Misclassification and discordance of measured blood pressure from patient’s true blood pressure in current clinical practice: a clinical trial simulation case study

  • Yuyan Jin
  • Robert Bies
  • Marc R. Gastonguay
  • Norman Stockbridge
  • Jogarao Gobburu
  • Rajanikanth Madabushi
Original Paper


Treatment decisions for hypertension using sphygmomanometer based measurements and the current clinical practice paradigm do not account for the timing of blood pressure (BP) measurement. This study aimed to evaluate the clinical implications of discordance between measured and true BP, to quantify BP misclassification rate at a typical clinical visit in current clinical practice, and to propose a BP calibration system to decrease the impact of timing of BP measurement. A clinical trial simulation case study was performed using an in silico Monte Carlo Simulation approach. The time-courses of BPs with and without an antihypertensive treatment effect were simulated from a baseline BP model combined with an antihypertensive PK/PD model. Virtual subject characteristics were sampled from the FDA internal database. The baseline BP model was qualified using observed 24 h ambulatory BP monitoring (ABPM) data from 225 subjects by a visual predictive check as well as a global sensitivity analysis. First of all, our results showed that the measured cuff BP in current typical clinical practice deviated from the true values. (1) Cuff BP deviated from the true values by more than 5 mmHg in 57 % (95 % CI: 54–61 %) of patients and more than 10 mmHg in 26 % (95 % CI: 22–32 %) of patients respectively. (2) These discordances were reduced to 28 % (deviation ≥5 mmHg, 95 % CI: 18–40 %) and 9 % (deviation ≥10 mmHg, 95 % CI: 4–18%) of patients assuming perfect sphygmomanometer measurement and thus represent the contribution of ignoring the daily circadian rhythm of BP. Secondly, our results showed 23–32 % of patients were misclassified to an incorrect BP category for a casual clinical visit based on JNC 7 guideline. In addition, the accuracy of the measured cuff BP varied by time of clinic visit. Specifically, 11:00 AM to 3:00 PM was identified to be the better time frame, while times before 9:00 AM were the worst time frame. Therefore, clinic visit time may need to be adjusted accordingly. Finally, we proposed an easy BP calibration method for clinic use to adjust for time of day differences due to circadian variability in case that the desirable clinic visit time cannot be tailored for practical reasons.


Hypertension Sphygmomanometer Circadian rhythm Modeling and simulation Blood pressure misclassification Blood pressure calibration Public health 

Supplementary material

10928_2012_9250_MOESM1_ESM.doc (347 kb)
Supplementary material 1 (DOC 347 kb)


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Copyright information

© Springer Science+Business Media, LLC (outside the USA) 2012

Authors and Affiliations

  • Yuyan Jin
    • 1
  • Robert Bies
    • 2
  • Marc R. Gastonguay
    • 3
  • Norman Stockbridge
    • 4
  • Jogarao Gobburu
    • 5
  • Rajanikanth Madabushi
    • 4
  1. 1.PharmaTherapeutics Clinical Research, Clinical PharmacologyPfizer Inc.GrotonUSA
  2. 2.Division of Clinical PharmacologyIndiana University, School of MedicineIndianapolisUSA
  3. 3.Metrum InstituteTariffvilleUSA
  4. 4.U.S. Food and Drug AdministrationSilver SpringUSA
  5. 5.Center for Translational Medicine, Schools of Pharmacy & MedicineUniversity of MarylandBaltimoreUSA

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