CONFOUNDERS OF AUSCULTATORY BLOOD-PRESSURE MEASUREMENT

The appropriate use of any test requires the clinician to appreciate that test's limitations. By recognizing the potential confounders of the auscultatory assessment of blood pressure, the clinician minimizes the likelihood of enacting therapeutic decisions based on inaccurate data. When approaching the treatment of a hypertensive patient, several points should be kept in mind. First, the measurement of persistent and severe hypertension in a patient receiving treatment who describes symptoms of orthostatic hypotension with apparently adequate standing blood pressure or who lacks corroborating retinal, echocardiographic, or electrocardiographic signs of hypertension should raise the concern of pseudohypertension or a white-coat response. Similarly, when one finds a normal or near-normal systolic blood pressure in a patient with a clinical picture consistent with severe hypertension, one should make a directed effort to look for an unrecognized auscultatory gap. Second, marked discrepancies in measurements as obtained by different operators or in different settings should raise concern of the white-coat response or methodologic errors by one operator, such as undercuffing, excessive pressure on the head of the stethoscope, rapid deflation of the cuff, or use of different arms. In treating hypertension in even the minimally obese patient, a special point must be made that an adequate size cuff be used for all blood pressure determinations. Third, when blood pressure is determined with the patient in any but the standardized back-and-arm-sup-ported seated position described above, the clinician should acknowledge the possibility that the position may alter the patient's classification. Fourth, the diagnosis and management of hypertension requires multiple measurements of blood pressure. To the extent possible, measurements on different days or at different times should be taken with conditions as identical as possible so that differences seen result from therapeutic interventions and not methodologic differences. © 1995 Society of General Internal Medicine.