About Blood Pressure Monitors

High Blood Pressure (hypertension) kills nearly 10 million people annually worldwide and is the major cause of disability across the globe. In the majority of people with hypertension, blood pressure is inadequately controlled and if blood pressure was controlled and lowered, many millions of deaths, strokes, heart attacks and other cardiovascular events would be prevented. Most adults do not know that they have hypertension and, for that reason, it has been termed the ‘Silent Killer’.

However, all assumptions relating to the diagnosis, management and treatment of hypertension is dependent on Blood Pressure Devices being accurate.

Unfortunately, over 80% of all Blood Pressure Monitors sold on the market today are not clinically validated and hence are not proven to be accurate.

Clinical Accuracy of Blood Pressure Monitors

Introduction

All assumptions relating to the diagnosis and management of hypertension are dependent on the accurate measurement of blood pressure.

History of blood pressure measurement

The history of blood pressure measurement makes fascinating reading. For a general history of the beginnings and evolution of blood pressure measurement over the centuries, see references 1 to 5.

Development of blood pressure device validation

All decisions relating to the diagnosis and treatment of high blood pressure are dependent on accurate measurement. The first efforts to have blood pressure devices clinically validated independently was in 1982 [6] and, in 1989, it was proposed that a standardised protocol should be produced for the independent validation of blood pressure measuring devices [7]. In the late nineteen-eighties, the American National Standards Institute (ANSI), with the Association for the Advancement of Medical Instrumentation (AAMI), and the Deutsches Institut für Normung (DIN) published standards for blood pressure measuring devices and there have been several revisions since then (see Clinical Validation Protocols for Blood Pressure Monitors below). In 1990, the British Hypertension Society Protocol was published [8] and revised in 1993 [9]. This protocol was succeeded by the International Protocol of the European Society of Hypertension in 2002 [10] and the revised International Protocol published in 2010 [11] became the protocol used most widely in the world for evaluating blood pressure measuring devices.

Current Protocols

The first universal protocol, called ISO 81060-2:2018 was published in December 2018 [12]. This extended the previous ISO 81060-2:2013 protocol [13] to include elements of the 2010 ESH protocol [11, 14, 15]. It was adopted by AAMI and ANSI in August 2019 [16] and by the EU and Great Britain in December 2019 [17] before becoming the official EU harmonised protocol on 25 March 2020 [18]. Therefore, this will be the harmonised protocol for blood pressure monitors that will be required for MDR compliance with EU 2017/745 regulations [19]. While these regulations were due to come into force in May 2020, the European Commission has made the following announcement [20]:

“Today (25 March 2020), the Commission announced that work on a proposal to postpone the date of application for the Medical Device Regulation (MDR) for one year is ongoing. The decision was reached with patient health and safety as a guiding principle. The Commission is working to submit this proposal in early April for the Parliament and the Council to adopt it quickly as the date of application is the end of May. This decision will relieve pressure from national authorities, notified bodies, manufacturers and other actors and will allow them to fully focus on urgent priorities related to the coronavirus crisis.”

In light of this, Medaval will continue to recognise new validations according to ISO 81060-2:2013 or ESH-IP 2010, as being according to a current protocol as long as the date of publication is no later than 31 December 2020.

Blood pressure measurement guidelines

National and international societies of hypertension publish guidelines on the management and drug treatment of hypertension but a need to publish guidelines devoted specifically to the measurement of blood pressure has been recognised and addressed by members of the Medaval’s Scientific Panel of experts over a number of years. [21-30]

  1. Laher M, O’Brien E. In search of Korotkoff. Br Med J (Clin Res Ed). 1982;285(6357):1796-8. PMID: 6816372.
  2. O’Brien E, Fitzgerald D. The history of indirect blood pressure measurement. In Blood Pressure easurement. Eds. E. O’Brien and K. O’Malley. Handbook of Hypertension. Eds. WH Birkenhager and JL Reid. Elsevier. Amsterdam. 1991. pp. 1-54.
  3. O’Brien E, Fitzgerald D. The history of blood pressure measurement. J Human Hypertens. 1994;8(2):73-84. PMID: 8207743.
  4. O’Brien E. Ave atque vale: the centenary of clinical sphygmomanometry. Lancet. 1996;348(9041):1569-70. PMID: 8950887.
  5. O’Brien E. History of the Blood Pressure Unit at the Charitable Infirmary and Beaumont Hospital 1978-2006. Heartwise. Winter 2006. 12-18. Download here.
  6. Fitzgerald DJ, O’Malley K, O’Brien ET. Inaccuracy of London School of Hygiene sphygmomanometer. Br Med J (Clin Res Ed). 1982;284(6308):18-9. PMID: 6797622.
  7. O’Brien E, O’Malley K, Sheridan J. The need for a standardized protocol for validating non-invasive blood pressure measuring devices. J Hypertens. 1989;7(3):S19-S20. PMID: 2760713.
  8. O’Brien E, Petrie J, Littler W, de Swiet M, Padfield PL, O’Malley K, Jamieson M, Altman D, Bland M, Atkins N. The British Hypertension Society Protocol for the evaluation of automated and semi-automated blood pressure measuring devices with special reference to ambulatory systems. J Hypertens. 1990;8(7):607-19. PMID: 2168451.
  9. O’Brien E, Petrie J, Littler WA, de Swiet M, Padfield PL, Altman D, Bland M, Coats A, Atkins N. The British Hypertension Society Protocol for the evaluation of blood pressure measuring devices. J Hypertens. 1993;11(suppl 2):S43-S63.
  10. O’Brien E, Pickering T, Asmar R, Myers M, Parati G, Staessen J, Mengden T, Imai Y, Waeber B, Palatini P, Atkins N, Gerin W; Working Group on Blood Pressure Monitoring of the European Society of Hypertension. Working Group on Blood Pressure Monitoring of the European Society of Hypertension International protocol for validation of blood pressure measuring devices in adults. Blood Press Monit. 2002;7(1):3-17. PMID: 12040236.
  11. O’Brien E, Atkins N, Stergiou G, Karpettas N, Parati G, Asmar R, Imai Y,Wang J, Mengden T, Shennan A; Working Group on Blood Pressure Monitoring of the European Society of Hypertension European Society of Hypertension. International Protocol revision 2010 for the validation of blood pressure measuring devices in adults. Blood Press Monit. 2010;15:23-38. doi: 10.1097/MBP.0b013e3283360e98. PMID: 20110786. Erratum in Blood Press Monit. 2010;15(3):171-2.
  12. ISO/TC 121/SC 3. ISO 81060-2:2018, Non-invasive Sphygmomanometers – Part 2: Clinical Investigation of Automated Measurement Type. Geneva, Switzerland: ISO; 2018 Nov 23. Information here.
  13. Association for the Advancement of Medical Instrumentation, American National Standards Institute, International Organization for Standardization. AAMI/ANSI/ISO 81060-2:2013, Non-invasive Sphygmomanometers – Part 2: Clinical Investigation of Automated Measurement Type. Arlington, VA, USA: AAMI; 2013.
  14. Stergiou GS, Alpert B, Mieke S, Asmar R, Atkins N, Eckert S, Frick G, Friedman B, Graßl T, Ichikawa T, Ioannidis JP, Lacy P, McManus R, Murray A, Myers M, Palatini P, Parati G, Quinn D, Sarkis J, Shennan A, Usuda T, Wang J, Wu CO, O’Brien E. A Universal Standard for the Validation of Blood Pressure Measuring Devices: Association for the Advancement of Medical Instrumentation/European Society of Hypertension/International Organization for Standardization (AAMI/ESH/ISO) Collaboration Statement. Hypertension. 2018 Mar; 71 (3):368-374. doi: 10.1161/HYPERTENSIONAHA.117.10237. Epub 2018 Jan 31. PMID: 29386350.
  15. Stergiou GS, Alpert B, Mieke S, Asmar R, Atkins N, Eckert S, Frick G, Friedman B, Graßl T, Ichikawa T, Ioannidis JP, Lacy P, McManus R, Murray A, Myers M, Palatini P, Parati G, Quinn D, Sarkis J, Shennan A, Usuda T, Wang J, Wu CO, O’Brien E. A universal standard for the validation of blood pressure measuring devices: Association for the Advancement of Medical Instrumentation/European Society of Hypertension/International Organization for Standardization (AAMI/ESH/ISO) Collaboration Statement. J Hypertens. 2018 Mar; 36 (3):472-8. doi: 10.1097/HJH.0000000000001634. PMID: 29384983.
  16. Association for the Advancement of Medical Instrumentation, American National Standards Institute, International Organization for Standardization. AAMI/ANSI/ISO 81060-2:2019, Non-invasive Sphygmomanometers – Part 2: Clinical Investigation of Automated Measurement Type. Arlington, VA, USA: AAMI; 2019 Aug 20.
  17. British Standards, European Norme, International Organization for Standardization. BS EN ISO 81060-2:2019, Non-invasive Sphygmomanometers – Part 2: Clinical Investigation of Automated Measurement Type. Brussels, Belgium: CEN; 2019 Dec 9.
  18. The European Commission. Commission Implementing Decision (EU) 2020/437 of 24 March 2020 on the harmonised standards for medical devices drafted in support of Council Directive 93/42/EEC. Official Journal of the European Union. 2020 Mar 25; C/2020/1901( L 90):1-24. Available from: eur-lex.europa.eu.
  19. The European Parliament and the Council of the European Union. Regulation (EU) 2017/745 of the European Parliament and of the Council of 5 April 2017 on medical devices, amending Directive 2001/83/EC, Regulation (EC) No 178/2002 and Regulation (EC) No 1223/2009 and repealing Council Directives 90/385/EEC and 93/42/EEC (Text with EEA relevance). Official Journal of the European Union. 2017 May 05;60(L 117):1-175. Available from: eur-lex.europa.eu.
  20. The European Commission. Commission working on proposal to postpone MDR application date for one year. (Announcement). 2020 Mar 25;SANTE.DDG1.B.6. Available from: ec.europa.eu.
  21. Stergiou GS, Karpettas N, Atkins N, O’Brien E. Impact of applying the more stringent validation criteria of the revised European Society of Hypertension International Protocol 2010 on earlier validation studies. Blood Press Monit. 2011;16:67–73. doi: 10.1097/MBP.0b013e32834331e7. PMID: 21258237.
  22. Amery A, Brunner HR, Clement DL, Distler A, Ganten D, Gotzen R, Imai Y, Mancia G, Meyer-Sabellek W, O’Brien E, Pickering T. Consensus document on non-invasive ambulatory blood pressure monitoring. The Scientific Committee. J Hypertens. 1990;8(suppl 6):135-40. PMID: 2081994.
  23. O’Brien E, Coats A, Owens P, Petrie J, Padfield P, Littler WA, de Swiet MA, Mee F. Use and interpretation of ambulatory blood pressure monitoring: recommendations of the British Hypertension Society. BMJ. 2000;320(7242):1128-34. PMID: 10775227.
  24. O’Brien E, Waeber B, Parati G, Staessen G, Myers MG. Blood pressure measuring devices: recommendations of the European Society of Hypertension. BMJ. 2001:322(7285):531-6. PMID: 11230071.
  25. O’Brien E, Asmar R, Beilin L, Imai Y, Mallion J-M, Mancia G, Mengden T, Myers M, Padfield P, Palatinin P, Parati G, Pickering T, Redon J, Staessen J, Stergiou G, Verdecchia P; European Society of Hypertension Working Group on Blood Pressure Monitoring. European Society of Hypertension recommendations for conventional, ambulatory and home blood pressure measurement. J Hypertens. 2003;21:821-48. PMID: 12714851.
  26. Parati G ,Stergiou GS, Asmar R, Bilo G, de Leeuw P, Imai Y, Kario K, Lurbe E, Manolis A, Mengden T, O’Brien E, Ohkubo T, Padfield P, Palatini P, Pickering T, Redon J, Revera M, Ruilope LM, Shennan A, Staessen JA, Tisler A, Waeber B, Zanchetti A, Mancia G; ESH Working Group on Blood Pressure Monitoring. European Society of Hypertension guidelines for blood pressure monitoring at home: a summary report of the Second International Consensus Conference on Home Blood Pressure Monitoring. J Hypertens. 2008;26:1505-26. doi: 10.1097/HJH.0b013e328308da66. PMID: 18622223.
  27. O’Brien E, Parati G, Stergiou G, Asmar R, Beilin L, Bilo G, Clement D, de la Sierra A, de Leeuw P, Dolan E, Fagard R, Graves J, Head GA, Imai Y, Kario K, Lurbe E, Mallion JM, Mancia G, Mengden T, Myers M, Ogedegbe G, Ohkubo T, Omboni S, Palatini P, Redon J, Ruilope LM, Shennan A, Staessen JA, van Montfrans G, Verdecchia P, Waeber B, Wang J, Zanchetti A, Zhang Y; European Society of Hypertension Working Group on Blood Pressure Monitoring. European Society of Hypertension position paper on ambulatory blood pressure monitoring. J Hypertens. 2013;31(9):1731-68. doi: 10.1097/HJH.0b013e328363e964. PMID: 24029863. Erratum in J Hypertens. 2013;31(12):2467.
  28. Stergiou GS, Parati G, Asmar R, O’Brien E; European Society of Hypertension Working Group on Blood Pressure Monitoring. Requirements for professional office blood pressure monitors. J Hypertens. 2012;30(3):537-42. doi: 10.1097/HJH.0b013e32834fcfa5. PMID 22241143.
  29. Stergiou GS, Karpettas N, Atkins N, O’Brien E. European Society of Hypertension International Protocol for the validation of blood pressure monitors: a critical review of its application and rationale for revision. Blood Press Monit. 2010;15(1):39-48. doi: 10.1097/MBP.0b013e3283360eaf. PMID: 20087174.
  30. Stergiou GS. Office blood pressure measurement with electronic devices: has the time come? Am J Hypertens. 2008;21(3):246. doi: 10.1038/ajh.2007.78. PMID: 18311123.

Clinical Validation Protocols for Blood Pressure Monitors

ISO CEN BSI AAMI ANSI
 81060-2:2018ISO/TC 121/SC 3. ISO 81060-2:2018, Non-invasive Sphygmomanometers – Part 2: Clinical Investigation of Automated Measurement Type. Geneva, Switzerland: ISO; 2018 Nov 23. Information here.
 idem quod
 Association for the Advancement of Medical Instrumentation, American National Standards Institute, International Organization for Standardization. AAMI/ANSI/ISO 81060-2:2019, Non-invasive Sphygmomanometers – Part 2: Clinical Investigation of Automated Measurement Type. Arlington, VA, USA: AAMI; 2019 Aug 20. Information here.
 idem quod
 British Standards, European Norme, International Organization for Standardization. BS EN ISO 81060-2:2019, Non-invasive Sphygmomanometers – Part 2: Clinical Investigation of Automated Measurement Type. Brussels, Belgium: CEN; 2019 Dec 9. Information here.
AAMI/ANSI/ISO
 81060-1:2013Association for the Advancement of Medical Instrumentation, American National Standards Institute, International Organization for Standardization. AAMI/ANSI/ISO 81060-1:2007/(R)2013, Non-Invasive Sphygmomanometers – Part 1: Requirements and Test Methods for Non-Automated Measurement Type. Arlington, VA, USA: AAMI; 2013. Preview available here.
IEEE
 1708:2014IEEE Engineering in Medicine and Biology Society. 1708-2014 – IEEE Standard for Wearable Cuffless Blood Pressure Measuring Devices. Piscataway, New Jersey, USA: IEEE; 2014. Available here.
DHL
 DHL:2016Deutsche Hochdruckliga e.V. DHL® Deutsche Gesellschaft für Hypertonie und Prävention [German Hypertension League e.V. DHL® German Society for Hypertension and Prevention]. Klinische Prüfung von Blutdruckmessgeräten zur Erlangung eines Prüfsiegels (Prüfsiegel DHL®: 2016-10). [Clinical testing of blood pressure monitors for obtaining a Quality Seal (Quality Seal DHL®: 2016-10).] Heidelberg: DHL; 2016. Download here.
JIS
 JIS T 1115:2018日本工業標準調査会 [Japan Industrial Standards Research Committee]. JIS T 1115:2018: 日本工業規格 – 非観血式電子血圧計 [Japan Industrial Standards – Non-invasive Automated Sphygmomanometers]. Tokyo: 日本規格協会 [Japan Standards Association];2018. Available here.

ESH
 ESH-IP:2010O’Brien E, Atkins N, Stergiou G, Karpettas N, Parati G, Asmar R, Imai Y, Wang J, Mengden T, Shennan A; Working Group on Blood Pressure Monitoring of the European Society of Hypertension European Society of Hypertension. International Protocol revision 2010 for the validation of blood pressure measuring devices in adults. Blood Press Monit. 2010;15:23-38. doi: 10.1097/MBP.0b013e3283360e98. PMID: 20110786. Erratum in Blood Press Monit. 2010;15(3):171-2.
 ESH-IP:2002O’Brien E, Pickering T, Asmar R, Myers M, Parati G, Staessen J, Mengden T, Imai Y, Waeber B, Palatini P, Atkins N, Gerin W; Working Group on Blood Pressure Monitoring of the European Society of Hypertension. Working Group on Blood Pressure Monitoring of the European Society of Hypertension International protocol for validation of blood pressure measuring devices in adults. Blood Press Monit. 2002;7(1):3-17. PMID: 12040236.
BHS
 BHS:1993O’Brien E, Petrie J, Littler WA, de Swiet M, Padfield PL, Altman D, Bland M, Coats A, Atkins N. The British Hypertension Society Protocol for the evaluation of blood pressure measuring devices. J Hypertens. 1993;11(suppl 2):S43-S63. Download here.
 BHS:1990O’Brien E, Petrie J, Littler W, de Swiet M, Padfield PL, O’Malley K, Jamieson M, Altman D, Bland M, Atkins N. The British Hypertension Society Protocol for the evaluation of automated and semi-automated blood pressure measuring devices with special reference to ambulatory systems. J Hypertens. 1990;8(7):607-19. PMID: 2168451.
AAMI/ANSI/ISO and DIN/EN
 81060-2:2013Association for the Advancement of Medical Instrumentation, American National Standards Institute, International Organization for Standardization. AAMI/ANSI/ISO 81060-2:2013, Non-invasive Sphygmomanometers – Part 2: Clinical Investigation of Automated Measurement Type. Arlington, VA, USA: AAMI; 2013.
 idem quod
 Deutsches Institut für Normung. DIN EN ISO 81060-2:2014-10: Nichtinvasive Blutdruckmessgeräte – Teil 2: Klinische Prüfung der automatisierten Bauart (ISO 81060-2:2013); Deutsche Fassung EN ISO 81060-2:2014. Berlin, Deutschland: DIN; 2014.
 81060-2:2009Association for the Advancement of Medical Instrumentation, American National Standards Institute, International Organization for Standardization. AAMI/ANSI/ISO 81060-2:2009, Non-invasive Sphygmomanometers – Part 2: Clinical Investigation of Automated Measurement Type. Arlington, VA, USA: AAMI; 2009.
 81060-1:2007Association for the Advancement of Medical Instrumentation, American National Standards Institute, International Organization for Standardization. AAMI/ANSI/ISO 81060-1:2007, Non-Invasive Sphygmomanometers – Part 1: Requirements and Test Methods for Non-Automated Measurement Type. Arlington, VA, USA: AAMI; 2008.
 idem quod
 Deutsches Institut für Normung, DIN EN ISO 81060-1:2012-08: Nicht invasive Blutdruckmessgeräte – Teil 1: Anforderungen und Prüfverfahren der nicht-automatisierten Bauart (ISO 81060-1:2007); Deutsche Fassung EN ISO 81060-1:2012. Berlin, Deutschland: DIN; 2012.
 SP10:2006American National Standards Institute, Association for the Advancement of Medical Instrumentation. ANSI/AAMI SP10:2002/A2:2006, Manual, electronic or automated sphygmomanometers. Arlington, VA, USA: AAMI; 2006.
 SP10:2003American National Standards Institute, Association for the Advancement of Medical Instrumentation. ANSI/AAMI SP10:2002/A1:2003, Manual, electronic or automated sphygmomanometers. Arlington, VA, USA: AAMI; 2003.
 SP10:2002American National Standards Institute, Association for the Advancement of Medical Instrumentation. ANSI/AAMI SP10:2002, Manual, electronic or automated sphygmomanometers. Arlington, VA, USA: AAMI; 2003.
 SP10:1996American National Standards Institute, ANSI/AAMI SP10:1992/A1:1996, Association for the Advancement of Medical Instrumentation. American National Standard. Electronic or automated sphygmomanometers. Arlington, VA, USA: AAMI; 1996.
 SP10:1992American National Standards Institute, Association for the Advancement of Medical Instrumentation. ANSI/AAMI SP10:1992, Electronic or automated sphygmomanometers. Arlington, VA, USA: AAMI; 1993.
 SP10:1987American National Standards Institute, Association for the Advancement of Medical Instrumentation. ANSI/AAMI SP10:1987, Electronic or automated sphygmomanometers. Arlington, VA, USA: AAMI; 1987.
EN
 1060-3:2009CEN Technical Committee 205. EN 1060-3:1997+A2:2009: Non-invasive sphygmomanometers – Part 3: Supplementary requirements for electro-mechanical blood pressure measuring systems. Brussels, Belgium: CEN; 2009. CEN information here.
 1060-4:2004CEN Technical Committee 205. EN 1060-4:2004: Non-invasive sphygmomanometers – Part 4: Test procedures to determine the overall system accuracy of automated non-invasive sphygmomanometers. Brussels, Belgium: CEN; 2004. CEN information here.
 idem quod
 Deutsches Institut für Normung. DIN EN 1060-4:2004-12: Nichtinvasive Blutdruckmessgeräte – Teil 4: Prüfverfahren zur Bestimmung der Messgenauigkeit von automatischen nichtinvasiven Blutdruckmessgeräten; Deutsche Fassung EN 1060-4:2004. Berlin, Deutschland: DIN; 2004.
DIN
 58130:1996Deutsches Institut für Normung. DIN 58130:1996-12: Nichtinvasive Blutdruckmeßgeräte – Klinische Prüfung [Non-invasive sphygmomanometers – Clinical investigation]. Berlin, Deutschland: DIN; 1996.
 58130:1995Deutsches Institut für Normung. DIN 58130:1995-01: Nichtinvasive Blutdruckmeßgeräte – Klinische Prüfung [Non-invasive sphygmomanometers – Clinical investigation]. Berlin, Deutschland: DIN; 1995.
DHL
 DHL:2007Deutsche Hochdruckliga (DHL) [German Hypertension League]. Klinische Prüfung von Blutdruckmessgeräten zur Erlangung eines Prüfsiegels der Deutschen Liga Hochdruckliga. [Clinical testing of blood pressure monitors for obtaining a German Hypertension League Quality Seal.] Heidelberg: DHL; 1999/A1:2007.
 DHL:1999Deutsche Hochdruckliga (DHL) [German Hypertension League]. Klinische Prüfung von Blutdruckmessgeräten zur Erlangung eines Prüfsiegels der Deutschen Liga Hochdruckliga. [Clinical testing of blood pressure monitors for obtaining a German Hypertension League Quality Seal.] Heidelberg: DHL; 1999.
JIS
 JIS T 1115:2005日本工業標準調査会 [Japan Industrial Standards Research Committee]. JIS T 1115:2005: 日本工業規格 – 非観血式電子血圧計 [Japan Industrial Standards – Non-invasive Automated Sphygmomanometers]. Tokyo: 日本規格協会 [Japan Standards Association];2005. Available here.
 JIS T 1115:1987Technical Committee on Medical Equipment. JIS T 1115:1987: 日本工業規格 -非侵害的电子血压计[Japan Industrial Standards – Non-invasive Electronic Sphygmomanometers]. Tokyo: 日本規格協会 [Japan Standards Association];1987 Feb 15.