Changes in the level and intra-visit variability of office blood pressure under non-standard measurement conditions in patients with hypertension

Objective. The aim of the study was to assess the dynamics of office blood pressure (BP) levels and to analyse factors associated with the individual variability in BP changes under different measurement conditions in patients with hypertension (HTN).
Design and methods. The study enrolled 200 outpatients with confirmed HTN, including 80 men. The median age was 68,0 (58–73) years. BP was measured using an automated oscillometric device according to the standard protocol (the reference BP), followed by a series of single measurements conducted under conditions simulating common protocol violations: the absence of back support, crossed legs, a mismatch between BP cuff size and arm circumference, the patient talking during the procedure, and preceding physical activity. The frequency of uncontrolled HTN (defined as systolic BP (SBP) ≥ 140 mmHg and/or diastolic BP (DBP) ≥ 90 mmHg) was assessed. For each participant, the absolute and percentage (PV) deviations from the reference BP were calculated, along with the individual BP variability (SDPV), defined as the standard deviation of PV across the different measurement conditions. Patients in the upper quartile of SDPV were classified as having high intra-visit BP variability. Predictors of high BP variability were identified using logistic regression and receiver operating characteristic (ROC) analysis.
Results. All non-standard measurement conditions, except for the use of an oversized BP cuff, resulted in a significant increase in BP compared with the reference values. The greatest increase was observed in the seated position with crossed legs, with an average rise of 13,5 mmHg in SBP and 3,0 mmHg in DBP. The proportion of patients classified as having uncontrolled HTN rose from 19 % (based on the reference BP) to 58,5 % under the crossed-legs condition. After adjustment of the regression model for sex, age, and body weight, high SBP changes variability (SDPV ≥ 9,0 %) was independently associated with a reference SBP < 122 mmHg (odds ratio [OR] 4,01; 95 % confidence interval [CI] 2,02–7,93) and a history of an acute cerebrovascular event (OR 2,55; 95 % CI 1,14–5,72). High DBP changes variability (SDPV ≥ 7,1 %) was independently associated with a reference DBP < 73 mmHg (OR 2,86; 95 % CI 1,49–5,50).
Conclusions. Non-adherence to the recommended BP measurement protocol predominantly leads to increased BP readings and contributes to the overdiagnosis of uncontrolled HTN. High intra-visit BP variability in response to altered measurement conditions is associated with a history of acute cerebrovascular events and lower reference BP levels. These findings underscore the critical importance of strict adherence to the established BP measurement protocol.

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