A Meta-analysis to Determine the Validity of Taking Blood Pressure Using the Indirect Cuff Method
Purpose of Review
The purpose of this meta-analysis was to compare the magnitude of systematic bias (mean difference) and random error (standard deviation of mean difference) between the cuff method of indirect blood pressure and directly measured intra-arterial pressure.
Blood pressure is almost exclusively assessed using the indirect cuff method; however, numerous individual studies have questioned the validity relative to directly measured intra-arterial blood pressure.
PubMed, SportsDiscus, and Scopus were searched through February 2018. Data were analyzed using a random effects model. A total of 62 studies met the inclusion criteria for quantitative analysis including 103 effect sizes for systolic and 114 effect sizes for diastolic blood pressure. Indirect measures of systolic blood pressure were underestimated (− 4.55 (95% CI = − 5.58 to − 3.53) mmHg), while diastolic blood pressure was overestimated (6.20 (95% CI = 5.09 to 7.31) mmHg). The random error (SD units) was 10.32 (95% CI = 9.29 to 11.36) for systolic and 7.92 (95% CI = 7.35 to 8.50) for diastolic blood pressure which corresponds to an estimation accuracy (95% confidence) of ± 20.2 mmHg for systolic blood pressure and ± 15.5 mmHg for diastolic blood pressure. These data indicate that it may be difficult to accurately estimate intra-arterial blood pressure using the cuff method. These results not only have implications for clinicians in diagnosing hypertension, but also may detail a potential underestimation of the association between blood pressure and numerous other health outcomes found in epidemiological studies.
KeywordsArtery Cardiovascular Diastolic Systolic Hypertension
American Association for the Advancement of Medical Instrumentation
British Hypertension Society
JPL and TA designed the study. SJD extracted the data for analysis. SJD analyzed the data. SJD drafted the initial manuscript. SJD, JPL, TA, and MK revised the manuscript and contributed to the intellectual content.
Compliance with Ethical Standards
Conflict of Interest
The authors declare no conflicts of interest relevant to this manuscript.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance
- 2.• Nwankwo T, Yoon SS, Burt V, Gu Q. Hypertension among adults in the United States: national health and nutrition examination survey, 2011-2012. NCHS Data Brief. 2013:1–8 This study details the prevalence of hypertension (using the cuff method) as well as the large proportion of hypertensive individuals taking medications to lower their blood pressure. Google Scholar
- 4.• O’Brien E, Waeber B, Parati G, Staessen J, Myers MG. Blood pressure measuring devices: recommendations of the European Society of Hypertension. BMJ. 2001;322:531–6 This paper provides a list of blood pressure devices that meet the AAMI and BHS recommendations. Notably, the blood pressure devices are compared to the auscultation method of taking indirect blood pressure. PubMedPubMedCentralGoogle Scholar
- 10.Borow KM, Newburger JW. Noninvasive estimation of central aortic pressure using the oscillometric method for analyzing systemic artery pulsatile blood flow: comparative study of indirect systolic, diastolic, and mean brachial artery pressure with simultaneous direct ascending aortic pressure measurements. Am Heart J. 1982;103:879–86.PubMedGoogle Scholar
- 12.Breit SN, O’Rourke MF. Comparison of direct and indirect arterial pressure measurements in hospitalized patients. Aust NZ J Med. 1974;4:485–91.Google Scholar
- 18.Forsberg SA, Guzman M, Berlind S. Validity of blood pressure measurement with cuff in the arm and forearm. J Intern Med. 1970;188:389–96.Google Scholar
- 27.Kaijser L. The indirect method of recording blood pressure during exercise—can the diastolic pressure be measured? Clin Physiol. 2008;7:175–9.Google Scholar
- 28.Karlefors T, Nilsén R, Westling H. On the accuracy of indirect auscultatory blood pressure measurements during exercise. Acta Medica Scand Suppl. 1966;449:81–7.Google Scholar
- 31.Kotte JH, Iglauer A, McGuire J. Measurements of arterial blood pressure in the arm and leg: comparison of sphygmomanometric and direct intra-arterial pressures, with special attention to their relationship in aortic regurgitation. Am Heart J. 1944;28:476–90.Google Scholar
- 45.O’Callaghan WG, Fitzgerald DJ, O’Malley K, O’Brien E. Accuracy of indirect blood pressure measurement in the elderly. Br Med J (Clin Res Ed). 1983;286:1545–6.Google Scholar
- 54.Saghiv M, Goldhammer E, Sagiv M, Ben-Sira D, Hanson P, et al. J Clin Exp Pharmacol. 2016;6:1–5.Google Scholar
- 67.• Wheatley CM, Snyder EM, Joyner MJ, Johnson BD, Olson TP. Comparison of intra-arterial and manual auscultation of blood pressure during submaximal exercise in humans. Appl Physiol Nutr Metab. 2013;38:537–44 This is the most recent paper that was included in the quantitative analysis that allows for a direct comparison of invasive and non-invasive blood pressure measurements. PubMedGoogle Scholar
- 69.Marín-Martínez F, Sánchez-Meca J. Weighting by inverse variance or by sample size in random-effects meta-analysis. Educ Psychol Meas. 2010;70:56–73.Google Scholar
- 74.Clancy F. Factors affecting correlation between direct and indirect arterial blood pressure measurements. J Clin Eng. 1978;3:49–51.Google Scholar