Problems and Solutions of Accurate Blood Pressure Measurement in Atrial Fibrillation

Relevance. Arterial hypertension (AH) is a common and independent risk factor for atrial fibrillation (AF). It contributes to AF onset and maintenance, while AF itself increases cardiovascular risk and represents the most common arrhythmia [3]. Hypertension and AF often coexist, and their incidence rising with age [1,3]. Current guidelines define blood pressure (BP) thresholds for diagnosing and when assessing the effectiveness of hypertension treatment in AF [1,3]. However, accurate BP measurement in this group of patients is challenging due to rhythm variability, which disrupts ventricular filling, stroke volume [3,4] and, consequently, pulse pressure. As a result, most used automatic BP monitors are not recommended for this patients [11,12]. However, additional errors and inaccuracies that are possible even when blood pressure is measured by a medical professional remain largely unstudied, highlighting the relevance of this research.

Objective. To assess the frequency and magnitude of BP overestimation and underestimation in AF patients using both Korotkov auscultatory and oscillometric methods, and to propose solutions.

Materials and Methods. This retrospective study analyzed digital signal archives from microphones and pressure sensors in arm and finger cuffs during synchronous BP measurements (auscultatory, oscillometric, and noninvasive continuous beat-by-beat) in 100 patients with permanent non-valvular AF and 92 patients with regular sinus rhythm.

The analyzed digital archive consisted of data from patients with permanent non-valvular AF undergone routine examination and treatment at the North-West Center for Arrhythmia Diagnostics and Treatment (St. Petersburg), as well as patients who had participated in prospective studies at the National Medical Research Center of Cardiology of the Russian Ministry of Health (from 2020 to 2025). Each of the latter studies was approved by the Independent Ethics Committee of the E.I. Chazov National Medical Research Center of Cardiology of the Russian Ministry of Health, and all participants signed an informed consent form.

For each patient, a «correct mean» BP value was calculated as follows. To compensate for large variations in individual BP values, as well as known physiological BP variability, the average value was calculated from ≥1000 «beat-by-beat BP values» obtained noninvasively over the entire measurement period (15 minutes). The average value of five BP readings was determined at the same time using the Korotkov or oscillometric methods. Differences between the «correct average» BP values and the average Korotkov and oscillometric methods values were analyzed statistically in MATLAB.

Results. It was shown that, in a regular sinus rhythm, Korotkov BP measurements had a high correlation and did not differ from correctly averaged «beat-bybeat» BP readings over several minutes, with no significant differences > 10 mmHg. However, in patients with AF, Korotkov systolic BP was overestimated by an average of 6.4±6.2 mmHg, and in 25% of patients overestimation can increases up to 25-30 mmHg. Korotkov diastolic BP was underestimated by −3.0±4.4 mmHg (p<0.005), and in 6% of cases this underestimation was > 10 mmHg. These discrepancies occurred mainly in patients with a pulse deficit >16% (low-amplitude BP pulsations). The oscillometric method did not reduce these discrepancies, indicating the need for noninvasive continuous beat-by-beat BP monitoring.

1. Aune D, Mahamat-Saleh Y, Kobeissi E et al. Blood pressure, hypertension and the risk of atrial fibrillation: a systematic review and meta-analysis of cohort studies. Eur J Epidemiol. 2023;38(2):145-178. https://doi.org/10.1007/s10654-022-00914-0

2. Antoun I, Layton GR, Nizam A et al. Hypertension and Atrial Fibrillation: Bridging the Gap Between Mechanisms, Risk, and Therapy. Medicina (Kaunas). 2025;61(2):362. https://doi.org/10.3390/medicina61020362

3. Chazova I.E., Golitsyn S.P., Zhernakova J.V., Zheleznova E.A., Kropacheva E.S., Mironov N.I., Kostiukevich M.V., Laiovich L.I., Utsumueva M.D., Iuricheva I.A., Litvin A.Yu., Elfimova E.M., Rogoza A.N., Panchenko E.P. Management of patients with arterial hypertension and atrial fibrillation. Systemic Hypertension. 2021;18(3):105-128. (In Russ.) https://doi.org/10.26442/2075082X.2021.3.201077]

4. Cohen DL, Townsend RR. Blood Pressure in Patients With Atrial Fibrillation: Part 1-Measurement. J Clin Hypertens (Greenwich). 2017;19(1):98-99. https://doi.org/10.1111/jch.12905

5. Pivovarov VV, Tichonenko VM, Kormilytsin AYu, Zaytsev GK.System «Cardiotechnika-SAKR» for measuring in each cardiac cycle true blood pressure in the shoulder with its high variability. Outpatient hospital. 2019;(1): 30-32. (In Russ.)

6. Stergiou GS, Kollias A, Destounis A, Tzamouranis D. Automated blood pressure measurement in atrial fibrillation: a systematic review and meta-analysis. J Hypertens. 2012;30(11):2074-2082. https://doi.org/10.1097/hjh.0b013e32835850d7

7. Šelmytė-Besusparė A, Barysienė J, Petrikonytė D et al. Auscultatory versus oscillometric blood pressure measurement in patients with atrial fibrillation and arterial hypertension. BMC Cardiovasc Disord. 2017;17(1):87. https://doi.org/10.1186/s12872-017-0521-6

8. Su H, Guo Z. Accuracy of non-invasive blood pressure measurement in patients with atrial fibrillation. J Hum Hypertens. 2022;36(3):229-234. https://doi.org/10.1038/s41371-021-00596-3

9. McEvoy JW, McCarthy CP, Bruno RM et al. ESC Scientific Document Group. 2024 ESC Guidelines for the management of elevated blood pressure and hypertension. Eur Heart J. 2024;45(38):3912-4018. Erratum in: Eur Heart J. 2025;46(14):1300. https://doi.org/10.1093/eurheartj/ehae178

10. Kobalava Zh.D., Konradi A.O., Nedogoda S.V. et al. 2024 Clinical practice guidelines for Hypertension in adults. Russian Journal of Cardiology. 2024;29(9):6117. (In Russ.) EDN: GUEWLU. https://doi.org/10.15829/1560-4071-2024-6117

11. Chazova I.E., Chikhladze N.M., Blinova N.V. et al. Clinical guidelines of the Russian Medical Society on arterial Hypertension (RSH) and the Eurasian association of Cardiologists (EaC) for the diagnosis and treatment of arterial hypertension (2024). Systemic Hypertension. 2024;21(4):5-109. (In Russ.) https:// doi.org/10.38109/2075-082X-2024-4-5-109

12. Zhernakova Yu.V., Rogoza A.N., Kislyak O.A. et al. Russian medical society of arterial hypertension experts consensus on standardized clinic (office) blood pressure measurement. Systemic Hypertension. 2025;22(1):5-11. (In Russ.) https://doi.org/10.38109/2075-082X-2025-1-5-11

13. Rogoza A.N., Oshchepkova E.V., Tsagareishvili E.V. et al. Modern non-invasive methods of measuring blood pressure for the diagnosis of arterial hypertension and assessing the effectiveness of antihypertensive therapy. Moscow: MEDICA. 2007. (In Russ.)

14. State standard R 52623.1-2008. Technologies for performing simple medical services of functional examination. Moscow: Standartinform. 2009. (In Russ.)

15. Peňáz J. Photoelectric measurement of blood pressure, volume and flow in the finger // Digest of the 10th International Conference on Medical and Biological Engineering. Dresden, 1973. P. 104.

16. Shubik V.V., Pivovarov V.V., Zaytsev G.K., et al. Beat-to-beat blood pressure measurement in patients with atrial fibrillation: a step towards personalized managemen. Journal of Arrhythmology. 2021;28(1):23-32. (In Russ.) https://doi.org/10.35336/VA-2021-1-23-32