AJH

2005; 18:1369 1374

New Algorithm for the Diagnosis of Hypertension

Canadian Hypertension
Education Program Recommendations (2005)
Martin G. Myers, Sheldon W. Tobe, Donald W. McKay,
Peter Bolli, Brenda R. Hemmelgarn, Finlay A. McAlister,
on behalf of the Canadian Hypertension Education Program
Most national and international guidelines for diagnosing
hypertension include 24-h ambulatory blood pressure monitoring (ABPM) and self (home) BP monitoring (SBPM) as
optional methods for identifying hypertensive patients. However, none of the current guidelines have yet included ABPM
or SBPM as fundamental tools for diagnosing hypertension,
preferring instead to rely on conventional office readings
recorded by mercury sphygmomanometry.
During the past 10 years, clinical outcome studies have
consistently reported 24-h ABPM and SBPM to be significantly better predictors of cardiovascular events compared with the office BP, even when recorded under

research conditions. Based on the available evidence,

the Canadian Hypertension Education Program has now
developed an algorithm for diagnosing hypertension that
offers three options: 1) conventional office BP, 2) SBPM,
or 3) 24-h ABPM. Out-of-office BP measurements are
recommended, whenever feasible, to minimize both measurement error associated with mercury sphygmomanometry and the white coat effect experienced by some
patients. Am J Hypertens 2005;18:1369 1374 2005
American Journal of Hypertension, Ltd.

As soon as the importance of making an accurate diagnosis of hypertension became evident, experts turned their

attention to how office BP should be measured. Organizations such as the American Heart Association produced
detailed guidelines for the measurement of BP in the office
with revisions being made on a regular basis to incorporate
new findings.1 At present, almost every set of national and
international guidelines on the management of hypertension includes a section on how to measure BP properly
using a mercury sphygmomanometer with special attention being given to factors that affect the reliability of
readings.
In addition to published guidelines, health professionals
now have access to a wide variety of training material
including video presentations, CD-ROM programs, interactive computer programs, and computerized testing for
individual competence in BP measurement. Each year,
there are as many articles published on potential sources of
error in measuring BP as there are on how to record it in
a proper manner.
Deficiencies associated with the assessment of BP in

Received February 7, 2005. First decision March 29, 2005. Accepted

April 28, 2005.
From the Division of Cardiology (MGM) and Division of Nephrology (SWT), Sunnybrook & Womens Health Sciences Centre, Toronto,
Ontario, Canada; Faculty of Medicine (DWMK), Memorial University of
Newfoundland, St. Johns, Newfoundland and Labrador, Canada; Hotel
Dieu Grace Hospital (PB), Windsor, Ontario, Canada; Division of Ne-

phrology (BRH), University of Calgary, Calgary, Alberta, Canada; and

Division of General Internal Medicine (FAMA), University of Alberta,
Edmonton, Alberta, Canada.
Address correspondence and reprint requests to Dr. Martin G. Myers,
Division of Cardiology, Sunnybrook & Womens College, Health Sciences Centre, 2075 Bayview Avenue, Room A2 02, Toronto, ON M4N
3M5; e-mail: martin.myers@sw.ca

lood pressure (BP) measured in the office by mercury sphygmomanometry has been the standard approach to diagnosing and treating hypertension for
more than half a century. Data collected by the insurance
industry on the relationship between BP and mortality in
hundreds of thousands of persons initially led to the establishment of normal values for BP and provided the basis for
considering hypertension as an important risk factor for cardiac disease. Landmark trials from the 1960s onward provided further support for the use of office BP as a measure of
response to therapy with treatment of hypertension associated
with improvements in morbidity and mortality.

Traditional Assessment
of BP Using
Mercury Sphygmomanometry

2005 by the American Journal of Hypertension, Ltd.

Published by Elsevier Inc.

Key Words: Hypertension, diagnosis, blood pressure

measurement.

0895-7061/05/$30.00
doi:10.1016/j.amjhyper.2005.04.024

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DIAGNOSIS OF HYPERTENSION

the office using mercury sphygmomanometry can be divided into device, observer, and patient related factors.2
Ideally each health professional measuring BP should
carefully follow the latest guidelines on how to take accurate readings. In reality the recommended procedures
are often not used. Observers frequently talk with patients,
fail to keep the upper arm at heart level, engage in digit
preference in documenting readings, lower the mercury
column too rapidly, or ignore other factors that may have
major effects on the BP readings.
Even when BP is taken with strict adherence to guidelines, there are still patient-related factors to address.
Many individuals become nervous when visiting a doctors office or other health care setting, with the increase in
anxiety causing a white coat response. Patients may hurry
to visit the doctor or may become impatient and agitated
by having to wait before being seen. Rarely is a visit to the
doctor considered a normal daily event, and BP readings
tend to reflect the patients status at this single moment in
time. Thus an accurate office BP may not give a true
representation of a persons BP status outside of the health
care setting.
As far back as 1940,3 researchers realized that office BP
is often higher than indicated by out-of-office readings. It
was not until the development of semi-automated BP
recorders4 in the early 1960s that it became possible to
measure BP noninvasively over 24 h during daily activities. The landmark publication of Perloff and Sokolow5 in
1983 showing the 24-h ambulatory BP to be a better
predictor of morbidity and mortality than the office BP
taken by mercury sphygmomanometry led to a new era in
automated BP measurement. For the first time, the dominant role of the mercury manometer as the gold standard
for diagnosing hypertension came into question.

Twenty-Four-Hour
Ambulatory BP Monitoring
There are currently more than ten studies515 that have
found 24-h ABP monitoring (ABPM) to be a better predictor of clinical outcome than office BP. Assessments of
untreated hypertensive patients and those already receiving antihypertensive therapy consistently show that mean
awake, 24-h, and nocturnal BP predict the likelihood of a
patient experiencing a cardiovascular event better than the
office BP, even when office readings are taken with strict
adherence to guidelines.
One example in which ABPM was shown to be superior to office BP in untreated patients can be found in a
substudy of the Systolic Hypertension in Europe (SystEur) trial.9 Assessment of office BP with standard mercury
sphygmomanometry and 24-h ABPM was performed in
the placebo arm of the study. During follow-up, only a
weak relationship was found between the office systolic
BP and clinical outcomes, whereas the mean 24-h, awake,
and nocturnal ambulatory BP gave much better predictions
of clinical outcome.

AJHOctober 2005VOL. 18, NO. 10

In treated hypertensive patients in the Office versus

Ambulatory Pressure Study (OvA), Clement et al13 reported that the ABP predicts outcome independent of the
office BP in both the hypertensive and normotensive office
BP range. In this study, the relative risk for cardiovascular
events was 1.34 (95% CI, 1.11 to 1.62) for each increase
in systolic BP of 1 standard deviation, even after adjusting
for other cardiovascular risk factors including office BP
readings.
For those who continue to see the mercury sphygmomanometer as the gold standard for BP measurement, a
new threat looms on the horizon. In many countries,
mercury is now considered to be an industrial hazard, with
at least two countries banning mercury from the work
place.16 In some American hospitals, there is already a
trend away from using mercury sphygmomanometers to
reduce the amount of mercury lost to the environment. The
replacement of the mercury sphygmomanometer by other
devices appears to be imminent.
Virtually all national and international guidelines have
recognized the superiority of 24-h ABPM over the usual
measurement of BP in the office using mercury sphygmomanometry. Nonetheless, despite the greater precision in
BP measurement, current guidelines still treat ABPM as an
extra to be considered only in special circumstances
such as when white coat hypertension is suspected or
when patients exhibit apparent resistance to drug therapy.
Despite an abundance of clinical outcome data demonstrating the superiority of ABPM over the office BP in
predicting cardiovascular risk, virtually all guidelines still
primarily focus on office readings as a measure of BP
status.

SelfBP Measurement in
the Diagnosis of Hypertension
Advances in out-of-office measurement of BP have not
been restricted solely to 24-h ABPM. The availability of
accurate and reliable automated recorders for self BP
measurement (SBPM, also referred to as home BP measurement) has led to several studies that have documented the advantages of using this approach to assess BP
status versus office readings taken with mercury sphygmomanometry. In the Study on Ambulatory Monitoring of
Blood Pressure and Lisinopril Evaluation (SAMPLE),17
improvements in left ventricular mass, an intermediate
measure of target organ damage, were predicted best by
24-h ABPM almost as well by SBPM, and least precisely
by carefully performed office BP readings. Two clinical
outcome studies have also demonstrated the superiority of
SBPM in predicting cardiovascular outcomes compared
with office BP.
In the first study, Bobrie et al18 followed 4939 treated
hypertensive patients for a mean of 3.2 years with both
office BP and SBPM. Increases in systolic BP measured by
SBPM were associated with higher cardiovascular event
rates (an increase of 17% [95% CI, 11% to 24%] for each

AJHOctober 2005VOL. 18, NO. 10

10 mm Hg increase in self BP), whereas the same increase in BP using office readings was not associated with
any significant change in clinical outcomes. It was found
that SBPM was predictive of outcomes even in patients
with normal office BP readings (RR 2.06, 95% CI 1.22
to 3.47 in subjects with normal BP readings in the clinic
but high readings at home compared with those with
normal readings in the clinic and at home). On the other
hand, persons with high office BP readings and normal
self-measured BP did not demonstrate any increase in
cardiovascular events (RR 1.18 [95% CI, 0.67 to 2.10]
compared with those with normal readings in the clinic
and at home).
In the Ohasama study,19 1913 individuals residing in a
Japanese community were followed for a mean of 5.0
years, with mortality being related to both the office BP
and SBPM. The predictive power of the BP taken in the
home was stronger than for the casual office BP. In a
subsequent report20 involving 1702 subjects from this
study followed for a mean of 11 years, the home BP was
found to be a better predictor of the occurrence of stroke
compared with the office BP.
Data from both the ABPM and SBPM literature21 define a normal value as being 135/85 mm Hg for the
self-measured BP and for the mean awake ABP with the
normal value for the 24-h ABP being 130/80 mm Hg.
Even lower values for normal ABP have been proposed
but have not gained general acceptance.21

A New Algorithm for the

Diagnosis of Hypertension
In the latest (2005) annual revision to their recommendations,22 the Canadian Hypertension Education Program
(CHEP) outlines a new diagnostic algorithm for hypertension (Fig. 1) that incorporates ABPM or SBPM or both to
address two areas of concern with prior approaches to
diagnosis (for detailed CHEP recommendations and related material, see also: www.hypertension.ca).
First, the observation that differences between treatment arms in cardiovascular outcomes in the early stages
of recent large clinical trials2325 were likely caused by
differences in the extent of early BP control raised concerns that diagnostic algorithms that rely on multiple office
visits over many months may expose hypertensive patients
to unnecessary risks. Thus the CHEP Task Force developed an algorithm that would serve to expedite the diagnosis of hypertension.
Second, the evidence15,18,20 that 24-h ABPM and SBPM
were not only more accurate predictors of cardiovascular
morbidity and mortality than casual office readings but
also provided additional prognostic information, even after
adjustment for office readings, led the CHEP Task Force to
develop an algorithm that would incorporate these modalities.22
The algorithm is intended to be used in patients being
assessed for essential hypertension, and it is based on the

DIAGNOSIS OF HYPERTENSION

1371

assumption that an elevated BP reading was detected before the first hypertension visit by usual screening activities (BP readings taken in the work place, community,
or during an office visit for a nonhypertension diagnosis).
Recognizing that it may not always be feasible to perform
SBPM or 24-h ABPM, the algorithm offers several options
for making a diagnosis of hypertension.
Patients presenting with features of hypertensive urgency or emergency should be diagnosed with hypertension after the initial assessment, and therapy should be
commenced.
After two clinic visits, patients with moderate BP elevations (140 to 179 mm Hg systolic or 90 to 109 mm Hg
diastolic) plus macrovascular target organ damage, diabetes mellitus, or chronic kidney disease, or patients with
severe BP elevations (BP 180 mm Hg systolic or 110
mm Hg diastolic), can be diagnosed with hypertension and
therapy commenced.
In persons without macrovascular target organ damage,
diabetes mellitus, or chronic kidney disease but with moderately elevated BP readings (BP 140 to 179 mm Hg
systolic or 90 to 109 mm Hg diastolic) after two visits, the
CHEP algorithm recommends any one of three approaches, described below.
Diagnosis Using Office BP Measurements
Individuals with mildly elevated readings, especially those
with minimal cardiovascular risk, can be followed on
multiple visits for up to 6 months before a decision needs
to be made about whether to initiate therapy (Fig. 1). For
example, in patients with BP in the range of 160 to
179/100 to 109 (without target organ damage or associated
conditions), a diagnosis should generally be made by the
third visit. On the other hand, in patients in whom cardiovascular risk is relatively low and BP is only slightly
elevated (140 to 159 / 90 to 99), a decision may be made
to defer drug therapy and to continue recommending lifestyle modifications and monitoring office BP over a more
prolonged period. The frequency of visits should take into
consideration the level of BP and overall cardiovascular
risk.
Diagnosis Using ABPM
Alternatively, if ABPM is readily available, individuals
with mildly elevated readings can undergo 24-h ABPM
with mean awake BP values 135 mm Hg systolic or 85
mm Hg diastolic or 24-h BP values 130 mm Hg systolic
or 80 mm Hg diastolic being used to diagnose hypertension (Fig. 1). Individuals found to have only white coat
hypertension (office BP 140/90 and mean awake ambulatory BP 135/85) can have treatment withheld and BP
followed with office, SBPM, or ABPM. Repeat 24-h
ABPM is recommended within 6 to 12 months to confirm
the diagnosis of white coat hypertension, as 24 h ABPM
does exhibit some variability although less so than office
BP. Subsequent follow-up with SBPM or ABPM may be

1372

DIAGNOSIS OF HYPERTENSION

AJHOctober 2005VOL. 18, NO. 10

FIG. 1. Canadian Hypertension Education Program algorithm for the expedited assessment and diagnosis of hypertension (HTN) in
patients with elevated blood pressure (BP) readings. ABPM ambulatory BP monitoring; DBP diastolic BP; office BPM office BP
monitoring; SBP systolic BP.

useful depending on the level of the office BP and overall

cardiovascular risk.
Diagnosis Using SMBP
If 24-h ABPM is not readily available, SBPM can be
performed using a validated device with a print-out or
memory for storing readings. A minimum of 7 days of
readings taken twice daily is recommended with the first
days measurements being discarded, as these readings are
often higher than subsequent values.22 If the mean self-

measured BP is 135 mm Hg systolic or 85 mm Hg

diastolic, hypertension can be diagnosed and therapy considered (with global cardiovascular risk being taken into
account for borderline values).
When the self-measured BP is 135/85 mm Hg, there
are two options. If 24-h ABPM is available on a limited
basis, individuals with apparent white coat hypertension
based on the office and self-measured BP can have this
diagnosis confirmed by undergoing 24-h ABPM. The results of this recording should be interpreted as for those
having ABPM as the initial diagnostic test (see above). If

AJHOctober 2005VOL. 18, NO. 10

ABPM is not feasible, individuals with a self-measured BP

135/85 mm Hg should continue to be monitored for the
development of more persistent hypertension with periodic office BP and SBPM. A decision to initiate drug
therapy at a later date can be made if there is a trend
toward higher self-measured BP readings (135/85 mm
Hg), especially if associated cardiovascular risk factors are
present.

Outstanding Issues
ABPM
The most obvious weakness in the CHEP algorithm is the
restricted availability of 24-h ABPM. In Canada, provincial government health care plans do not yet reimburse the
costs of 24-h ABPM, and only a few private insurance
companies provide coverage for this test. In contrast, in
the United States, Medicare has recognized the value of
ABPM and covers the costs for individuals suspected of
having white coat hypertension.26 According to CHEP, the
advantages of 24-h ABPM in the diagnosis of hypertension will only become evident to all third-party insurers if
ABPM is incorporated fully into the primary algorithm for
diagnosing hypertension.
SBPM
Although the measurement of BP in the home is much
more readily available than 24-h ABPM, it is not without
its limitations. Of the hundreds of devices on the market,
only a handful have passed validation studies, and even
fewer have memory for storing readings. Reliance on
individuals to convey self-measured BP readings to their
doctors may be subject to reporting bias, with selected
high or low readings being used to provide a measure of
out-of-office BP.27 Validated devices with a memory or
printout of readings are recommended by CHEP because
they eliminate inaccurate reporting of self-measured BP.
Proper training for SBPM is another important consideration.28
Automated Office BP
There are now validated automated devices available for
measurement of BP in the office setting without anyone
being present in the examining room.29,30 These devices
minimize observer error but do not eliminate patientrelated factors that tend to increase office BP in some
individuals. The extent to which the use of these devices in
routine clinical practice will reduce white coat reactions is
not yet known.

DIAGNOSIS OF HYPERTENSION

data.32,33 The increasing use of automated BP recorders in

the office setting will likely add further confusion, in that
a BP reading of 140/90 mm Hg taken with an automated
device may not convey the same risks as a similar reading
taken with a mercury sphygmomanometer.
Regardless of how one defines a normal BP, it is clear
that the use of artificial cut-points for normal versus high
BP will always be arbitrary. It was recognized as far back
as the 1960s34 that BP is a continuous variable when it
comes to cardiovascular risk, with separations into high
and low values being artificial. It is now evident that
individuals with a lower normal BP have a lower cardiovascular risk than those with a higher normal BP, especially if associated conditions such as diabetes mellitus are
present.35 In addition normotensive patients with heart
failure,36 stroke,37 and coronary artery disease38,39 appear
to receive the same benefit as hypertensive patients from
drugs that decrease BP, such as angiotensin-converting
enzyme inhibitors.
For the CHEP algorithm, the diagnosis of hypertension
and decision to initiate therapy need to take into account
all factors that have impacts on cardiovascular risk, the
same as would be done for managing hypertension based
on the office BP. CHEP has incorporated ABPM and
SBPM to allow hypertension to be diagnosed more accurately and with less delay than is currently possible with
office BP, especially in patients with BP 140 to 179 / 90 to
109 mm Hg and without diabetes, chronic kidney disease,
or target organ damage who would otherwise require multiple visits over 6 months before making a diagnosis.

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2.
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4.

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What Is Normal BP?

Studies in ABPM and SBPM have generated considerable
debate on what constitutes normal BP.21,31 CHEP has
selected a mean awake ambulatory BP and self-measured
BP of 135/85 mm Hg to define normality based on
clinical outcome data and supported by cross-sectional BP

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