A Meta-analysis to Determine the Validity of Taking Blood Pressure Using the Indirect Cuff Method

  • Scott J. Dankel
  • Minsoo Kang
  • Takashi Abe
  • Jeremy P. LoennekeEmail author
Guidelines, Clinical Trials, and Meta-Analysis (William J. Kostis, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Guidelines/Clinical Trials/Meta-Analysis


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.

Recent Findings

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.


Artery Cardiovascular Diastolic Systolic Hypertension 



American Association for the Advancement of Medical Instrumentation


British Hypertension Society


Confidence interval


Effect size


Author Contributions

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

  1. 1.
    Booth J. A short history of blood pressure measurement. Proc R Soc Med. 1977;70:793–9.PubMedPubMedCentralGoogle Scholar
  2. 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
  3. 3.
    • Kannel WB. Blood pressure as a cardiovascular risk factor: prevention and treatment. JAMA. 1996;275:1571–6 This prospective analysis of the Framingham Study details the increased risk of various cardiovascular events that accompany hypertension. CrossRefGoogle Scholar
  4. 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. CrossRefGoogle Scholar
  5. 5.
    Nash CA. Ensuring the accuracy of digital sphygmomanometers for home use. Mayo Clin Proc. 1994;69:1006–10.CrossRefGoogle Scholar
  6. 6.
    Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet. 1986;1:307–10.CrossRefGoogle Scholar
  7. 7.
    Araghi A, Bander JJ, Guzman JA. Arterial blood pressure monitoring in overweight critically ill patients: invasive or noninvasive? Crit Care. 2006;10:R64.CrossRefGoogle Scholar
  8. 8.
    Arnold JM, McDevitt DG. Indirect blood pressure measurement during intravenous isoprenaline infusions. Br J Clin Pharmacol. 1985;19:114–6.CrossRefGoogle Scholar
  9. 9.
    Belmin J, Visintin JM, Salvatore R, Sebban C, Moulias R. Osler’s maneuver: absence of usefulness for the detection of pseudohypertension in an elderly population. Am J Med. 1995;98:42–9.CrossRefGoogle Scholar
  10. 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.CrossRefGoogle Scholar
  11. 11.
    Bos WJ, van Goudoever J, Wesseling KH, Rongen GA, Hoedemaker G, Lenders JW, et al. Pseudohypertension and the measurement of blood pressure. Hypertension. 1992;20:26–31.CrossRefGoogle Scholar
  12. 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.CrossRefGoogle Scholar
  13. 13.
    Brown MA, Reiter L, Smith B, Buddle ML, Morris R, Whitworth JA. Measuring blood pressure in pregnant women: a comparison of direct and indirect methods. Am J Obstet Gynecol. 1994;171:661–7.CrossRefGoogle Scholar
  14. 14.
    Burch GE, Shewey L. Sphygmomanometric cuff size and blood pressure recordings. JAMA. 1973;225:1215–8.CrossRefGoogle Scholar
  15. 15.
    Byra-Cook CJ, Dracup KA, Lazik AJ. Direct and indirect blood pressure in critical care patients. Nurs Res. 1990;39:285–8.CrossRefGoogle Scholar
  16. 16.
    Fagher B, Magnússon J, Thulin T. Direct and indirect blood pressure in normotensive and hypertensive subjects. J Intern Med. 1994;236:85–90.CrossRefGoogle Scholar
  17. 17.
    Finnie KJ, Watts DG, Armstrong PW. Biases in the measurement of arterial pressure. Crit Care Med. 1984;12:965–8.CrossRefGoogle Scholar
  18. 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
  19. 19.
    Ganio MS, Brothers RM, Lucas RAI, Hastings JL, Crandall CG. Validity of auscultatory and Penaz blood pressure measurements during profound heat stress alone and with an orthostatic challenge. Am J Physiol Regul Integr Comp Physiol. 2011;301:R1510–6.CrossRefGoogle Scholar
  20. 20.
    Goldstein S, Killip T. Comparison of direct and indirect arterial pressures in aortic regurgitation. N Engl J Med. 1962;267:1121–4.CrossRefGoogle Scholar
  21. 21.
    Gould BA, Hornung RS, Kieso HA, Altman DG, Cashman PM, Raftery EB. Evaluation of the Remler M2000 blood pressure recorder. Comparison with intraarterial blood pressure recordings both at hospital and at home. Hypertension. 1984;6:209–15.CrossRefGoogle Scholar
  22. 22.
    Gravlee GP, Brockschmidt JK. Accuracy of four indirect methods of blood pressure measurement, with hemodynamic correlations. J Clin Monit. 1990;6:284–98.CrossRefGoogle Scholar
  23. 23.
    Henschel A, De La Vega F, Taylor HL. Simultaneous direct and indirect blood pressure measurements in man at rest and work. J Appl Physiol. 1954;6:506–8.CrossRefGoogle Scholar
  24. 24.
    Holland WW, Humerfelt S. Measurement of blood-pressure: comparison of intra-arterial and cuff values. Br Med J. 1964;2:1241–3.CrossRefGoogle Scholar
  25. 25.
    Horváth IG, Németh A, Lenkey Z, Alessandri N, Tufano F, Kis P, et al. Invasive validation of a new oscillometric device (arteriograph) for measuring augmentation index, central blood pressure and aortic pulse wave velocity. J Hypertens. 2010;28:2068–75.CrossRefGoogle Scholar
  26. 26.
    Hunyor S, Nyberg G. Comparison of intra-arterial and indirect blood pressures at rest and during isometric exercise in hypertensive patients before and after metoprolol. Br J Clin Pharmacol. 1978;6:109–14.CrossRefGoogle Scholar
  27. 27.
    Kaijser L. The indirect method of recording blood pressure during exercise—can the diastolic pressure be measured? Clin Physiol. 2008;7:175–9.CrossRefGoogle Scholar
  28. 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
  29. 29.
    Karvonen MJ, Telivuo LJ, Järvinen EJ. Sphygmomanometer cuff size and the accuracy of indirect measurement of blood pressure. Am J Cardiol. 1964;13:688–93.CrossRefGoogle Scholar
  30. 30.
    Kirshon B, Lee W, Cotton DB, Giebel R. Indirect blood pressure monitoring in the postpartum patient. Obstet Gynecol. 1987;70:799–801.PubMedGoogle Scholar
  31. 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.CrossRefGoogle Scholar
  32. 32.
    Kuwajima I, Hoh E, Suzuki Y, Matsushita S, Kuramoto K. Pseudohypertension in the elderly. J Hypertens. 1990;8:429–32.CrossRefGoogle Scholar
  33. 33.
    Lewis RR, Evans PJ, McNabb WR, Padayachee TS. Comparison of indirect and direct blood pressure measurements with Osler’s manoeuvre in elderly hypertensive patients. J Hum Hypertens. 1994;8:879–85.PubMedGoogle Scholar
  34. 34.
    Manios E, Vemmos K, Tsivgoulis G, Barlas G, Eleni K, Spengos K, et al. Comparison of noninvasive oscillometric and intra-arterial blood pressure measurements in hyperacute stroke. Blood Press Monit. 2007;12:149–56.CrossRefGoogle Scholar
  35. 35.
    Manolio TA, Fishel SC, Beattie C, Torres J, Christopherson R, Merritt WT, et al. Evaluation of the Dinamap continuous blood pressure monitor. Am J Hypertens. 1988;1:161S–7S.CrossRefGoogle Scholar
  36. 36.
    Marks LA, Groch A. Optimizing cuff width for noninvasive measurement of blood pressure. Blood Press Monit. 2000;5:153–8.CrossRefGoogle Scholar
  37. 37.
    McMahon N, Hogg LA, Corfield AR, Exton AD. Comparison of non-invasive and invasive blood pressure in aeromedical care. Anaesthesia. 2012;67:1343–7.CrossRefGoogle Scholar
  38. 38.
    Melamed R, Johnson K, Pothen B, Sprenkle MD, Johnson PJ. Invasive blood pressure monitoring systems in the ICU: influence of the blood-conserving device on the dynamic response characteristics and agreement with noninvasive measurements. Blood Press Monit. 2012;17:179–83.CrossRefGoogle Scholar
  39. 39.
    Messerli FH, Ventura HO, Amodeo C. Osler’s maneuver and pseudohypertension. N Engl J Med. 1985;312:1548–51.CrossRefGoogle Scholar
  40. 40.
    Nagle FJ, Naughton J, Balke B. Comparisons of direct and indirect blood pressure with pressure-flow dynamics during exercise. J Appl Physiol. 1966;21:317–20.CrossRefGoogle Scholar
  41. 41.
    Nielsen PE, Janniche H. The accuracy of auscultatory measurement of arm blood pressure in very obese subjects. Acta Med Scand. 1974;195:403–9.CrossRefGoogle Scholar
  42. 42.
    Nielsen PE, Larsen B, Holstein P, Poulsen HL. Accuracy of auscultatory blood pressure measurements in hypertensive and obese subjects. Hypertension. 1983;5:122–7.CrossRefGoogle Scholar
  43. 43.
    Norman E, Gadaleta D, Griffin CC. An evaluation of three blood pressure methods in a stabilized acute trauma population. Nurs Res. 1991;40:86–9.CrossRefGoogle Scholar
  44. 44.
    Nystrom E, Reid KH, Bennett R, Couture L, Edmonds HL. A comparison of two automated indirect arterial blood pressure meters: with recordings from a radial arterial catheter in anesthetized surgical patients. Anesthesiology. 1985;62:526–30.CrossRefGoogle Scholar
  45. 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.CrossRefGoogle Scholar
  46. 46.
    Ochiai H, Miyazaki N, Miyata T, Mitake A, Tochikubo O, Ishii M. Assessment of the accuracy of indirect blood pressure measurements. Jpn Heart J. 1997;38:393–407.CrossRefGoogle Scholar
  47. 47.
    Oliner CM, Elliott WJ, Gretler DD, Murphy MB. Low predictive value of positive Osler maneuver for diagnosing pseudohypertension. J Hum Hypertens. 1993;7:65–70.PubMedGoogle Scholar
  48. 48.
    Penny JA, Shennan AH, Halligan AW, Taylor DJ, de Swiet M, Anthony J. The relative accuracy of sequential same-arm and simultaneous opposite-arm measurements for the intra-arterial validation of blood pressure monitors. Blood Press Monit. 1999;4:91–5.CrossRefGoogle Scholar
  49. 49.
    Raftery EB, Gould BA. The effect of placebo on indirect and direct blood pressure measurements. J Hypertens Suppl. 1990;8:S93–100.PubMedGoogle Scholar
  50. 50.
    Rasmussen PH, Staats BA, Driscoll DJ, Beck KC, Bonekat HW, Wilcox WD. Direct and indirect blood pressure during exercise. Chest. 1985;87:743–8.CrossRefGoogle Scholar
  51. 51.
    Roberts LN, Smiley JR, Manning GW. A comparison of direct and indirect blood-pressure determinations. Circulation. 1953;8:232–42.CrossRefGoogle Scholar
  52. 52.
    Rossen NB, Laugesen E, Peters CD, Ebbehøj E, Knudsen ST, Poulsen PL, et al. Invasive validation of arteriograph estimates of central blood pressure in patients with type 2 diabetes. Am J Hypertens. 2014;27:674–9.CrossRefGoogle Scholar
  53. 53.
    Russell AE, Wing LM, Smith SA, Aylward PE, McRitchie RJ, Hassam RM, et al. Optimal size of cuff bladder for indirect measurement of arterial pressure in adults. J Hypertens. 1989;7:607–13.CrossRefGoogle Scholar
  54. 54.
    Saghiv M, Goldhammer E, Sagiv M, Ben-Sira D, Hanson P, et al. J Clin Exp Pharmacol. 2016;6:1–5.Google Scholar
  55. 55.
    Sagiv M, Ben-Sira D, Goldhammer E. Direct vs. indirect blood pressure measurement at peak anaerobic exercise. Int J Sports Med. 1999;20:275–8.CrossRefGoogle Scholar
  56. 56.
    Sagiv M, Hanson PG, Ben-Sira D, Nagle FJ. Direct vs indirect blood pressure at rest and during isometric exercise in normal subjects. Int J Sports Med. 1995;16:514–8.CrossRefGoogle Scholar
  57. 57.
    Simpson JA, Jamieson G, Dickhaus DW, Grover RF. Effect of size of cuff bladder on accuracy of measurement of indirect blood pressure. Am Heart J. 1965;70:208–15.CrossRefGoogle Scholar
  58. 58.
    Spence JD, Sibbald WJ, Cape RD. Pseudohypertension in the elderly. Clin Sci Mol Med Suppl. 1978;4:399s–402s.PubMedGoogle Scholar
  59. 59.
    Stolt M, Sjönell G, Aström H, Hansson L. Factors affecting the validity of the standard blood pressure cuff. Clin Physiol. 1993;13:611–20.CrossRefGoogle Scholar
  60. 60.
    Stolt M, Sjönell G, Aström H, Rössner S, Hansson L. Improved accuracy of indirect blood pressure measurement in patients with obese arms. Am J Hypertens. 1993;6:66–71.CrossRefGoogle Scholar
  61. 61.
    Turjanmaa V. Determination of blood pressure level and changes in physiological situations: comparison of the standard cuff method with direct intra-arterial recording. Clin Physiol. 1989;9:373–87.CrossRefGoogle Scholar
  62. 62.
    Ulrych M, Burianová B, Hornych A, Mydlík M, Dousa T, Hejl Z. Comparison of direct and indirect methods of measurement of arterial blood pressure in man. Cor Vasa. 1966;8:77–88.PubMedGoogle Scholar
  63. 63.
    Vardan S, Mookherjee S, Warner R, Smulyan H. Systolic hypertension. Direct and indirect BP measurements. Arch Intern Med. 1983;143:935–8.CrossRefGoogle Scholar
  64. 64.
    Weber F, Lindemann M, Erbel R, Philipp T. Indirect and direct simultaneous, comparative blood pressure measurements with the Bosotron 2 device. Kidney Blood Press Res. 1999;22:166–71.CrossRefGoogle Scholar
  65. 65.
    Weisser B, Velling P, Geller C, Kraft K, Göbel B, Vetter H, et al. Pseudohypertension in hypertensive patients on multiple drug therapy. J Hypertens Suppl. 1990;8:S79–81.PubMedGoogle Scholar
  66. 66.
    Whalen P, Ream AK. A quantitative evaluation of the Hewlett-Packard 78354A noninvasive blood pressure meter. J Clin Monit. 1988;4:21–30.CrossRefGoogle Scholar
  67. 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. CrossRefGoogle Scholar
  68. 68.
    White WB, Lund-Johansen P, Omvik P. Assessment of four ambulatory blood pressure monitors and measurements by clinicians versus intraarterial blood pressure at rest and during exercise. Am J Cardiol. 1990;65:60–6.CrossRefGoogle Scholar
  69. 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.CrossRefGoogle Scholar
  70. 70.
    White WB, Berson AS, Robbins C, Jamieson MJ, Prisant LM, Roccella E, et al. National standard for measurement of resting and ambulatory blood pressures with automated sphygmomanometers. Hypertension. 1993;21:504–9.CrossRefGoogle Scholar
  71. 71.
    O’Brien E, Petrie J, Littler W, de Swiet M, Padfield PL, O’Malley K, et al. The British hypertension society protocol for the evaluation of automated and semi-automated blood pressure measuring devices with special reference to ambulatory systems. J Hypertens. 1990;8:607–19.CrossRefGoogle Scholar
  72. 72.
    Frese EM, Fick A, Sadowsky HS. Blood pressure measurement guidelines for physical therapists. Cardiopulm Phys Ther J. 2011;22:5–12.CrossRefGoogle Scholar
  73. 73.
    Sacks AH. Indirect blood pressure measurements: a matter of interpretation. Angiology. 1979;30:683–95.CrossRefGoogle Scholar
  74. 74.
    Clancy F. Factors affecting correlation between direct and indirect arterial blood pressure measurements. J Clin Eng. 1978;3:49–51.CrossRefGoogle Scholar
  75. 75.
    Romagnoli S, Ricci Z, Quattrone D, Tofani L, Tujjar O, Villa G, et al. Accuracy of invasive arterial pressure monitoring in cardiovascular patients: an observational study. Crit Care. 2014;18:644.CrossRefGoogle Scholar

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© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Scott J. Dankel
    • 1
  • Minsoo Kang
    • 2
  • Takashi Abe
    • 1
  • Jeremy P. Loenneke
    • 1
    Email author
  1. 1.Department of Health, Exercise Science, and Recreation Management. Kevser Ermin Applied Physiology LaboratoryThe University of MississippiUniversityUSA
  2. 2.Department of Health, Exercise Science and Recreation Management, Health and Sports Analytics LaboratoryThe University of MississippiUniversityUSA

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