Methodology of Casual Blood Pressure Measurement

  • Guido FillerEmail author
  • Ajay P. Sharma
Reference work entry


The key to diagnosing hypertension in both children and adults involves first accurately measuring the blood pressure and then accurately interpreting the obtained results. In the pursuit of understanding the importance of this measurement and over the course of centuries and countless experiments, first invasive (using arterial lines) and then refined noninvasive methods for measuring blood pressure were developed. In a contemporary clinical outpatient setting, unless a research study requires patients to have their blood pressure measured according to a specific procedure, a sphygmomanometer is applied to a patient when he or she is at rest; this is referred to as “casual or office blood pressure.” In the following chapter, we will review current methods employed to measure casual blood pressure and identify their advantages, disadvantages, and pitfalls.


Aneroid Auscultation Beat-to-beat variability Casual blood pressure Interpretation of casual blood pressure Korotkoff sounds Observer Oscillometry Sphygmomanometer Validation 



The authors would like to thank Marta Kobrzynski, Research Assistant to Dr. Filler, for her help in editing the manuscript and for providing relevant background literature.


  1. Adrogue HE, Sinaiko AR (2001) Prevalence of hypertension in junior high school-aged children: effect of new recommendations in the 1996 Updated Task Force Report. Am J Hypertens 14(5 Pt 1):412–414Google Scholar
  2. Alpert BS (2011) Validation of the Welch Allyn SureBP (inflation) and StepBP (deflation) algorithms by AAMI standard testing and BHS data analysis. Blood Press Monit 16(2):96–98Google Scholar
  3. Amoore JN, Lemesre Y, Murray IC, Mieke S, King ST, Smith FE, Murray A (2008) Automatic blood pressure measurement: the oscillometric waveform shape is a potential contributor to differences between oscillometric and auscultatory pressure measurements. J Hypertens 26(1): 35–43Google Scholar
  4. Arafat M, Mattoo TK (1999) Measurement of blood pressure in children: recommendations and perceptions on cuff selection. Pediatrics 104(3):e30Google Scholar
  5. Banker A, Bell C, Gupta-Malhotra M, Samuels J (2016) Blood pressure percentile charts to identify high or low blood pressure in children. BMC Pediatr 16:98PubMedCentralPubMedGoogle Scholar
  6. Beevers G, Lip GY, O’Brien E (2001) ABC of hypertension: blood pressure measurement. Part II-conventional sphygmomanometry: technique of auscultatory blood pressure measurement. BMJ 322(7293):1043–1047PubMedCentralPubMedGoogle Scholar
  7. Bhyravavajhala S, Velam V, Polapragada NV, Pallempati P, Iragavarapu TR, Patnaik AN, Damera SR (2015) Reliability of Doppler-based measurement of pulmonary vascular resistance in congenital heart disease with left-to-right shunt lesions. Echocardiography 32(6):1009–1014Google Scholar
  8. Booth J (1977) A short history of blood pressure measurement. Proc R Soc Med 70(11):793–799PubMedCentralPubMedGoogle Scholar
  9. Brady TM, Solomon BS, Neu AM, Siberry GK, Parekh RS (2010) Patient-, provider-, and clinic-level predictors of unrecognized elevated blood pressure in children. Pediatrics 125(6):e1286–e1293Google Scholar
  10. Briasoulis A, Androulakis E, Palla M, Papageorgiou N, Tousoulis D (2016) White-coat hypertension and cardiovascular events: a meta-analysis. J Hypertens 34(4):593–599Google Scholar
  11. Burke MJ, Towers HM, O’Malley K, Fitzgerald DJ, O’Brien ET (1982) Sphygmomanometers in hospital and family practice: problems and recommendations. Br Med J (Clin Res Ed) 285(6340):469–471Google Scholar
  12. Campbell NR, Khalsa T, (World Hypertension League Executive) Lackland DT, Niebylski ML, Nilsson PM, Redburn KA, Orias M, Zhang XH, (International Society of Hypertension Executive) Burrell L, Horiuchi M, Poulter NR, Prabhakaran D, Ramirez AJ, Schiffrin EL, Touyz RM, Wang JG, Weber MA, World Stroke Organization, International Diabetes Federation, International Council of Cardiovascular Prevention and Rehabilitation, International Society of Nephrology (2016) High blood pressure 2016: why prevention and control are urgent and important. The World Hypertension League, International Society of Hypertension, World Stroke Organization, International Diabetes Foundation, International Council of Cardiovascular Prevention and Rehabilitation, International Society of Nephrology. J Clin Hypertens (Greenwich) 18(8):714–717Google Scholar
  13. Canzanello VJ, Jensen PL, Schwartz GL (2001) Are aneroid sphygmomanometers accurate in hospital and clinic settings? Arch Intern Med 161(5):729–731Google Scholar
  14. Cavallini MC, Roman MJ, Blank SG, Pini R, Pickering TG, Devereux RB (1996) Association of the auscultatory gap with vascular disease in hypertensive patients. Ann Intern Med 124(10):877–883Google Scholar
  15. Chahine MN, Assemaani N, Sayed Hassan G, Cham M, Salameh P, Asmar R (2015) Validation of the OMRON M3500 blood pressure measuring device using normal- and high-speed modes in adult and specific populations (obese and children) according to AAMI Protocol. J Clin Hypertens (Greenwich) 17(8):622–629Google Scholar
  16. Chiolero A, Paradis G, Lambert M (2010) Accuracy of oscillometric devices in children and adults. Blood Press 19(4):254–259Google Scholar
  17. Chubb H, Simpson JM (2012) The use of Z-scores in paediatric cardiology. Ann Pediatric Cardiol 5(2):179–184Google Scholar
  18. Cook H, Briggs J (1903) Clinical observations of blood pressure. Johns Hopkins Hosp Rep 11:451–534Google Scholar
  19. Crapanzano MS, Strong WB, Newman IR, Hixon RL, Casal D, Linder CW (1996) Calf blood pressure: clinical implications and correlations with arm blood pressure in infants and young children. Pediatrics 97:220–224Google Scholar
  20. Crossland DS, Furness JC, Abu-Harb M, Sadagopan SN, Wren C (2004) Variability of four limb blood pressure in normal neonates. Arch Dis Child Fetal Neonatal Ed 89(4):F 325–F 327Google Scholar
  21. Cushman WC, Cooper KM, Horne RA, Meydrech EF (1990) Effect of back support and stethoscope head on seated blood pressure determinations. Am J Hypertens 3(3):240–241Google Scholar
  22. Din-Dzietham R, Liu Y, Bielo MV, Shamsa F (2007) High blood pressure trends in children and adolescents in national surveys, 1963 to 2002. Circulation 116(13):1488–1496Google Scholar
  23. Elseed AM, Shinebourne EA, Joseph MC (1973) Assessment of techniques for measurement of blood pressure in infants and children. Arch Dis Child 48(12):932–936PubMedCentralPubMedGoogle Scholar
  24. Flynn JT (2013) Assessment of blood pressure in children: it’s all in the details. J Clin Hypertens (Greenwich) 15(11):772–773Google Scholar
  25. Flynn JT (2016) Auscultatory blood pressure measurement: a lost art in pediatric practice. Arch Pediatr 23(8):781–7833Google Scholar
  26. Flynn JT, Kaelber DC, Baker-Smith CM et al (2017) Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics 2017;140(3):e20171904Google Scholar
  27. Flynn JT, Pierce CB, Miller ER 3rd, Charleston J, Samuels JA, Kupferman J, Furth SL, Warady BA (2012a) Reliability of resting blood pressure measurement and classification using an oscillometric device in children with chronic kidney disease. J Pediatr 160:434–440. .e1Google Scholar
  28. Flynn J, Zhang Y, Solar-Yohay S, Shi V (2012b) Clinical and demographic characteristics of children with hypertension. Hypertension 60(4):1047–1054Google Scholar
  29. Forster FK, Turney D (1986) Oscillometric determination of diastolic, mean and systolic blood pressure–a numerical model. J Biomech Eng 108:359–364Google Scholar
  30. Gould BA, Hornung RS, Altman DG, Cashman PM, Raftery EB (1985) Indirect measurement of blood pressure during exercise testing can be misleading. Br Heart J 53(6):611–615PubMedCentralPubMedGoogle Scholar
  31. Gupta-Malhotra M, Banker A, Shete S, Hashmi SS, Tyson JE, Barratt MS, Hecht JT, Milewicz DM, Boerwinkle E (2015) Essential hypertension vs. secondary hypertension among children. Am J Hypertens 28(1):73–80Google Scholar
  32. Hansen ML, Gunn PW, Kaelber DC (2007) Underdiagnosis of hypertension in children and adolescents. JAMA 298(8):874–879Google Scholar
  33. He X, Ng KW, Shi J (2003) Marginal versus joint Box-Cox transformation with applications to percentile curve construction for IgG subclasses and blood pressures. Stat Med 22(3):397–408Google Scholar
  34. Henschel A, De La Vega F, Taylor HL (1954) Simultaneous direct and indirect blood pressure measurements in man at rest and work. J Appl Physiol 6(8):506–508Google Scholar
  35. Imai Y, Abe K, Sasaki S, Minami N, Munakata M, Sakuma H, Hashimoto J, Sekino H, Imai K, Yoshinaga K (1989) Clinical evaluation of semiautomatic and automatic devices for home blood pressure measurement: comparison between cuff-oscillometric and microphone methods. J Hypertens 7(12):983–990Google Scholar
  36. James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, Lackland DT, LeFevre ML, MacKenzie TD, Ogedegbe O, Smith SC Jr, Svetkey LP, Taler SJ, Townsend RR, Wright JT Jr, Narva AS, Ortiz E (2014) 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 311(5):507–520PubMedCentralPubMedGoogle Scholar
  37. Jhalani J, Goyal T, Clemow L, Schwartz JE, Pickering TG, Gerin W (2005) Anxiety and outcome expectations predict the white-coat effect. Blood Press Monit 10(6):317–319Google Scholar
  38. Kaelber DC, Pickett F (2009) Simple table to identify children and adolescents needing further evaluation of blood pressure. Pediatrics 123(6):e972–e974Google Scholar
  39. King GE (1963) Influence of rate of cuff inflation and deflation on observed blood pressure by sphygmomanometry. Am Heart J 65:303–306Google Scholar
  40. Kit BK, Kuklina E, Carroll MD, Ostchega Y, Freedman DS, Ogden CL (2015) Prevalence of and trends in dyslipidemia and blood pressure among US children and adolescents, 1999–2012. JAMA Pediatr 169(3):272–279Google Scholar
  41. Krmar RT, Holtback U, Bergh A, Svensson E, Wuhl E (2015) Oscillometric casual blood pressure normative standards for Swedish children using ABPM to exclude casual hypertension. Am J Hypertens 28(4):459–468Google Scholar
  42. Landgraf J, Wishner SH, Kloner RA (2010) Comparison of automated oscillometric versus auscultatory blood pressure measurement. Am J Cardiol 106(3):386–388Google Scholar
  43. Lewis WH (1941) The evolution of clinical sphygmomanometry. Bull N Y Acad Med 17(11):871–881PubMedCentralPubMedGoogle Scholar
  44. Lurbe E, Agabiti-Rosei E, Cruickshank JK, Dominiczak A, Erdine S, Hirth A, Invitti C, Litwin M, Mancia G, Pall D, Rascher W, Redon J, Schaefer F, Seeman T, Sinha M, Stabouli S, Webb NJ, Wuhl E, Zanchetti A (2016) 2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents. J HypertensGoogle Scholar
  45. Ma Y, Temprosa M, Fowler S, Prineas RJ, Montez MG, Brown-Friday J, Carrion-Petersen ML, Whittington T (2009) Evaluating the accuracy of an aneroid sphygmomanometer in a clinical trial setting. Am J Hypertens 22(3):263–266Google Scholar
  46. Martin CJ (1905) Remarks on the determination of arterial blood pressure in clinical practice. Br Med J 1(2312):865–870PubMedCentralPubMedGoogle Scholar
  47. Maxwell MH, Waks AU, Schroth PC, Karam M, Dornfeld LP (1982) Error in blood-pressure measurement due to incorrect cuff size in obese patients. Lancet 2(8288):33–36Google Scholar
  48. McCubbin JA, Wilson JF, Bruehl S, Brady M, Clark K, Kort E (1991) Gender effects on blood pressures obtained during an on-campus screening. Psychosom Med 53(1):90–100Google Scholar
  49. Mejia AD, Egan BM, Schork NJ, Zweifler AJ (1990) Artefacts in measurement of blood pressure and lack of target organ involvement in the assessment of patients with treatment-resistant hypertension. Ann Intern Med 112(4):270–277Google Scholar
  50. Messelbeck J, Sutherland L (2000) Applying environmental product design to biomedical products research. Environ Health Perspect 108(Suppl 6):997–1002PubMedCentralPubMedGoogle Scholar
  51. Mitchell CK, Theriot JA, Sayat JG, Muchant DG, Franco SM (2011) A simplified table improves the recognition of paediatric hypertension. J Paediatr Child Health 47(1–2):22–26Google Scholar
  52. Mitsnefes MM, Kimball TR, Witt SA, Glascock BJ, Khoury PR, Daniels SR (2003) Left ventricular mass and systolic performance in pediatric patients with chronic renal failure. Circulation 107(6):864–868Google Scholar
  53. Muller JE, Kaufmann PG, Luepker RV, Weisfeldt ML, Deedwania PC, Willerson JT (1997) Mechanisms precipitating acute cardiac events: review and recommendations of an NHLBI workshop. National Heart, Lung, and Blood Institute. Mechanisms Precipitating Acute Cardiac Events Participants. Circulation 96(9):3233–3239Google Scholar
  54. Muntner P, He J, Cutler JA, Wildman RP, Whelton PK (2004) Trends in blood pressure among children and adolescents. JAMA 291(17):2107–2113Google Scholar
  55. Myers MG, Godwin M, Dawes M, Kiss A, Tobe SW, Kaczorowski J (2012) Conventional versus automated measurement of blood pressure in the office (CAMBO) trial. Fam Pract 29(4):376–382Google Scholar
  56. Narang R, Saxena A, Ramakrishnan S, Dwivedi SN, Bagga A (2015) Oscillometric blood pressure in Indian school children: simplified percentile tables and charts. Indian Pediatr 52(11):939–945Google Scholar
  57. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children, Adolescents (2004) The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics 114(2 Suppl 4th Report):555–576Google Scholar
  58. Nelson RM, Stebor AD, Groh CM, Timoney PM, Theobald KS, Friedman BA (2002) Determination of accuracy in neonates for non-invasive blood pressure device using an improved algorithm. Blood Press Monitor 7(2):123–129Google Scholar
  59. Niyonsenga T, Vanasse A, Courteau J, Cloutier L (2008) Impact of terminal digit preference by family physicians and sphygmomanometer calibration errors on blood pressure value: implication for hypertension screening. J Clin Hypertens (Greenwich) 10(5):341–347Google Scholar
  60. Nunn JF (1996) Ancient Egyptian medicine. Trans Med Soc Lond 113:57–68Google Scholar
  61. Ogedegbe G, Pickering T (2010) Principles and techniques of blood pressure measurement. Cardiol Clin 28(4):571–586PubMedCentralPubMedGoogle Scholar
  62. Parati G, Pomidossi G, Casadei R, Mancia G (1985) Lack of alerting reactions to intermittent cuff inflations during noninvasive blood pressure monitoring. Hypertension 7(4):597–601Google Scholar
  63. Parati G, Casadei R, Groppelli A, Di Rienzo M, Mancia G (1989) Comparison of finger and intra-arterial blood pressure monitoring at rest and during laboratory testing. Hypertension 13(6 Pt 1):647–655Google Scholar
  64. Park MK, Lee D (1989) Normative arm and calf blood pressure values in the newborn. Pediatrics 83:240–243Google Scholar
  65. Park MK, Menard SW, Yuan C (2001) Comparison of auscultatory and oscillometric blood pressures. Arch Pediatr Adolesc Med 155(1):50–53Google Scholar
  66. Parker ED, Sinaiko AR, Kharbanda EO, Margolis KL, Daley MF, Trower NK, Sherwood NE, Greenspan LC, Lo JC, Magid DJ, O’Connor PJ (2016) Change in weight status and development of hypertension. Pediatrics 137(3):e20151662PubMedCentralPubMedGoogle Scholar
  67. Peterson KL, Jacobs JP, Allender S, Alston LV, Nichols M (2016) Characterising the extent of misreporting of high blood pressure, high cholesterol, and diabetes using the Australian Health Survey. BMC Public Health 16:695PubMedCentralPubMedGoogle Scholar
  68. Petrie JC, O’Brien ET, Littler WA, de Swiet M (1986) Recommendations on blood pressure measurement. Br Med J (Clin Res Ed) 293(6547):611–615Google Scholar
  69. Pickering TG, Hall JE, Appel LJ, Falkner BE, Graves J, Hill MN, Jones DW, Kurtz T, Sheps SG, Roccella EJ (2005) Recommendations for blood pressure measurement in humans and experimental animals: part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Hypertension 45(1):142–161PubMedGoogle Scholar
  70. Rao G (2016) Diagnosis, epidemiology, and management of hypertension in children. Pediatrics 138(2)Google Scholar
  71. Redwine KM, Acosta AA, Poffenbarger T, Portman RJ, Samuels J (2012) Development of hypertension in adolescents with pre-hypertension. J Pediatr 160(1):98–103Google Scholar
  72. Roguin A (2006) Scipione Riva-Rocci and the men behind the mercury sphygmomanometer. Int J Clin Pract 60(1):73–79Google Scholar
  73. Rose G (1965) Standardisation of observers in blood-pressure measurement. Lancet 1(7387):673–674Google Scholar
  74. Rosner B, Cook NR, Daniels S, Falkner B (2013) Childhood blood pressure trends and risk factors for high blood pressure: the NHANES experience 1988–2008. HypertensionGoogle Scholar
  75. Salvadori M, Sontrop JM, Garg AX, Truong J, Suri RS, Mahmud FH, Macnab JJ, Clark WF (2008) Elevated blood pressure in relation to overweight and obesity among children in a rural Canadian community. Pediatrics 122(4):e821–e827Google Scholar
  76. Schell K, Briening E, Lebet R, Pruden K, Rawheiser S, Jackson B (2011) Comparison of arm and calf automatic noninvasive blood pressures in pediatric intensive care patients. J Pediatr Nurs 26(1):3–12Google Scholar
  77. Shapiro DJ, Hersh AL, Cabana MD, Sutherland SM, Patel AI (2012) Hypertension screening during ambulatory pediatric visits in the United States, 2000–2009. Pediatrics 130(4):604–610Google Scholar
  78. Sharma M, Kupferman JC, Brosgol Y, Paterno K, Goodman S, Prohovnik I, Kirkham FJ, Pavlakis SG (2010) The effects of hypertension on the paediatric brain: a justifiable concern. Lancet Neurol 9(9):933–940Google Scholar
  79. Sharma AP, Mohammed J, Thomas B, Singh RN, Filler G (2015) Using simplified blood pressure tables to avoid underdiagnosing childhood hypertension. Paediatr Child Health 20(6):297–301PubMedCentralPubMedGoogle Scholar
  80. Smirk FH (1976) Casual, basal and supplemental blood pressures in 519 first-degree relatives of substantial hypertensive patients and in 350 population controls. Clin Sci Mol Med Suppl 3:13s–17sGoogle Scholar
  81. Song BM, Kim HC, Shim JS, Lee MH, Choi DP (2016) Inter-arm difference in brachial blood pressure in the general population of Koreans. Korean Circulation J 46(3):374–383Google Scholar
  82. Sorof JM, Lai D, Turner J, Poffenbarger T, Portman RJ (2004) Overweight, ethnicity, and the prevalence of hypertension in school-aged children. Pediatrics 113(3 Pt 1):475–482PubMedGoogle Scholar
  83. Still JL, Cottom D (1967) Severe hypertension in childhood. Arch Dis Child 42(221):34–39PubMedCentralPubMedGoogle Scholar
  84. Sun SS, Grave GD, Siervogel RM, Pickoff AA, Arslanian SS, Daniels SR (2007) Systolic blood pressure in childhood predicts hypertension and metabolic syndrome later in life. Pediatrics 119(2):237–246Google Scholar
  85. Tran N, Hackett H, Cadaver C, Fichera S, Azen C (2014) Comparison of calf and brachial blood pressures in infants: is there a difference between calf and brachial blood pressures? J Vasc Nurs 32(4):139–143Google Scholar
  86. Tschumi S, Noti S, Bucher BS, Simonetti GD (2011) Is childhood blood pressure higher before or after clinic consultation? Acta Paediatr 100:775–777Google Scholar
  87. van Popele N, Bos W, de Beer N, van der Kuip D, Hoffman A, Diederick E, CM W (2000) Arterial stiffness as underlying mechanism of disagreement between oscillometric blood pressure monitor and sphygmomanometer. Hypertension 36:484–488Google Scholar
  88. Verdecchia P, Schillaci G, Borgioni C, Ciucci A, Zampi I, Gattobigio R, Sacchi N, Porcellati C (1995) White coat hypertension and white coat effect. Similarities and differences. Am J Hypertens 8(8):790–798Google Scholar
  89. Vischer AS, Burkard T (2016) Principles of blood pressure measurement – current techniques, office vs ambulatory blood pressure measurement. Adv Exp Med BiolGoogle Scholar
  90. Voors AW, Foster TA, Frerichs RR, Webber LS, Berenson GS (1976) Studies of blood pressures in children, ages 5–14 years, in a total biracial community: the Bogalusa Heart Study. Circulation 54(2):319–327Google Scholar
  91. Wong SN, Tz Sung RY, Leung LC (2006) Validation of three oscillometric blood pressure devices against auscultatory mercury sphygmomanometer in children. Blood Press Monitor 11(5):281–291Google Scholar
  92. Yang Q, Zhang Z, Kuklina EV, Fang J, Ayala C, Hong Y, Loustalot F, Dai S, Gunn JP, Tian N, Cogswell ME, Merritt R (2012) Sodium intake and blood pressure among US children and adolescents. Pediatrics 130(4):611–619Google Scholar
  93. Zheng D, Amoore JN, Mieke S, Murray A (2011) Estimation of mean arterial pressure from the oscillometric cuff pressure: comparison of different techniques. Medi Biol Engineer Comput 49(1):33–39Google Scholar
  94. Zuijdwijk C, Feber J, Murnaghan O, Nakhla M (2013) Detection of hypertension and prehypertension in paediatric patients with type 1 diabetes using a simple blood pressure table. Paediatr Child Health 18(9):461–464PubMedCentralPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  1. 1.Department of PaediatricsUniversity of Western OntarioLondonCanada
  2. 2.Department of PaediatricsChildren’s Hospital, London Health Sciences CentreLondonCanada

Section editors and affiliations

  • Karen M. Redwine
    • 1
  1. 1.Department of Pediatrics, Arkansas Children's HospitalUniversity of Arkansas for Medical SciencesLittle RockUSA

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