JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. 70, NO.

5, 2017

2017 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION ISSN 0735-1097/$36.00

PUBLISHED BY ELSEVIER http://dx.doi.org/10.1016/j.jacc.2017.05.064

Accuracy of Cuff-Measured Blood Pressure

Systematic Reviews and Meta-Analyses

Dean S. Picone, BMEDRES(HONS),a Martin G. Schultz, PHD,a Petr Otahal, GDIPSCI,a Svend Aakhus, MD, PHD,b
Ahmed M. Al-Jumaily, PHD,c J. Andrew Black, MBBS(HONS),a,d Willem J. Bos, MD, PHD,e John B. Chambers, MD,f
Chen-Huan Chen, MD,g Hao-Min Cheng, MD, PHD,g Antoine Cremer, MD,h Justin E. Davies, PHD,i
Nathan Dwyer, MBBS, PHD,a,d Brian A. Gould, MD, PHD,j Alun D. Hughes, MBBS, PHD,k Peter S. Lacy, PHD,l
Esben Laugesen, MD, PHD,m Fuyou Liang, PHD,n Roman Melamed, MD,o Sandy Muecke, PHD,p
Nobuyuki Ohte, MD, PHD,q Sho Okada, MD, PHD,r Stefano Omboni, MD,s Christian Ott, MD,t Xiaoqing Peng, MPHARM,a
Telmo Pereira, PHD,u Giacomo Pucci, MD,v Ronak Rajani, MD,f Philip Roberts-Thomson, MBBS,a,d
Niklas B. Rossen, MD, PHD,m Daisuke Sueta, MD, PHD,w Manish D. Sinha, PHD,x Roland E. Schmieder, MD,t
Harold Smulyan, MD,y Velandai K. Srikanth, PHD,a,z,aa Ralph Stewart, MD,bb George A. Stouffer, MD,cc
Kenji Takazawa, MD, PHD,dd Jiguang Wang, MD, PHD,ee Berend E. Westerhof, PHD,ff Franz Weber, MD,gg
Thomas Weber, MD,hh Bryan Williams, MD,l Hirotsugu Yamada, MD, PHD,ii Eiichiro Yamamoto, MD, PHD,w
James E. Sharman, PHDa

ABSTRACT

BACKGROUND Hypertension (HTN) is the single greatest cardiovascular risk factor worldwide. HTN management is
usually guided by brachial cuff blood pressure (BP), but questions have been raised regarding accuracy.

OBJECTIVES This comprehensive analysis determined the accuracy of cuff BP and the consequent effect on BP
classication compared with intra-arterial BP reference standards.

METHODS Three individual participant data meta-analyses were conducted among studies (from the 1950s to 2016)
that measured intra-arterial aortic BP, intra-arterial brachial BP, and cuff BP.

RESULTS A total of 74 studies with 3,073 participants were included. Intra-arterial brachial systolic blood pressure
(SBP) was higher than aortic values (8.0 mm Hg; 95% condence interval [CI]: 5.9 to 10.1 mm Hg; p < 0.0001) and
intra-arterial brachial diastolic BP was lower than aortic values (
1.0 mm Hg; 95% CI:
2.0 to
0.1 mm Hg; p 0.038).
Cuff BP underestimated intra-arterial brachial SBP (
5.7 mm Hg; 95% CI:
8.0 to
3.5 mm Hg; p < 0.0001) but
overestimated intra-arterial diastolic BP (5.5 mm Hg; 95% CI: 3.5 to 7.5 mm Hg; p < 0.0001). Cuff and intra-arterial
aortic SBP showed a small mean difference (0.3 mm Hg; 95% CI:
1.5 to 2.1 mm Hg; p 0.77) but poor agreement (mean
absolute difference 8.0 mm Hg; 95% CI: 7.1 to 8.9 mm Hg). Concordance between BP classication using the Seventh
Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure cuff
BP (normal, pre-HTN, and HTN stages 1 and 2) compared with intra-arterial brachial BP was 60%, 50%, 53%, and 80%,
and using intra-arterial aortic BP was 79%, 57%, 52%, and 76%, respectively. Using revised intra-arterial thresholds
based on cuff BP percentile rank, concordance between BP classication using cuff BP compared with intra-arterial
brachial BP was 71%, 66%, 52%, and 76%, and using intra-arterial aortic BP was 74%, 61%, 56%, and 65%, respectively.

CONCLUSIONS Cuff BP has variable accuracy for measuring either brachial or aortic intra-arterial BP, and this
adversely inuences correct BP classication. These ndings indicate that stronger accuracy standards for BP devices
may improve cardiovascular risk management. (J Am Coll Cardiol 2017;70:57286) 2017 by the American College of
Cardiology Foundation.

Listen to this manuscripts

audio summary by
JACC Editor-in-Chief
Dr. Valentin Fuster.

From the aMenzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia; b
Department of
Circulation and Medical Imaging, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway;
c
Institute of Biomedical Technologies, Auckland University of Technology, Auckland, New Zealand; dRoyal Hobart Hospital,
Hobart, Tasmania, Australia; eDepartment of Internal Medicine, St. Antonius Hospital, Nieuwegein, the Netherlands; fCardiology
Department, Guys and St. Thomas Hospitals, London, United Kingdom; gDepartment of Medicine, National Yang-Ming University,
JACC VOL. 70, NO. 5, 2017 Picone et al. 573
AUGUST 1, 2017:57286 Accuracy of Cuff-Measured BP

C ardiovascular disease is the number 1 cause bias for cuff BP to underestimate intra- ABBREVIATIONS

of mortality worldwide, with elevated blood arterial brachial systolic blood pressure AND ACRONYMS

pressure (BP) as the single largest risk factor (SBP) but overestimate intra-arterial brachial
(13). Noninvasive brachial cuff BP is the principal diastolic blood pressure (DBP), and thereby,
method for hypertension (HTN) diagnosis and man- underestimate intra-arterial pulse pressure
agement; thus, accurate BP measurement is among (PP) (911). Second, cuff BP devices being
the most important medical tests performed (4). Rela- tested for accuracy against other noninvasive
tively small errors in cuff BP measurement can have measurements according to
major public health ramications. An inaccuracy of validation protocols may perform to a pass
BP = blood pressure
DBP = diastolic blood pressure
HTN = hypertension
JNC 7 = Seventh Report of the
Joint National Committee on
international Prevention, Detection,
Evaluation, and Treatment of

5 mm Hg is estimated to result in the misclassication standard even when clinically signicant High Blood Pressure

of BP of 48 million people each year in the United measurement errors occur among many pa- PP = pulse pressure

States alone (21 million underestimated BP, 27 million tients (12). Third, there is large individual SBP = systolic blood pressure

overestimated BP) (5). BP underestimation leads to
missed therapeutic potential and unnecessary eleva-
tion of cardiovascular risk (6). BP overestimation cre-
ates additional cost and exposure to the possible
adverse effects of unnecessary treatment (5). The
recognition of pre-hypertension as a nonbenign clin-
ical presentation (7), and the benet to some patient
populations of achieving low BP targets (8), further
emphasizes the need for accurate cuff BP across the
range of BP classications.
SEE PAGE 587
Several lines of evidence question the accuracy of
cuff BP. First, many small studies indicate a possible
variability in intra-arterial BP between the aorta and
brachial artery (9,13,14), and whether oscillometric or
auscultatory cuff BP accurately measures either
aortic or brachial BP has never been systematically
determined. This question is important to resolve,
given: 1) the possibility that aortic BP is more clini-
cally relevant than brachial BP (13,1517); and 2) the
burgeoning of commercial devices purporting to
measure aortic BP (18) to (theoretically) better assess
cardiovascular risk (19). However, this is a contro-
versial theory (20,21), with some investigators
asserting that there is a lack of evidence to justify
departing from standard cuff BP (20,22). Others sug-
gest that brachial cuff BP may already accurately

Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan; hDepartment of Cardiology/Hypertension,
University Hospital of Bordeaux, Bordeaux, France; iInternational Centre for Circulatory Health, Imperial College London,
London, United Kingdom; jBMI Hospital Blackheath, London, United Kingdom; kInstitute of Cardiovascular Sciences, University
College London, London, United Kingdom; lInstitute of Cardiovascular Sciences University College London (UCL) and National
Institute for Health Research (NIHR) UCL/UCL Hospitals Biomedical Research Centre, London, United Kingdom; mDepartment of
Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark; nSchool of Naval Architecture, Ocean and
Civil Engineering, Shanghai Jiao Tong University, Shanghai, China; oAbbott Northwestern Hospital, Allina Health, Minneapolis,
Minnesota; pDepartment of Critical Care Medicine, Flinders University, Adelaide, South Australia, Australia; qDepartment of
Cardio-Renal Medicine and Hypertension, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan;
r
Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan; sClinical Research Unit,
Italian Institute of Telemedicine, Varese, Italy; tDepartment of Nephrology and Hypertension, University Hospital Erlangen,
Friedrich-Alexander University Erlangen-Nrnberg, Erlangen, Germany; uPolytechnic Institute of Coimbra, Coimbra College of
Health Technology, Department of Cardiopneumology, Lous, Portugal; vUnit of Internal Medicine at Terni University Hospital,
w
Department of Medicine, University of Perugia, Perugia, Italy; Department of Cardiovascular Medicine, Graduate School of
Medical Sciences, Kumamoto University, Kumamoto, Japan; xDepartment of Clinical Pharmacology and Department of Paediatric
Nephrology, Kings College London, Evelina London Childrens Hospital, Guys and St. Thomas NHS Foundation Trust, London,
United Kingdom; yDepartment of Medicine, State University of New York, Upstate Medical University, Cardiology Division,
Syracuse, New York; zCentral Clinical School, Faculty of Medicine, Monash University, Melbourne, Victoria, Australia; aa
Depart-
ment of Medicine, Peninsula Health, Melbourne, Victoria, Australia; bbGreen Lane Cardiovascular Service, Auckland City Hospital,
University of Auckland, Auckland, New Zealand; ccDivision of Cardiology, University of North Carolina at Chapel Hill, Chapel Hill,
dd
North Carolina; Center for Health Surveillance and Preventive Medicine, Tokyo Medical University Hospital, Tokyo, Japan;
ee
Centre for Epidemiological Studies and Clinical Trials, Shanghai Key Laboratory of Hypertension, The Shanghai Institute of
Hypertension, Department of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China;
ff gg
Department of Pulmonary Diseases, VU University Medical Center, Amsterdam, the Netherlands; Department of Nephrology,
hh
Center for Internal Medicine, University Clinic Essen, University Duisburg-Essen, Essen, Germany; Cardiology Department,
Klinikum Wels-Grieskirchen, Wels, Austria; and the iiDepartment of Cardiovascular Medicine, Tokushima University Hospital,
Tokushima, Japan. Microlife Co., Ltd., and National Yang-Ming University have signed a contract for transfer of the noninvasive
central blood pressure technique. The contract of technology transfer includes research funding for conducting the validation
study. Dr. Chen has served as a speaker or a member of a speakers bureau for AstraZeneca, Pzer, Bayer AG, Bristol-Myers Squibb,
Boehringer Ingelheim, Daiichi-Sankyo, Novartis Pharmaceuticals, Servier, Merck & Co., Sano, and Takeda Pharmaceuticals
International. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Manuscript received February 23, 2017; revised manuscript received May 26, 2017, accepted May 30, 2017.
574 Picone et al.
Accuracy of Cuff-Measured BP
measure aortic BP, eliminating the need for specialist
devices (2325).
These issues create uncertainty as to whether cuff
BP accurately measures intra-arterial BP, either at the
brachial or aortic level. Better understanding of these
issues is relevant to validation protocol standards for
cuff BP devices, and could lead to improved clinical
management of cardiovascular risk through more
accurate BP measurement and classication. We
completed 3 separate but inter-related systematic
reviews and individual participant data meta-
analyses to determine the accuracy of cuff BP mea-
surement methods. We rst aimed to determine the
true level of intra-arterial BP agreement between
the aorta and brachial artery (meta-analysis 1), and
then whether cuff BP accurately measured either
intra-arterial brachial BP (meta-analysis 2) or intra-
arterial aortic BP (meta-analysis 3). Potential clinical
consequences of cuff BP measurement error were
determined by the concordance between cuff and
intra-arterial BP for classifying HTN according to
criteria of the Seventh Report of the Joint National
Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure (JNC 7) (26).
METHODS
SEARCH TECHNIQUE AND STUDY ELIGIBILITY. The
search technique, study eligibility criteria, data
collection, synthesis, and statistical analysis were
conducted similarly across each meta-analysis, with
minor differences reecting the specic needs of each
question. The Preferred Reporting Items for System-
atic Review and Meta-Analyses of individual partici-
pant data were adhered to (Online Table 1) (27). Two
reviewers (D.S.P, M.G.S) identied eligible studies by
title, abstract, or full-text review and performed a
separate data quality assessment. All of these activ-
ities were undertaken with each reviewer blinded to
the other reviewers results. Discrepancies were
resolved via consensus. Results from meta-analysis 1
are provided in the Online Appendix.
Four online databases (PubMed, Scopus, Embase,
and Web of Knowledge) were systematically searched
for eligible papers from database inception until May
9, 2016, with slight modications for each meta-
analysis (Online Table 2). Additional studies were
found by searching the reference lists of identied
studies and personal communication with authors.
Unpublished data was accepted if sufcient
methodology was provided (Online Appendix 1).
Study eligibility was not restricted by subject age,
language, or year of publication. We included studies
that measured intra-arterial BP by high-delity
JACC VOL. 70, NO. 5, 2017
AUGUST 1, 2017:57286
micromanometer tip or uid-lled catheters, as well
as indwelling arterial needles and cannulas. For each
meta-analysis, studies were only included if the BP
measurements being compared were recorded within
the immediate period of each other, rather than at
different times (28), due to possible hemodynamic
changes between measurement periods (29). Studies
that measured BP at multiple arterial sites (e.g.,
brachial and radial) in the same study were included if
authors were able to provide separated data. Studies
that recorded data under nonbasal conditions
involving hemodynamic shifts (e.g., exercise or
administration of vasoactive drugs that altered BP
during the recording procedure) were excluded. There
was some minor variability of the inclusion and
exclusion criteria that were specic to the goal of each
meta-analysis. These included cuff BP methods of
auscultation (mercury or aneroid), and oscillometric
and automatic Korotkoff sound devices for meta-
analyses 2 and 3. Studies were also excluded if the
goal of the work was to determine the effect of
different cuff sizes on the relationship between cuff
and intra-arterial BP, because of the expectation of
cuff BP measurement error (30). For meta-analyses 1
and 3, studies that measured aortic BP distal to
the aortic arch were excluded because potential
amplication of SBP along the aorta (31) could
contribute to discordance of comparisons between
BP measurements.
DATA COLLECTION. For each eligible study, indi-
vidual participant-level deidentied BP data were
requested from authors. PP was calculated as
SBP DBP. Clinical information, including age, sex,
anthropometry, medications, and disease status, was
also requested if available. Data were standardized to
be in the international system of units, except for
pressure units. Individual data supplied by authors
were checked for consistency with published aggre-
gate data where available. If discrepancies were
identied, clarication was sought from authors. If no
response was received to data requests, or authors
were not contactable, individual data were extracted
from within published tables (Online Appendix 2) or
from gure scatterplots using extraction software,
when possible (32). Data obtained from scatterplots
were only included in the meta-analyses when accu-
racy could be veried by comparison with published
summary data or correlation coefcients (Online
Table 3). A quality score was applied to each study
to account for important study design attributes that
may have affected data quality (Online Appendix 3,
Online Tables 4 to 6). The University of Tasmania
Health and Medical Human Research Ethics
JACC VOL. 70, NO. 5, 2017
AUGUST 1, 2017:57286
Committee approved this study (reference number:
H0015048).
MAGNITUDE OF BP DIFFERENCES. The proportion
of cuff BP measurements that were $5, $10,
or $15 mm Hg different from intra-arterial BP were
determined as a measure of accuracy (33).
BP CLASSIFICATION. To determine accuracy of cuff
BP for BP classication, each individuals cuff BP
was classied according to JNC 7 criteria (normal
BP <120/80 mm Hg; pre-HTN SBP 120 to 139 mm Hg or
DBP 80 to 89 mm Hg; stage 1 HTN SBP 140 to
159 mm Hg or DBP 90 to 99 mm Hg; and stage 2 HTN
SBP $160 mm Hg or DBP $100 mm Hg) (26), and
then compared for concordance with the BP classi-
cation according to the measurement of BP by intra-
arterial brachial and aortic BP. For example, for
an individual with cuff BP classied as normal
(<120/80 mm Hg), the corresponding intra-arterial
BP for that individual was classied into the appro-
priate category (e.g., normal, pre-HTN, or stage 1 or
2 HTN), and found to be concordant if also falling into
the same normal BP classication (<120/80 mm Hg).
This approach enabled an assessment of the potential
effect of cuff BP inaccuracy on clinical practice, but
also involves a level of arbitrariness with BP cut
points because there is a continuous relationship
between BP and cardiovascular risk. Additional ana-
lyses were also undertaken in which the risk cut
points for intra-arterial BP (both brachial and aortic)
were drawn at equal percentile ranks to the tradi-
tional cuff BP cut points. Sensitivity and specicity
of cuff BP for delineating HTN at a cut point
of $140/90 mm Hg was also assessed.
STATISTICAL ANALYSIS. BP and clinical character-
istics are presented as mean and 95% condence
interval (95% CI) unless otherwise specied. BP dif-
ferences were calculated as brachial artery BP minus
aortic BP (meta-analysis 1) and cuff BP minus intra-
arterial brachial or aortic BP (meta-analyses 2 and 3).
Both 1- and 2-stage meta-analysis was used. The re-
sults generated from each method are considered
equivalent in individual participant data meta-
analysis (34). Two-stage meta-analyses were used to
analyze mean BP differences, because this method
allowed production of summary forest plots to illus-
trate the level of the BP difference across included
studies. For this method, data were rst analyzed
study by study, and were then synthesized using
random effects meta-analysis due to the observa-
tional nature of the data. Correlation coefcients
from individual studies were used to calculate sum-
mary correlation coefcients on the relationship
between BP measurements in each meta-analysis.
Picone et al. 575
Accuracy of Cuff-Measured BP
This same method was used for sensitivity and
specicity analyses for cuff BP delineating HTN based
on the 140/90-mm Hg cut point. Linear mixed
modeling (1-stage meta-analysis) was used to account
for clustering of individuals within each study for
mean absolute difference, BP classication analysis,
percentile calculation for the revised intra-arterial BP
thresholds, and potential predictors of BP differ-
ences. Mean absolute difference was calculated as the
absolute value of the BP difference at the individual
participant level. In meta-analysis 3, Laugesen et al.
(35) and Rossen et al. (36) were pooled for analysis,
because participants were from the same population
and the measurement protocols used were identical,
except for the type of cuff BP device.
Sensitivity analyses were among studies that
received the maximum study quality score to assess
whether results were inuenced by study design
factors and to separately assess published data sour-
ces compared with unpublished data sources. To
determine the inuence on results of meta-analyses
2 and 3, sensitivity analyses were conducted for sin-
gle BP measurements compared with the average of
multiple cuff BP measures, as well as the type of
catheter used for intra-arterial BP measurement. A
p value < 0.05 was considered statistically signicant.
Data were synthesized and analyzed using R version
3.1.2 (R Foundation for Statistical Computing, Vienna,
Austria), primarily using the metafor and lme4 pack-
ages, and Stata version 14 (StataCorp, College Station,
Texas) (2015, metandi module). Additional statistical
methods are in Online Appendix 4.
RESULTS
ELIGIBLE STUDIES AND SUBJECT CHARACTERISTICS.
A total of 75,071 studies were identied from the 3
meta-analysis searches. After review based on title
and abstract, we performed a full-text review of 371
studies, and 152 of these were deemed eligible for
inclusion in the meta-analyses. Individual participant
data were not available from 7, 48, and 23 studies for
meta-analyses 1, 2, and 3, respectively. This left 13,
22, and 39 studies for SBP analysis, respectively,
whereas 12, 18, and 36 studies, respectively, were
available for analysis relating to DBP and PP (Online
Tables 7 to 10, Online References). Systematic re-
view ow diagrams and study characteristics for all
meta-analyses are detailed in Online Figures 1 to 6
and Online Tables 7 to 12. Data were extracted from
published tables in 11 studies (Online Appendix 2),
and from published gures in 6 studies (Online
Table 3). Data was sourced from 18 countries
(Australia, New Zealand, China, Japan, Singapore,
576 Picone et al. JACC VOL. 70, NO. 5, 2017

Accuracy of Cuff-Measured BP AUGUST 1, 2017:57286

F I G U R E 1 Forest Plot of Brachial Cuff and Intra-Arterial Brachial BP Difference

A
Mean Difference
Author(s) and Year Patients [95% CI]
Berliner et al, 1961 100 4.3 [1.0 , 7.6]
Blank et al, 1988 11 14.3 [21.5 , 7.1]
Bos et al, 1992 57 3.3 [5.0 , 1.6]
Cheng et al, 2010 100 5.4 [7.0 , 3.7]
Cheng et al, unpublished 14 9.4 [16.5 , 2.3]
Ding et al, 2013 33 18.7 [22.7 , 14.7]
Freis et al, 1968 6 0.1 [1.9 , 1.7]
Gelman et al, 1981 5 14.6 [23.7 , 5.5]
Gould et al, 1984 28 4.3 [8.0 , 0.7]
Hayashi et al, 2014 55 1.6 [3.2 , 0.1]
Hunyor et al, 1978 9 9.9 [12.0 , 7.7]
Kobayashi et al, 2013 20 8.2 [12.0 , 4.3]
Lin et al, 2012 78 4.3 [6.8 , 1.8]
Melamed et al, 2012 3 4.3 [13.4 , 4.7]
Muecke et al, 2009 2 5.1 [15.0 , 4.8]
Omboni et al, 1997 12 4.7 [7.8 , 1.7]
Picone et al, unpublished 40 11.5 [14.9 , 8.1]
Pucci et al, unpublished 29 10.5 [15.0 , 6.0]
Raftery and Ward, 1968 50 4.8 [8.3 , 1.3]
Roberts et al, 1953 47 12.3 [16.6 , 7.9]
Sagiv et al, 1999 12 6.9 [3.8 , 10.1]
Vardan et al, 1983 24 2.0 [3.4 , 7.4]
Mean difference model for all studies 5.7 [8.0 , 3.5]
Intra-arterial brachial SBP higher Brachial cuff SBP higher

22.0 10.0 2.0 10.0

Mean Difference Between Brachial Cuff and Intra-Arterial Brachial SBP

B
Mean Difference
Author(s) and Year Patients [95% CI]
Berliner et al, 1961 100 6.6 [4.4 , 8.7]
Bos et al, 1992 57 1.9 [0.3 , 3.5]
Cheng et al, 2010 100 5.8 [4.4 , 7.2]
Cheng et al, unpublished 14 5.4 [0.4 , 10.5]
Ding et al, 2013 33 1.3 [3.8 , 1.2]
Freis et al, 1968 6 8.7 [7. 1 , 10.4]
Gelman et al, 1981 5 1.0 [5.9 , 7.9]
Gould et al, 1984 28 10.4 [6.9 , 13.8]
Hayashi et al, 2014 55 5.0 [2.8 , 7.3]
Hunyor et al, 1978 9 8.0 [4.0 , 12.0]
Lin et al, 2012 78 7.0 [4.7 , 9.2]
Melamed et al, 2012 3 1.3 [11.8 , 14.4]
Muecke et al, 2009 2 9.6 [1.6 , 17.7]
Omboni et al, 1997 12 15.4 [12.9 , 17.8]
Picone et al, unpublished 40 6.9 [5.4 , 8.4]
Pucci et al, unpublished 29 1.1 [1.1 , 3.3]
Raftery and Ward, 1968 50 6.1 [3.4 , 8.9]
Roberts et al, 1953 47 2.8 [5.9 , 0.3]
Mean difference model for all studies 5.5 [3.5 , 7.5]
Intra-arterial brachial DBP higher Brachial cuff DBP higher

12.0 0.0 8.0 16.0

Mean Difference Between Brachial Cuff and Intra-Arterial Brachial DBP

Pooled mean difference and 95% condence interval (CI) for meta-analysis 2, the comparison of brachial cuff and intra-arterial brachial
systolic blood pressure (SBP) (A), diastolic blood pressure (DBP) (B), and pulse pressure (PP) (C). BP blood pressure.

Continued on the next page

JACC VOL. 70, NO. 5, 2017 Picone et al. 577
AUGUST 1, 2017:57286 Accuracy of Cuff-Measured BP

F I G U R E 1 Continued

C
Author(s) and Year
Berliner et al, 1961
Bos et al, 1992
Cheng et al, 2010
Cheng et al, unpublished
Ding et al, 2013
Freis et al, 1968
Gelman et al, 1981
Gould et al, 1984
Hayashi et al, 2014
Hunyor et al, 1978
Lin et al, 2012
Melamed et al, 2012
Muecke et al, 2009
Omboni et al, 1997
Picone et al, unpublished
Pucci et al, unpublished
Raftery and Ward, 1968
Roberts et al, 1953
Mean difference model for all studies
Mean Difference
Patients [95% CI]
100 2.2 [5.0 , 0.5]
57 5.2 [7.3 , 3.1]
100 11.1 [13.0 , 9.3]
14 14.8 [22.2 , 7.4]
33 17.4 [20.6 , 14.2]
6 8.9 [11.1 , 6.7]
5 15.6 [29.4 , 1.8]
28 14.7 [18.1 , 11.3]
55 6.7 [9.4 , 3.9]
9 17.9 [21.3 , 14.5]
78 11.3 [14.0 , 8.6]
3 5.7 [27.1 , 15.8]
2 14.7 [32.7 , 3.2]
12 20.1 [22.8 , 17.3]
40 18.4 [21.4 , 15.4]
29 11.6 [16.5 , 6.7]
50 10.9 [14.6 , 7.2]
47 9.5 [14.5 , 4.4]
12.0 [14.7 , 9.3]
Intra-arterial brachial PP higher Brachial cuff PP higher

36.0 24.0 12.0 0.0 8.0

Mean Difference Between Brachial Cuff and Intra-Arterial Brachial PP

United States, Canada, England, Scotland, France,
Germany, Italy, Austria, Portugal, the Netherlands,
Denmark, Norway, and Israel). Across the 3 meta-
analyses, subjects were generally of middle-to-older
age, predominately male, and overweight according
to body mass index (Online Tables 13 to 15). When
individual participant data were checked as per
guidelines (27), no important issues, such as incon-
sistency with published aggregate data, arose. There
were minor differences between the number of sub-
jects in some published papers and the number of
subjects used in the meta-analyses (see explanation
in Online Appendix 5).
META-ANALYSES ON BP DIFFERENCES. See
Online Appendix for all results from meta-analysis 1
(Online Appendix 6, Online Figures 7 to 9).
In meta-analysis 2, brachial cuff BP methods
signicantly underestimated intra-arterial brachial
SBP and PP, but signicantly overestimated intra-
arterial brachial DBP (p < 0.0001 for all) (Figures 1A
to 1C). The mean absolute difference for SBP was
7.9 mm Hg (95% CI: 6.5 to 9.5 mm Hg). Intra-arterial
brachial SBP was underestimated among studies
that used either oscillometric or mercury sphyg-
momanometric techniques, although this was only
of borderline signicance for the latter (Online
Table 16). However, both oscillometric and mercury
sphygmomanometric cuff methods signicantly
overestimated intra-arterial brachial DBP, and there-
fore, also signicantly underestimated intra-arterial
brachial PP. Strong correlations were observed be-
tween brachial cuff and intra-arterial brachial SBP
(r 0.89; 95% CI: 0.86 to 0.93), DBP (r 0.78; 95% CI:
0.72 to 0.85), and PP (r 0.82; 95% CI: 0.76 to 0.88),
with p < 0.0001 for all (Online Figure 10).
In meta-analysis 3, there was no signicant differ-
ence between brachial cuff and intra-arterial aortic SBP
(Figure 2A) (p 0.77); however, this was due to a rela-
tive balance in the number of studies reporting either
signicant overestimation (7 studies) or signicant
the underestimation (7 studies) of intra-arterial aortic SBP
by cuff SBP. Indeed, the mean absolute difference was
8.0 mm Hg (95% CI: 7.1 to 8.9 mm Hg). Brachial cuff
methods signicantly overestimated intra-arterial
aortic DBP, and thus signicantly underestimated
intra-arterial aortic PP (Figures 2B and 2C) (p < 0.0001
for both). Oscillometric and mercury sphygmomano-
metric cuff methods were not analyzed separately as
per meta-analysis 2, because the mercury method was
only used in 2 studies, totaling 21 individuals. There
were strong relationships between brachial cuff and
intra-arterial aortic SBP based on the pooled correla-
tion coefcients (r 0.88; 95% CI: 0.86 to 0.90), DBP
(r 0.75; 95% CI: 0.70 to 0.80), and PP (r 0.81;
578 Picone et al. JACC VOL. 70, NO. 5, 2017

Accuracy of Cuff-Measured BP AUGUST 1, 2017:57286

F I G U R E 2 Forest Plot of Brachial Cuff and Intra-Arterial Aortic BP Difference

A
Mean Difference
Author(s) and Year Patients [95% CI]
Aakhus et al, 1993 28 2.5 [4.9 , 0.0]
Bhatt et al, 2011 98 7.4 [9.9 , 4 .9]
Borow et aI, 1982 30 0.7 [1.1 , 2.5]
Bos et al, 1992 19 0.6 [2.4 , 3.7]
Broyd et al, unpublished 25 12.0 [18.0 , 6.1]
Cheng et al, 2010 100 2.9 [1.0 , 4.8]
Cheng et al, unpublished 17 3.9 [9.5 , 1.7]
Costello et al, 2015 40 0.8 [4.1 , 2.5]
Cremer et al, 2012 144 6.5 [8.9 , 4.1]
Davies et al, 2003 28 3.4 [0.5 , 7.3]
Ding et al, 2013 33 0.8 [4.0 , 2.4]
Kobayashi et al, 2013 20 4.8 [8.8 , 0.8]
Korolkova et al, unpublished 14 9.5 [0.6 , 19.5]
Laugesen/Rossen et al, 2014 37 3.8 [1.0 , 6.6]
Lin AC et al, 2012 35 1.8 [2.6 , 6.1]
Lin MM et al, 2012 78 1.3 [1.4 , 4.0]
Lowe et al, 2009 37 0.7 [5.1 , 3.7]
Milne et al, 2015 9 6.8 [0.5 , 14.1]
Nagle et al, 1966 2 3.4 [8.7 , 1.9]
Nakagomi et al, 2016 139 4.8 [7.3 , 2.4]
Ohte et al, 2007 82 1 .8 [4.3 , 0.8]
Ott et al, 2012 52 10.9 [6.5 , 15.3]
Park et al, 2014 6 0.0 [7.5 , 7.5]
Pereira et al, 2014 15 8.6 [6.4 , 10.8]
Picone et al, unpublished 146 3.1 [1.6 , 4.6]
Pucci et al, 2013 58 1.7 [1.0 , 4.4]
Pucci et al, unpublished 29 2.7 [6.2 , 0.9]
Rajani et al, 2008 14 2.3 [2.4 , 6.9]
Saul et al, 1995 97 1.0 [1.3 , 3.2]
Smulyan et al, 2003 25 18.4 [13.0 , 23.8]
Smulyan et al, 2008 100 0.8 [3.0 , 1.4]
Smulyan et al, 2010 25 0.2 [4.5 , 4.9]
Sueta et al, 2015 85 13.4 [15.5 , 11.4]
Takazawa et al, 2007 18 4.1 [0.8 , 9.0]
Takazawa et al, 2012 52 1.4 [1.7 , 4.5]
Weber et al, 1999 36 1.6 [1.4 , 4.6]
Weber et al, 2011 30 8.8 [12.5 , 5.1]
Williams et al, 2011 20 7.5 [5.2 , 9.8]
Mean difference model for all studies 0.3 [1.5 , 2.1]
Intra-arterial aortic SBP higher Brachial cuff SBP higher

20.0 16.0 12.0 8.0 4.0 0.0 4.0 8.0 12.0 16.0 20.0 24.0
Mean Difference Between Brachial Cuff and Intra-Arterial Aortic SBP

B
Mean Difference
Author(s) and Year Patients [95% CI]
Aakhus et al, 1993 28 7.8 [6.0 , 9.5]
Bhatt et al, 2011 98 5.2 [3.7 , 6.7]
Borow et aI, 1982 30 1.8 [0.7 , 2.9]
Bos et al, 1992 19 5.8 [3.7 , 7.9]
Broyd et al, unpublished 25 4.3 [2.2 , 6.5]
Cheng et al, 2010 100 7.3 [5.6 , 9.0]
Cheng et al, unpublished 17 5.6 [1.1 , 10.1]
Costello et al, 2015 40 10.2 [7.4 , 13.0]
Cremer et al, 2012 142 8.2 [6.5 , 9.9]
Ding et al, 2013 33 1.2 [3.6 , 1.3]
Korolkova et al, unpublished 14 17.8 [14.9 , 20.8]
Laugesen/Rossen et al, 2014 37 13.1 [10.9 , 15.2]
Lin AC et al, 2012 35 4.1 [1.5 , 6.7]
Lin MM et al, 2012 78 6.7 [4.4 , 9.0]
Lowe et al, 2009 37 3.8 [1.5 , 6.2]
Milne et al, 2015 9 10.9 [18.3 , 3.5]
Nagle et al, 1966 2 1.4 [15.9 , 13.1]
Nakagomi et al, 2016 139 12.8 [11.3 , 14.4]
Ohte et al, 2007 82 4.5 [2.5 , 6.5]
Ott et al, 2012 52 0.6 [2.7 , 1.4]
Park et al, 2014 6 7.3 [5.3 , 9.3]
Pereira et al, 2014 15 2.5 [0.1 , 5.2]
Picone et al, unpublished 146 8.5 [7.7 , 9.3]
Pucci et al, 2013 58 4.8 [2.8 , 6.9]
Pucci et al, unpublished 29 2.8 [5.1 , 0.6]
Rajani et al, 2008 14 5.0 [0.2 , 9.7]
Smulyan et al, 2003 25 13.1 [7.5 , 18.8]
Smulyan et al, 2008 100 2.0 [0.6 , 3.5]
Smulyan et al, 2010 25 1.8 [1.6 , 5.2]
Sueta et al, 2015 85 0.4 [1.9 , 1.1]
Takazawa et al, 2007 18 10.8 [7.9 , 13.8]
Takazawa et al, 2012 52 1.3 [1.6 , 4.3]
Weber et al, 1999 36 5.5 [3.9 , 7.1]
Weber et al, 2011 30 6.7 [4.1 , 9.3]
Williams et al, 2011 20 13.5 [11.9 , 15.1]
Mean difference model for all studies 5.5 [4.0 , 7.1]
Intra-arterial aortic DBP higher Brachial cuff DBP higher

20.0 16.0 12.0 8.0 4.0 0.0 4.0 8.0 12.0 16.0 20.0 24.0
Mean Difference Between Brachial Cuff and Intra-Arterial Aortic DBP

Pooled mean difference and 95% CI for meta-analysis 3, the comparison of brachial cuff and intra-arterial aortic SBP (A), DBP (B), and PP (C).
Abbreviations as in Figure 1.

Continued on the next page

JACC VOL. 70, NO. 5, 2017 Picone et al. 579
AUGUST 1, 2017:57286 Accuracy of Cuff-Measured BP

F I G U R E 2 Continued

C
Mean Difference
Author(s) and Year Patients [95% CI]
Aakhus et al, 1993 28 10.3 [12.7 , 7.9]
Bhatt et al, 2011 98 12.6 [14.8 , 10.4]
Borow et aI, 1982 30 1.0 [2.9 , 0.9]
Bos et al, 1992 19 5.2 [7.7 , 2.7]
Broyd et al, unpublished 25 16.4 [22.3 , 10.4]
Cheng et al, 2010 100 4.4 [6.4 , 2.3]
Cheng et al, unpublished 17 9.5 [15.5 , 3.4]
Costello et al, 2015 40 11.0 [15.1 , 6.8]
Cremer et al, 2012 142 14.8 [17.5 , 12.0]
Ding et al, 2013 33 0.4 [2.2 , 2.9]
Korolkova et al, unpublished 14 8.4 [16.8 , 0.1]
Laugesen/Rossen et al, 2014 37 9.3 [12.7 , 5.8]
Lin AC et al, 2012 35 2.3 [8.2 , 3.5]
Lin MM et al, 2012 78 5.4 [8.2 , 2.7]
Lowe et al, 2009 37 4.5 [10.2 , 1.1]
Milne et al, 2015 9 17.7 [13.4 , 21 .9]
Nagle et al, 1966 2 2.0 [11.2 , 7.2]
Nakagomi et al, 2016 139 17.7 [20.0 , 15.3 ]
Ohte et al, 2007 82 6.3 [8.8 , 3.7]
Ott et al, 2012 52 11.5 [7.1 , 16.0]
Park et al, 2014 6 7.3 [15.6 , 1.0]
Pereira et al, 2014 15 6.1 [3.4 , 8.7]
Picone et al, unpublished 146 5.4 [6.8 , 3.9]
Pucci et al, 2013 58 3.1 [5.6 , 0.6]
Pucci et al, unpublished 29 0.2 [3.5 , 3.9]
Rajani et al, 2008 14 2.7 [7.7 , 2.3]
Smulyan et al, 2003 25 5.3 [1.4 , 12.0]
Smulyan et al, 2008 100 2.8 [5.0 , 0.6]
Smulyan et al, 2010 25 1.6 [6.0 , 2.8]
Sueta et al, 2015 85 13.0 [15.0 , 1 1.1]
Takazawa et al, 2007 18 6.8 [12.5 , 1.1]
Takazawa et al, 2012 52 0.1 [4.0 , 4.2]
Weber et al, 1999 36 3.9 [7.8 , 0.0]
Weber et al, 2011 30 15.5 [20.3 , 10.6]
Williams et al, 2011 20 6.0 [8.3 , 3.7]
Mean difference model for all studies 4.8 [7.1 , 2.6]
Intra-arterial aortic PP higher Brachial cuff PP higher

22.0 14.0 6.0 2.0 2.0 6.0 10.0 14.0 18.0 22.0
Mean Difference Between Brachial Cuff and Intra-Arterial Aortic PP

95% CI: 0.76 to 0.85), p < 0.0001 for all (Online
Figure 11). In all meta-analyses, there was signicant
heterogeneity between studies for the SBP, DBP, and
PP analyses (I 2 > 86%; p < 0.0001 for all).
BP CLASSIFICATION BASED ON CUFF BP COMPARED
WITH INTRA-ARTERIAL BP. Among individuals with
BP classied as either pre-HTN or stage 1 HTN, only
50% to 60% of brachial cuff BP measures were
concordant with intra-arterial BP measures. Under-
estimation of BP classication was the predominant
issue for brachial cuff comparisons with intra-arterial
brachial BP, whereas intra-arterial aortic BP classi-
cations were similarly overestimated and under-
estimated. However, there was
concordance between brachial cuff and intra-arterial
BP (brachial or aortic) values measured among
individuals with stage 2 HTN ($160/100 mm Hg)
according to intra-arterial BP. There
reasonable concordance between cuff and intra-
arterial aortic BP for BP classication in the normal
range (<120/80 mm Hg) (Table 1). There were similar
ndings when BP classication was only based on SBP
thresholds (Online Table 17). When revised percentile
rank intra-arterial BP thresholds were used, there was
an improvement in concordance compared with the
traditional threshold analysis in some BP categories
(for example, in meta-analysis 2, normal and pre-HTN
categories changed from 60% to 71% and from 50%
to 66%). However, concordance remained similar or
was reduced among other categories (Table 2). The
revised thresholds shifted the systematic underesti-
mation of risk using cuff BP compared with intra-
arterial brachial BP among the categories of pre-HTN
and stage 1 HTN to a more even distribution of over-
estimation and underestimation of the correct BP
classication category. For example, in the category
of cuff BP pre-HTN, the percentage of intra-arterial
brachial BP cases that were in the stage 1 HTN cate-
reasonable gory was reduced from 36% to 17% (cuff underesti-
mation). However, in the category of cuff BP
pre-HTN, the percentage of intra-arterial brachial BP
in the normal category increased from 9% to 13% (cuff
was also overestimation). Similarly, in the category of cuff BP
stage 1 HTN, the percentage of intra-arterial brachial
BP cases that were in either stage 2 HTN or pre-HTN
categories changed from 32% to 20% (cuff underes-
timation) and from 13% to 26% (cuff overestimation),
respectively. With respect to delineating HTN at the
traditional cut-off of 140/90 mm Hg, in meta-analysis
2 the sensitivity was 78.5% (95% CI: 66.8% to 87.0%),
580 Picone et al. JACC VOL. 70, NO. 5, 2017

Accuracy of Cuff-Measured BP AUGUST 1, 2017:57286

T A B L E 1 Number of Subjects and Percentage Concordance Between Brachial Cuff and Intra-Arterial Brachial and Aortic Systolic and Diastolic BP for
Classication of BP Control

Normal Pre-Hypertension Stage 1 Hypertension Stage 2 Hypertension

SBP <120 mm Hg and SBP 120139 mm Hg and/or SBP 140159 mm Hg and/or SBP $160 mm Hg or
Cuff Blood Pressure DBP <80 mm Hg DBP 8089 mm Hg DBP 9099 mm Hg DBP $100 mm Hg

Intra-Arterial Brachial BP (n 668)

Normal 80 (60) 41 (35) 4 (4) 1 (1)
SBP <120 and DBP <80 mm Hg
Pre-hypertension 22 (9) 124 (50) 71 (36) 7 (5)
SBP 120139 and/or DBP 8089 mm Hg
Stage 1 hypertension 1 (2) 20 (13) 79 (53) 43 (32)
SBP 140159 and/or DBP 9099 mm Hg
Stage 2 hypertension 0 (0) 1 (1) 31 (19) 143 (80)
SBP $160 or DBP $100 mm Hg
Pre-hypertension and stage 1 hypertension combined 23 (6) 294 (78) 50 (16)
SBP 120159 and/or DBP 8099 mm Hg
Intra-Arterial Aortic BP (n 1,676)
Normal 322 (79) 78 (19) 4 (1) 2 (1)
SBP <120 and DBP <80 mm Hg
Pre-hypertension 112 (19) 341 (57) 130 (22) 13 (2)
SBP 120139 and/or DBP 8089 mm Hg
Stage 1 hypertension 16 (4) 103 (24) 221 (52) 94 (20)
SBP 140159 and/or DBP 9099
Stage 2 hypertension 0 (0) 7 (3) 48 (21) 185 (76)
SBP $160 or DBP $100 mm Hg
Pre-hypertension and stage 1 hypertension combined 128 (12) 795 (78) 107 (10)
SBP 120159 and/or DBP 8099 mm Hg

Values are n (%), and each row adds to 100%. Linear mixed modeling was used to account for clustering of subjects within studies. Brachial cuff blood pressure (BP) measurements were classied based on
Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure guidelines, and compared for concordance by applying the same cut points to the
intra-arterial brachial and aortic systolic blood pressure (SBP) and diastolic blood pressure (DBP). The proportion of intra-arterial brachial or aortic measurements concordant with brachial cuff BP is reported
as a percentage. A value of 100% within the bolded cells is equal to complete concordance of BP classication. Pre-hypertension and stage 1 hypertension were merged as a combined category to explore the
possible clinical implication of cuff BP accuracy at this BP level.

and specicity was 95.2% (95% CI: 86.5% to 98.4%).
In meta-analysis 3, sensitivity was 81.7% (95% CI:
74.9% to 87.0%) and specicity was 88.5% (95% CI:
83.4% to 92.2%).
MAGNITUDE OF DIFFERENCE BETWEEN CUFF AND
INTRA-ARTERIAL BP. Brachial
were $5, $10 or $15 mm Hg different from intra-
arterial brachial SBP in 465 (67%), 275 (41%), and 173
(26%) of subjects of meta-analyses 2 (Figure 3A).
Similarly, when compared with intra-arterial aortic BP,
brachial cuff SBP was $5, $10 or $15 mm Hg different
in 1,236 (67%), 748 (40%), and 411 (22%) of subjects of
meta-analyses 3 (Figure 3B). Results were similar for
DBP differences, although there was better agreement
for DBP differences $15 mm Hg (Online Figure 12).
CLINICAL AND DEMOGRAPHIC CORRELATES. Older
age and higher body mass index were related in uni-
variable analysis to less underestimation of intra-
arterial brachial and aortic SBP and PP by brachial
cuff SBP and PP (Online Tables 18 and 19). In multi-
variable analysis, age and body mass index both
remained signicantly related to the difference in PP,
but age was not signicantly related to the difference
between brachial cuff and intra-arterial brachial
SBP, whereas body mass index was not signicantly
related to the difference between brachial cuff and
intra-arterial aortic SBP. There were no consistent
associations observed for brachial cuff DBP versus
cuff BP readings
intra-arterial DBP.
SENSITIVITY ANALYSIS. There were signicantly
more males in the maximum-rated studies in meta-
analyses 2 and 3. There were no other signicant
differences between the maximum-rated and non
maximum-rated studies (p > 0.05 all) (Online
Tables 20 to 22). There were no signicant differ-
ences in BP values for published versus unpublished
data (p > 0.05) (Online Tables 23 to 25). In meta-
analyses 2 and 3, there were no signicant differ-
ences when data was analyzed based on single-cuff
BP measures versus the average of multiple-cuff BP
measures. Furthermore, BP classication analysis was
consistent irrespective of the number of cuff mea-
sures. Correlations between cuff and intra-arterial BP
were also similar irrespective of the number of cuff BP
measures. Differences between cuff and intra-arterial
JACC VOL. 70, NO. 5, 2017 Picone et al. 581
AUGUST 1, 2017:57286 Accuracy of Cuff-Measured BP

T A B L E 2 Number of Subjects and Percentage Concordance Between Brachial Cuff and Intra-Arterial Brachial and Aortic Systolic and Diastolic BP for Classication
of BP Control Based on Revised Intra-Arterial Thresholds

Intra-Arterial Brachial BP (n 668)

Normal Pre-Hypertension Stage 1 Hypertension Stage 2 Hypertension

SBP <124.5 and SBP 124.5 to <150 and/or SBP 150 to <167 and/or SBP $167 or
DBP <74 mm Hg DBP 74 to <85 mm Hg DBP 85 to <91 mm Hg DBP $91 mm Hg
Cuff Blood Pressure Centiles <19th 19th to <54th 54th to <76th $76th

Normal <19th 93 (71) 31 (27) 1 (1) 1 (1)

SBP <120 and DBP <80 mm Hg
Pre-hypertension 19th to <54th 28 (13) 156 (66) 34 (17) 6 (4)
SBP 120 to 139 and/or
DBP 80 to 89 mm Hg
Stage 1 hypertension 54th to <76th 3 (2) 38 (26) 73 (52) 29 (20)
SBP 140 to 159 and/or
DBP 90 to 99 mm Hg
Stage 2 hypertension $76th 0 (0) 6 (3) 31 (21) 138 (76)
SBP $160 or DBP $100 mm Hg
Pre-hypertension and stage 1 19th to <76th 31 (9) 301 (81) 35 (10)
hypertension combined
SBP 120 to 159 and/or
DBP 80 to 99 mm Hg

Intra-Arterial Aortic Blood Pressure (n 1,676)

Normal Pre-Hypertension Stage 1 Hypertension Stage 2 Hypertension

SBP <119.1 and SBP 119.1141.8 and/or SBP 141.8165.1 and/or SBP $165.1 or
DBP <74 mm Hg DBP 7483.5 mm Hg DBP 83.593.1 mm Hg DBP $93.1 mm Hg
Cuff Blood Pressure Centiles <24th 24th to <59th 59th to 86th $86th

Normal <24th 302 (74) 97 (25) 6 (1) 1 (0)

SBP <120 and DBP <80 mm Hg
Pre-hypertension 24th to <59th 89 (15) 364 (61) 133 (22) 10 (2)
SBP 120139 and/or DBP
8089 mm Hg
Stage 1 hypertension 59th to <86th 14 (3) 108 (27) 245 (56) 67 (14)
SBP 140159 and/or
DBP 9099 mm Hg
Stage 2 hypertension $86th 0 (0) 8 (5) 66 (30) 166 (65)
SBP $160 or DBP $100 mm Hg
Pre-hypertension and stage 1 24th to <86th 103 (10) 850 (83) 77 (7)
hypertension combined
SBP 120159 and/or
DBP 8099 mm Hg

Data are presented as n (%), and each row adds to 100%. Linear mixed modeling was used to account for clustering of subjects within studies. Brachial cuff BP measurements were classied based on
Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure guidelines, and were compared for concordance with classication of the
corresponding intra-arterial brachial and aortic systolic and diastolic BP. The proportion of intra-arterial brachial or aortic measurements concordant with brachial cuff BP is reported as a percentage. A value
of 100% within the bolded cells is equal to complete concordance of BP classication. Modied intra-arterial thresholds have been calculated from the equivalent percentile rank of cuff BP thresholds.
Pre-hypertension and stage 1 hypertension were merged as a combined category to explore the possible clinical implication of cuff BP accuracy at this BP level.
Abbreviations as in Table 1.

BP were not signicantly inuenced by the type of
catheter used for intra-arterial BP measurement (data
not shown).
DISCUSSION
With HTN as the single major risk factor for global
disease burden (1), the accuracy of clinic BP methods
is critical. Our study had several key ndings. First,
we conrmed the expectation that intra-arterial
brachial SBP was higher than intra-arterial aortic
SBP, and also that there was little difference in DBP
between the central and peripheral arterial sites.
However, there was extreme individual variability
in the magnitude of central-to-peripheral differences
for both SBP and DBP. Second, we found that cuff
BP underestimated intra-arterial brachial SBP (and
PP), but overestimated intra-arterial brachial DBP
irrespective of BP technique (e.g., oscillometric or
auscultation using mercury methods). This is conr-
mation of perceived dogma relating to oscillometric
devices, but as far as we know is the rst compre-
hensive analysis of all cuff BP methods to be
reported. Third, when cuff SBP was compared with
582 Picone et al. JACC VOL. 70, NO. 5, 2017

Accuracy of Cuff-Measured BP AUGUST 1, 2017:57286

F I G U R E 3 Individual Brachial Cuff and Intra-Arterial BP Differences

A 70
Mean Difference (Brachial Cuff Minus Intra-Arterial

60
50
40
Brachial Systolic BP), mm Hg

30
20 5 10 15 mm Hg
10
0
10
20 33% 59% 74%
30
40
50
60
70

60 80 100 120 140 160 180 200 220 240 260

Mean of Brachial Cuff and Intra-Arterial Brachial Systolic BP, mm Hg

B 70
Mean Difference (Brachial Cuff Minus Intra-Arterial

60
50
40
Aortic Systolic BP), mm Hg

30
20 5 10 15 mm Hg
10
0
10
20 33% 60% 78%
30
40
50
60
70

60 80 100 120 140 160 180 200 220 240

Mean of Brachial Cuff and Intra-Arterial Aortic Systolic BP, mm Hg

Plots of brachial cuff and intra-arterial brachial (A), as well as brachial cuff and intra-arterial aortic (B) SBP. The mean of the brachial cuff SBP and
intra-arterial SBP is on the x-axis, and the mean difference between brachial cuff SBP and the intra-arterial SBP is on the y-axis. The proportion of brachial
cuff SBP values within 5 mm Hg of the intra-arterial SBP measures is represented by the green dashed line, and is reported under the 5 bar. The
same presentation is provided for cuff SBP values within 10 mm Hg (orange dotted line) and 15 mm Hg (red dot-dashed line). The solid blue
horizontal line represents the mean SBP difference calculated as brachial cuff minus intra-arterial BP. Abbreviations as in Figure 1.

intra-arterial aortic SBP, there was a small mean and indicate the need to improve accuracy stan-
difference but poor agreement between measures at dards of cuff BP devices.
the individual level, whereas cuff DBP overestimated CLINICAL IMPLICATIONS. A key problem in
and cuff PP underestimated intra-arterial aortic addressing the global burden of disease related to
values. Finally, the observed variability in cuff BP high BP is improving the diagnosis and characteriza-
accuracy adversely inuenced correct classication of tion of the hypertensive phenotype (37). A funda-
BP (compared against intra-arterial classication) mental problem with BP accuracy was identied
across all JNC 7 categories, with particular discor- in our study that affects most (but not all) cuff
dance in the range from pre-HTN to stage 1 HTN. BP devices. Despite strong correlations between cuff
These data are summarized in the Central Illustration BP and intra-arterial BP, 16 of 22 examined cuff BP
JACC VOL. 70, NO. 5, 2017 Picone et al. 583
AUGUST 1, 2017:57286 Accuracy of Cuff-Measured BP

C ENTR AL I LL U STRA T I O N Accuracy of Cuff-Measured BP

Hypertension (elevated blood pressure (BP))

is the single largest risk factor for cardiovascular disease mortality

Non-invasive brachial (upper arm) cuff BP is the principal method

for hypertension diagnosis and management
Does the cuff accurately measure BP?

For patients with For patients with For patients with

Normal BP Prehypertension (120/80 to <140/90 mm Hg) Stage 2 hypertension
<120/80 mm Hg or Stage 1 hypertension (140/90 to <160/100 mm Hg) 160/100 mm Hg

Reasonable Cuff overestimates diastolic BP at brachial and aortic level Reasonable

confidence can be Cuff underestimates systolic BP at brachial level confidence can be
placed in cuff BP placed in cuff BP
Cuff variably under- or overestimates SBP at the aorta
readings readings

Improved accuracy is recommended

Picone, D.S. et al. J Am Coll Cardiol. 2017;70(5):57286.

Summary ndings from individual participant data meta-analyses of cuff blood pressure (BP) accuracy. This illustration depicts BP classication based on cuff BP
measurements and corresponding concordance with intra-arterial BP classication. The results are calculated using all available individual participant data from the
1950s to 2016. Reasonable condence can be placed in cuff BP readings <120/80 mm Hg or $160/100 mm Hg to predict intra-arterial brachial or aortic BP. Improved
accuracy is recommended in the BP range from pre-hypertension ($120/80 mm Hg to <140/90 mm Hg) to stage 1 hypertension ($140/90 mm Hg
to <160/100 mm Hg), where concordance with intra-arterial BP was not strong. SBP systolic blood pressure.

devices signicantly underestimated intra-arterial identication of risk related to BP in clinical practice

brachial SBP (Figure 1A) and 15 of 18 signicantly
underestimated PP (Figure 1C). The mean difference
in the magnitude of the underestimation often
exceeded 10 mm Hg. Translating these error margins
to the traditional classication of BP based on intra-
arterial SBP readings, cuff BP correctly identied
pre-HTN and stage 1 HTN in only about one-half of
the participants, whether based on intra-arterial
brachial or aortic SBP (Table 1). Concordance with
revised intra-arterial brachial BP thresholds (based on
cuff BP percentile rank) was improved from 50% to
66% in the pre-HTN range (Tables 1 and 2). This
analysis also resulted in reduced systematic under-
estimation of risk using cuff BP among the categories
of pre-HTN and stage 1 HTN. Instead, a relatively
even distribution was observed toward both over-
estimation and underestimation of correct classica-
tion of intra-arterial BP (Table 2).
implications of these ndings with
will require future studies.
It could be argued that our ndings are not a major
clinical problem, because HTN thresholds have been
derived from well conducted clinical trial data using
the same (or similar) cuff BP methods to that analyzed
in this current work. Thus, whether cuff BP is
measuring the intra-arterial BP could be largely
irrelevant if risk can still be gauged relative to the BP
methods employed in the clinical trials. This
contention would be valid if there were consistent
systematic error(s), but in fact there was wide inter-
device variability with respect to SBP, DBP, and PP
accuracy. To clarify the issue, separate analysis on
the accuracy of BP devices used in all the seminal
clinical trials would be required. In any case, a
reasonable degree of condence that cuff BP is
representative of intra-arterial brachial or aortic
The true SBP is associated with readings <120/80 mm Hg
respect to or $160/100 mm Hg (Tables 1 and 2).
584 Picone et al.
Accuracy of Cuff-Measured BP
CUFF BP VALIDATION STANDARDS. Guidance on
validation protocols for cuff BP devices is provided by
several scientic bodies (33,3842); however, there
are many procedural differences between guidelines
on features such as sample size, acceptable margin
of error, and pass criteria (43). When comparing BP
device performance with the reference standard
(which can be intra-arterial BP or, most often, mer-
cury sphygmomanometry), differences of 0 to
5 mm Hg are considered to be very accurate,
whereas differences >15 mm Hg are very inaccurate
(40). Although there are many ways to determine
pass criteria for BP devices, the British Hyperten-
sion Society provide the highest grade pass (A) if
60% of differences fall within 5 mm Hg and only 5%
of differences fall outside of 15 mm Hg (33). The
analysis we have conducted cannot be directly
compared with results of validation studies assessing
the performance of individual BP devices. However, it
is of note that only 33% of cuff SBP readings fell
within 0 to 5 mm Hg, and >20% were >15 mm Hg from
intra-arterial SBP (Figure 3). That would equate to a
grade D (fail) device performance. From the available
data, weak associations among age, body mass index,
and cuff BP differences were observed in meta-
analyses 2 and 3, but we were unable to determine
clear-cut reasons for the disparity between cuff and
intra-arterial BP.
A novel nding with respect to the use of mercury
sphygmomanometry as a reference standard in BP
validation protocols is that this method demonstrated
sizable imprecision. Compared with intra-arterial
brachial BP, the mercury method performed better
than oscillometric BP with respect to the level of SBP
underestimation, but signicant overestimation of
DBP and underestimation of PP was still observed
(Online Table 16). There was insufcient data on
mercury BP to compare this method with oscillo-
metric BP for accuracy compared with intra-arterial
aortic BP. Overall, the analyses cast some doubt on
the robustness of mercury sphygmomanometry as the
standard against which BP device performance is
gauged (possibly due to inuences of operator error),
albeit acknowledging that it is the best noninvasive
option currently available. Intra-arterial BP measured
under rigorous criteria has the strongest level of
BP accuracy and may be a better choice as the
comparator for BP device validation. But, it is less
practical, and it is not ethical to use among some
populations. In any case, our observation of signi-
cant differences (and marked variability) between
intra-arterial aortic and brachial BP clearly shows that
it is not acceptable to assume peripheral BP is repre-
sentative of central BP. This nding is applicable to
JACC VOL. 70, NO. 5, 2017
AUGUST 1, 2017:57286
BP device validation protocols in which cuff BP is
compared against intra-arterial BP at the radial (44),
brachial (10), or aortic (45) level. Improvement of BP
device accuracy standards is desirable (29).
STUDY STRENGTHS AND LIMITATIONS. Individual-
level data were acquired from a wide variety of
studies employing high-quality techniques and
spanning several decades of investigations, alto-
gether comprising relatively large sample sizes for
each meta-analysis. However, this also probably
contributed to the observed statistical heterogeneity,
indicating excess variation among experimental pro-
tocols and a degree of uncertainty regarding effect
estimates. Although intra-arterial BP is the reference
standard measurement of BP (46,47), inaccurate BP
is possible due to numerous sources of error: 1) if
operators do not follow appropriate techniques
(e.g., catheter handling and dynamic response) (48);
2) variability in BP between the recording of cuff
and intra-arterial measurements; 3) if measures being
compared are recorded sequentially rather than
simultaneously; or 4) if measures are being compared
within contralateral rather than ipsilateral arterial
sites. Reassuringly, sensitivity analyses showed no
signicant difference between the studies that
received the maximum quality rating for experi-
mental design taking into consideration these sources
of error versus those that did not. Availability of
repeated data would have helped address this issue
further, but this was unavailable in most studies.
Finally, the study populations were generally typical
of patients presenting with clinical indications for
coronary artery catheterization, and therefore, there
was bias toward overweight, middle- to older-age
men, and the ndings cannot be widely generalized.
CONCLUSIONS
Cuff BP is the cornerstone measurement in HTN
management. The most important nding of the
present study was the inaccuracy of cuff BP when
compared with intra-arterial brachial BP and aortic
BP. These deviations substantially inuenced BP
classication according to clinical guideline criteria.
The inadequacies of cuff BP identied within this
work could be improved with better noninvasive cuff
BP methods to estimate brachial or aortic BP. This
should then lead to enhanced clinical diagnosis and
management of HTN.
ADDRESS FOR CORRESPONDENCE: Prof. James E.
Sharman, Menzies Institute for Medical Research,
University of Tasmania, Private Bag 23, Hobart, Tasmania
7000, Australia. E-mail: James.Sharman@utas.edu.au.
JACC VOL. 70, NO. 5, 2017
AUGUST 1, 2017:57286
PERSPECTIVES
COMPETENCY IN MEDICAL KNOWLEDGE:
Measurement of BP with pneumatic cuff devices is subject
to considerable variability that affects correlations
with direct intra-arterial brachial and aortic pressure
measurements. When compared with intra-arterial
pressures, brachial cuff sphygmomanometry generally
underestimates systolic and overestimates diastolic BP.
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KEY WORDS blood pressure determination,
hemodynamics, sphygmomanometers
A PPE NDI X For an expanded Methods section,
as well as supplemental gures and tables,
please see the online version of this article.