis in the 2017 US guidelines, which are the first and essential steps before further evaluation and intervention can be decided. Other important aspects, such as the new definition of hypertension and the treatment BP targets, are not discussed in this article.
Office BP Measurement
The 2017 US guidelines provide detailed instructions for OBPM, including the auscultatory method.1 However, it is now accepted that although in a research laboratory the auscultatory technique remains the reference for testing the accuracy of novel BP measuring devices, in clinical practice it has too many sources of error and therefore electronic (oscillometric) devices are preferable.1 Moreover, the use of electronic devices is currently evidence based, given that all the hypertension outcome trials in the past two decades have used such devices for OBPM. Only, validated upper-arm-cuff devices should be used. …