By now, most physicians charged with managing their patients’ blood pressure (BP) have likely seen the American College of Cardiology’s new guidance on hypertension.

The 2025 recommendations, released last summer, reaffirm 130/80 mm Hg as the threshold for diagnosing hypertensionand emphasize the importance of accurate measurement.In the previous guidelines, though, a systolic BP of ≥ 140 mm Hg or a diastolic BP of ≥ 90 mm Hg were the thresholds to initiate medication for primary prevention. The new guidelines, however, recommend drug therapy if BP remains ≥ above 130/80 mm Hg after 3-6 months of lifestyle changes.

Since the guidelines’ release, some physicians are re-sounding the alarm that BP is often mismeasured in the office, and that underlying mistakes surrounding the shortfall deserve reexamination. In a commentary about the updated guidelines for Medscape Medical News, John Mandrola, MD, a clinical electrophysiologist at Baptist Medical Associates in Louisville, Kentucky, wrote that it “boggles my mind how badly BP is taken in the healthcare setting.”

“I am not sure how the culture evolved not to care about accurate BP measurement,” Mandrola wrote. “Mediocrity has been codified as standard when it comes to measuring BP.” 

Recent research underscores the prevalence of inaccurate in-office BP measurement.

A 2021 analysis in the American Journal of Preventive Cardiology, for example, found that accurate BP assessment “continues to remain suboptimal in clinical practice,” even among cardiologists. Despite the inaccuracy of BP measurement, there is a high level of confidence in BP readings, the authors concluded.

An estimated 10%-50% of patients with high office BP readings have normal BP outside the office, according to a recent analysis of barriers to accurate BP measurement in Journal of Primary Care & Community Health. Falsely elevated BP measurements can lead to unnecessary initiation or escalation of BP medications, adverse effects, and added care costs, the study found. The American Medical Association (AMA) reports that inaccurate BP measurement results in inappropriate management decisions in 20%-45% of cases.

So what is causing such off-track readings? And what can be done to improve in-office BP measurement? Physician leaders say the reasons behind poor BP measurement are complex and center on each individual practice. Meanwhile, a range of solutions have been proposed to fix the problem, starting with physicians taking a closer look at their BP measurement processes.

Measuring BP correctly is not technically difficult, but it requires a number of steps that may not be followed in a busy clinic, said Kevin O. Hwang, MD, MPH, an internist at the University of Texas Health Science Center at Houston and medical director of the UT Physicians Internal Medicine in the Texas Medical Center Clinic.

“It’s time to step back and think: If we don’t measure BP correctly, why do it at all?” said Hwang, lead author of the Journal of Primary Care & Community Health study. “Nobody would knowingly continue using an inaccurate glucometer to measure someone’s blood sugar, but somehow, we have tolerated bad BP measurements. We need to do better.” 

Barriers to Accurate In-Office Measurement

A primary challenge to accurately measuring BP in the office is time, according to Hwang.

“Specifically, it takes longer to prepare the patient, get them in the right position, and take multiple measurements,” he said. “In a busy clinic, every minute counts, so the path of least resistance is to just take one quick BP measurement and move on.” 

Hwang’s recent study analyzed BP measurement at six primary care clinics during 54 routine patient encounters. Investigators found barriers to accurate BP measurement are related to staff knowledge and behavior, workflow constraints, equipment and clinic layout, as well as patient characteristics and behavior.

“It also became obvious that many of these issues are beyond the immediate control of the staff whom we ask to measure BP,” Hwang said. “For example, if the physician is pressuring the staff to room the patients quickly, the staff might skip crucial steps, such as taking a second BP measurement.

A number of patient and physical factors within an office contribute to the challenges, added Ian Kronish, MD, MPH, an associate professor of medicine and co-director of theColumbia Hypertension CenteratColumbia University Irving Medical Center in New York City.

Although it’s recommended that patients be seated for at least 3 minutes with their feet on the floor before the reading, that doesn’t always happen, said Kronish, who has studied challenges in BP management. Patients may get up to go to the bathroom; they may get distracted by family members, or they may be eating or drinking, for example.

“Depending on how offices are set up, patients might have to walk all the way down the hallway [to get to the room],” he said. “And then blood pressure is the first thing the nurses or the doctor check. The patient is not really sitting for a few minutes quietly in a peaceful setting. There’s a lot of ways for it to go wrong.” 

As most physicians know, the “white coat effect” also impacts BP measurement. Research shows that even someone walking to the room that just “looks like a doctor wearing a white coat” can lead to instant increases in people’s BP, Kronish said.

“It’s just hardwired into people’s reactions and their physiology,” he said.

The use of aneroid devices by some physicians aren’t much help, Kronish added.

A 2025 analysis in Annals of Family Medicine noted that aneroid sphygmomanometers (ASMs) can deform with use, leading to inaccuracy. Although manufacturers recommend annual ASM retesting, this rarely occurs, “potentially leading to errors in hypertension diagnosis/treatment,” according to the article.

“There’s lots of errors introduced when you’re relying on these devices,” Kronish said. “So even when doctors think they’re doing a better job, they’re often not.” 

How Can Doctors Improve In-Office BP Measurement? 

When evaluating patients’ BP at his practice, Kronish uses the electronic health record to review results from their past two or three office visits.

“I know there is always this up and down variation in BP from visit to visit and really, you’re trying to get the average over time,” he said. “So I usually don’t make decisions based on one BP reading in isolation. I look at the pattern of the BP [over] office visits.”

He also recommends physicians take a look at Target: BP, a new national initiative co-led by the AMA and the American Heart Association to improve BP readings. The initiative features resources for training clinical staff in how to accurately measure BP, including a template that addresses BP device procurement and maintenance, healthcare team training and skills testing, and BP measurement processes and workflow.

Using the right-sized cuff is among the top recommendations in the Target BP guidance.

The No. 1 measurement error is incorrect cuff size, AMA improvement specialist Jane Drage said in a statement about the guidance.

“If you’re unsure of the correct cuff size to use for a patient, the range and index line usually found on that cuff bladder can provide that guidance,” she said. “You can also measure the arm circumference to find the correct size cuff for the patient.”

Really, it’s about having a very standardized protocol and working with staff to overcome any problems or shortfalls there may be with measurements, Kronish said. Some potential interventions may involve: having a strong protocol about when BP is taken during a visit, ensuring patients are sitting quietly for the right amount of time, and limiting distractions and other conversations before the test.

“I’ve done a little bit of this where we work with our nurses and medical systems to think through and do quick checklist audits of how BP is being measured in routine practice, and trying to think of ways that you can get as close to the guidelines as you can,” he said.

Bringing Home Monitoring Into the Mix

Matthew Francis Muldoon, MD, MPH, said his strategy is not focusing too much on in-office measurements but instead emphasizing home readings.

Part of the solution for ideally managing hypertension is engaging patients in measuring their BP at home, said Muldoon, a hypertension specialist and founding director of the Hypertension Center at the University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh.

“One, it allows you to get lots of readings, so the variability day-to-day could be washed out by taking the average over several readings over several days,” Muldoon said. “Two, it gets patients engaged in their care, so they feel like they have a role. They see the BP readings themselves, and it becomes feedback to them on whether they're taking their pills or they're exercising. They become part of the team instead of passive.”

While measuring BP sounds simple, doing it correctly and consistently isn’t easy in the primary care setting unless you’re intentional about it, added Hwang.

His study in Journal of Primary Care & Community Health noted strategies that involve systems change, technology, and education are the most promising interventions for improved measurement. Proper BP measurement requires an estimated 7 more minutes than a casual measurement, according to the analysis.

Lasting change requires a systems approach with support from leadership, Hwang said.

“Reconfiguring the physical space, designing the way in which patients are roomed, acquiring validated BP machines, training staff, and achieving consensus on the importance of BP measurement — all that is necessary for proper BP measurement across a healthcare organization,” he said. “We owe this to our patients.”