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  • Review Article
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Blood pressure and its variability: classic and novel measurement techniques

Nature Reviews Cardiology volume 19, pages 643–654 (2022)Cite this article

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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.

Key points

  • Although the dynamic nature of blood pressure (BP) is well-known, hypertension guidelines recommend using the average values of static BP readings (office or out-of-office), specifically aiming to level the fluctuations and peaks in BP readings.

  • All current BP measurement methods have imperfect reproducibility owing to the continuous fluctuation in BP readings, making it difficult to accurately diagnose hypertension.

  • Accumulating evidence from clinical trials, large registries and meta-analyses shows that increased BP variability predicts cardiovascular outcome, independently of the average BP values.

  • To date, BP variability is overlooked, with limited application in clinical practice, probably owing to a variety of complex non-standardized BP variability assessment methods and indices, and uncertain thresholds and clinical usefulness.

  • Novel cuffless wearable BP technologies can provide very large numbers of readings for days and months without the discomfort of traditional BP monitoring devices, and have the potential to replace current BP methods, once accuracy issues are resolved and their clinical usefulness is proved.

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Fig. 1: History of blood pressure assessment and technology development.
Fig. 2: Short-term and long-term blood pressure variability.
Fig. 3: The concept of time at target blood pressure levels.
Fig. 4: Advantages and disadvantages of classic and novel blood pressure monitoring methods and capacity to capture blood pressure variability.
Fig. 5: Capacity of classic blood pressure monitoring methods to assess blood pressure variability.

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Authors and Affiliations

  1. School of Population Health, University of New South Wales, The George Institute for Global Health, Sydney, Australia

    Aletta E. Schutte

  2. Hypertension in Africa Research Team, MRC Unit for Hypertension and CVD, North-West University, Potchefstroom, South Africa

    Aletta E. Schutte

  3. Hypertension Centre STRIDE-7, School of Medicine, Third Department of Medicine, Sotiria Hospital, National and Kapodistrian University of Athens, Athens, Greece

    Anastasios Kollias & George S. Stergiou

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A.E.S. has received speaker honoraria from Omron and IEM and has conducted accuracy studies for Aktiia. A.K. has contributed to validation studies for InBody and Microlife. G.S.S. has conducted research for and advised Huawei, InBody and Microlife.

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Schutte, A.E., Kollias, A. & Stergiou, G.S. Blood pressure and its variability: classic and novel measurement techniques. Nat Rev Cardiol 19, 643–654 (2022). https://doi.org/10.1038/s41569-022-00690-0

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