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Relative effectiveness of clinic and home blood pressure monitoring compared with ambulatory blood pressure monitoring in diagnosis of hypertension: systematic review

BMJ 2011; 342 doi: (Published 24 June 2011) Cite this as: BMJ 2011;342:d3621
  1. J Hodgkinson, research fellow1,
  2. J Mant, professor2,
  3. U Martin, clinical reader in clinical pharmacology3,
  4. B Guo, research fellow4,
  5. F D R Hobbs, professor1,
  6. J J Deeks, professor4,
  7. C Heneghan, reader in evidence based medicine 5,
  8. N Roberts, information specialist6,
  9. R J McManus, professor1
  1. 1Primary Care Clinical Sciences, University of Birmingham, Edgbaston, Birmingham B15 2PP
  2. 2General Practice and Primary Care Research Unit, University of Cambridge, Cambridge CB2 0SR
  3. 3School of Clinical and Experimental Medicine, University of Birmingham, Edgbaston
  4. 4Public Health, Epidemiology and Biostatistics, University of Birmingham, Edgbaston
  5. 5Department of Primary Health Care, University of Oxford, Headington, Oxford OX3 7LF
  6. 6Bodleian Health Care Libraries, Knowledge Centre, ORC Medical Research Building, Oxford OX3 7DQ
  1. Correspondence to: R J McManus r.j.mcmanus{at}
  • Accepted 17 April 2011


Objective To determine the relative accuracy of clinic measurements and home blood pressure monitoring compared with ambulatory blood pressure monitoring as a reference standard for the diagnosis of hypertension.

Design Systematic review with meta-analysis with hierarchical summary receiver operating characteristic models. Methodological quality was appraised, including evidence of validation of blood pressure measurement equipment.

Data sources Medline (from 1966), Embase (from 1980), Cochrane Database of Systematic Reviews, DARE, Medion, ARIF, and TRIP up to May 2010.

Eligibility criteria for selecting studies Eligible studies examined diagnosis of hypertension in adults of all ages using home and/or clinic blood pressure measurement compared with those made using ambulatory monitoring that clearly defined thresholds to diagnose hypertension.

Results The 20 eligible studies used various thresholds for the diagnosis of hypertension, and only seven studies (clinic) and three studies (home) could be directly compared with ambulatory monitoring. Compared with ambulatory monitoring thresholds of 135/85 mm Hg, clinic measurements over 140/90 mm Hg had mean sensitivity and specificity of 74.6% (95% confidence interval 60.7% to 84.8%) and 74.6% (47.9% to 90.4%), respectively, whereas home measurements over 135/85 mm Hg had mean sensitivity and specificity of 85.7% (78.0% to 91.0%) and 62.4% (48.0% to 75.0%).

Conclusions Neither clinic nor home measurement had sufficient sensitivity or specificity to be recommended as a single diagnostic test. If ambulatory monitoring is taken as the reference standard, then treatment decisions based on clinic or home blood pressure alone might result in substantial overdiagnosis. Ambulatory monitoring before the start of lifelong drug treatment might lead to more appropriate targeting of treatment, particularly around the diagnostic threshold.


  • Contributors: CH, FDRH, and RJMcM had the original idea and gained the funding. NR did the electronic searches; JH, RJMcM, JM, and UM extracted the data. BG, JH, and JJD undertook the analyses. All authors contributed to the manuscript and approved the final version. RJMcM is guarantor.

  • Funding: This work forms part of a larger programme on monitoring in primary care supported by the National Institute for Health Research. The views and opinions expressed are those of the authors and do not necessarily reflect those of the NHS, NIHR, or the Department of Health. RJMcM holds an NIHR career development fellowship.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: Not required.

  • Data sharing: Dataset available from the corresponding author at r.j.mcmanus{at} The dataset includes only anonymised material already in the public domain.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

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