Table 1.

Suggested Arm Positions (If Any) According to Clinical Hypertension Guidelines for ABPM

Author, Year (Reference)	Recommended Arm Position	Comments
Fourth International Consensus Conference on 24‐Hour Ambulatory Blood Pressure Monitoring, 199512	“Measurement error caused by the position of the upper arm may be prevented during the day by asking subjects to ensure that the arm is always parallel to the trunk when the cuff is inflated. However, this is not feasible at night.”	This statement directly addressed the issue of arm position. However, the advice has not been consistently integrated into guidelines. The failure of subsequent guidelines to incorporate this recommendation may reflect concerns about hydrostatic pressure. The position differs from that promulgated for seated measurements by most authorities, thus producing a measured blood pressure (BP) differentially perturbed by hydrostatic pressure. Nonetheless, this remains the most practical, and likely the most reproducible, arm position.
British Hypertension Society 200027	“Instruct patients • to keep their arm steady during measurement • to keep their arm at heart level during measurement”	Patients and physicians may be unsure whether this recommendation is better achieved with a relaxed or fully extended arm (neither of which is consistent with the usual interpretation of “at heart level”). The location of “heart level” is not specified.
Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), 200328	No recommendation regarding arm position in ambulatory BP monitoring (ABPM).	This lack of advice may lead to the adoption of widely varying arm positions in clinical practice.
European Society of Hypertension, 200329	“It is essential, therefore, for the arm to be supported during blood pressure measurement, especially when the individual is in the standing position, and this is best achieved in practice by having the observer hold the person's arm at the elbow, although in research the use of an arm support on a stand has much to commend it.” “Posture affects blood pressure, with a general tendency for it to decrease from the lying to sitting or standing position. However, in most people posture is unlikely to lead to significant error in blood pressure measurement, provided the arm is supported at heart level.” “The forearm must also be at the level of the heart as denoted by the mid‐sternal level. Dependency of the arm below heart level leads to an overestimation of systolic and diastolic pressures and raising the arm above heart level leads to underestimation. The magnitude of this error can be as great as 10 mm Hg for systolic and diastolic readings. This source of error becomes especially important for the sitting and standing positions, when the arm is likely to be dependent by the individual's side.” “The key to successful ABPM is educating the patient on the process of monitoring and the instructions should be explained and printed on a diary card.” The instructions described are: • “Give patient written instructions and a diary card • Instruct patient how to remove and inactivate monitor after 24 h”	The authors make several comments on arm position in BP measurement. The comments center on the importance of keeping the forearm at heart level and the error introduced by allowing dependency of the arm, especially during standing. The authors acknowledge the importance of patient instructions in ABPM but do not specify the instructions. No comment on arm position specifically during ABPM is made, but the comments on arm position during BP measurement in general state that the arm should not be in the dependent position. We agree that the BP measured with the arm in the dependent position will be higher compared with BP measured when the arm is at the level of the heart. Yet, we believe that this shortcoming is outweighed by the convenience and patient‐oriented nature of the instruction we have proposed, since even healthcare providers may disagree about the meaning of “heart level.”
British Hypertension Society guidelines, 200430	Arm position in clinic BP measurement is described. However, no advice is offered regarding arm position in ambulatory BP monitoring.	This lack of advice may lead to the adoption of widely varying arm positions in clinical practice.
American Heart Association Scientific Statement, 20054	“It is important to instruct the patient to hold the arm still by the side while the device is taking a reading.”	No comment is made regarding the position of the arm.
Brazilian Society of Cardiology guidelines, 200531	“Keep the arm still and hanging relaxed along the body.”	These guidelines present detailed patient instructions.
European Societies of Hypertension and Cardiology guidelines, 200732	“Instruct the patients to engage in normal activities but to refrain from strenuous exercise, and to keep the arm extended and still at the time of cuff inflations.”	The “extended arm” position is at odds with earlier guidelines. Also, extending the arm involves isometric exercise or the use of an arm support, which cannot be assumed to be available during ambulatory monitoring. Moreover, the height of the arm relative to the heart in this extended position is vague.
Italian Society of Hypertension guidelines, 200533	“The patient should be instructed about the procedures to follow during each automatic BP measurement and in particular he or she should be asked to keep the arm still and to remain motionless at the time of automatic cuff inflations.”	The position of the arm is not described.
Japanese Circulation Society ABPM Guidelines–Digest Version, 201234	“Instructions for subjects Do not move the cuffed upper arm during measurement.”	The position of the arm is not described.
National Institute for Clinical Excellence (NICE) guidelines, 201135	“When measuring blood pressure in the clinic or in the home, standardise the environment and provide a relaxed, temperate setting, with the person quiet and seated, and their arm outstretched and supported.” “When using ABPM, patients need some understanding of how the device works and instruction about manual deflation, missed readings, arm position, and machine location: fitting takes 15–30 min.”	The guideline does not state whether “arm outstretched and supported” applies to ABPM, but the context suggests it does not.
British Hypertension Society Standard Operating Procedure for ABPM, developed in response to 2011 NICE guidelines36	“Tell them to stand or sit still with their arm supported during the measurement. (They can support their arm with their other arm if they are standing or rest it on a desk, table, cushion or pillow when sitting)…. The cuff must be at heart level whenever a measurement is done.”	These guidelines clearly state the importance of arm position but do not provide guidance on “heart level.”
Australian Consensus Statement, 201237	“When the cuff starts inflating, keep the cuff at heart level, temporarily stop moving or talking for about 1 min, keep the arm immobilized and relaxed and try to relax and breathe normally.”	Patients and physicians may be unsure whether this recommendation is better achieved with a relaxed, partially extended or fully extended arm. Again, “heart level” is not well‐described.
Canadian Hypertension Education Program guidelines, 201338	The position of the arm is not described.	This lack of advice may lead to widely varying arm positions adopted in clinical practice.
International Society for Chronobiology, American Association of Medical Chronobiology and Chronotherapeutics, Spanish Society of Applied Chronobiology, Chronotherapy, and Vascular Risk, Spanish Society of Atherosclerosis, and Romanian Society of Internal Medicine guidelines, 201339	“Patients must be specifically instructed to: keep the cuff at heart level, cease moving or talking, keep the arm still and relaxed, and breathe normally when the cuff starts to inflate”	Patients and physicians may be unsure whether this recommendation is better achieved with a relaxed, partially extended, or fully extended arm. Again, “heart level” is not well‐described.
European Society of Hypertension Position Paper on Ambulatory Blood Pressure Monitoring, 201340	“It is important to emphasize to the patient to follow his/her usual daily activities but, as much as possible, to remain still with the arm relaxed and not extended or contracted at heart level during each BP measurement.”	The patient is instructed to place the arm at “heart level,” but “heart level” is not defined, leaving the arm position open to interpretation by healthcare providers and patients.