The conventional versus automated measurement of blood pressure in the office (CAMBO) trial: masked hypertension sub-study

OBJECTIVES:: To determine the prevalence of masked hypertension [normal office blood pressure (BP) with high awake ambulatory BP] using automated office BP (AOBP) or conventional manual office BP (MOBP) measurement in routine clinical practice. METHODS:: The prevalence of masked hypertension was evaluated on three consecutive visits during a median 6 months period in patients with systolic hypertension randomized to management with AOBP (n?=?140) or continued conventional MOBP (n?=?112) in routine primary care practice. AOBP was recorded using the automated BpTRU device with the patient resting alone in a quiet examining room. All patients underwent 24-h ambulatory BP monitoring. RESULTS:: The prevalence of masked hypertension on any one of three visits calculated using only SBP varied between 12 and 17% in the AOBP group compared with 19 and 22 % in the MOBP group. Masked hypertension was present on both of the first two visits in 7 and 12% and on all three visits in 6 and 7% of AOBP and MOBP patients, respectively. The prevalence for masked hypertension based upon both SBP and DBP was similar being 11-15% for AOBP and 19-20% for MOBP patients on single visits, but decreased to 6 and 10% when readings from the first two visits were used and to 4 and 6% when all three visits were used for the AOBP and MOBP groups, respectively. CONCLUSION:: The prevalence of masked hypertension is lower with AOBP compared with MOBP. The number of patients with masked hypertension decreases if the criteria for having this condition need to be met on multiple visits.     

BpTRUth: Do automated blood pressure monitors outperform mercury?

Manual measurement of blood pressure (BP) in the office (MOBP) is inferior in accuracy when compared with ambulatory BP measurements (ABPM) since it misses white coat and masked effects on BP. BpTRU, an automated office BP device (AOBP), has been reported to reduce white coat effect. We performed a retrospective review of the diagnostic accuracy of MOBP (taken by a trained nurse in clinical hypertension) and AOBP using the Bland-Altman method in hypertensive patients referred to a Renal Hypertension Clinic. In 329 hypertensive patients, the 95% limits of agreement between systolic AOBP and ABPM were ?31 mm Hg to 33 mm Hg and for MOBP and ABPM were ?27.8 mm Hg to 37.4 mm Hg. The bias between systolic MOBP and systolic ABPM was 4.9 mm Hg (95% confidence interval, 3.0–6.6 mm Hg) whereas the bias between the systolic AOBP and the systolic ABPM was ?3.2 (95% confidence interval, ?1.3 to ?5.0). AOBP did not improve treatment relevant classification errors compared with MOBP (28% vs. 23%; P = .052). Our data support findings by others showing that AOBP improves, but does not eliminate, white coat effect. The increased detection of white coat effect appears related to systematic downward bias by BpTRU. As a result, detection of masked effect is undermined by BpTRU.     

The optimal use of automated office blood pressure measurement in clinical practice

This evidence‐based article endorses the use of automated office blood pressure (AOBP). AOBP is the most favorable office blood pressure (BP) measuring technique as it provides accurate readings with 3‐15 mm Hg lower values than the casual conventional office measurements with auscultatory or semi‐automated oscillometric devices and relates closely to awake ABP readings. The AOBP technique seems to be superior to conventional office BP in predicting hypertension‐mediated organ damage and appears to be equally reliable to awake ABP in the prediction of cardiovascular (CV) disease. AOBP readings should be obtained either unattended, with the patient alone in the examination room, or attended with the presence of personnel in the room but with no talking to the patient, although this recommendation is not frequently followed in routine clinical practice. To optimize office BP readings, the type of device, the rest period before AOBP measurements (preceding rest), and the time intervals between measurements were evaluated. As AOBP readings have the advantage of removing many confounding factors, the authors propose to perform measurements with a preceding rest in all patients at the initial visit; if AOBP readings remain <130 mm Hg in subsequent visits, measurements could be accepted, otherwise, if are higher, patients should be evaluated by out‐of‐office BP measurements.     

Unattended automated office blood pressure measurement: Time efficiency and barriers to implementation/utilization

Unattended automated office blood pressure (BP) measurement (u‐AOBP) improves office BP measurement accuracy and reduces white‐coat BP elevation, but there are reservations about its time efficiency in primary care. We used time‐stamp methodology to measure u‐AOBP procedure times performed without a rest period in 130 patients during routine clinic visits to three primary care clinics with 2.5‐4.9 years u‐AOBP experience. We documented the clinical activities of 30 medical assistants during the u‐AOBP procedures. We also assessed MA and clinician satisfaction and knowledge about u‐AOBP performance and interpretation. Median u‐AOBP procedure time was <5 minutes, and MAs engaged in productive clinical activities during 83% of the procedures. Ninety‐three percent of MAs and 100% of clinicians in the clinics agreed that u‐AOBP is an efficient method to improve hypertension management. Barriers to effective u‐AOBP implementation and ongoing utilization included initial difficulty incorporating u‐AOBP into clinic workflow and medical staff knowledge deficiencies concerning correct u‐AOBP performance and interpretation despite prior training and experience with the procedure. Intensive u‐AOBP education and training programs are needed to facilitate effective u‐AOBP implementation into primary care. The time required to perform u‐AOBP can be utilized productively by staff.     

The great myth of office blood pressure measurement

Clinical practice guidelines have traditionally recommended manual blood pressure (BP) measurement in the office setting as the standard method for diagnosing hypertension. In reality, manual BP in routine clinical practice is relatively inaccurate, over-diagnoses hypertension by provoking office-induced increases in BP and correlates poorly with both the awake ambulatory BP and target organ damage. The most recent guidelines recommend 24-h ambulatory BP and home BP for diagnosing hypertension. The advent of automated office BP (AOBP) represents a third alternative to conventional manual BP measurement, one that maintains the role of office BP readings in the diagnosis and management of hypertension. AOBP has three basic principles: multiple readings taken using a fully automated sphygmomanometer with the patient resting quietly alone. AOBP eliminates office-induced hypertension such that the cut-point for a normal AOBP is the same as for the awake ambulatory BP and home BP. As compared to routine manual office BP, AOBP provides more accurate BP readings, is more consistent during repeated office visits and in different settings and correlates better with both the awake ambulatory BP and target organ damage. The advantages of AOBP over manual BP measurement support its use in routine clinical practice.     

Blood pressure measurement: Should technique define targets?

Accurate assessment of blood pressure (BP) is the cornerstone of hypertension management. The objectives of this study were to quantify the effect of medical personnel presence during BP measurement by automated oscillometric BP (AOBP) and to compare resting office BP by AOBP to daytime average BP by 24‐h ambulatory BP monitoring (ABPM). This study is a prospective randomized cross‐over trial, conducted in a referral population. Patients underwent measurements of casual and resting office BP by AOBP. Resting BP was measured as either unattended (patient alone in the room during resting and measurements) or as partially attended (nurse present in the room during measurements) immediately prior to and after 24‐h ABPM. The primary outcome was the effect of unattended 5‐min rest preceding AOBP assessment as the difference between casual and resting BP measured by the Omron HEM 907XL. Ninety patients consented and 78 completed the study. The mean difference between the casual and Omron unattended systolic BP was 7.0 mm Hg (95% confidence interval [CI] 4.5, 9.5). There was no significant difference between partially attended and unattended resting office systolic BP. Resting office BP (attended and partially attended) underestimated daytime systolic BP load from 24‐h ABPM. The presence or absence of medical personnel does not impact casual office BP which is higher than resting office AOBP. The requirement for unattended rest may be dropped if logistically challenging. Casual and resting office BP readings by AOBP do not capture the complexity of information provided by the 24‐h ABPM.     

Automated office blood pressure

Manual blood pressure (BP) is gradually disappearing from clinical practice with the mercury sphygmomanometer now considered to be an environmental hazard. Manual BP is also subject to measurement error on the part of the physician/nurse and patient-related anxiety which can result in poor quality BP measurements and office-induced (white coat) hypertension. Automated office (AO) BP with devices such as the BpTRU (BpTRU Medical Devices, Coquitlam, BC) has already replaced conventional manual BP in many primary care practices in Canada and has also attracted interest in other countries where research studies using AOBP have been undertaken. The basic principles of AOBP include multiple readings taken with a fully automated recorder with the patient resting alone in a quiet room. When these principles are followed, office-induced hypertension is eliminated and AOBP exhibits a much stronger correlation with the awake ambulatory BP as compared with routine manual BP measurements. Unlike routine manual BP, AOBP correlates as well with left ventricular mass as does the awake ambulatory BP. AOBP also simplifies the definition of hypertension in that the cut point for a normal AOBP (< 135/85 mm Hg) is the same as for the awake ambulatory BP and home BP. This article summarizes the currently available evidence supporting the use of AOBP in routine clinical practice and proposes an algorithm in which AOBP replaces manual BP for the diagnosis and management of hypertension.     

Étude PASTIS : pression artérielle sans intervention de soignant. Évaluation d’une mesure de la pression artérielle automatisée en cabinet

ObjectiveThe evaluation of automated office blood pressure (AOBP) measurement compared to 24-hour ambulatory BP monitoring (ABPM), Home BP measurement and manual BP.Patients and methodologyA total of 123 hypertensive patients were included. Overall, 68 completed the 4 measurement: Manual BP in the office (Omron 705 CP 3 measurements), ABPM (Spacelab of 96 measurement/per 24 hours), Home BP (18 measurement during 3 days), AOBP using the SPRINT methodology: lying patient, isolated with an automatic measurement (Dinamap) every minutes during 8 minutes (average of the last 3 measurement). Twenty-two out of 123 patients (26%) did not complete the Home BP measurement.ResultsThe average of AOBP measurement using SPRINT is 132 ± 12/69 ± 9 mmHg, of ABPM 134 ± 13/79 ± 9, of Home BP: 135 ± 13/70 ± 13 and of manual BP: 138 ± 13/72 ± 11 mmHg The Bland & Altman method highlight that the AOBP, the ABPM and home BP measurement are 3 substitutable methods. The confidence interval is smaller between the ABPM and the AOBP than with the home BP.ConclusionThe automated office blood pressure, as the Home BP measurement, can be considered a reliable substitute for the ABPM, when the later is not accessible, and when a repeated therapeutic evaluation is needed, or when the home BP measurement is not done. These results encourage us to use it more frequently as the Canadian Hypertension Education Program recommend it.     

Comparison of awake ambulatory blood pressure and automated office blood pressure using linear regression analysis in untreated patients in routine clinical practice

The recent American hypertension guidelines recommended a threshold of 130/80 mmHg to define hypertension on the basis of office, home or ambulatory blood pressure (BP). Despite recognizing the potential advantages of automated office (AO)BP, the recommendations only considered conventional office BP, without providing supporting evidence and without taking into account the well documented difference between office BP recorded in research studies versus routine clinical practice, the latter being about 10/7 mmHg higher. Accordingly, we examined the relationship between AOBP and awake ambulatory BP, which the guidelines considered to be a better predictor of future cardiovascular risk than office BP. AOBP readings and 24‐hour ambulatory BP recordings were obtained in 514 untreated patients referred for ambulatory BP monitoring in routine clinical practice. The relationship between mean AOBP and mean awake ambulatory BP was examined using linear regression analysis with and without adjustment for age and sex. Special attention was given to the thresholds of 130/80 and 135/85 mmHg, the latter value being the recognized threshold for defining hypertension using awake ambulatory BP, home BP and AOBP in other guidelines. The mean adjusted AOBP of 130/80 and 135/85 mmHg corresponded to mean awake ambulatory BP values of 132.1/81.5 and 134.4/84.6 mmHg, respectively. These findings support the use of AOBP as the method of choice for determining office BP in routine clinical practice, regardless of which of the two thresholds are used for diagnosing hypertension, with an AOBP of 135/85 mmHg being somewhat closer to the corresponding value for awake ambulatory BP.     

Why use automated office blood pressure measurements in clinical practice?

Automated office blood pressure (AOBP) measurement with the patient resting alone in a quiet examining room can eliminate the white-coat effect associated with conventional readings taken by manual sphygmomanometer. The key to reducing the white-coat response appears to be multiple blood pressure (BP) readings taken in a non-observer office setting, thus eliminating any interaction that could provoke an office-induced increase in BP. Furthermore, AOBP readings have shown a higher correlation with the mean awake ambulatory BP compared with BP readings recorded in routine clinical practice. Although there is a paucity of studies connecting AOBP with organ damage, AOBP values were recently found to be equally associated with left ventricular mass index as those of ambulatory BP. This concludes that in contrast to routine manual office BP, AOBP readings compare favourably with 24-hour ambulatory BP measurements in the appraisal of cardiac remodelling and, as such, could be complementary to ambulatory readings in a way similar to home BP measurements.     

Comparison between unattended automated office blood pressure and conventional office blood pressure under the environment of health checkup among Japanese general population

Unattended automated office blood pressure (AOBP) measurement has been endorsed as the preferred in‐office measurement modality in recent Canadian and American clinical practice guidelines. However, the difference between AOBP and conventional office blood pressure (CBP) under the environment of a health checkup remains unclear. We aimed to identify the clinical significance of AOBP as compared to CBP under the environment of a health checkup. There were 491 participants (333 females, mean age of 62.5 years) who were at least 20 years old, including 179 participants who were previously diagnosed with hypertension. Mean AOBPs were 131.8 ± 20.9/76.6 ± 11.7 mm Hg, and CBPs were 135.6 ± 21.6/77.3 ± 11.5 mm Hg. There was a difference of 3.9 mm Hg in systolic blood pressure (SBP) and 0.8 mm Hg in diastolic BP between AOBP and CBP. In all participants, SBP and pulse pressure, as well as the white coat effect (WCE), increased with age. The cutoff value used was 140/90 mm Hg for CBP and 135/85 mm Hg for AOBP, and the prevalence of WCE and masked hypertension effect (MHE) was 12.4% and 14.1%, respectively. Even in a health checkup environment of the general population, there was a difference between the AOBP and CBP, and the WCE was observed more strongly in the elderly with a history of hypertension, suggesting that a combination of AOBP with CBP may be useful in detecting WCE and MHE in all clinical scenarios including health checkups, and help solve the “hypertension paradox” not only in Japan but in all over the world.     

Comparative assessment of four blood pressure measurement methods in hypertensives

Introduction

Discordance between blood pressure (BP) measurement methods can occur and create ambiguity. New automated office BP monitors (AOBPs) are widely available, but their role is presently unclear. The objectives of this study are to quantify concordance among BP measurement methods and to define the diagnostic sensitivity, specificity, and predictive value of AOBPs in a population of hypertensive patients.

Methods

The office mercury sphygmomanometer, the AOBP, an ambulatory BP monitor (ABPM), and home self-measurement with an automatic device were compared in a randomized, crossover study. BP averages and achievement of therapeutic goals were defined. Comparisons and agreement tests were performed. Diagnostic indices were calculated for the AOBP.

Results

A total of 101 patients were enrolled. Average BP results were similar between measurement methods with the exception of daytime ABPM, which was significantly higher; figures are mean ± standard deviation (SD): sphygmomanometer, 129.9 ± 13.7/80.9 ± 9.3 mm Hg; AOBP, 128.4 ± 13.9/80.0 ± 9.4 mm Hg; 24-hour ABPM, 131.4 ± 11.7/78.7 ± 9.7 mm Hg; day ABPM, 135.5 ± 11.4/82.0 ± 11.9 mm Hg; home self-measurement, 131.0 ± 14.3/82.5 ± 8.2 mm Hg. Discordance in the achievement of therapeutic goals was observed in 58 patients, with only 26 cases being explained by masked hypertension or “white coat syndrome” according to all measurements. Disagreement was greater when office methods were compared with ambulatory methods.

Conclusions

This study shows that the 4 measurement strategies provide similar average BP estimates but generate many discordant results. The AOBP device can be very valuable as a replacement for the sphygmomanometer.     

Automated office blood pressure measurements obtained with and without preceding rest are associated with awake ambulatory blood pressure

Automated office blood pressure (AOBP) measurement, attended or unattended, eliminates the white coat effect (WCE) showing a strong association with awake ambulatory blood pressure (ABP). This study examined the difference in AOBP readings, with and without 5 minutes of rest prior to three readings recorded at 1‐min intervals. Cross‐sectional data from 100 randomized selected hypertensives, 61 men and 39 women, with a mean age of 52.2 ± 10.8 years, 82% treated, were analyzed. The mean systolic AOBP values without preceding rest were 127.0 ± 18.2 mm Hg, and the mean systolic AOBP values with 5 minutes of preceding rest were 125.7 ± 17.9 mm Hg (P = .05). A significant order effect was observed for the mean systolic BP values when AOBP without 5 minutes of preceding rest was performed as the first measurement (130.0 ± 17.7 vs 126.5 ± 16.2, P = .008). When we used a target systolic AOBP ≥ 130 mm Hg, awake ABP yielded lower readings, while at a target systolic AOBP value of < 130 mm Hg higher awake ABP values were obtained. Our findings indicate that systolic AOBP can be initially checked without any preceding rest and if readings are normal can be accepted. Otherwise, when AOBP is ≥ 130 mm Hg, measurements should be rechecked with 5 minutes of rest.     

Comparability of Automated Office Blood Pressure to Daytime 24-Hour Ambulatory Blood Pressure

Background

Clinical practice guidelines endorse automated office blood pressure (AOBP) measurement as the preferred in-office measurement modality. However, recent data indicate that this method may underestimate daytime ambulatory BP. The objective of this study was to further assess the comparability of mean AOBP and daytime ambulatory BP in clinical practice.

Office blood pressure threshold of 130/80 mmHg better predicts uncontrolled out‐of‐office blood pressure in apparent treatment‐resistant hypertension

The objective of this study was to compare the diagnostic accuracy of office blood pressure (BP) threshold of 140/90 and 130/80 mmHg for correctly identifying uncontrolled out‐of‐office BP in apparent treatment‐resistant hypertension (aTRH). We analyzed 468 subjects from a prospectively enrolled cohort of patients with resistant hypertension in South Korea (clinicaltrials.gov: {"type":"clinical-trial","attrs":{"text":"NCT03540992","term_id":"NCT03540992"}}NCT03540992). Resistant hypertension was defined as office BP ≥ 130/80 mmHg with three different classes of antihypertensive medications including thiazide‐type/like diuretics, or treated hypertension with four or more different classes of antihypertensive medications. We conducted different types of BP measurements including office BP, automated office BP (AOBP), home BP, and ambulatory BP. We defined uncontrolled out‐of‐office BP as daytime BP ≥ 135/85 mmHg and/or home BP ≥ 135/85 mmHg. Among subjects with office BP < 140/90 mmHg and subjects with office BP < 130/80 mmHg, 66% and 55% had uncontrolled out‐of‐office BP, respectively. The prevalence of controlled and masked uncontrolled hypertension was lower, and the prevalence of white‐coat and sustained uncontrolled hypertension was higher, with a threshold of 130/80 mmHg than of 140/90 mmHg, for both office BP and AOBP. The office BP threshold of 130/80 mmHg was better able to diagnose uncontrolled out‐of‐office BP than 140/90 mmHg, and the net reclassification improvement (NRI) was 0.255. The AOBP threshold of 130/80 mmHg also revealed better diagnostic accuracy than 140/90 mmHg, with NRI of 0.543. The office BP threshold of 130/80 mmHg showed better than 140/90 mmHg in terms of the correspondence to out‐of‐office BP in subjects with aTRH.     

Automated measurement of blood pressure in routine clinical practice

In recent years, automated devices have been developed to record blood pressure (BP) accurately in the home and during usual daily activities. Clinical outcome studies have clearly shown home BP and 24-hour ambulatory BP to be significantly better predictors of future cardiovascular events compared with BP recorded in the office setting using mercury sphygmomanometry. It is also now possible to measure office BP with the patient resting quietly alone in the examining room using an automated device. Studies in routine clinical practice using this approach have demonstrated that automated office BP can eliminate most of the white coat effect seen with manual BP measurement. The automated office BP also correlates significantly better than does the routine office BP with the 24-hour ambulatory BP, the gold standard for predicting risk of future cardiovascular events. Sufficient evidence now exists to consider incorporating automated office BP into an algorithm for diagnosing hypertension.     

Automated Office Blood Pressure is Associated with Urine Albumin Excretion in Hypertensive Subjects

BackgroundWe aimed to investigate the association between automated office blood pressure (AOBP) readings and urine albumin excretion (UAE), and to assess if this association is as close as that between 24-h ambulatory blood pressure (ABP) and UAE. A strong association would suggest that AOBP may serve as an indicator of early renal impairment.MethodsIn a sample of 162 hypertensives, we compared AOBP with ABP measurements and their associations with UAE in two consecutive 24-h urine collections measured by an immunoturbidimetric assay. Microalbuminuria was defined as UAE of 30-300 mg/24 h.ResultsThe age of the subjects was 53 ± 13 (mean ± s.d.) years. Twenty-two were microalbuminuric. In those, AOBP and 24-h ABP were higher than in the normoalbuminuric subjects: 152 ± 19 and 147 ± 20 vs. 138 ± 15 and 130 ± 11 mm Hg for systolic blood pressure (SBP), and 97 ± 15 and 92 ± 14 vs. 86 ± 10 and 82 ± 8 mm Hg for diastolic blood pressure (DBP) (P < 0.001). Correlations between AOBP and 24-h ABP with log-transformed urine albumin were 0.30 (P < 0.001) and 0.43 (P < 0.001) for SBP and 0.27 (P < 0.001) and 0.33 (P < 0.001) for DBP. Adjusting for age, sex, body mass index, and estimated glomerular filtration rate, both AOBP and 24-h ABP were independently associated with urine albumin (P < 0.001 for both associations). Receiver operating characteristics curve analysis showed a similar predictive ability for microalbuminuria for AOBP and for 24-h ABP (area under the curve: 0.819 (P < 0.001) for SBP, 0.836 (P < 0.001) for DBP vs. 0.830 (P < 0.001) for SBP and 0.845 (P < 0.001) for DBP).ConclusionsIn this study, microalbuminuria correlated similarly with high-quality AOBP and ABP readings, further supporting the use of AOBP in the clinical setting.American Journal of Hypertension 2012; doi:10.1038/ajh.2012.76.     

Antecedent rest may not be necessary for automated office blood pressure at lower treatment targets

In SPRINT (Systolic Blood Pressure Intervention Trial), use of the Omron 907XL blood pressure (BP) monitor set at 5 minutes of antecedent rest to record BP produced an automated office BP value 7/6 mm Hg lower than awake ambulatory BP at 27 months. The authors studied the impact on automated office BP of setting the Omron 907XL to 0 minutes instead of 5 minutes of rest in patients with readings in the lower normal BP range, similar to on‐treatment BP in the SPRINT intensive therapy group. Patients (n = 100) in cardiac rehabilitation were randomized to three BP readings at 1‐minute intervals using an Omron 907XL BP device set for 5 or 0 minutes of antecedent rest. Mean (±standard deviation) automated office BP (mm Hg) after 5 minutes of rest (120.2 ± 14.6/66.9 ± 8.6 mm Hg) was lower (P < .001/P < .01) than without rest (124.2 ± 16.4/67.9 ± 9.1 mm Hg). When target BP is in the lower normal range, automated office BP recorded without antecedent rest using an Omron 907XL device should be higher and closer to the awake ambulatory BP, compared with readings taken after 5 minutes of rest.     

Automated office blood pressure is in agreement with awake and mean 24‐hour ambulatory blood pressure at the lower blood pressure range

Automated office blood pressure measurement eliminates the white coat effect and is associated with awake ambulatory blood pressure. This study examined whether automated office blood pressure values at lower limits were comparable to those of awake and mean 24‐hour ambulatory blood pressure. A total of 552 patients were included in the study, involving 293 (53.1%) men and 259 (46.9%) women, with a mean age 55.0 ± 12.5, of whom 36% were treated for hypertension. Both systolic and diastolic automated office blood pressures exhibited lower values compared to awake ambulatory blood pressure among 254 individuals with systolic automated office blood pressure <130 mm Hg (119 ± 8 mm Hg vs 125 ± 11 mm Hg, P < .0001 and 75 ± 9 mm Hg vs 79 ± 9 mm Hg, P < .0001 for systolic and diastolic BPs, respectively). Furthermore, the comparison of systolic automated office blood pressure to the mean 24‐hour ambulatory blood pressure levels also showed lower values (119 ± 8 vs 121 ± 10, P = .007), whereas the diastolic automated office blood pressure measurements were similar to 24‐hour ambulatory blood pressure values. Our findings show that when automated office blood pressure readings express values <130/80 mm Hg in repeated office visits, further investigation should be performed only when masked hypertension is suspected; otherwise, higher automated office blood pressure values could be used for the diagnosis of uncontrolled hypertension, especially in individuals with organ damage.     

Automated blood pressure measurement for diagnosing hypertension

Guidelines for the management of hypertension have started to include home blood pressure (BP) and 24-h ambulatory BP monitoring as preferred methods for diagnosing hypertension. The next step will be to incorporate automated office BP measurement into the algorithm for diagnosing hypertension. Recent studies support this approach with automated office BP readings being closely correlated with the ambulatory BP.