Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Ambulatory and home blood pressure monitoring and white coat hypertension in adults

Norman M Kaplan, MD
Raymond R Townsend, MD
Section Editors
George L Bakris, MD
Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
Deputy Editor
John P Forman, MD, MSc


Ambulatory blood pressure monitoring (ABPM) is becoming increasingly recommended for routine clinical practice [1,2]. It may be particularly useful in evaluating the patient with variable blood pressure readings in the office or in the patient with wide discrepancies between the blood pressure readings at home and at the clinician's office (ie, "white coat" hypertension). ABPM and, in particular, nocturnal blood pressure readings may also provide prognostic data [3].

This topic provides an overview of ABPM, white coat hypertension, indications for ABPM, and the utility of ABPM in clinical practice. An overview of issues related to hypertension and the initial evaluation of hypertensive patients is presented separately. (See "Overview of hypertension in adults" and "Initial evaluation of the hypertensive adult".)


In accordance with published practice guidelines and expert panel recommendations, ambulatory blood pressure monitoring (ABPM) can be used in the following circumstances [4-6]:

Suspected white coat hypertension

Suspected episodic hypertension (eg, pheochromocytoma)


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Oct 13, 2015.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Pickering TG, Miller NH, Ogedegbe G, et al. Call to action on use and reimbursement for home blood pressure monitoring: executive summary: a joint scientific statement from the American Heart Association, American Society Of Hypertension, and Preventive Cardiovascular Nurses Association. Hypertension 2008; 52:1.
  2. Head GA, Mihailidou AS, Duggan KA, et al. Definition of ambulatory blood pressure targets for diagnosis and treatment of hypertension in relation to clinic blood pressure: prospective cohort study. BMJ 2010; 340:c1104.
  3. Fan HQ, Li Y, Thijs L, et al. Prognostic value of isolated nocturnal hypertension on ambulatory measurement in 8711 individuals from 10 populations. J Hypertens 2010; 28:2036.
  4. Hemmelgarn BR, McAllister FA, Myers MG, et al. The 2005 Canadian Hypertension Education Program recommendations for the management of hypertension: part 1- blood pressure measurement, diagnosis and assessment of risk. Can J Cardiol 2005; 21:645.
  5. Weber MA, Schiffrin EL, White WB, et al. Clinical practice guidelines for the management of hypertension in the community a statement by the American Society of Hypertension and the International Society of Hypertension. J Hypertens 2014; 32:3.
  6. Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens 2013; 31:1281.
  7. Piper MA, Evans CV, Burda BU, et al. Diagnostic and predictive accuracy of blood pressure screening methods with consideration of rescreening intervals: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med 2015; 162:192.
  8. O'Brien E, Asmar R, Beilin L, et al. Practice guidelines of the European Society of Hypertension for clinic, ambulatory and self blood pressure measurement. J Hypertens 2005; 23:697.
  9. Mancia G, De Backer G, Dominiczak A, et al. 2007 Guidelines for the Management of Arterial Hypertension: The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens 2007; 25:1105.
  10. Pickering TG, Shimbo D, Haas D. Ambulatory blood-pressure monitoring. N Engl J Med 2006; 354:2368.
  11. Staessen JA, Fagard RH, Lijnen PJ, et al. Mean and range of the ambulatory pressure in normotensive subjects from a meta-analysis of 23 studies. Am J Cardiol 1991; 67:723.
  12. White WB, Dey HM, Schulman P. Assessment of the daily blood pressure load as a determinant of cardiac function in patients with mild-to-moderate hypertension. Am Heart J 1989; 118:782.
  13. Zachariah PK, Sheps SG, Bailey KR, et al. Age-related characteristics of ambulatory blood pressure load and mean blood pressure in normotensive subjects. JAMA 1991; 265:1414.
  14. Vasan RS, Beiser A, Seshadri S, et al. Residual lifetime risk for developing hypertension in middle-aged women and men: The Framingham Heart Study. JAMA 2002; 287:1003.
  15. Staessen JA, Bieniaszewski L, O'Brien E, et al. Nocturnal blood pressure fall on ambulatory monitoring in a large international database. The "Ad Hoc' Working Group. Hypertension 1997; 29:30.
  16. Andersen MJ, Khawandi W, Agarwal R. Home blood pressure monitoring in CKD. Am J Kidney Dis 2005; 45:994.
  17. Fujii T, Uzu T, Nishimura M, et al. Circadian rhythm of natriuresis is disturbed in nondipper type of essential hypertension. Am J Kidney Dis 1999; 33:29.
  18. Gatzka CD, Schobel HP, Klingbeil AU, et al. Normalization of circadian blood pressure profiles after renal transplantation. Transplantation 1995; 59:1270.
  19. Hansen TW, Jeppesen J, Rasmussen S, et al. Ambulatory blood pressure and mortality: a population-based study. Hypertension 2005; 45:499.
  20. Dolan E, Stanton A, Thijs L, et al. Superiority of ambulatory over clinic blood pressure measurement in predicting mortality: the Dublin outcome study. Hypertension 2005; 46:156.
  21. White WB. Relating cardiovascular risk to out-of-office blood pressure and the importance of controlling blood pressure 24 hours a day. Am J Med 2008; 121:S2.
  22. Salles GF, Leite NC, Pereira BB, et al. Prognostic impact of clinic and ambulatory blood pressure components in high-risk type 2 diabetic patients: the Rio de Janeiro Type 2 Diabetes Cohort Study. J Hypertens 2013; 31:2176.
  23. Fagard RH, Staessen JA, Thijs L. Prediction of cardiac structure and function by repeated clinic and ambulatory blood pressure. Hypertension 1997; 29:22.
  24. Campbell NR, Culleton BW, McKay DW. Misclassification of blood pressure by usual measurement in ambulatory physician practices. Am J Hypertens 2005; 18:1522.
  25. Stergiou GS, Tzamouranis D, Nasothimiou EG, et al. Are there really differences between home and daytime ambulatory blood pressure? Comparison using a novel dual-mode ambulatory and home monitor. J Hum Hypertens 2010; 24:207.
  26. Myers MG, Godwin M, Dawes M, et al. Measurement of blood pressure in the office: recognizing the problem and proposing the solution. Hypertension 2010; 55:195.
  27. Clement DL, De Buyzere ML, De Bacquer DA, et al. Prognostic value of ambulatory blood-pressure recordings in patients with treated hypertension. N Engl J Med 2003; 348:2407.
  28. Redon J, Campos C, Narciso ML, et al. Prognostic value of ambulatory blood pressure monitoring in refractory hypertension: a prospective study. Hypertension 1998; 31:712.
  29. Salles GF, Cardoso CR, Muxfeldt ES. Prognostic influence of office and ambulatory blood pressures in resistant hypertension. Arch Intern Med 2008; 168:2340.
  30. Muxfeldt ES, Cardoso CR, Salles GF. Prognostic value of nocturnal blood pressure reduction in resistant hypertension. Arch Intern Med 2009; 169:874.
  31. Agarwal R, Andersen MJ. Prognostic importance of ambulatory blood pressure recordings in patients with chronic kidney disease. Kidney Int 2006; 69:1175.
  32. Minutolo R, Agarwal R, Borrelli S, et al. Prognostic role of ambulatory blood pressure measurement in patients with nondialysis chronic kidney disease. Arch Intern Med 2011; 171:1090.
  33. Pickering TG, Davidson K, Gerin W, Schwartz JE. Masked hypertension. Hypertension 2002; 40:795.
  34. Mallion JM, Clerson P, Bobrie G, et al. Predictive factors for masked hypertension within a population of controlled hypertensives. J Hypertens 2006; 24:2365.
  35. Pierdomenico SD, Cuccurullo F. Prognostic value of white-coat and masked hypertension diagnosed by ambulatory monitoring in initially untreated subjects: an updated meta analysis. Am J Hypertens 2011; 24:52.
  36. Hänninen MR, Niiranen TJ, Puukka PJ, et al. Target organ damage and masked hypertension in the general population: the Finn-Home study. J Hypertens 2013; 31:1136.
  37. Fagard RH, Cornelissen VA. Incidence of cardiovascular events in white-coat, masked and sustained hypertension versus true normotension: a meta-analysis. J Hypertens 2007; 25:2193.
  38. Björklund K, Lind L, Zethelius B, et al. Isolated ambulatory hypertension predicts cardiovascular morbidity in elderly men. Circulation 2003; 107:1297.
  39. Bobrie G, Chatellier G, Genes N, et al. Cardiovascular prognosis of "masked hypertension" detected by blood pressure self-measurement in elderly treated hypertensive patients. JAMA 2004; 291:1342.
  40. Ohkubo T, Kikuya M, Metoki H, et al. Prognosis of "masked" hypertension and "white-coat" hypertension detected by 24-h ambulatory blood pressure monitoring 10-year follow-up from the Ohasama study. J Am Coll Cardiol 2005; 46:508.
  41. Boggia J, Li Y, Thijs L, et al. Prognostic accuracy of day versus night ambulatory blood pressure: a cohort study. Lancet 2007; 370:1219.
  42. Ben-Dov IZ, Kark JD, Ben-Ishay D, et al. Predictors of all-cause mortality in clinical ambulatory monitoring: unique aspects of blood pressure during sleep. Hypertension 2007; 49:1235.
  43. Verdecchia P, Schillaci G, Gatteschi C, et al. Blunted nocturnal fall in blood pressure in hypertensive women with future cardiovascular morbid events. Circulation 1993; 88:986.
  44. Tsivgoulis G, Vemmos KN, Zakopoulos N, et al. Association of blunted nocturnal blood pressure dip with intracerebral hemorrhage. Blood Press Monit 2005; 10:189.
  45. Metoki H, Ohkubo T, Kikuya M, et al. Prognostic significance for stroke of a morning pressor surge and a nocturnal blood pressure decline: the Ohasama study. Hypertension 2006; 47:149.
  46. Ingelsson E, Björklund-Bodegård K, Lind L, et al. Diurnal blood pressure pattern and risk of congestive heart failure. JAMA 2006; 295:2859.
  47. Kario K, Pickering TG, Umeda Y, et al. Morning surge in blood pressure as a predictor of silent and clinical cerebrovascular disease in elderly hypertensives: a prospective study. Circulation 2003; 107:1401.
  48. Lurbe E, Redon J, Kesani A, et al. Increase in nocturnal blood pressure and progression to microalbuminuria in type 1 diabetes. N Engl J Med 2002; 347:797.
  49. Vörös P, Lengyel Z, Nagy V, et al. Diurnal blood pressure variation and albuminuria in normotensive patients with insulin-dependent diabetes mellitus. Nephrol Dial Transplant 1998; 13:2257.
  50. Davidson MB, Hix JK, Vidt DG, Brotman DJ. Association of impaired diurnal blood pressure variation with a subsequent decline in glomerular filtration rate. Arch Intern Med 2006; 166:846.
  51. Mancia G, Parati G, Pomidossi G, et al. Alerting reaction and rise in blood pressure during measurement by physician and nurse. Hypertension 1987; 9:209.
  52. Myers MG, Godwin M. Automated office blood pressure. Can J Cardiol 2012; 28:341.
  53. Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003; 289:2560.
  54. Watson RD, Lumb R, Young MA, et al. Variation in cuff blood pressure in untreated outpatients with mild hypertension--implications for initiating antihypertensive treatment. J Hypertens 1987; 5:207.
  55. Pickering TG, James GD, Boddie C, et al. How common is white coat hypertension? JAMA 1988; 259:225.
  56. Niiranen TJ, Jula AM, Kantola IM, Reunanen A. Prevalence and determinants of isolated clinic hypertension in the Finnish population: the Finn-HOME study. J Hypertens 2006; 24:463.
  57. Mancia G, Bombelli M, Brambilla G, et al. Long-term prognostic value of white coat hypertension: an insight from diagnostic use of both ambulatory and home blood pressure measurements. Hypertension 2013; 62:168.
  58. Muxfeldt ES, Bloch KV, Nogueira Ada R, Salles GF. True resistant hypertension: is it possible to be recognized in the office? Am J Hypertens 2005; 18:1534.
  59. Verdecchia P, Palatini P, Schillaci G, et al. Independent predictors of isolated clinic ('white-coat') hypertension. J Hypertens 2001; 19:1015.
  60. Khattar RS, Senior R, Lahiri A. Cardiovascular outcome in white-coat versus sustained mild hypertension: a 10-year follow-up study. Circulation 1998; 98:1892.
  61. Verdecchia P, Reboldi GP, Angeli F, et al. Short- and long-term incidence of stroke in white-coat hypertension. Hypertension 2005; 45:203.
  62. Verdecchia P, Porcellati C, Schillaci G, et al. Ambulatory blood pressure. An independent predictor of prognosis in essential hypertension. Hypertension 1994; 24:793.
  63. Muscholl MW, Hense HW, Bröckel U, et al. Changes in left ventricular structure and function in patients with white coat hypertension: cross sectional survey. BMJ 1998; 317:565.
  64. Palatini P, Mormino P, Santonastaso M, et al. Target-organ damage in stage I hypertensive subjects with white coat and sustained hypertension: results from the HARVEST study. Hypertension 1998; 31:57.
  65. Cavallini MC, Roman MJ, Pickering TG, et al. Is white coat hypertension associated with arterial disease or left ventricular hypertrophy? Hypertension 1995; 26:413.
  66. Bidlingmeyer I, Burnier M, Bidlingmeyer M, et al. Isolated office hypertension: a prehypertensive state? J Hypertens 1996; 14:327.
  67. Grin JM, McCabe EJ, White WB. Management of hypertension after ambulatory blood pressure monitoring. Ann Intern Med 1993; 118:833.
  68. Muller JE, Abela GS, Nesto RW, Tofler GH. Triggers, acute risk factors and vulnerable plaques: the lexicon of a new frontier. J Am Coll Cardiol 1994; 23:809.
  69. Li Y, Thijs L, Hansen TW, et al. Prognostic value of the morning blood pressure surge in 5645 subjects from 8 populations. Hypertension 2010; 55:1040.
  70. Neutel JM, Schnaper H, Cheung DG, et al. Antihypertensive effects of beta-blockers administered once daily: 24-hour measurements. Am Heart J 1990; 120:166.
  71. Meredith PA, Donnelly R, Elliott HL, et al. Prediction of the antihypertensive response to enalapril. J Hypertens 1990; 8:1085.
  72. Kario K. Time for focus on morning hypertension: pitfall of current antihypertensive medication. Am J Hypertens 2005; 18:149.
  73. Hermida RC, Calvo C, Ayala DE, et al. Treatment of non-dipper hypertension with bedtime administration of valsartan. J Hypertens 2005; 23:1913.
  74. Staessen JA, Byttebier G, Buntinx F, et al. Antihypertensive treatment based on conventional or ambulatory blood pressure measurement. A randomized controlled trial. Ambulatory Blood Pressure Monitoring and Treatment of Hypertension Investigators. JAMA 1997; 278:1065.
  75. Krakoff LR, Eison H, Phillips RH, et al. Effect of ambulatory blood pressure monitoring on the diagnosis and cost of treatment for mild hypertension. Am Heart J 1988; 116:1152.
  76. Krakoff LR. Cost-effectiveness of ambulatory blood pressure: a reanalysis. Hypertension 2006; 47:29.
  77. Rickerby J. The role of home blood pressure measurement in managing hypertension: an evidence-based review. J Hum Hypertens 2002; 16:469.
  78. Kleinert HD, Harshfield GA, Pickering TG, et al. What is the value of home blood pressure measurement in patients with mild hypertension? Hypertension 1984; 6:574.
  79. Verberk WJ, Kroon AA, Kessels AG, de Leeuw PW. Home blood pressure measurement: a systematic review. J Am Coll Cardiol 2005; 46:743.
  80. Asayama K, Ohkubo T, Kikuya M, et al. Prediction of stroke by self-measurement of blood pressure at home versus casual screening blood pressure measurement in relation to the Joint National Committee 7 classification: the Ohasama study. Stroke 2004; 35:2356.
  81. Niiranen TJ, Hänninen MR, Johansson J, et al. Home-measured blood pressure is a stronger predictor of cardiovascular risk than office blood pressure: the Finn-Home study. Hypertension 2010; 55:1346.
  82. Uhlig K, Patel K, Ip S, et al. Self-measured blood pressure monitoring in the management of hypertension: a systematic review and meta-analysis. Ann Intern Med 2013; 159:185.
  83. Agarwal R, Bills JE, Hecht TJ, Light RP. Role of home blood pressure monitoring in overcoming therapeutic inertia and improving hypertension control: a systematic review and meta-analysis. Hypertension 2011; 57:29.
  84. Cappuccio FP, Kerry SM, Forbes L, Donald A. Blood pressure control by home monitoring: meta-analysis of randomised trials. BMJ 2004; 329:145.
  85. Bosworth HB, Olsen MK, Grubber JM, et al. Two self-management interventions to improve hypertension control: a randomized trial. Ann Intern Med 2009; 151:687.
  86. McManus RJ, Mant J, Haque MS, et al. Effect of self-monitoring and medication self-titration on systolic blood pressure in hypertensive patients at high risk of cardiovascular disease: the TASMIN-SR randomized clinical trial. JAMA 2014; 312:799.
  87. Margolis KL, Asche SE, Bergdall AR, et al. Effect of home blood pressure telemonitoring and pharmacist management on blood pressure control: a cluster randomized clinical trial. JAMA 2013; 310:46.
  88. McManus RJ, Mant J, Bray EP, et al. Telemonitoring and self-management in the control of hypertension (TASMINH2): a randomised controlled trial. Lancet 2010; 376:163.
  89. Yi SS, Tabaei BP, Angell SY, et al. Self-blood pressure monitoring in an urban, ethnically diverse population: a randomized clinical trial utilizing the electronic health record. Circ Cardiovasc Qual Outcomes 2015; 8:138.
  90. Hebert PL, Sisk JE, Tuzzio L, et al. Nurse-led disease management for hypertension control in a diverse urban community: a randomized trial. J Gen Intern Med 2012; 27:630.
  91. Parati G, Pickering TG. Home blood-pressure monitoring: US and European consensus. Lancet 2009; 373:876.
  92. Stergiou GS, Skeva II, Baibas NM, et al. Diagnosis of hypertension using home or ambulatory blood pressure monitoring: comparison with the conventional strategy based on repeated clinic blood pressure measurements. J Hypertens 2000; 18:1745.
  93. Parati G, Stergiou GS, Asmar R, et al. European Society of Hypertension guidelines for blood pressure monitoring at home: a summary report of the Second International Consensus Conference on Home Blood Pressure Monitoring. J Hypertens 2008; 26:1505.
  94. Parati G, Stergiou GS, Asmar R, et al. European Society of Hypertension practice guidelines for home blood pressure monitoring. J Hum Hypertens 2010; 24:779.
  95. Niiranen TJ, Johansson JK, Reunanen A, Jula AM. Optimal schedule for home blood pressure measurement based on prognostic data: the Finn-Home Study. Hypertension 2011; 57:1081.
  96. Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J 2013; 34:2159.
  97. Mengden T, Hernandez Medina RM, Beltran B, et al. Reliability of reporting self-measured blood pressure values by hypertensive patients. Am J Hypertens 1998; 11:1413.
  98. Asmar R, Zanchetti A. Guidelines for the use of self-blood pressure monitoring: a summary report of the First International Consensus Conference. Groupe Evaluation & Measure of the French Society of Hypertension. J Hypertens 2000; 18:493.
  99. Beevers G, Lip GY, O'Brien E. ABC of hypertension: Blood pressure measurement. Part II-conventional sphygmomanometry: technique of auscultatory blood pressure measurement. BMJ 2001; 322:1043.
  100. Pickering TG. The influence of daily activity on ambulatory blood pressure. Am Heart J 1988; 116:1141.