There is a large market for blood pressure measuring devices not only in clinical medicine but also among the public where the demand for self measurement of blood pressure is growing rapidly. For consumers, whether medical or lay, accuracy should be of prime importance when selecting a device to measure blood pressure. However, most devices have not been evaluated for accuracy independently using the two most widely used protocols: the British Hypertension Society (BHS) protocol and the standard set by the US Association for the Advancement of Medical Instrumentation (AAMI). 1 2 The Working Group on Blood Pressure Monitoring of the European Society of Hypertension has decided to review blood pressure measuring devices regularly to guide purchasers.3 For this first report devices for which there is published evidence of independent validation using these protocols have been surveyed. Because most blood pressure devices have not been independently validated, only a fraction of the many devices available have been surveyed. Devices that have been validated recently for which results have not yet been published were not included, but this shortcoming should be addressed in future.

#### Summary points

Two manual sphygmomanometers have been validated, one is recommended

Five devices for clinical use in hospitals have been validated, two are recommended

23 devices for self measurement of blood pressure have been validated, five are recommended

24 devices for ambulatory measurement of blood pressure have been validated, 16 are recommended

Validations and recommendations will be updated on the BMJ 's website

### Validation standards

In 1987, the American Association for the Advancement of Medical Instrumentation published a standard for sphygmomanometers which included a protocol for evaluating the accuracy of devices.4 In 1990 a protocol was devised by the British Hypertension Society.5 Both protocols have since been revised. 1 2 Since the two protocols can be reconciled the …

https://www.bmj.com/content/bmj/322/7285/531.1.full.pdf

Blood pressure measuring devices: recommendations of the European Society of Hypertension

Background Twenty-four-hour ambulatory blood pressure monitoring (ABPM) is an essential tool in the diagnosis and therapeutic monitoring of arterial hypertension in children. The statistical use of pediatric ABPM reference values has been compromised by the non-Gaussian distribution of 24-h blood pr

Distribution of 24-h ambulatory blood pressure in children: normalized reference values and role of body dimensions

Ambulatory blood pressure monitoring (ABPM) has established roles in the evaluation and management of hypertension in adults but has only been applied to children and adolescents more recently.1 In 2008, the American Heart Association (AHA) issued the first set of consensus recommendations for performance and interpretation of ABPM in pediatrics. Since then, ABPM has found increasing use in children and adolescents, as recently summarized.2 The present document updates the 2008 AHA statement on the use of ABPM in the pediatric population3 with additional data published since the release of that report and also presents a revised interpretation schema. Because no outcome studies are yet available relating ABPM levels in children to outcomes such as myocardial infarction or stroke, these guidelines are largely driven by expert opinion, although they are also informed by available pediatric data on ABPM and surrogate markers of cardiovascular disease.

### Epidemiology of Hypertension

High blood pressure (BP) is the leading risk factor–related cause of death throughout the world, accounting for 12.8% of all deaths, including 51% of stroke deaths and 45% of coronary heart disease deaths.4 In the United States, 33.0% of adults >20 years of age have hypertension.5 As our population continues to age, this will only increase, because 90% of people with normal BP at age 55 years will go on to develop hypertension in their lifetimes.6

The prevalence of hypertension in youths is also on the rise. US National Health and Nutrition Examination Survey (NHANES) data from 1963 to 2002 showed a 2.3% increase in prehypertension and a 1% increase in hypertension from 1988 to 1999, with higher rates in non-Hispanic blacks and Mexican Americans.7 In fact, the entire distribution of childhood BP has shifted upward in the United States by 1.4 mm Hg for systolic BP (SBP) and 3.3 …

Update: Ambulatory Blood Pressure Monitoring in Children and Adolescents A Scientific Statement From the American Heart Association

Throughout the world, 1 in every 4 adults suffers from hypertension,1 a disease that contributes to 49% of ischemic heart disease and 62% of strokes worldwide. Inadequately controlled hypertension is currently the number one attributable risk for death across the globe.2 Data from the Framingham Heart Study predict that 90% of people who are normotensive at age 55 years will go on to develop hypertension in their lifetime.3 Hypertension in youth is also being diagnosed with increasing frequency.4 The global obesity epidemic is leading to a shift in the blood pressure (BP) distribution toward increasing levels in children and adolescents.5 This is particularly relevant because BP levels in the higher end of the distribution track into adulthood,6 resulting in prehypertension, which marks individuals at high risk for progressing to sustained hypertension.7

Autopsy studies such as the Bogalusa Heart Study and the Pathobiologic Determinates of Atherosclerosis in Youth (PDAY) Study have demonstrated increased atherosclerosis at higher BP levels in youth.8,9 Therefore, accurate assessment and management of BP is essential for the prevention of target organ damage.10 Ambulatory BP monitoring (ABPM), which can more precisely characterize changes in BP throughout daily activities,6 has been found to be superior to clinic BP (CBP) monitoring in predicting cardiovascular morbidity and mortality.11 For this reason, ABPM is seeing more widespread use in evaluation for hypertension and risk of end-organ damage in adults.

In children and adolescents, ABPM is gaining acceptance as a useful modality for the evaluation of BP levels in both hypertension research and in the clinic setting.12,13 This statement summarizes the current research and clinical applications of ABPM in children and adolescents and offers recommendations on implementation of ABPM in practice and interpretation of results. Because no outcome studies are yet …

/pdf/ambulatory-blood-pressure-monitoring-in-children-and-31a8l62hyd.pdf

Ambulatory Blood Pressure Monitoring in Children and Adolescents: Recommendations for Standard Assessment A Scientific Statement From the American Heart Association Atherosclerosis, Hypertension, and Obesity in Youth Committee of the Council on Cardiovascular Disease in the Young and the Council for High Blood Pressure Research

Objective: To study the prevalence of hypertension in a cohort of patients using the current strategy of repair in early childhood.

Patients: The cohort of patients with coarctation of the aorta born between 1983 and 1992.

Intervention: Casual (mean of three resting readings) and 24 hour blood pressure were measured in 119 children and compared with data from 1034 normal controls. The arch repair and left ventricular parameters were assessed using Doppler echocardiography.

Results: Median ages at first intervention and at blood pressure measurement were 0.2 years (interquartile range 0.04–2.0) and 12.0 years (9.0–14.5), respectively. Doppler velocity in the descending aorta was significantly associated with blood pressure (r = 0.28, p = 0.002 for casual systolic blood pressure (SBP); r = 0.26, p = 0.005 for mean 24 hour SBP). Patients were classified as having “no” (n = 70) or “mild” (n = 49) arch obstruction. Casual SBP was > 95th centile in 28% (34 of 119) overall and in 21% (15 of 70) of the no arch obstruction group. Mean 24 hour SBP was > 95th centile in 30% (36 of 119) overall and in 19% (13 of 70) of the no obstruction group. The sensitivity and specificity of casual SBP in detecting increased 24 hour SBP were 66% and 88%, respectively.

Conclusions: This unique study of a large cohort of patients treated for coarctation in early childhood showed that a disappointingly high prevalence of hypertension is already apparent in children aged 7–16 years in the absence of significant arch obstruction, whether assessed by 24 hour or by casual blood pressure measurement.

https://heart.bmj.com/content/heartjnl/88/2/163.full.pdf

Prevalence of hypertension in children after early repair of coarctation of the aorta: a cohort study using casual and 24 hour blood pressure measurement

OBJECTIVE To define the range and variability of ambulatory blood pressure in normal schoolchildren. DESIGN Prospective study. METHODS Resting blood pressure of 1121 schoolchildren from Newcastle upon Tyne was recorded. An ambulatory blood pressure device, which uses both auscultatory (Korotkoff) and oscillometric methods of blood pressure measurement, was then put in place for 24 hours. RESULTS The day was divided into three time periods: school, home, and night time. Normal centiles for blood pressure for each of these time periods were obtained and many daytime readings were outside reported normal resting levels. The normal variation of blood pressure was quantified by comparing each of these time periods with the resting readings. Resting systolic blood pressure did not predict 24 hour mean systolic blood pressure. CONCLUSIONS The availability of normal ambulatory blood pressure data on the level and variation of blood pressure in children may facilitate the early identification of hypertension in this age group.

https://adc.bmj.com/content/archdischild/80/6/529.full.pdf

Ambulatory blood pressure in schoolchildren.

The purpose of this study was to assess the accuracy of an ambulatory monitor (Takeda 2421; A&D company) which measures blood pressure using oscillometric and Korotkoff methods, in children. Blood pressure was measured simultaneously by the device and two observers in 529 children aged 7-15 years. The Korotkoff method received BHS grade A for sitting and standing readings in all age groups except for age 13-15 years (grade C). The diastolic readings (phase V) received grade B for sitting and C when standing. The oscillometric method received grade C or worse for systolic and diastolic blood pressure in both sitting and standing positions except for systolic readings in those aged 13-15 years (grade B). During the ambulatory phase 30% of the Korotkoff readings and 4% of the oscillometric readings gave an error code. The Takeda 2421 ambulatory monitor achieved generally satisfactory grades using the Korotkoff system but the oscillometric readings were generally unacceptable. Ambulatory devices should be specifically validated in children before being accepted into clinical paediatric practice.

Validation of the Takeda 2421 ambulatory blood pressure monitor in children

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Ambulatory blood pressure in schoolchildren.

Validation of the Takeda 2421 ambulatory blood pressure monitor in children