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medications.82 Potential advantages of ABPM over HBPM include diagnosing nocturnal hypertension or symptomatic transient hypotension or hypertension with exertion. As such, ABPM and HBPM should be considered complementary and additive, rather than competing approaches to long-term BP management.83

5.5 Measuring blood pressure in selected

groups 5.5.1. Pregnancy Monitoring BP during pregnancy is typically done at antenatal visits, which vary dependent on trimester (with increasing frequency towards term). BP tends to reach a nadir at 20–30 weeks of pregnancy before increasing towards term at 40 weeks.84 Only a small number of automated oscillometric BP monitors have been adequately validated in pregnancy and several have failed, usually due to providing BP values that are erroneously high.85 Auscultatory measurement with sphygmomanometry is consequently the clinical standard in pregnancy.85 Self-monitoring at home is not yet proven to be effective in gestational hypertension.86,87 While norms for BP during pregnancy remain unclear, the 2022 Chronic Hypertension and Pregnancy (CHAP) trial indicated benefit of targeting clinic BP below 140/90 mmHg.88 Consideration of secondary causes of hypertension is important in young women with gestational hypertension. Further details are provided in Section 9.2 and the 2018 ESC Guideline for the management of cardiovascular disease during pregnancy.89

5.5.2 Atrial fibrillation

Hypertension is a risk factor for AF.90,91 Oscillometric BP monitors are not always accurate in the presence of AF, due to the greater variability of BP beat to beat, so multiple auscultatory measurements are recommended.48,92,93 Some oscillometric BP monitors include an algorithm for detecting AF, but an electrocardiogram (ECG) is still required to confirm the diagnosis.49,94

5.5.3 Orthostatic hypotension

Postural or orthostatic hypotension is common,95,96 present in approximately 10% of all hypertensive adults and up to 50% of older institutionalized adults.97,98 Orthostatic hypotension is defined as a BP drop of ≥20/10 mmHg 1 and/or 3 min after standing following a 5-min period in the seated or lying position.99–101 Diagnosis is made in the office. Routine ABPM is not currently suitable for formally assessing orthostatic hypotension,102 though it may help in some cases, particularly when accompanied by a patient symptom diary.103

5.6 Novel methods of measuring blood

pressure New methods to measure BP are under development. Continuous office and out-of-office BP recordings and ABPM and HBPM have been developed that derive beat-to-beat, reading-to-reading, and day-to-day BP variability. However, there is no agreement on the optimum approach to measuring variability, and there is no trial evidence that reducing BP variability specifically can reduce CVD events.104 Other emerging technologies include wearable, wrist-based BP measurement devices, devices evaluating central BP, and cuffless devices implementing plethysmographic or other technologies.105,106 However, there is at present insufficient scientific consensus on the accuracy standards and validation procedures that these cuffless devices must comply with prior to commercialization.43,44,107–109

In view of these issues, none of these cuffless measurement modalities are currently recommended for routine clinical use.

Recommendation Table 1 — Recommendations for measuring blood pressure (see Evidence Tables 1–8)

Recommendations Classa Levelb

It is recommended to measure BP using a validated and calibrated device, to enforce the correct measurement technique, and to apply a consistent approach to BP measurement for each patient.41,42 I B All adult patients (≥18 years) are recommended to have their office and/or out-of-office BP measured on an opportunistic basis and recorded in their medical file, and be told what their current BP is. I C Out-of-office BP measurement is recommended for diagnostic purposes, particularly because it can detect both white-coat hypertension and masked hypertension. Where out-of-office measurements are not logistically and/or economically feasible, then it is recommended that the diagnosis be confirmed with a repeat office BP measurement using the correct standardized measurement technique.70 I B It is recommended that office BP should be measured in both arms at least at the first visit, because a between-arm systolic BP difference of >10 mmHg is associated with an increased CVD risk and may indicate arterial stenosis.55,110 I B If a between-arm difference of >10 mmHg in systolic BP is recorded, then it is recommended that all subsequent BP readings use the arm with the higher BP reading.110 I B Out-of-office BP measurement is recommended for ongoing management to quantify the effects of treatment and guide BP-lowering medication titration, and/or identify possible causes of side effects (e.g. symptomatic hypotension). Where out-of-office measurements are not logistically and/ or economically feasible, then ongoing management is recommended to be based on repeated office BP measurements using the correct standardized measurement technique.74,111,112 I B It is recommended that all patients undergoing BP measurement also undergo pulse palpation at rest to determine heart rate and arrhythmias such as AF.113 I C Most automated oscillometric monitors have not been validated for BP measurement in AF; BP measurement should be considered using a manual auscultatory method in these circumstances where possible.47–49 IIa C

Continued

ESC Guidelines                                                                                                                                                                                          3935

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