What are the proper instructions for home blood pressure (BP) monitoring?

Home Blood Pressure Monitoring Instructions

For accurate home blood pressure monitoring, patients should use a validated automated upper-arm device, measure twice daily (morning before medications and evening) for 7 consecutive days, taking 2 readings per session 1-2 minutes apart, and average all readings except the first day to guide treatment decisions. 1, 2, 3

Equipment Selection and Setup

Device Requirements

• Use only a validated automated oscillometric device with an upper-arm cuff that has passed standardized validation protocols (AAMI, BHS, or International Protocol) 1, 3
• Select a device with memory storage capability to automatically record all measurements 1, 3
• Ensure appropriate cuff size that encircles 80% of the arm circumference 3
• Critical pitfall: Most commercially available devices have never been properly validated—only use devices listed on validated device registries (dableducational.org or bhsoc.org) 1, 4

Device Accuracy Verification

• Bring the home monitor to clinic initially to verify accuracy against office measurements 1
• Re-evaluate device accuracy and patient technique annually 1, 3
• Replace devices older than 4 years as they may become inaccurate 1

Pre-Measurement Preparation

Patient Positioning (Critical for Accuracy)

• Sit in a chair with back supported and feet flat on the floor 1, 3
• Keep legs uncrossed 1, 3
• Support the arm on a flat surface at heart level 1, 3
• Remain silent during the entire measurement period 1, 3

Pre-Measurement Requirements

• Empty bladder before measuring 1, 3
• Avoid caffeine, tobacco, alcohol, and exercise for 30 minutes before measurement 1, 3
• Rest quietly for 5 minutes in the seated position before taking readings 1, 3

Measurement Protocol

Timing and Frequency

• Morning measurements: Take before breakfast and before taking antihypertensive medications, but not immediately after awakening 1, 2
• Evening measurements: Take before dinner or before going to bed 1, 2
• Measure at the same times each day for consistency 1

Number of Readings

• Take 2 readings per session, separated by 1-2 minutes 1, 2, 3
• Measure twice daily (morning and evening) 1, 2, 3
• Use the non-dominant arm (or arm with highest BP if there is >10 mmHg difference between arms) 1, 2

Measurement Schedule by Clinical Context

Initial Assessment (When Starting Home Monitoring)

• Conduct measurements for 7 consecutive days 1, 3
• Exclude the first day's measurements from analysis 1, 3
• This provides a minimum of 12 morning and 12 evening measurements (24 total readings) 1
• Calculate the average of all readings (excluding day 1) as the reference value 1, 3

Dose Titration Phase (Adjusting Medications)

• Measure for 3-7 days a few weeks after initiating or changing medication 1
• Take morning measurements as trough values (before medication) 1
• Use the average of measurements after 2-4 weeks to assess treatment effect 1
• Make all measurements under identical conditions and at the same times as initial values 1

Long-Term Monitoring (Stable, Controlled Patients)

• Conduct measurements for 1 week per quarter (minimum 12 morning and evening measurements) 1
• Measure more frequently in patients with poor medication adherence 1
• Obtain readings for 3-7 days before scheduled clinic visits 1

Interpretation of Results

Diagnostic Thresholds

• Hypertension: Average home BP ≥135/85 mmHg (equivalent to office BP ≥140/90 mmHg) 1, 2, 3
• Elevated BP: Average home BP 120-134/70-84 mmHg 1, 2, 3
• Target for treated patients: <135/85 mmHg, or <130/80 mmHg for patients with diabetes, coronary heart disease, or chronic kidney disease 1, 2

Data Recording and Reporting

• Record all readings or use a device with automatic memory storage 1, 2, 3
• Base treatment decisions on the average of all readings over the measurement period (minimum 12 readings) 1
• Present all recorded values to the clinician 1, 3

Patient Education Requirements

Essential Training Content

• Hypertension and cardiovascular risk 1
• Proper BP measurement procedure and positioning 1
• Use of validated monitors and appropriate cuff sizing 1
• Interpretation of BP readings and understanding BP variability 1
• Understanding that the monitor is for their use only (not to be shared) 1

Common Pitfalls to Avoid

• Never use wrist or finger monitors—they are inaccurate and not recommended for clinical use 1, 5
• Do not measure immediately after awakening—allow time for stabilization 1, 2
• Avoid talking during measurements as this elevates readings 1, 3
• Do not rely on a single day's measurements—always average multiple days 1, 3
• Never assume a commercially available device is accurate without verification of validation status 1, 4
• Patients with atrial fibrillation or frequent ectopic beats may have inaccurate oscillometric readings and require alternative measurement methods 6