title: Automated Versus Manual Blood Pressure Measurement: A Randomized Crossover Trial in the Emergency Department of a Tertiary Care Hospital in Karachi, Pakistan: Are Third World Countries Ready for the Change?
abstract: BACKGROUND
  Hypertension has proven to be a strong liability with 13.5% of all mortality worldwide being attributed to elevated blood pressures in 2001. An accurate blood pressure measurement lies at the crux of an appropriate diagnosis. Despite the mercury sphygmomanometer being the gold standard, the ongoing deliberation as to whether mercury sphygmomanometers should be replaced with the automated oscillometric devices stems from the risk mercury poses to the environment.
  
  
  OBJECTIVE
  This study was performed to check the validity of automated oscillometric blood pressure measurements as compared to the manual blood pressure measurements in Karachi, Pakistan.
  
  
  METHODS
  Blood pressure was recorded in 200 individuals aged 15 and above using both, an automated oscillometric blood pressure device (Dinamap Procare 100) and a manual mercury sphygmomanometer concomitantly. Two nurses were assigned to each patient and the device, arm for taking the reading and nurses were randomly determined. SPSS version 20 was used for analysis. Mean and standard deviation of the systolic and diastolic measurements from each modality were compared to each other and P values of 0.05 or less were considered to be significant. Validation criteria of British Hypertension Society (BHS) and the US Association for the Advancement of Medical Instrumentation (AAMI) were used.
  
  
  RESULTS
  Two hundred patients were included. The mean of the difference of systolic was 8.54 ± 9.38 while the mean of the difference of diastolic was 4.21 ± 7.88. Patients were further divided into three groups of different systolic blood pressure <= 120, > 120 to = 150 and > 150, their means were 6.27 ± 8.39 (p-value 0.175), 8.91 ± 8.96 (p-value 0.004) and 10.98 ± 10.49 (p-value 0.001) respectively. In our study 89 patients were previously diagnosed with hypertension; their difference of mean systolic was 9.43 ± 9.89 (p-value 0.000) and difference of mean diastolic was 4.26 ± 7.35 (p-value 0.000).
  
  
  CONCLUSIONS
  Systolic readings from a previously validated device are not reliable when used in the ER and they show a higher degree of incongruency and inaccuracy when they are used outside validation settings. Also, readings from the right arm tend to be more precise.
authors.affiliation: Dr. Ziauddin University Hospital, Karachi, Pakistan.
authors.forename: Kanaan
authors.initials: K
authors.lastname: Mansoor
authors.affiliation: Dialysis Unit, The Kidney Centre, Karachi, Pakistan.
authors.forename: Saba
authors.initials: S
authors.lastname: Shahnawaz
authors.affiliation: Sindh Government Hospital, Karachi, Pakistan.
authors.forename: Mariam
authors.initials: M
authors.lastname: Rasool
authors.affiliation: New Mehran Medical Centre, Karachi, Pakistan.
authors.forename: Huwad
authors.initials: H
authors.lastname: Chaudhry
authors.affiliation: Dr. Ziauddin University Hospital, Karachi, Pakistan.
authors.forename: Gul
authors.initials: G
authors.lastname: Ahuja
authors.affiliation: Dr. Ziauddin University Hospital, Karachi, Pakistan.
authors.forename: Sara
authors.initials: S
authors.lastname: Shahnawaz
keywords: Automated oscillometer; Sphygmomanometers; blood pressure