Twenty-four-hour ambulatory blood pressure monitoring in atrial fibrillation

Assessment of aortic stiffness during atrial fibrillation: solutions and considerations

Background

Methods to assess aortic stiffness are not validated during ongoing atrial fibrillation (AF) We aimed to determine whether aortic stiffness can be assessed reliably in patients during AF.

Methods and results

Carotid-to-femoral and aortic pulse wave velocity (cf/aoPWV), central blood pressure (BP), and augmentation index (AIx) were assessed by a two-site applanation method and a one-site cuff-based oscillometric method in 40 patients with persistent AF and repeated after cardioversion to SR. Mean age was 63 ± 8 years, 73% male, 50% hypertensive. For the two-site method, cfPWV values were slightly higher in AF than in SR (9.3 ± 1.8 vs. 8.5 ± 1.6 m/s, p < 0.001), whereas the one-site method provided similar values in AF and SR (10.1 ± 1.5 vs. 10.0 ± 1.8 m/s).The variability indices from the device was higher in AF for the two-site method (SD 2.5 ± 1.7 vs. 1.0 ± 0.5 m/s, p < 0.001) but similar in AF and SR with the one-site method (SD 0.7 ± 0.2 vs. 0.6 ± 0.2 m/s). Both methods yielded higher central BP (+4.8/+6.6 and +4.1/+5.7 mm Hg) and lower Aix (-6.8 and -9.1 mm Hg) in AF.

Conclusions

Aortic stiffness can be assessed during AF. Both methods yielded higher central BP and lower AIx in AF, but similar results for PWV in AF and SR, also when adjusted for BP changes. The two-site method showed high variability necessitating repeated measurements. The one-site method showed lower device-calculated variability and needed fewer repeated measurements.

Blood pressure in atrial fibrillation and in sinus rhythm during ambulatory blood pressure monitoring: data from the TEMPLAR project

The coexistence of hypertension and atrial fibrillation (AF) is common and accounts for a worse prognosis. Uncertainties exist regarding blood pressure (BP) measurements in AF patients by automated oscillometric devices. The Microlife WatchBP 03 AFIB ambulatory BP monitoring (ABPM) device including an AF algorithm with each measurement was used in 430 subjects aged >65 years referred for ABPM and with assumed paroxysmal AF to perform intra-individual comparisons of BP during both AF-indicated and sinus rhythm. Only subjects with >30% of measurements indicating AF and episodes >30 min for assumed AF and for sinus rhythm were included. Mean age was 78 ± 7 years, 43% were male, 77% hypertensive, and 72% were treated. Compared to sinus rhythm, 24-h mean arterial pressure was similar (87.2 ± 9.5 vs 87.5 ± 10.6 mm Hg, p = 0.47), whereas 24-h systolic BP tended to be lower (123.6 ± 13.9 vs 124.7 ± 16.1 mm Hg, p = 0.05) and night-time diastolic BP higher (64.6 ± 10.9 vs 63.3 ± 10.4 mm Hg, p = 0.01) in assumed AF. Diastolic (not systolic) BP variability was higher in AF (p < 0.001). Results were similar with heart rates <90 and ≥90 bpm. In conclusion, this is the first study to use intra-individual comparisons of averaged BP during an ABPM in assumed paroxysmal AF and sinus rhythm. Our results imply that ABPM is feasible and informative also in patients with AF. We also suggest that an AF detection algorithm offers a new approach to evaluate the reliability of averaged BP values in AF compared to SR during an ABPM.

Effects of Early-Stage Blood Pressure Variability on the Functional Outcome in Acute Ischemic Stroke Patients With Symptomatic Intracranial Artery Stenosis or Occlusion Receiving Intravenous Thrombolysis

Background

Studies exploring the relationship between blood pressure (BP) fluctuations and outcome in acute ischemic stroke (AIS) patients treated with intravenous thrombolysis (IVT) are limited. We aimed to investigate the influence of blood pressure variability (BPV) during the first 24 h after IVT on early neurological deterioration (END) and 3-month outcome after IVT in terms of different stroke subtypes.

Methods

Clinical data from consecutive AIS patients who received IVT were retrospectively analyzed. The hourly systolic BP of all patients were recorded during the first 24 h following IVT. We calculated three systolic BPV parameters, including coefficient of variability (CV), standard deviation of mean BP (SD) and successive variation (SV), within the first 6, 12, and 24 h after IVT. END was defined as neurological deterioration with an increase in the National Institutes of Health Stroke Scale (NIHSS) score ≥ 4 points within the first 72 h after admission. Follow-up was performed at 90 days after onset, and favorable and poor outcomes were defined as a modified Rankin Scale scores (mRS) of ≤1 or ≥2, respectively.

Results

A total of 339 patients, which were divided into those with (intracranial artery stenosis or occlusion group, SIASO group) and without (non-SIASO group) SIASO, were included. Among them, 110 patients (32.4%) were with SIASO. Patients in SIASO group had higher NIHSS on admission and difference in term of mRS at 90 days compared with non-SIASO group (P < 0.001). In SIASO group, patients in favorable outcome group were younger and had lower NIHSS on admission, lower SV-24 h (14.5 ± 4.3 vs. 11.8 ± 3.2, respectively) and lower SD-24 h (12.7 ± 3.8 vs. 10.9 ± 3.3, respectively), compared with patients with poor outcome (all P < 0.05). In the multivariable logistic regression analysis, compared with the lowest SV (SV < 25% quartile), SV_50−75% [odds ratio (OR) = 4.449, 95% confidence interval (CI) = 1.231–16.075, P = 0.023] and SV_>75% (OR = 8.676, 95% CI = 1.892–39.775, P = 0.005) were significantly associated with poor outcome at 3 months in patients with SIASO, adjusted for age, NIHSS on admission and atrial fibrillation. No BPV parameters were associated with END in SIASO group. In non-SIASO group, there were no significant association between BPV patterns and END or 90-day outcome.

Conclusions

SV-24 h had a negative relationship with 3-month outcome in AIS patients with SIASO treated with IVT, indicating that BPV may affect the outcome of AIS.

Does the mean 24-h pulse rate from ambulatory blood pressure monitoring reflect the mean 24-h ventricular rate from Holter electrocardiogram in atrial fibrillation patients?

BACKGROUND

Ambulatory blood pressure monitoring (ABPM) on the oscillometric method is applicable in patients with atrial fibrillation, but the mean pulse rate is or not similar to the ventricular rate from the Holter in atrial fibrillation patients remains unknown.

METHODS

This study included 228 persistent atrial fibrillation patients who received simultaneous 24-h ABPM and 24-h Holter. The mean 24-h pulse rate and the mean 24-h ventricular rate were calculated, and mVR-mPR was used to reflect the difference between them. The SD of 24-h pulse rate values was calculated as SD-pulse rate. Furthermore, according to the SD-pulse rate, the patients were divided into ≤5, 6-10, 11-15 and >15 bpm subgroups.

RESULTS

For the total population, the mean 24-h pulse rate is positively correlated with the mean 24-h ventricular rate, and the Bland-Altman plot showed quite wide 95% limits. As the SD-pulse rate increased, the 24-h mVR-mPR also increased. The mean 24-h mVR-mPR was 0.5 bpm when SD-pulse rate ≤5, 3.5 bpm when SD-pulse rate of 6-10, 7.6 bpm when SD-pulse rate of 11-15, and 12.5 bpm when SD-pulse rate >15 bpm, respectively. Meanwhile, in the SD-pulse rate 0-10 subgroup, the 95% limits were only from -13.8 to 19.7 bpm, while in the >10 subgroup, these values were from -19.5 to 36.5 bpm.

CONCLUSION

The mean 24-h pulse rate should not be used to represent the true ventricular rate for all atrial fibrillation patients. However, when lower the SD-pulse rate, the mVR-mPR becomes smaller.

Changes in 24-h ambulatory blood pressure following restoration of sinus rhythm in patients with atrial fibrillation

OBJECTIVE

The interplay between atrial fibrillation and blood pressure (BP) is insufficiently studied. In symptomatic patients with persistent atrial fibrillation, electrical cardioversion (ECV) is often used to restore sinus rhythm. In this prospective study, we investigated how restoration of sinus rhythm affected 24-h ambulatory BP.

METHODS

Ninety-eight patients with persistent atrial fibrillation were examined with 24-h ambulatory BP monitoring before and approximately a week after ECV.

RESULTS

Sixty-two patients remained in sinus rhythm at the time of the second ambulatory BP monitoring (AF-SR group), whereas 36 patients had relapsed into atrial fibrillation (AF-AF group). In the AF-SR group, there was a significant increase in mean systolic 24-h BP (5.6 mmHg), a significant decrease in mean diastolic 24-h BP (-4.7 mmHg) and accordingly, a significant 25% (10.4 mmHg) increase in mean 24-h pulse pressure.

CONCLUSION

These findings may reflect the haemodynamic conditions that are prevalent in atrial fibrillation, ambulatory BP measurement bias in atrial fibrillation or a combination of both factors. From a clinical standpoint, our results suggest that an increased attention to BP is needed when sinus rhythm is restored, as underlying hypertension may be masked by BP changes during atrial fibrillation. From a general standpoint, it may be speculated that BP, as indicated by the relatively large difference in pulse pressure, may be inherently different in atrial fibrillation and may therefore not be interpretable in the equivalent manner as BP in sinus rhythm.

Effects of vascular compression on the rostral ventrolateral medulla for blood pressure variability in stroke patients

BACKGROUNDS

Vascular compression of the rostral ventrolateral medulla (RVLM) has been associated with hypertension or blood pressure (BP) variability. For acute ischemic stroke patients, increased BP variability may cause poor functional outcomes. We tested the hypothesis that RVLM compression was associated with increased BP variability or stroke outcome in acute ischemic stroke patients.

METHODS

Acute ischemic stroke patients (n = 622) with 24-h ambulatory BP monitoring during the subacute phase of stroke (median 9 days from onset) were retrospectively studied. Variability in BP was evaluated with the SD and coefficient of variation of SBP and DBP. The morning surge was also evaluated. The presence of RVLM compression was evaluated using time-of-flight three-dimensional MRI. A poor outcome was defined as a modified Rankin Scale score of 3-6 at 3 months.

RESULTS

Patients with RVLM compression (n = 213) had significantly higher 24-h SBP mean, 24-h SBP SD, 24-h SBP coefficient of variation, 24-h DBP mean, 24-h DBP SD, and 24-h DBP coefficient of variation values and a higher prevalence of morning surge than those without (n = 409). Multiple regression analysis revealed that RVLM compression was associated with increased SBP variability, DBP variability, and morning surge. Despite the significant association between RVLM compression and BP variability, RVLM compression was not associated with poor stroke outcome.

CONCLUSION

Although RVLM compression was closely associated with BP variability in the subacute ischemic stroke phase, an effect of RVLM compression on stroke outcome was not observed.

Blood pressure measurement in atrial fibrillation: review and meta-analysis of evidence on accuracy and clinical relevance

: Atrial fibrillation (AF) often coexists with hypertension in the elderly and multiplies the risk of stroke and death. Blood pressure (BP) measurement in patients with AF is difficult and uncertain and has been a classic exclusion criterion in hypertension clinical trials leading to limited research data. This article reviews the evidence on the accuracy of BP measurement in AF performed using different methods (office, ambulatory, home) and devices (auscultatory, oscillometric) and its clinical relevance in predicting cardiovascular damage. The current evidence suggests the following: (i) Interobserver and intra-observer variation in auscultatory BP measurement is increased in AF because of increased beat-to-beat BP variability and triplicate measurement is required; (ii) Data from validation studies of automated electronic BP monitors in AF are limited and methodologically heterogeneous and suggest reasonable accuracy in measuring SBP and a small yet consistent overestimation of DBP; (iii) 24-h ambulatory BP monitoring is feasible in AF, with similar proportion of errors as in individuals without AF; (iv) both auscultatory and automated oscillometric BP measurements appear to be clinically relevant in AF, providing similar associations with intra-arterial BP measurements and with indices of preclinical cardiac damage as in patients without AF, and predict cardiovascular events and death; (v) Screening for AF in the elderly using an AF-specific algorithm during routine automated office, home or ambulatory BP measurement has high diagnostic accuracy. In conclusion, in AF patients, BP measurement is important, reliable, and clinically relevant and should not be neglected in clinical research and in practice.

The usefulness of 24-hour blood pressure monitoring for the patients with atrial fibrillation: based on the variability of blood pressure parameters

OBJECTIVE

The aim of this study was to test whether ambulatory blood pressure monitoring (ABPM) in patients with atrial fibrillation is reliable as in patients with sinus rhythm.

METHOD

This study included 92 persistent atrial fibrillation patients (50% females; mean age 70.49 ± 11.56 years) and 92 matched sinus rhythm patients (46% females; mean age 69.23 ± 12.63 years). The participants were examined simultaneously with 24-hour ABPM and 24-hour Holter electrocardiography. The mean 24-hour (24-hour-), daytime (day-) and nighttime (night-) BP, types of BP curve, morning systolic BP (SBP) surge (MBPS), the SD of BP readings and the coefficient of variability (the SD/mean BP × 100%) were compared between atrial fibrillation and sinus rhythm patients.

RESULTS

No differences of 24-hour-, day- and night-SBP levels were observed between two groups. Meanwhile, the 24-hour-SD, day-SD and night-SD, as well as the coefficient of variability for SBP were also similar between two groups. There was no significant difference in the number of MBPS between the two groups. On diastolic BP (DBP), the similar 24 hour and day levels, the 24-hour-SD, day-SD and night-SD as well as the coefficient of variability were also similar between two groups. But the nighttime DBP levels and the night-SD were higher in atrial fibrillation than in sinus rhythm.

CONCLUSION

ABPM provides data with similar SBP variability in patients with atrial fibrillation as in subject with normal cardiac rhythm. The ABPM on oscillometric method may be suitable for the atrial fibrillation patients, especially for the SBP evaluation.

Accuracy of automated blood pressure measurements in the presence of atrial fibrillation: systematic review and meta-analysis

Atrial fibrillation (AF) affects ~3% of the general population and is twice as common with hypertension. Validation protocols for automated sphygmomanometers exclude people with AF, raising concerns over accuracy of hypertension diagnosis or management, using out-of-office blood pressure (BP) monitoring, in the presence of AF. Some devices include algorithms to detect AF; a feature open to misinterpretation as offering accurate BP measurement with AF. We undertook this review to explore accuracy of automated devices, with or without AF detection, for measuring BP. We searched Medline and Embase to October 2018 for studies comparing automated BP measurement devices to a standard mercury sphygmomanometer contemporaneously. Data were extracted by two reviewers. Mean BP differences between devices and mercury were calculated, where not reported and compared; meta-analyses were undertaken where possible. We included 13 studies reporting 14 devices. Mean systolic and diastolic BP differences from mercury ranged from -3.1 to + 6.1/-4.6 to +9.0 mmHg. Considerable heterogeneity existed between devices (I²: 80 to 90%). Devices with AF detection algorithms appeared no more accurate for BP measurement with AF than other devices. A previous review concluded that oscillometric devices are accurate for systolic but not diastolic BP measurement in AF. The present findings do not support that conclusion. Due to heterogeneity between devices, they should be evaluated on individual performance. We found no evidence that devices with AF detection measure BP more accurately in AF than other devices. More home or ambulatory automated BP monitors require validation in populations with AF.

Automated measurement of office, home and ambulatory blood pressure in atrial fibrillation

1. Hypertension and atrial fibrillation (AF) often coexist and are strong risk factors for stroke. Current guidelines for blood pressure (BP) measurement in AF recommend repeated measurements using the auscultatory method, whereas the accuracy of the automated devices is regarded as questionable. This review presents the current evidence on the feasibility and accuracy of automated BP measurement in the presence of AF and the potential for automated detection of undiagnosed AF during such measurements. 2. Studies evaluating the use of automated BP monitors in AF are limited and have significant heterogeneity in methodology and protocols. Overall, the oscillometric method is feasible for static (office or home) and ambulatory use and appears to be more accurate for systolic than diastolic BP measurement. 3. Given that systolic hypertension is particularly common and important in the elderly, the automated BP measurement method may be acceptable for self-home and ambulatory monitoring, but not for professional office or clinic measurement. 4. An embedded algorithm for the detection of asymptomatic AF during routine automated BP measurement with high diagnostic accuracy has been developed and appears to be a useful screening tool for elderly hypertensives.

Ambulatory blood pressure monitoring in elderly patients with chronic atrial fibrillation: is it absolutely contraindicated or a useful tool in clinical practice and research?

The aim of this study was to test whether ambulatory blood pressure monitoring (ABPM) in elderly patients with atrial fibrillation (AF) is as feasible and reliable as ABPM is in patients with normal sinus rhythm (SR). Studies of ABPM in the elderly remain limited, and the use of this method in patients with AF remains controversial. The Italian SIIA 2008 guidelines consider ABPM 'absolutely contraindicated' for AF patients. This study was conducted on 200 hospitalized patients aged ≥ 65 years (68% females; mean age 82.4 ± 6.3 years): 100 patients with SR and 100 patients with permanent AF. Each patient completed serial blood pressure (BP) measurements with a clinical sphygmomanometer (Sphyg) and ABPM. Differences in mean heart rate (HR) between patient groups were not statistically significant. A total of 99.5% of patients were hypertensive. There were no significant differences between SR and AF patients in mean systolic BP (SBP) and diastolic BP (DBP) values, as measured with the Sphyg or by ABPM. Compared with the Sphyg, errors associated with BP measurements obtained by ABPM did not significantly differ between the two groups. ABPM proved to be as feasible as Sphyg measurements in both AF patients (intraclass correlation coefficients=0.73, 0.67 and 0.74 for SBP, DBP and HR, respectively) and SR patients (intraclass correlation coefficients=0.74, 0.58 and 0.67 for SBP, DBP and HR, respectively). A Bland-Altman plot analysis confirmed that there was good agreement between the two methods. Stable AF (HR 60-100 b.p.m.) should not be considered as an absolute contraindication for the use of ABPM, even in the elderly; it could be a 'relative' contraindication for very unstable AF patients.

Clinical characteristics by topographical distribution of brain microbleeds, with a particular emphasis on diffuse microbleeds

From the perspective of the underlying pathogenesis of primary intracerebral hemorrhage (pICH), the topographical distribution of brain microbleeds (MBs) is divided into the lobar area and the deep brain or infratentorial areas. We investigated clinical features, including ambulatory blood pressure (ABP), of patients with MBs distributed in both areas (diffuse MBs). A total of 124 patients with first-ever acute stroke were enrolled prospectively. Gradient-echo T2∗-weighted magnetic resonance imaging (MRI) was performed using a 1.5-T scanner. Patients were classified into 4 groups: MBs-negative group (n=68), those with MBs in lobar areas (lobar group; n=6), those with MBs in deep or infratentorial areas (deep or infratentorial group; n=31), and those with MBs in both areas (diffuse group; n=19). The admission casual BP (CBP) was recorded in all patients, and ABP was measured in the ischemic stroke patients. There were significant differences in the distribution of MBs (P=.004) among the 6 stroke subtypes. All stroke subtypes except transient ischemic attack had diffuse MBs; pICH had the highest prevalence of it (35%). The severity of white matter hyperintensity (WMH) differed among the 4 groups (P < .0001), with the diffuse group having the highest prevalence of early confluent (47%) and confluent types (21%). ABP and CBP were significantly higher in the deep and diffuse groups compared with the MBs-negative group, but did not differ between the lobar group and the MBs-negative group. Our data suggest that diffuse MBs are associated with hypertensive stroke, elevated BP, and severe WMH. The pathogenesis of diffuse MBs may be related to the more severe microangiopathy involved in hypertensive arteriopathy and cerebral amyloid angiopathy.

Association of diurnal blood pressure pattern with risk of hospitalization or death in men with heart failure

BACKGROUND

An altered diurnal blood pressure (BP) pattern has been linked to the risk of developing heart failure (HF). We tested whether an altered diurnal BP pattern is associated with adverse outcomes (death or hospitalization for HF exacerbation) in patients with HF.

METHODS AND RESULTS

A total of 118 patients with HF were enrolled from a tertiary care HF clinic and followed for death or HF hospitalization for up to 4 years; 24-hour ambulatory BP was monitored. Forty patients (34%) had a normal BP dipping pattern (night-day ambulatory BP ratio < 0.9), 44 patients (37%) had a nondipping pattern (0.9 < or = night-day ambulatory BP ratio < 1.0), and 34 patients (29%) had a reverse dipping BP pattern (night-day ambulatory BP ratio > or = 1.0). A total of 39 patients had an adverse outcome. Adverse outcome rates were the lowest in dippers and the highest in reverse dippers (log rank P = .052). Predictors of adverse outcomes, selected on the basis of log likelihood contrast, were as follows: New York Heart Association functional class (hazard ratio [HR] 1.96, 95% confidence interval [CI] 1.11-3.44), anemia (HR 2.50, 95% CI 1.23-5.08), and dipping status (HR 1.65, 95% CI 1.08-2.50).

CONCLUSION

In addition to other traditional predictors, BP dipping status may be an important prognostic factor in HF.

Comparison of noninvasive oscillometric and intra-arterial blood pressure measurements in hyperacute stroke

OBJECTIVES

This study aims to compare automatic oscillometric blood pressure recordings with simultaneous direct intra-arterial blood pressure measurements in hyperacute stroke patients to test the accuracy of oscillometric readings.

METHODS

A total of 51 first-ever stroke patients underwent simultaneous noninvasive automatic oscillometric and intra-arterial blood pressure monitoring within 3 h of ictus. Casual blood pressure was measured in both arms using a standard mercury sphygmomanometer on hospital admission. Patients who received antihypertensive medication during the blood pressure monitoring were excluded.

RESULTS

The estimation of systolic blood pressure (SBP) using oscillometric recordings underestimated direct radial artery SBP by 9.7 mmHg (95% confidence interval: 6.5-13.0, P<0.001). In contrast, an upward bias of 5.6 mmHg (95% confidence interval: 3.5-7.7, P<0.001) was documented when noninvasive diastolic blood pressure (DBP) recordings were compared with intra-arterial DBP recordings. For SBP and DBP, the Pearson correlation coefficients between noninvasive and intra-arterial recordings were 0.854 and 0.832, respectively. When the study population was stratified according to SBP bands (group A: SBP<or=160 mmHg; group B: SBP>160 mmHg and SBP<or=180 mmHg, group C: SBP>180 mmHg), higher mean DeltaSBP (intra-arterial SBP-oscillometric SBP) levels were documented in group C (+19.8 mmHg, 95% confidence intervals: 12.2-27.4) when compared with groups B (+8.5 mmHg, 95% confidence intervals: 2.7-14.5; P=0.025) and A (+5.9 mmHg, 95% confidence intervals: 1.8-9.9; P=0.002).

CONCLUSION

Noninvasive automatic oscillometric BP measurements underestimate direct SBP recordings and overestimate direct DBP readings in acute stroke. The magnitude of the discrepancy between intra-arterial and oscillometric SBP recordings is even more prominent in patients with critically elevated SBP levels.

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

Accurate measurement of blood pressure is essential to classify individuals, to ascertain blood pressure-related risk, and to guide management. The auscultatory technique with a trained observer and mercury sphygmomanometer continues to be the method of choice for measurement in the office, using the first and fifth phases of the Korotkoff sounds, including in pregnant women. The use of mercury is declining, and alternatives are needed. Aneroid devices are suitable, but they require frequent calibration. Hybrid devices that use electronic transducers instead of mercury have promise. The oscillometric method can be used for office measurement, but only devices independently validated according to standard protocols should be used, and individual calibration is recommended. They have the advantage of being able to take multiple measurements. Proper training of observers, positioning of the patient, and selection of cuff size are all essential. It is increasingly recognized that office measurements correlate poorly with blood pressure measured in other settings, and that they can be supplemented by self-measured readings taken with validated devices at home. There is increasing evidence that home readings predict cardiovascular events and are particularly useful for monitoring the effects of treatment. Twenty-four-hour ambulatory monitoring gives a better prediction of risk than office measurements and is useful for diagnosing white-coat hypertension. There is increasing evidence that a failure of blood pressure to fall during the night may be associated with increased risk. In obese patients and children, the use of an appropriate cuff size is of paramount importance.

Recommendations for Blood Pressure Measurement in Humans and Experimental Animals

Accurate measurement of blood pressure is essential to classify individuals, to ascertain blood pressure-related risk, and to guide management. The auscultatory technique with a trained observer and mercury sphygmomanometer continues to be the method of choice for measurement in the office, using the first and fifth phases of the Korotkoff sounds, including in pregnant women. The use of mercury is declining, and alternatives are needed. Aneroid devices are suitable, but they require frequent calibration. Hybrid devices that use electronic transducers instead of mercury have promise. The oscillometric method can be used for office measurement, but only devices independently validated according to standard protocols should be used, and individual calibration is recommended. They have the advantage of being able to take multiple measurements. Proper training of observers, positioning of the patient, and selection of cuff size are all essential. It is increasingly recognized that office measurements correlate poorly with blood pressure measured in other settings, and that they can be supplemented by self-measured readings taken with validated devices at home. There is increasing evidence that home readings predict cardiovascular events and are particularly useful for monitoring the effects of treatment. Twenty-four-hour ambulatory monitoring gives a better prediction of risk than office measurements and is useful for diagnosing white-coat hypertension. There is increasing evidence that a failure of blood pressure to fall during the night may be associated with increased risk. In obese patients and children, the use of an appropriate cuff size is of paramount importance.