Author: Paolo Spriano
Medscape Medical News
This article reviews the accuracy of blood pressure (BP) measurement, emphasizing sex differences and the impact of cuff size and arm anatomy. While the Riva-Rocci-Korotkoff method remains the gold standard, modern practice largely relies on automated oscillometric cuff devices, which introduce potential errors.
Recent findings show that automated systolic BP readings tend to underestimate true intra-arterial BP values, particularly in women. The underestimation is most pronounced with larger cuff sizes, reaching -6.4 mm Hg in women with extra-large cuffs compared to -2.4 mm Hg in men. Anatomical differences in arm shape—especially variation between proximal and distal arm circumference—contribute to poor cuff fit and inaccurate readings. As cuff size increases, agreement between automated and manual BP classifications declines, potentially leading to misdiagnosis and undertreatment of hypertension.
What You Should Know
• Automated BP devices systematically underestimate systolic BP in women compared to men.
• The error worsens with increasing cuff size, particularly in women.
• Arm shape and adiposity influence accuracy, especially with extra-large cuffs.
• Reduced agreement between automated and manual BP readings may affect hypertension classification.
Practice Implication
Clinicians should be aware that women, especially those requiring larger cuffs, are at higher risk for underestimation of BP by automated devices. This may contribute to missed or undertreated hypertension and could partially explain sex disparities in cardiovascular outcomes. Careful cuff selection, validation of automated devices against manual methods, and consideration of anatomical factors are essential to ensure accurate diagnosis and treatment.
References
Spriano P. August 04, 2025.
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