Hypertension Research (2010) 33, 1186–1191

& 2010 The Japanese Society of Hypertension All rights reserved 0916-9636/10 $32.00
www.nature.com/hr

ORIGINAL ARTICLE

Accuracy of a single rigid conical cuff with

standard-size bladder coupled to an automatic
oscillometric device over a wide range of arm
circumferences
Elisa Bonso, Francesca Saladini, Ada Zanier, Elisabetta Benetti, Francesca Dorigatti and Paolo Palatini

Although the upper arm has the shape of a truncated cone, cylindrical cuffs and bladders are currently used for blood pressure
(BP) measurement. The aims of this study were to describe upper arm characteristics and to test the accuracy of a standard
adult-size conical cuff coupled to an oscillometric device over a wide range of arm circumferences. Arm characteristics were
studied in 142 subjects with arm circumferences ranging from 22 to 45 cm (study 1). In a subset of 33 subjects with the same
range of arm circumferences, a rigid conical cuff with standard-size bladder (12.624.0 cm) and a rigid cylindrical cuff
(13.324.0 cm), both coupled to a Microlife BP A100 device, were tested according to the requirements of the protocol of the
European Society of Hypertension (ESH; study 2). Study 1. In all subjects, upper-arm shape was tronco-conical with slant
angles ranging from 89.51 to 82.21. In a multiple linear regression analysis, only arm circumference was an independent
predictor of conicity (Po0.001). Study 2. The rigid conical cuff passed all three phases of the ESH protocol for systolic and
diastolic BPs. Mean device-observer BP differences obtained with the conical cuff were unrelated to arm circumference. When
the rigid cylindrical cuff was used, ESH criteria were not satisfied, and the cuff overestimated systolic BPs in subjects with large
arms. BP can be measured accurately with the use of a standard-size rigid conical cuff coupled to a BP A100 device for a wide
range of arm circumferences.
Hypertension Research (2010) 33, 1186–1191; doi:10.1038/hr.2010.146; published online 5 August 2010

Keywords: blood pressure; conical; cuff; device; measurement

INTRODUCTION study the shape of the upper arm in a large sample of subjects with a
Although the upper arm has the shape of a truncated cone, cylindrical wide range of arm circumferences and to test a conical cuff potentially
(rectangular) cuffs and bladders are currently used for brachial blood suitable for the majority of the subjects. We also evaluated the
pressure (BP) measurement. However, when the arm circumference accuracy of a rigid conical cuff in comparison with a rigid cylindrical
near the shoulder is much greater than the arm circumference near the cuff, both coupled to a validated oscillometric automatic device (BP
elbow, a cylindrical cuff may challenge the ability of a health care A100 model, Bonso et al.2) in a subsample of the main group.
provider to measure BP. In such arms, the elbow end of the cuff
remains loose and may extend past the elbow in subjects with short METHODS
humerus bones. When a large-size cylindrical cuff is inflated, it will Subjects
expand irregularly over the lower part of a conical arm, making it Arm characteristics were studied in 142 subjects (of whom 74 were men) aged
impossible for a doctor to perform a reliable measurement. This 58±18 years, with mid-arm circumference ranging from 22 to 45 cm (study 1).
problem is even greater for cuffs made of rigid material, which can This study was designed with the aim of assessing the shape of the arm in a
large sample. A validation study was performed in 33 out of these 142 subjects
barely fit the distal part of a conical arm. In a previous study
with BPs within the range required by European Society of Hypertension (ESH)
performed with obese patients, a conical cuff was shown to reflect rules (study 2). In all, 28 subjects were excluded from the validation study
arterial BP more accurately than standard cylindrical cuffs.1 However, because the BP ranges were complete (n¼18), Korotkoff sounds were of poor
this problem has been overlooked in the literature, and it is not known quality (n¼4), the BP was out of range (n¼4) or there was atrial fibrillation
what shape and size an optimal cuff should have in order to fit the (n¼2). All subjects agreed to participate in the protocol and gave informed
arms of most subjects. Thus, the aims of the present study were to consent.

Department of Clinical and Experimental Medicine, University of Padova, Padua, Italy

Correspondence: Professor P Palatini, Dipartimento di Medicina Clinica e Sperimentale, Università di Padova, via Giustiniani, Padova 2-35128, Italy.
E-mail: palatini@unipd.it
Received 18 February 2010; revised 11 May 2010; accepted 17 June 2010; published online 5 August 2010
 Conical cuff and blood pressure measurement
E Bonso et al
1187

Measurements Both observers were blinded to each other’s measurement values and took
To calculate the frustum of a cone slant angle, the length of the upper arm was BP measurements with a mercury sphygmomanometer placed on the upper
measured from the axilla to the antecubital fossa, the proximal arm circum- arm. For arm circumferences p30 cm, a 1224 cm bladder was used. For arm
ference was measured just below the axilla, and the distal arm circumference circumferences 430 cm, the bladder had to cover at least 80% of the arm
was measured just above the antecubital fossa. For all measurements, subjects circumference. A series of graduated-size sphygmomanometer cuffs were used;
were placed in the supine position with arms resting comfortably at the sides each cuff was adapted for use on a limb of a size related to that cuff.2
and forearms in the pronated position. To quantify the error due to miscuffing in large arms, observer measurements
In this calculation, the limb is visualized to be in the shape of a truncated were also performed with a standard bladder (1224 cm) in the subjects with
cone. The circumferences of the extremity at the proximal and distal limits of arm circumferences 430 cm (n¼17). Sequential measurements of the same
the segment, together with the length between them, were used to calculate the arm were performed. Before starting comparative readings, the two observers
slant angle (SA, in degrees), using the formula: took a BP measurement, and the mean values were used to categorize the
participant into a low, medium or high range for both SBP and DBP, separately.
SA ¼ arccosineððC1  C2 Þ=ð2pLÞÞð360=2pÞ; Then, BP was measured with the test device by the supervisor, in order to allow
the test instrument to determine the BP characteristics of the subject. There-
where ‘C1’ is the proximal arm circumference, ‘C2’ is the distal arm circum-
after, four sequential readings were taken by observers 1 and 2 (BP1, BP3, BP5
ference and ‘L’ is the arm length. The conicity index (CI, in percent) was
and BP7), and three readings were taken by the supervisor with each of the
calculated from the formula:
two cuffs connected to the oscillometric device (BP2conical and BP2cylindrical,
BP4conical and BP4cylindrical, and BP6conical and BP6cylindrical). The conical and
CI ¼ 100ðD1  D2 Þ=L
cylindrical cuffs were tested in a crossover manner. The discrepancy between
where ‘D1’ is the proximal arm diameter, ‘D2’ is the distal arm diameter and ‘L’ the readings provided by the device coupled to each of the two cuffs and the
is the arm length. The upper-arm middle circumference was measured at the mean of observers’ measurements were allocated into three zones of accuracy,
midpoint of the distance between the acromion and the olecranon. Skinfold as suggested by ESH protocol.3 In the 17 subjects with arm circumference
thickness was measured in triplicate at the triceps and biceps with a manual 430 cm, observer measurements were also performed with a 1224 cm
caliper, and the average of the six measurements was defined as the skinfold bladder (ST) soon after the first measurements, with an appropriately sized
thickness. BP was measured with a mercury sphygmomanometer in the sitting bladder (A-S). Thus, in these subjects, the observer measurement sequence was
position. BP1AS and BP1ST, BP3AS and BP3ST, BP5AS and BP5ST, BP7AS and BP7ST.

Procedures
All procedures followed were in accordance with institutional guidelines. For Cuffs and BP device
study 1, anthropometric characteristics were measured for 142 subjects. A rigid conical cuff and a rigid cylindrical cuff, both coupled to a Microlife
Evaluation of the accuracy of the conical cuff vs. that of the cylindrical BPA100 device, were tested in this study. The cuffs were formed of a flexible
cuff (study 2) was performed according to ESH protocol, using the same 33 compliant laminate having two layers that are impermeable to air. The conical
subjects for assessment of each cuff type.3 The validation team consisted of cuff was formed with an upper, longer, arcuate edge of 28.6 cm and a lower,
three persons experienced in device validation. The two observers used for the shorter edge of 27.2 cm (Figure 1). Radial edges extended between the upper
present validation study (EB and FD) have participated in previous published and lower edges. The slant angle of the frustum of the cone corresponding to
validation studies.2,4 Devices were tested according to the suggestions of the the cuff and bladder when the cuff was encompassing a limb was 881. In the
ESH, and the agreement between these two observers was 0.7±2.1 mm Hg cylindrical cuff, both the upper and lower sides had the same length (27.0 cm).
for systolic BP (SBP) and 0.5±2.8 mm Hg for diastolic BP (DBP). The cylindrical cuff was provided with a rectangular 13.324.0 cm bladder.
123 mm

129 mm

BLADDER

240 mm

272 mm

VELCRO

CUFF

286 mm

670 mm

Figure 1 Schematic representation of a conical cuff.

Hypertension Research
 Conical cuff and blood pressure measurement
E Bonso et al
1188

The bladder for the conical cuff had a slightly arcuate upper edge and was and CI were greater in the subjects who participated in the validation
12.924.0 cm in size (Figure 1). The BPA 100 device used was an oscillometric study (Table 1).
automatic device, which has proved accurate for BP measurement at the upper The standard-size rigid conical cuff coupled to the BPA100 device
arm.2,5 This device included novel technology that performed an analysis of the passed all three phases of the ESH protocol for systolic and diastolic
oscillometric signal amplitude during cuff inflation. After this analysis, a BPs (Table 2). In contrast, when the standard-size rigid cylindrical cuff
microprocessor made an adjustment of the gain factor based on the individual
connected to the BP A100 device was tested, the requirements of the
arm characteristics for the following deflationary measurement phase.2
ESH protocol were not satisfied for SBP (Table 3). Device-observer BP
differences obtained with the cuff with conical shape are presented in
Statistical analysis
Data are presented as mean±s.d. unless specified. For comparisons, ANOVA Figure 2. Differences were unrelated to arm circumference for both
was used adjusting for age and sex. The significance of differences in categorical SBP (r¼0.21, P¼0.24) and DBP (r¼0.11, P¼0.55). In addition,
variables was assessed with the w2-test or Fisher’s exact test. Relationships when the subjects were divided into two subgroups of arm circum-
between continuous variables were assessed using Pearson’s correlation test. ference above or below the median (30.0 cm), similar device-observer
Predictors of CI and of the discrepancy between observer and device measure- differences (either with sign or in absolute values) were observed in
ments were included in linear multivariable regression analyses. A P-value
o0.05 was considered statistically significant Table 2 Validation table for the rigid conical cuff coupled to the BP
A100 device
RESULTS
Study 1 p5 mm Hg p10 mm Hg p15 mm Hg Grade
Arm characteristics were evaluated in 142 subjects (74 men) aged
Phase 1
58±18 years, with mid-arm circumferences ranging from 22 to 45 cm.
Required
The mean±s.d. SBP was 146±21 mm Hg, (range, 110–180 mm Hg),
One of 25 35 40
and the mean DBP was 90±15 mm Hg (range, 54–112 mm Hg). In all
Achieved
subjects, upper-arm shape was tronco-conical, with slant angles
SBP 31 42 45 Passed
ranging from 89.51 to 82.21 (mean, 86.2±1.61) and conicity indices
DBP 38 43 45 Passed
ranging from 1.3 to 27.6% (mean, 13.3±5.6%). The circumference
near the shoulder was always greater than the circumference near the Phase 2.1
elbow with differences ranging from 1 to 20 cm and a mean value of Required
8.7±3.8 cm. Conicity indices were similar in men and women and Two of 65 80 95
were correlated to mid-arm circumference (Po0.001), average skin- All of 60 75 90
fold thickness (Po0.001), and body weight (Po0.001), but were Achieved
unrelated to arm length. However, in a multiple linear regression SBP 66 87 96 Passed
including age, sex, BP and all anthropometric variables, only arm DBP 82 94 98 Passed
circumference independently predicted the CI (Po0.001).
Phase 2.2
Study 2 Subjects 2/3 within 5 mm Hg 0/3 within 5 mm Hg
In all, 33 subjects (19 men) with BP values within the range required Required
by ESH rules were used for the validation study. Their average SBP At least X22
was 144±21 mm Hg (range, 110–180 mm Hg), and their average DBP At most p3
was 87±15 mm Hg (range, 54–110 mm Hg). Characteristics of the 33 Achieved
subjects used for the validation study and those of the rest of the SBP 24 3 Passed
DBP 30 0 Passed
group are reported in Table 1. Demographic variables were similar in
the two groups. However, upper arm length, proximal circumference Abbreviations: BP, blood pressure; DBP, diastolic BP; SBP, systolic BP.

Table 1 Characteristics of the whole group and of the subsample used for the validation study

Variable Validation group (n¼33) Rest of group (n¼109) P-value adjusted for age and sex

Age, years 55.6±17.1 58.7±18.8 NSa

Gender (men), n (%) 19 (57.6%) 55 (50.5%) NSa
Body weight, kg 78.8±16.4 80.9±17.2 NS
Height, cm 170.3±10.5 169.6±9.3 NS
Upper arm lengthb, cm 22.3±1.7 20.5±2.5 o0.001
Arm proximal circumference, cm 39.3±6.6 35.9±6.0 0.009
Arm middle circumference, cm 31.0±4.8 31.8±5.0 NS
Arm distal circumference, cm 27.4±4.2 28.2±3.9 NS
Biceps skinfold thickness, cm 1.3±0.8 1.6±1.1 NS
Triceps skinfold thickness, cm 2.1±1.1 2.2±1.1 NS
Conicity index, % 17.1±5.8 12.1±5.0 o0.001

Abbreviation: NS, not significant.

aUnadjusted.
bMeasured from axilla to elbow.

Hypertension Research
 Conical cuff and blood pressure measurement
E Bonso et al
1189

Table 3 Device validation table for the rigid cylindrical cuff coupled Systolic blood pressure
to the BP A100 device 30
25

measurement (mmHg)
20
p5 mm Hg p10 mm Hg p15 mm Hg Grade

Device - observer
15
10
Phase 1
5
Required 0
One of 25 35 40 -5
Achieved -10
SBP 15 27 32 Failed -15
DBP 28 43 44 Passed
-20
-25
-30
Phase 2.1 80 90 100 110 120 130 140 150 160 170 180 190
Required Mean device & observer measurement (mmHg)
Two of 65 80 95
All of 60 75 90 Diastolic blood pressure
Achieved 30
25
SBP 59 78 85 Failed

measurement (mmHg)
20
DBP 61 94 98 Passed

Device - observer
15
10
Phase 2.2 5
Subjects 2/3 within 5 mm Hg 0/3 within 5 mmHg 0
Required -5
-10
At least X22
-15
At most p3 -20
Achieved -25
SBP 21 7 Failed -30
30 40 50 60 70 80 90 100 110 120 130 140
DBP 23 1 Passed
Mean device & observer measurement (mmHg)
Abbreviations: BP, blood pressure; DBP, diastolic BP; SBP, systolic BP.
Figure 2 Plots of systolic (upper plot) and diastolic (lower plot) BP A100-
observer blood pressure differences obtained with the rigid conical cuff. The
x axis represents the mean of device and observer measurements. The y axis
the two groups (Table 4). However, when the rigid cylindrical cuff was represents the difference between the device and observer measurements.
tested, a marked overestimation of SBP was observed in the subjects A positive value indicates that the device measurement was greater than the
with arm circumference 430 cm (Table 4). The device-observer observer measurement.
discrepancies differed significantly according to arm size for DBP as
well, but there was not a clear tendency for the device to overestimate ple regression analysis, only arm circumference remained an indepen-
DBP in the group with larger arms. dent predictor of the CI.
In a multiple linear regression, both systolic and diastolic device- The conical shape of the upper arm often challenges the ability of
observer BP differences obtained with the rigid conical cuff were the health care personnel to measure BP accurately. In fact, the use of a
unrelated to age, sex, BP, body height and weight, arm length and cylindrical cuff on large arms may cause an overestimation of the true
circumference, skinfold thickness and arm CI (Figure 3). Systolic and BP, as shown many years ago by Maxwell et al.1 with the auscultatory
diastolic device-observer BP differences obtained with the rigid method in a general population. Using a conical cuff, these authors
cylindrical cuff were closely correlated to arm circumference obtained lower SBP and DBP readings compared with those obtained
(Po0.001), skinfold thickness (Po0.001) and CI (Po0.001, Figure 4). with a cylindrical cuff in obese individuals. This discrepancy was
In multiple regression analyses, independent predictors of the SBP attributed to the fact that the conical cuff fits better on larger upper
device-observer differences obtained with the rigid cylindrical cuff arms than the cylindrical cuff. BP measurement with a cuff of the
included male gender (P¼0.001), CI (P¼0.001), skinfold thickness appropriate size is particularly difficult in obese subjects with short
(P¼0.028) and arm length in an inverse manner (P¼0.020). Inde- humerus bones. In such arms, the elbow end of a thigh-sized cuff may
pendent predictors of the DBP device-observer difference included extend past the elbow by several centimeters. These problems are
male gender (P¼0.005) and CI (Po0.001). In the 17 subjects with clearly greater when cuffs made of rigid material are used.6 Typically, a
arm circumferences 430 cm, the auscultatory BP measurement per- user (who may be the patient, if the patient is taking his or her own
formed by the observers with the standard-size cuff overestimated BP) will wrap the cuff, using his or her own tactile sense to gauge the
systolic and diastolic BPs taken with the appropriate-size cuffs by amount of tension applied to the cuff, often resulting in improper
15.0±8.9 mm Hg and 14.5±7.4 mm Hg, respectively. wrapping of the cuff. Improper cuff tension will result in an incorrect
BP measurement. If too little tension is provided, too much air must
DISCUSSION be pumped into the bladder and the measurement cycle may be
Our results show that the upper arm shape was tronco-conical in all unnecessarily long, resulting in an inaccurate measurement. If too
subjects investigated, with the circumference near the shoulder being much tension is provided, the blood vessels in the arm may be
greater than the circumference near the elbow. The difference between compressed before the bladder being inflated, also resulting in an
the circumferences ranged from 1 to 20 cm, with an average value of inaccurate measurement. Therefore, there exists a need for a cuff that a
8.7 cm. The conical shape of the arm was closely correlated to the user can apply while being assured that the proper amount of tension
degree of obesity and arm circumference. However, in a linear multi- is being used for its placement. A solution may be achieved with the

Hypertension Research
 Conical cuff and blood pressure measurement
E Bonso et al
1190

Table 4 Device-observer blood pressure differences with sign or without sign in the whole validation group and in the patients divided
according to whether their arm circumference was below (p30 cm) or above (430 cm) the median in the group

Conical cuff coupled to the BP A100 device

All p30 cm (n¼16) 430 cm (n¼17) P-value

Arm circumference 32.3±5.6 27.2±2.0 37.0±3.4 —

SBP difference with sign (mm Hg) 0.9±6.5 1.3±5.3 0.1±4.6 NS
DBP difference with sign (mm Hg) 0.5±4.6 1.2±3.7 0.3±4.4 NS
SBP difference without sign (mm Hg) 4.8±4.4 4.7±4.8 4.9±4.6 NS
DBP difference without sign (mm Hg) 3.3±3.2 3.6±2.7 3.0±2.9 NS

Cylindrical cuff coupled to the BP A100 device

All p30 cm (n¼16) 430 cm (n¼17) P-value

SBP difference with sign (mm Hg) 3.8±8.5 0.5±5.4 7.9±8.9 o0.001
DBP difference with sign (mm Hg) 0.1±5.9 2.1±5.3 1.8±5.9 0.001
SBP difference without sign (mm Hg) 6.8±6.3 4.1±3.6 9.4±7.2 o0.001
DBP difference without sign (mm Hg) 4.8±3.4 4.6±3.3 5.0±3.5 NS

Abbreviation: NS, not significant.

SBP and DBP indicate systolic and diastolic blood pressure in mm Hg.

Systolic blood pressure Systolic blood pressure

30 30
25 25
measurement (mmHg)
measurement (mmHg)

20 20 R=0.52
Device - observer
Device - observer

15 15 P<0.001
10 10
5 5
0 0
-5 -5
-10 -10
-15 R=0.12 -15
-20 P=n.s. -20
-25 -25
-30 -30
0 5 10 15 20 25 30 0 5 10 15 20 25 30
Conicity Index (%) Conicity Index (%)

Diastolic blood pressure Diastolic blood pressure

30 30
25 25
measurement (mmHg)
measurement (mmHg)

20 20 R=0.54
Device - observer
Device - observer

15 15 P<0.001
10 10
5 5
0 0
-5 -5
-10 -10
-15 R=-0.21 -15
-20 P=n.s. -20
-25 -25
-30 -30
0 5 10 15 20 25 30 0 5 10 15 20 25 30
Conicity Index (%) Conicity Index (%)

Figure 3 Plots of the systolic (upper plot) and diastolic (lower plot) BP Figure 4 Plots of the systolic (upper plot) and diastolic (lower plot) BP
A100-observer blood pressure differences obtained with the rigid conical A100-observer blood pressure differences obtained with the rigid cylindrical
cuff. The x axis represents the conicity index. The y axis represents the cuff. The x axis represents the conicity index. The y axis represents the
difference between the device and observer measurements. A positive value difference between the device and observer measurements. A positive value
indicates that the device measurement was greater than the observer indicates that the device measurement was greater than the observer
measurement. Systolic and diastolic blood pressure differences were measurement. Systolic and diastolic blood pressure differences were
unrelated to conicity index. correlated with the conicity index.

use of rigid cuffs, for which the amount of tension may be pre-set by tissue overlying the artery. This condition can be frequently encoun-
the manufacturer to conform to the amount of tension required for tered in subjects with large arms (for whom large-size cuffs should be
accurate BP measurement. However, a rigid cylindrical cuff cannot used) and can be an important source of measurement errors,
exert a uniform pressure on a conical arm, because the distal part will particularly in men with muscular arms.7 Indeed, in the present
remain loose and will transmit a lower pressure to the subcutaneous study, male gender was a significant predictor of the device-observer

Hypertension Research
 Conical cuff and blood pressure measurement
E Bonso et al
1191

BP discrepancy observed with the use of the cylindrical cuff, which 2 Bonso E, Dorigatti F, Palatini P. Accuracy of the BP A100 blood pressure measuring
may be because of the effect of bulging bicep muscles in individuals device coupled with a single cuff with standard-size bladder over a wide range of arm
circumferences. Blood Press Monit 2009; 14: 216–219.
whose arms have highly muscular compositions. 3 O’Brien E, Pickering T, Asmar R, Myers M, Parati G, Staessen J, Mengden T, Imai Y,
Today, standard-size cuffs are available that, when coupled to Waeber B, Palatini P, Gerin W. Working Group on Blood Pressure Monitoring of the
European Society of Hypertension. European Society of Hypertension International
oscillometric devices, can provide accurate measurements over protocol for validation of blood pressure measuring devices in adults. Blood Press Monit
a wide range of arm circumferences, up to 40 cm and higher.2,8 2002; 7: 3–17.
It should be noted that the present recommendations for cuff size 4 Bonso E, Dorigatti F, Palatini P. Validation of Panasonic EW3106 and EW3109 devices
for blood pressure measurement according to the International Protocol. Blood Press
with relation to arm circumference apply to the auscultatory method, Monit 2010; 15: 55–58.
whereas little is known about the relationship between cuff size and 5 Stergiou GS, Giovas PP, Neofytou MS, Adamopoulos DN. Validation of the Microlife
performance for oscillometric devices. Some oscillometric devices are BPA100 Plus device for self-home blood pressure measurement according to the
International Protocol. Blood Press Monit 2006; 11: 157–160.
provided along with software that performs an analysis of the 6 Evans CE, Haynes RB, Goldsmith CH, Hewson SA. Home blood pressure-measuring
measurement signal during cuff inflation and, subsequently, adjusts devices: a comparative study of accuracy. J Hypertension 1989; 7: 133–142.
7 Fonseca-Reyes S, Fajardo-Flores I, Montes-Casillas M, Forsyth-MacQuarrie A. Differ-
the device parameters based on the characteristics of the individual ences and effects of medium and large adult cuffs on blood pressure readings in
arm being measured for the following deflationary phase.2,8 These individuals with muscular arms. Blood Press Monit 2009; 14: 166–171.
devices have been shown to provide reliable BP readings when coupled 8 Stergiou GS, Tzamouranis D, Nasothimiou EG, Protogerou AD. Can an electronic device
with a single cuff be accurate in a wide range of arm size? Validation of the Visomat
to cuffs of standard size as well, but such cuffs are considered Comfort 20/40 device for home blood pressure monitoring. J Hum Hypertens 2008; 22:
inappropriate for measuring BP with traditional sphygmomanometry 796–800.
in subjects with arm circumference 432 cm.9,10 However, if a rigid 9 Hussain A, Cox JG. An audit of the use of sphygmomanometers. Br J Clin Pract 1996;
50: 136–137.
cylindrical cuff is used these devices may also provide inaccurate 10 Villegas I, Arias IC, Botero A, Escobar A. Evaluation of the technique used by health-
readings when used in large-size conical arms because of the afore- care workers for taking blood pressure. Hypertension 1995; 26: 1204–1206.
11 O’Brien E. Review: a century of confusion; which bladder for accurate blood pressure
mentioned reasons. In the present study, when the rigid cylindrical measurement? J Hum Hypertens 1996; 10: 565–572.
cuff was used in combination with the BP A100 monitor, the device 12 Alpert BS. Cuff width and accuracy of measurement of blood pressure. Blood Press
performed better than the auscultatory method, especially for DBP. Monit 2000; 5: 151–152.
13 McKay DW, Campbell NR, Parab LS, Chockalingam A, Fodor JG. Clinical assessment of
However, this combination clearly overestimated SBP in the group of blood pressure. J Hum Hypertens 1990; 4: 639–645.
subjects with mid-point arm circumferences 430 cm. In contrast, 14 Stergiou GS, Malakos JS, Voutsa AV, Achimastos AD, Mountokalakis TD. Home
when the conical cuff was used, the device provided accurate readings, monitoring of blood pressure: limited value in general practice. J Hum Hypertens
1996; 10: 219–232.
with similar device-observer differences in the group with standard
arm sizes and the group with large arms, and comfortably passed APPENDIX
phases 1 and 2 of the ESH protocol. In this appendix, basic information about the Microlife BP A100 is
Although choice of appropriate cuff is a key element for obtaining reported.
an accurate BP measurement,11–13 data from the literature indicate Device identification:
that arm size is not taken into account by patients performing home Microlife BP A100
BP monitoring and even by some health care professionals.11,14 Microlife AG, Espenstrasse 139, CH 9443, Widnau, Switzerland.
The use of a single cuff able to measure BP accurately over a wide This device is a fully automatic, upper-arm type blood pressure
range of arm circumferences, would thus improve the accuracy of BP monitor. Its measurement range spreads over 30–280 mmHg for BP.
measurement. The present results obtained with the BP A100 monitor The applied rigid conical cuff is suitable for arm circumferences
coupled to a standard size rigid conical cuff show that this equipment ranging from 22.0 to 44.0 cm.
can measure BP accurately in subjects with arm circumferences ranging Thirty data memory. PAD: Pulse arrhythmia detection during
from 22 to 44 cm. The results further emphasize the importance of measurement.
using a conical cuff in subjects with large arms, at least when the non- Method of BP measurement:
stretch bag surrounding the bladder is constructed of rigid material. Oscillometric, corresponding to the Korotkoff method: phase I
systolic, phase V diastolic.
ACKNOWLEDGEMENTS Factors affecting accuracy: movement artifacts, arrhythmias
This work was funded by a grant from Microlife AG, Espenstrasse 139, CH Validation studies:
9443, Widnau, Switzerland and by the University of Padova, Padua, Italy. EN 1060-4: 2004, ANSI/AAMI SP10:2002/(R)2008+Amendments
Service facilities:
Microlife distributors—refer to www.microlife.com or Microlife
1 Maxwell GF, Pruijt JF, Arntzenius AC. Comparison of the conical cuff and the standard European Headquarter: Microlife AG, Espenstrasse 139, CH 9443,
rectangular cuffs. Int J Epidemiol 1985; 14: 468–472. Widnau, Switzerland.

Hypertension Research