The Japanese Society of Hypertension (JSH) Guidelines have emphasized the significance of self-measured blood pressure (BP), also referred to as home BP measurement (HBPM), over traditional office BP measurement, especially since 2014 [1, 2]. This position is upheld in the updated JSH 2025 Guidelines, as HBPM offers highly reproducible BP values and is more effective than office BP measurements in predicting cardiovascular outcomes and managing hypertension [3]. These conclusions are supported by several extensive large-scale epidemiological studies, including the Ohasama Study [4,5,6], and recent systematic reviews demonstrating that HBPM yields a greater antihypertensive effect than management based on office BP [7, 8]. Meanwhile, the perspectives on HBPM in the JSH Guidelines vary significantly from those outlined in other major international guidelines, namely the European Society of Hypertension (ESH) 2023 Guidelines for the Management of Arterial Hypertension [9], the European Society of Cardiology (ESC) 2024 Guidelines for the Management of Elevated Blood Pressure and Hypertension [10], and the American Heart Association/American College of Cardiology (AHA/ACC) 2025 Guidelines for the Management of Hypertension [11], as discussed in this review.

Position of home BP in hypertension diagnosis

Although the JSH Guidelines adopt office BP as the diagnostic standard, they have clearly stated since the 2014 edition that “when there is a discrepancy in diagnosis between office BP and home BP, a home BP-based diagnosis should have priority” [1, 2].

The ESH 2023, ESC 2024, and AHA/ACC 2025 Guidelines assert that office BP measurements remain the fundamental basis for diagnosis [9,10,11]. Although it is commonly stated that the use of out-of-office BP measurements, including HBPM, is recommended to identify white-coat hypertension, there are some differences in statements regarding the utilization of HBPM. The ESH 2023 Guidelines state that office BP ≥ 140/90 mmHg should be confirmed by at least two to three visits for the diagnosis of hypertension and recommend the use of ABPM, HBPM, or both [9]. However, they highlighted the feasibility challenges of collecting out-of-office BP data from a diverse range of patients in clinical practice and concerns regarding the limited evidence on the use of out-of-office BP measurements for diagnosing hypertension. In the ESC 2024 Guidelines, out-of-office BP measurement (using HBPM or ABPM) is recommended for the diagnosis of hypertension when office BP is ≥140/90 mmHg, or when elevated BP (120–139/70–89 mmHg) is accompanied by high cardiovascular risk conditions or a 10-year cardiovascular disease risk estimated by the Systematic COronary Risk Evaluation 2 (SCORE2) or SCORE2–Older Persons (SCORE2-OP) algorithms of ≥10%, or 5–<10% with additional risk modifiers [10]. The AHA/ACC 2025 Guidelines do not contain any direct statements regarding the use of HBPM in the evaluation and diagnosis of hypertension [11]. Meanwhile, the guidelines acknowledge that out-of-office BP measurements enhance the accuracy and precision of detecting a patient’s true and usual BP [11].

Reference values for home BP according to office BP

According to the JSH Guidelines, the diagnostic reference value for hypertension based on HBPM corresponding to an office BP of 140/90 mmHg is 135/85 mmHg. This threshold is consistent with the ESH and ESC Guidelines [9]. Meanwhile, for BP classifications other than this hypertension threshold, differences were observed among the guidelines regarding home BP values corresponding to various office BP values.

The JSH Guidelines adopt criteria indicating that systolic and diastolic home BP values should be 5 mmHg lower than the corresponding office BP values. The recommended home BP values are 135/85 mmHg, 125/75 mmHg, and 115/75 mmHg, corresponding to office BP values of 140/90 mmHg, 130/80 mmHg, and 120/80 mmHg, respectively [3]. These values were mainly derived from the findings of international population-based individual-level meta-analyses of patients not treated with antihypertensive medication [12], which determined the home BP values that correspond to the equivalent cardiovascular risk for specific office BP measurements. Although they differ slightly from the actual equivalent values, the JSH classification considers values ending in five or zero because of the need to classify BP into comprehensive numerical values for ease of understanding in clinical and public health settings.

According to international guidelines, the differences between office and home BP thresholds tend to converge at lower BP levels [9, 10]. The ESC 2024 Guidelines provide a corresponding table and address the category of “elevated BP” [10]. They defined a home BP of 120–134/70–84 mmHg, corresponding to an office BP of 120–139/70–89 mmHg, for the classification of elevated BP. The lower limit for elevated BP was identical between office and home measurements, both set at 120/70 mmHg [10]. The AHA/ACC 2025 Guidelines indicate that an office BP of 120/80 mmHg corresponds to a home BP of 120/80 mmHg, and an office BP of 130/80 mmHg corresponds to a home BP of 130/80 mmHg [11]. The ESH 2023 Guidelines do not provide corresponding home BP values for office BP levels other than 140/90 mmHg [9]. In developing their BP classifications, the ESC 2024 and ESH 2023 Guidelines primarily stated that they based their BP categorization on descriptive data from randomized controlled trials involving treated patients with hypertension [9, 10] rather than on prognostic evidence in untreated individuals in the general population, as in the JSH guidelines.

Home BP as a therapeutic target value

A unique feature of the JSH Guidelines is that they explicitly define the target levels for home BP as part of the treatment goals. This is because studies conducted in Japan have reported that home BP has a stronger prognostic value than office BP, even among treated patients [13,14,15]. Furthermore, the JSH Guidelines have uniquely conducted meta-analyses and indicated that HBPM-guided antihypertensive treatment can lower ambulatory BP compared with office BP-guided antihypertensive treatment [7, 16]. In contrast, other major international guidelines primarily use office BP as the basis for treatment targets. The ESH 2023 Guidelines highlight that while HBPM and ABPM provide better prognostic information than office BP, there is still limited evidence to determine whether treatment guided by out-of-office BP leads to greater cardiovascular protection or what the optimal out-of-office BP targets should be [9].

Advantages of HBPM

HBPM is a well-known method for identifying BP phenotypes, such as the white-coat and masked (or masked uncontrolled) hypertension. HBPM is recognized as a reliable method for assessing individuals’ BP for long-term and day-to-day BP variability [9,10,11].

International guidelines state that HBPM is beneficial for hypertension control, especially when integrated with patient education, telemonitoring, team-based care, and digital health interventions [9,10,11]. Furthermore, the clinical question of whether HBPM using an upper-arm cuff device can lower BP in adults was included in the JSH 2025 revision. A meta-analysis on this topic demonstrated that home BP self-measurement can effectively lower BP, particularly when combined with remote monitoring or healthcare provider involvement and when using upper-arm cuff devices [8].

Current issues for HBPM

Across international guidelines, common concerns regarding HBPM include the use of invalid devices and inaccurate measurement techniques [9,10,11]. In contrast, the JSH considers this issue less problematic because most devices manufactured in Japan are validated per international standards. In addition, the high affinity of the Japanese population for self-monitoring [17] makes HBPM recommendations particularly feasible in Japan, contributing to the strong emphasis of the JSH Guidelines on HBPM. According to the National Health and Nutrition Survey, over 70% of hypertensive individuals own a home blood pressure monitor [18, 19], and data also indicate that over 4 million home blood pressure monitors are sold annually [20].

Regarding HBPM devices, the JSH Guidelines specifically recommend the use of upper-arm devices. Except for individuals with extremely thick and short upper arms, wrist devices are not recommended because of the difficulty in maintaining the wrist position at the heart level (hydrostatic pressure correction) and anatomical challenges in achieving consistent arterial compression. Validation information can be obtained from official sources, including the JSH website (https://www.jpnsh.jp/com_ac_wg1.html) in Japan and the STRIDE BP website (https://www.stridebp.org/).

According to the ESH 2023 Guidelines, the limitations of HBPM include the need for appropriate patient training and the potential to induce anxiety or promote excessive self-measurement, which may lead to self-adjustment of therapy [9]. The ESC 2024 Guidelines note that only static BP at rest is typically available with HBPM, which represents another crucial disadvantage compared with ABPM [10].

Differences in HBPM conditions

Table 1 summarizes the major conditions for HBPM according to these guidelines. The JSH 2025 Guidelines outline the detailed conditions for morning HBPM as follows: within 1 h after waking up, after urination, before medication and breakfast, and after 1–2 min of rest. The early morning period is characterized by heightened sympathetic nervous system activity and increased secretion of endocrine hormones such as aldosterone. By setting the measurement time window to “within 1 h after waking up,” BP characteristics during this critical morning period can be captured, which is clinically relevant for cardiovascular risk assessment. Meanwhile, the description of the morning HBPM timing in the ESH 2023 Guidelines is concise, specifying only that measurements should be taken “before drug intake if treated” [9]. The ESC 2024 Guideline states that “morning HBPM readings should be obtained before breakfast and before intake of medication but not immediately after awakening” [10]. The AHA/ACC 2025 Guideline adds “after urination” as an additional condition in its figure illustration [11]. Regarding evening measurements, a few international guidelines provide specific instructions. In Japan, the JSH 2025 Guidelines define evening measurements as being taken before bedtime but indicate additional conditions, including “before dinner, before taking evening medication, before bathing, or before drinking alcohol.” The latter two additional conditions are based on the cultural habits of evening bathing and alcohol consumption, which are less common in Western countries. Evening bathing and alcohol consumption can cause acute BP fluctuations that may confound the interpretation of true BP status. By instructing patients to avoid BP measurement immediately after bathing or alcohol intake, clinicians can obtain stable evening BP values that are unaffected by these conditions.

Table 1 Summary of HBPM conditions recommended by guidelines
Full size table

The JSH Guidelines recommend taking average measurements in the morning and evening for at least 5 days, preferably 7 days. This point is supported by the previous report demonstrating that, when comparing home BP values obtained from two separate measurement periods, repeatability improved up to 5 days of measurement, with diminishing additional benefits thereafter [21]. The ESH 2023, ESC 2024, and AHA/ACC 2025 Guidelines recommend performing HBPM two times daily for at least 3 days, preferably 7 days [9,10,11]. The ESH 2023 Guidelines recommend the same measurement protocol but specify that the readings from the first day should be discarded [9].

Conclusion

This article highlights the differences in attitudes toward HBPM between the JSH and major international hypertension guidelines. Over the past few decades, the use of HBPM in hypertension management has grown steadily, leading to a corresponding increase in HBPM-related recommendations in international guidelines. In this context, the JSH Guidelines can be regarded as progressive in positioning HBPM as the main element of hypertension management. The widespread adoption of HBPM in Japan may have been promoted by its close compatibility with the characteristics of Japanese society [17].