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This is a corrected version of the article that appeared in print.

Am Fam Physician. 2021;104(2):237-243

Related FPM article: Implementing Ambulatory Blood Pressure Monitoring in Primary Care Practice

Patient information: See related handout on checking blood pressure at home, written by the authors of this article.

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial affiliations.

Home blood pressure monitoring provides important diagnostic information beyond in-office blood pressure readings and offers similar results to ambulatory blood pressure monitoring. Home blood pressure monitoring involves patients independently measuring their blood pressure with an electronic device, whereas ambulatory blood pressure monitoring involves patients wearing a portable monitor for 24 to 48 hours. Although ambulatory blood pressure monitoring is the diagnostic standard for measurement, home blood pressure monitoring is more practical and accessible to patients, and its use is recommended by the U.S. Preventive Services Task Force and the American College of Cardiology/American Heart Association. Home blood pressure monitoring generally results in lower blood pressure readings than in-office measurements, can confirm the diagnosis of hypertension after an elevated office blood pressure reading, and can identify patients with white coat hypertension or masked hypertension. Best practices for home blood pressure monitoring include using an appropriately fitting upper-arm cuff on a bare arm, emptying the bladder, avoiding caffeinated beverages for 30 minutes before taking the measurement, resting for five minutes before taking the measurement, keeping the feet on the floor uncrossed and the arm supported with the cuff at heart level, and not talking during the reading. An average of multiple readings, ideally two readings in the morning and again in the evening separated by at least one minute each, is recommended for one week. Home blood pressure readings can be used in hypertension quality measures.

The home measurement of blood pressure allows patients with hypertension to become more involved in their care and allows clinicians to diagnose hypertension and monitor therapy more accurately. Evidence shows that home blood pressure measurements are generally lower than blood pressure measured in a clinician's office.1,2 The current expansion of telemedicine has increased the need to monitor blood pressure at home and decreased the number of in-office blood pressure measurements.

Clinical recommendationEvidence ratingComments
To diagnose hypertension based on readings from a home blood pressure monitor, patients should obtain two measurements separated by at least one minute twice per day. Patients should be instructed to record their readings over the course of three (minimum) to seven (ideal) days. These readings should then be averaged.6,912 CPrimary literature based on randomized controlled trials, a cross-sectional study, and disease-oriented evidence
Home blood pressure monitoring or ambulatory blood pressure monitoring can identify several hypertension patterns, including confirmed, white coat, and masked, with the goal of reducing cardiovascular events.9,14,15 AU.S. Preventive Services Task Force and American College of Cardiology/American Heart Association guidelines, and primary literature based on good-quality patient-oriented evidence and limited-quality patient-oriented evidence
Patients should be encouraged to use a validated and fully automated blood pressure measurement device with an appropriately sized upper arm cuff that stores measurements.9 CExpert opinion based on American Heart Association guidelines and validation protocols
Patients should be educated on proper technique to obtain the most accurate reading from a home blood pressure monitor. During the measurement, patients should be seated with their back supported, legs uncrossed, feet flat on the floor, and arm resting on a flat surface and should avoid talking and texting.9,15 CExpert opinion based on American Heart Association guidelines and validation protocols

Historically, blood pressure has been measured in a clinician's office using auscultation and a mercury or aneroid cuff. Many practices now use automated office blood pressure devices that were initially used in clinical studies. In the Systolic Blood Pressure Intervention Trial, patients were placed in a room where an automated device was used to take an average of several blood pressure measurements after a five-minute rest.3 However, out-of-office measurement of blood pressure (notably ambulatory blood pressure monitoring and home blood pressure monitoring) provide additional diagnostic information about blood pressure.

Ambulatory Blood Pressure Monitoring

Ambulatory blood pressure monitoring involves patients wearing a portable device for 24 to 48 hours. Blood pressure is measured at regular intervals while the patient is at home doing normal activities. It is considered the most accurate method for measuring blood pressure and diagnosing hypertension.

Information on how to implement ambulatory blood pressure monitoring has been published in the FPM journal.4 Ambulatory blood pressure monitoring requires that a patient obtain a monitoring device from the clinician's office and use it continuously for a full monitoring period. The device is then returned to the clinician so that the data can be downloaded and interpreted.

Higher systolic blood pressure readings on ambulatory blood pressure monitoring positively correlate with total mortality and cardiovascular outcomes.5 Ambulatory blood pressure monitoring can also detect blood pressure variables associated with an increased risk of cardiovascular events, such as blood pressure measurements that are higher in the morning than in the evening.6

Although ambulatory blood pressure monitoring provides a thorough blood pressure report with validated variables, it is not widely available outside of academic medical centers. Home blood pressure monitoring is an alternative method and the focus of this article.

Home Blood Pressure Monitoring

Home blood pressure monitoring involves patients independently measuring their blood pressure with an electronic device. Combining home blood pressure monitoring with remote or telephone physician monitoring of results (i.e., self-measured blood pressure with clinician support) is a strategy recommended by the Centers for Disease Control and Prevention Community Preventive Services Task Force.7

Home blood pressure monitoring is more sensitive (90% vs. 81%) and more specific (84% vs. 76%) than in-office blood pressure measurements for the diagnosis of hypertension when ambulatory blood pressure monitoring is used as the reference standard.8 The American Heart Association recommends two measurements separated by at least one minute twice per day to diagnose hypertension using home blood pressure monitoring. Patients should be instructed to record their readings for three (minimum) to seven (ideal) days leading up to their clinic appointment.912 Some guidelines recommend omitting the first day of readings because they tend to be more elevated than other readings.10,13 The recorded readings should be averaged.

Home blood pressure monitoring received increased attention in 2015 when the U.S. Preventive Services Task Force recommended using out-of-office measurements to confirm hypertension before initiating treatment; this recommendation was reaffirmed in 2021.14 The 2017 American College of Cardiology/American Heart Association (ACC/AHA) guideline for high blood pressure in adults also recommends out-of-office blood pressure monitoring for confirmation of hypertension and titration of pharmaceutical treatment. However, the guideline states that in-office measurement is acceptable for diagnosis of hypertension if proper techniques are used.15 The ACC/AHA guideline provides a table that correlates blood pressure measured in the office with the generally lower readings using home blood pressure monitoring and ambulatory blood pressure monitoring (Table 1).15

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