Editorial comment 1915
Accuracy of blood pressure measurement:
sphygmomanometer calibration and beyond
Gianfranco Paratia,b, Andrea Fainia and Paolo Castiglionic
Journal of Hypertension 2006, 24:19151918
a
Department of Clinical Medicine and Prevention, University of Milano-Bicocca,
Milan, bII Cardiology Unit, San Luca Hospital, IRCCS, Istituto Auxologico Italiano,
Milan and cBioengineering Center, Don C. Gnocchi Foundation, IRCCS, Milan, Italy
Correspondence and requests for reprints to Gianfranco Parati, Department of
Cardiology, San Luca Hospital, Istituto Auxologico Italiano, Via Spagnoletto, 3,
20149 Milan, Italy
Tel: +39 02 619112890; fax: +39 02 619112956;
e-mail: gianfranco.parati@unimib.it
See original paper on page 1931
The importance of accurate blood pressure measurement
in the diagnosis of arterial hypertension, and in the
precise titration of antihypertensive treatment, is largely
acknowledged in clinical practice. The relevance of this
issue has recently been further emphasized by hyper-
tension management guidelines [13]. Health care givers
as well as patients are now aware of the need to follow
carefully standardized procedures when measuring
blood pressure, aimed at achieving the highest possible
accuracy of blood pressure estimates.
Conversely, the possible negative impact that poor main-
tenance of blood pressure-measuring devices may have
on the accuracy of patients blood pressure assessment, is
still largely underestimated or disregarded, even by
physicians and nurses. This phenomenon should be
considered with concern because a technical problem
such as sphygmomanometer calibration might impor-
tantly affect the effectiveness of hypertension manage-
ment and, surprisingly enough, its influence may be
greater now than some years ago. This is due to the more
and more frequent tendency among hospital staff and
general practitioners to shift from use of the classical
mercury sphygmomanometer to the adoption of other
blood pressure-measuring techniques, such as aneroid
sphygmomanometers and electronic devices.
In this issue of the journal, Turner et al. [4] provide
further evidence to support the clinical relevance of
sphygmomanometer calibration. By means of mathe-
matical simulations, the authors have extended the
results of previous studies [5,6], and have estimated
the combined effects exerted on the detection of arterial
hypertension by random blood pressure variability
(including intra-individual blood pressure variability as
well as random measurement errors) and by systematic
errors due to inadequate sphygmomanometer calibration.
The main findings of their mathematical simulation
0263-6352 2006 Lippincott Williams & Wilkins
Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
are summarized in Fig. 2 of their paper [4]. The percent-
age of subjects correctly labelled as hypertensives
(a measure of the sensitivity of the diagnostic procedure)
increased significantly with the increase in the number of
doctors visits, when correctly calibrated blood pressure-
measuring devices were employed. This increase reflects
a reduction in random error obtained by averaging the
blood pressure values measured over successive visits.
Conversely, when non-calibrated devices were used not
only the sensitivity of the diagnostic procedure was lower
at the first visit, but also the increment in sensitivity with
repeated visits, observed over subsequent measurements
when using calibrated manometers, was less pronounced.
This is because the non-calibrated sphygmomanometer
introduces a systematic error in the blood pressure esti-
mate that cannot be reduced by averaging several
measurements. Because of this, the sensitivity curves
typical of calibrated and of non-calibrated devices dis-
played a tendency to diverge with the increase in the
number of visits.
A specific feature of the study by Turner et al. [4], which
deserves some discussion, is represented by the mathe-
matical model employed to assess the clinical relevance
of sphygmomanometer calibration, a model which may
not necessarily be familiar to some researchers. The
authors used a simple Monte Carlo simulation to estimate
the combined effects of systematic sphygmomanometer
error and day-to-day random variability of blood pressure
measurements on the over- and under-detection of hy-
pertension in adults aged 18 years and older. Monte Carlo
methods are a class of computational algorithms for
simulating the behaviour of various physical and mathe-
matical systems. These techniques are used in situations
where the analytic solution of a problem is either hardly
achievable or time consuming. In other words, a Monte
Carlo algorithm is a method used to find solutions to
mathematical problems (which may be characterized by
many variables) that cannot easily be solved, for example,
by integral calculus, or by other numerical methods. Its
efficiency when compared with other numerical methods
increases with the increase in the dimension of the
problem to be solved. A Monte Carlo technique can be
differentiated from other simulation methods because of
its stochastic nature (i.e. because it is characterized by
non-deterministic algorithms, through use of random
numbers).
Monte Carlo techniques have a long history in math-
ematics, with their earliest application probably being
 1916 Journal of Hypertension 2006, Vol 24 No 10
represented by Buffons Needle in 1733. The name
Monte Carlo was given by Nicholas Metropolis (in
honour of his uncle Ulam, who was a gambler) during
the Manhattan Project of World War II, and specifically
refers to the famous casino in Monaco. The use of
randomness and the repetitive nature of the analytic
process characteristic of a Monte Carlo model are both
analogous to the gambling activities conducted in a
casino. Perhaps the most famous early use of this model
was made by Enrico Fermi in 1930, when he employed a
random method to calculate the properties of the newly-
discovered neutron. Monte Carlo methods were central
to the simulations required for the Manhattan Project,
although they were strongly limited by the computational
tools available at that time. It was only after electronic
computers became available (i.e. from 1945 onwards) that
Monte Carlo methods began to be studied in depth. In
the 1950s, they were used at Los Alamos for some early
work aimed at the development of the hydrogen bomb,
and became popular in the fields of physics and oper-
ations research. The Rand Corporation and the US Air
Force were two of the major organizations responsible for
funding and disseminating information on Monte Carlo
methods during this period, which found wide appli-
cations in many different fields. The use of Monte Carlo
methods requires large amounts of random numbers
and, indeed, it was their use that spurred the develop-
ment of pseudorandom number generators, which were
far quicker to use than the tables of random numbers
previously used for statistical sampling.
Monte Carlo methods have diverse applications, ranging
from the simulation of complex physical phenomena,
such as radiation transport in the earths atmosphere or
simulation of the esoteric subnuclear processes in high-
energy physics experiments, to daily entertainments,
such as the simulation of a Bingo game. The analogy
of Monte Carlo methods to games of chance is intriguing,
but the game when addressing a scientific problem is a
physical system, and the outcome of the game is not a pot
of money or a stack of chips (unless simulated) but rather
a satisfactory solution for the problem under assessment.
Factors involved in the accuracy of blood
pressure measurements: device calibration
and beyond
The classic approach to blood pressure measurement is
based on use of the mercury sphygmomanometer, which
has long been regarded as the gold standard for blood
pressure readings in a clinical setting since its first
description by Scipione Riva-Rocci, published in 1896
on the Gazzetta Medica di Torino [7,8]. Its use is based
on the theory of the occlusion technique: the pressure of
air within the arm cuff is balanced by the weight of a
mercury column contained in a graded glass tube.
The height of the column therefore measures the air
pressure in the arm cuff in mmHg. In spite of its
Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
worldwide use, the conventional sphygmomanometric
measurement of blood pressure through the Riva-Rocci
manometer coupled with use of Korotkoff sounds is
known to be affected by a number of limitations. A first
important problem is the high between-measurement
variation in office blood pressure readings, which reflects
both the physiological variations in blood pressure level
and frequently also errors in the technique of measure-
ment, due to conditions of measurement, arm position,
observers attitude. In 1964, Geoffrey Rose [9] classified
the observer error into three categories: (i) systematic
errors, which lead to both intraobserver and interobserver
error; (ii) terminal digit preference, which results in the
observer rounding off the pressure reading to a preferred
digit, most often to zero [10]; and (iii) observer prejudice
or bias, leading the observer simply to adjust the blood
pressure readings to meet his or her preconceived notion
of what the blood pressure should be. All these problems
contribute to the between-observer variability in the
accuracy of blood pressure readings, mostly due to differ-
ences in skill and training [3]. Other factors, not of a
technological nature, can introduce systematic errors in
sphygmomanometric blood pressure measurements.
These include errors in arm cuff positioning, as well as
the choice of an inappropriate cuff-size, in relation to
patients arm circumference. The latter problem has
recently received more attention due to the progressive
increase in the prevalence of obesity and overweight in
developed countries, without a parallel increase in the
frequency of large arm-cuff use [11]. A second major
problem affecting the accuracy of sphygmomanometric
blood pressure readings is the discrepancy between blood
pressure values obtained in the office and those measured
outside of a clinic setting (i.e. the so-called white-coat
effect). This phenomenon shows high inter-individual
variations, limited reproducibility and its prognostic
importance is still a matter of controversy, but it certainly
interferes with the assessment of subjects true blood
pressure levels [1216].
Beyond all these factors possibly involved in determining
the accuracy of blood pressure measurements, another
critical issue in this context is represented by perform-
ance of a regular calibration of the device employed. This
is the case for mercury, oscillometric and electronic
devices, even with important technical differences.
Given the simple structure of the mercury device, its
maintenance is relatively simple [3], and a loss of cali-
bration is observed rarely. The latter is mainly due to
mercury oxidation, a process that occurs in a relatively
slow manner. When such a phenomenon is observed, the
instrument can be easily recalibrated by simply replacing
the mercury in the reservoir. This procedure, even if
some attention is needed due to mercury toxicity, can be
easily carried out by the sphygmomanometer users, and
does not require any intervention by the manufacturer.
However, increasing concerns about the toxicity of

mercury for individuals using or servicing mercury sphyg-
momanometers, and, more importantly, the great concern
about the toxic effects of mercury on the environment,
have determined a progressive shift towards other kind of
blood pressure-measuring devices [17,18]. The most
commonly employed alternative to mercury manometers
is represented by aneroid sphygmomanometers. As indi-
cated by the name itself (aneroid means without fluid, in
the Greek language), these devices do not contain mer-
cury, and are generally of smaller size and easier to handle
than the classic mercury manometers. Typically, they
consist of a thin brass corrugated bellows that is expanded
by the air pressure in the cuff. The expansion moves a pin
resting on the bellows. The movement is mechanically
amplified and transmitted to a dial. This bellows and
lever system is mechanically more complex than the
mercury reservoir and column [19]. Moreover, besides
being prone to all the problems of the auscultatory
technique (namely observer bias and terminal digit pre-
ference), aneroid manometers are easily damaged and can
go out of calibration without detection [3], due to
mechanical shocks and changes in environmental
temperature related to everyday use. They usually lead
to falsely low readings with the consequent underestima-
tion of blood pressure. When calibrated against a mercury
sphygmomanometer a mean difference of 3 mmHg is
considered to be acceptable; however, 58% of aneroid
sphygmomanometers have been shown to have errors
greater than 4 mmHg, with approximately one-third of
these having errors higher than 7 mmHg [3,20]. Aneroid
sphygmomanometers must therefore be checked every
6 months against an accurate mercury sphygmomano-
meter over the entire pressure range, which can be carried
out by connecting the aneroid sphygmomanometer via a
Y-piece to the tubing of the mercury sphygmomanometer
and inflating the cuff around a metal or wood cylinder. If
inaccuracies or other faults are found, the instrument
must be returned to the manufacturer or supplier for
repair, given the difficulties which users often have to
face when trying to re-calibrate them [3]. In practice, in
spite of their easier use, this implies that these devices
are often employed under suboptimal conditions, or
even with evident calibration problems and loss of
measurement linearity.
The observer-related errors as well as the errors related to
the inaccuracy of aneroid manometers, could in theory be
eliminated by using automated electronic devices, such
as those proposed for self blood pressure measurement at
home [3]. Accurate automated sphygmomanometers,
capable of providing print-outs of systolic, diastolic and
mean blood pressure together with heart rate and the
time and date of measurement, would eliminate errors of
interpretation and abolish observer bias and terminal
digit preference. Moreover, the need for observer training
would no longer be necessary, although a period of
instruction and assessment of proficiency in using the
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Calibration of sphygmomanometers Parati et al. 1917
automated device will always be necessary. Another
advantage carried by automated blood pressure-
measuring devices is their ability to store data for later
analysis and/or to allow for remote teletransmission.
These favourable properties have promoted the diffusion
of these devices, and a number of large research studies
are already employing automated technology to measure
blood pressure instead of the traditional mercury gold
standard.
However, most of these devices are based on the oscillo-
metric method for blood pressure measurement. This
implies that only mean blood pressure values are
measured, whereas systolic and diastolic blood pressure
are determined through proprietary and undisclosed
algorithms, built in each device, and different between
different manometers [3]. Moreover, the cuff deflation
rate may be different in different devices, thus introdu-
cing another possible source of error in automated blood
pressure measurements. All these problems may lead to
significant differences in the blood pressure values pro-
vided by automated oscillometric devices produced by
different manufacturers [3,21,22]. Thus, although auto-
mated devices may eliminate observer-related systematic
errors, they may unfortunately introduce other manu-
facturer-related errors. Moreover, most of the available
automated devices were designed for self-measurement
of blood pressure at home, and may not necessarily be
suitable for clinical application. Evidence is still lacking
concerning whether they will remain accurate with long-
term use in a clinic setting, although some of them have
been used successfully in hospital practice and/or in large
hypertension studies. Furthermore, oscillometric tech-
niques cannot measure blood pressure in all situations,
particularly in patients with dysrhythmias such as rapid
atrial fibrillation. Finally, many doctors do not trust
automated measurements, and prefer manual blood pres-
sure readings. To improve this situation, and to minimize
problems of accuracy related to their use, only automated
devices validated according to internationally accepted
protocols should be considered [2327]. Complying with
this recommendation may help to reduce systematic
errors, while the known stability of electronic transducers
means that calibration needs only be performed at rela-
tively long time intervals. The latter advantage applies
also when electronic devices are used manually.
Notwithstanding the blood pressure-measuring tech-
nique selected, it should be noted that the parameter
under assessment (i.e. blood pressure) is by no means
constant over time, and is characterized by a pronounced
variability not only between different behavioural con-
ditions, but also on a beat-by-beat basis at rest [2830].
This means that, even when making use of a perfect
blood pressure-measuring tool in ideal environmental
conditions, the same observer will unavoidably measure
different blood pressure values over successive visits and
 1918 Journal of Hypertension 2006, Vol 24 No 10
even at different times within the same visit. This is
exemplified by calculations made in our laboratory over
10-min segments of continuous finger blood pressure
recordings performed in healthy volunteers by a
Portapres device (Finapres Medical Systems, Amster-
dam, The Netherlands) [31]. Spontaneous systolic and
diastolic blood pressure variability in the sitting position,
expressed as the standard deviation of the average blood
pressure level determined over this time window,
amounted to 7 and 4 mmHg, respectively.
In conclusion, given the crucial clinical importance of
obtaining accurate blood pressure measurements, a great
deal of methodological care is needed whenever assessing
blood pressure values, also on the background of the
spontaneous variability that characterizes blood pressure.
This includes not only compliance with the procedures
recommended in blood pressure measurement guidelines
[3], but also regular performance of sphygmomanometer
calibration, regardless of the type of blood pressure-
measuring device employed.
References
1 Guidelines Committee. 2003 European Society of Hypertension
European Society of Cardiology guidelines for the management of arterial
hypertension. J Hypertens 2003; 21:10111053.
2 Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr,
et al., for the National High Blood Pressure Education Program
Coordinating Committee. The seventh report of the Joint National
Committee on Prevention, Detection, Evaluation, and Treatment of High
Blood Pressure (JNC VII). JAMA 2003; 289:25602572.
3 OBrien E, Asmar R, Beilin L, Imai Y, Mallion JM, Mancia G, et al., for the
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; 21:821848.
4 Turner MJ, Irwig L, Bune AJ, Kam PC, Baker AB. Lack of
sphygmomanometer calibration causes over- and under-detection of
hypertension a computer simulation study. J Hypertens 2006; 24:1931
1938.
5 Rouse A, Marshall T. The extent and implications of sphygmomanometer
calibration error in primary care. J Hum Hypertens 2001; 15:587
591.
6 Marshall T. When measurements are misleading: modelling the effects of
blood pressure misclassification in the English population. BMJ 2004;
328:933.
7 Riva-Rocci S. Un nuovo sfigmomanometro. Gaz Med di Torino 1896;
50:981996.
8 Parati G, Mancia G. History of blood pressure measurement from the pre-
Riva-Rocci era to the 20-first century. In: Birkenhager WH, Reid JL, editors.
Handbook of hypertension, vol. 22. Amsterdam: Elsevier BV; 2004.
pp. 332.
9 Rose G. Standardisation of observers in blood pressure measurement.
Lancet 1965; 1:673674.
10 Wen SH, Kramer MS, Joey J, Hanley JA, Usher RH. Terminal digit
preference, random error and bias in routine clinical measurement of blood
pressure. J Clin Epidemiol 1993; 46:11871193.
11 Pickering TG, Hall JE, Appel LJ, Falkner BE, Graves JW, Hill MN, et al.
Recommendations for blood pressure measurement in humans and
experimental animals. Part 1: blood pressure measurement in humans.
Circulation 2005; 111:697716.
12 La Batide-Alanore A, Chatellier G, Bobrie G, Fofol I, Plouin P-F.
Comparison of nurse- and physician-determined clinic blood
pressure levels in patients referred to a hypertension clinic: implications for
subsequent management. J Hypertens 2000; 18:391
398.
13 Mancia G, Bertinieri G, Grassi G, Parati G, Pomidossi G, Ferrari A, et al.
Effects of blood pressure measurements by the doctor on patients blood
pressure and heart rate. Lancet 1983; 2:695698.
Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
14 Mancia G, Parati G, Pomidossi G, Grassi G, Casadei R, Zanchetti A.
Alerting reaction and rise in blood pressure during measurements by
physician and nurse. Hypertension 1987; 9:209215.
15 Parati G, Bilo G, Mancia G. Blood pressure measurement in research and
clinical practice: recent evidence. Curr Opin Nephrol Hypertens 2004;
13:343357.
16 Parati G, Bilo G, Mancia G. White coat effect and white coat hypertension:
what do they mean? Cardiovasc Rev Rep 2003; 24:477484.
17 Jones DW, Frohlich ED, Grim CM, Grim CE, Taubert KA. Mercury
sphygmomanometers should not be abandoned: an advisory statement
from the Council for High Blood Pressure Research, American Heart
Association. Hypertension 2001; 37:185186.
18 OBrien E. Replacing the mercury sphygmomanometer. Requires clinicians
to demand better automated devices. BMJ 2000; 320:815816.
19 Beevers G, Lip GHY, OBrien E. ABC of Hypertension. Part II. Conventional
sphygmomanometry: technique of auscultatory blood pressure
measurement. BMJ 2001; 322:10431047.
20 Mion D, Pierin AMG. How accurate are sphygmomanometers? J Hum
Hypertens 1998; 12:245248.
21 Amoore JN, Scott DH. Can simulators evaluate systematic differences
between oscillometric non-invasive blood-pressure monitors? Blood Press
Monit 2000; 5:8189.
22 Mancia G, Di Rienzo M, Parati G. Ambulatory blood pressure monitoring.
Research and clinical applications. Hypertension 1993; 21:510524.
23 Association For The Advancement Of Medical Instrumentation. American
national standard for electronic or automated sphygmomanometers: ANSI/
AAMI SP10-1993. Arlington, VA: AAMI; 1993.
24 OBrien E, Petrie J, Littler WA, de Swiet M, Padfield PL, Altman D, et al. The
British Hypertension Society protocol for the evaluation of blood pressure
measuring devices. J Hypertens 1993; 11 (Suppl 2):S43S63.
25 OBrien E, Pickering T, Asmar R, Myers M, Parati G, Staessen J, et al., on
behalf of the 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;
7:317.
26 OBrien E. State of the market in 2002 for blood pressure measuring
devices. Blood Press Monit 2001; 6:171176.
27 OBrien E, Waeber B, Parati G, Staessen J, Myers MG. Blood pressure
measuring devices: recommendations of the European Society of
Hypertension. BMJ 2001; 322:531535.
28 Mancia G, Ferrari A, Gregorini L, Parati G, Pomidossi G, Bertinieri G, et al.
Blood pressure and heart rate variabilities in normotensive and
hypertensive human beings. Circ Res 1983; 53:96104.
29 Parati G, Bilo G, Vettorello M, Groppelli A, Maronati A, Tortorici E, et al.
Assessment of overall blood pressure variability and its different
components. Blood Press Monit 2003; 8:155159.
30 Mancia G, Parati G, Di Rienzo M, Zanchetti A. Blood pressure variabiity. In:
Zanchetti A, Mancia G, editors. Handbook of hypertension, vol.17:
pathophysiology of hypertension. Amsterdam: Elsevier Science BV; 1997.
pp. 117169.
31 Parati G, Ongaro G, Bilo G, Glavina F, Castiglioni P, Di Rienzo M, Mancia
G. Non-invasive beat-to-beat blood pressure monitoring: new
developments. Blood Press Monit 2003; 8:3136.