Unattended office blood pressure (BP) measurement (UOBPM) has become an increasingly discussed method in the management of arterial hypertension. This approach involves measuring BP without the presence of a health care professional, typically in clinical settings but away from a direct influence of the clinical staff.1,2 It aims to minimize the “white coat” effect, where patients exhibit elevated BP levels in clinical settings due to anxiety or stress from interacting with medical personnel.

Recent guidelines have begun to acknowledge the utility of UOBPMs in diagnosing and managing hypertension. In fact, the guidelines issued by the Canadian Hypertension Society3 prefer this method of BP assessment over traditional clinic-based measurements. However, the 2023 European Society of Hypertension guidelines4 stress that, in contrast with standard office measurements, evidence on UOBPM ability to predict a reduction of outcomes by treatment is limited to a single SPRINT (Systolic Blood Pressure Intervention Trial) study.5 Furthermore, little is known on the value of unattended measurements in the accurate prediction of cardiovascular events, including morbidity and mortality, in the general population.6 Consequently, these guidelines suggest that UOBPMs can only complement traditional clinic measurements and other forms of BP monitoring, such as home or 24-hour ambulatory monitoring.

In the current issue of Polish Archives of Internal Medicine, Stopa et al7 compared the values of unattended and attended BP measurements in terms of their association with various forms of hypertension-mediated organ damage (HMOD), including left ventricular hypertrophy, left atrial enlargement, left ventricular systolic and diastolic dysfunction, intima-media complex thickening, microalbuminuria, and abnormal pulse wave velocity. In agreement with previous studies,8,9 blood pressure readings during unattended measurements were significantly lower. However, this method did not prove to be superior in predicting any of the various types of HMOD. These findings expand the results of previous studies,10-12 which focused on individual types of HMOD at a time and never, in contrast with the current study, compared 2 methods of BP measurement in predicting the presence of microalbuminuria and systolic and diastolic dysfunction. Taken together, there is a growing body of evidence questioning the superiority of unattended vs attended measurements.

What is the future of UOBPMs? Table 1 outlines the key considerations in employing UOBPM within clinical or research settings, highlighting how it can improve measurement accuracy, while also noting potential drawbacks in patient management and infrastructure needs.

Table 1. Advantages and disadvantages of unattended office blood pressure (BP) measurements

Aspect

Advantage

Disadvantage

Accuracy

Reduces the white coat effect, potentially providing a more accurate representation of true BP levels.

Requires proper setup and patient adherence to the protocol.

Patient experience

Less stressful without a health care worker present.

Some patients may feel anxious or confused without guidance; some may fall asleep.

Consistency

Standardized procedure can reduce variability associated with different measurement techniques.

Requires strict protocol adherence, which might be challenging in unsupervised settings.

Comprehensive assessment

Focused solely on obtaining accurate BP measurements.

May miss other vital signs or symptoms requiring attention.

Clinical efficiency

Frees up health care workers to perform other tasks, potentially increasing clinical efficiency.

Might require additional resources to manage and maintain measurement stations.

UOBPMs aim to reduce the white coat effect, where patients exhibit elevated BP levels in clinical settings, but cannot fully replicate the natural, varied environments that a patient might experience daily. Home BP monitoring mitigates this issue more effectively by allowing for measurements in a genuinely relaxed state over many days or weeks, thus avoiding the spikes caused by anxiety associated with clinical settings.

Therefore, home BP measurement is likely to strengthen its position as the preferred method for managing arterial hypertension over both unattended and attended office BP measurements for several compelling reasons.13 By actively participating in their care, patients often show better adherence to treatment and lifestyle modifications. Modern home BP monitors are more user-friendly and accurate. Many devices now feature digital interfaces that can store measurements, track trends over time, and transfer data directly to health care providers.

Furthermore, development of wearable technologies may allow for continuous BP monitoring without the need for traditional cuff-based methods, providing real-time data with minimal user involvement.14,15 Integration of artificial intelligence and machine learning algorithms can provide further predictive insights into patient data, potentially identifying trends and risks earlier than the current approaches. Continuous data collection can lead to development of better predictive models for cardiovascular events and more tailored treatment plans. This level of detailed and ongoing monitoring is something that cannot be easily replicated with UOBPMs.

In summary, while UOBPMs are an improvement over traditional office visits, home BP measurement, especially with development and integration of cuffless monitoring technologies, offers unique benefits in terms of personalization, convenience, continuous monitoring, and potential for integration with health management tools. These advantages make it a preferred choice for the foreseeable future in managing arterial hypertension.