Interpretation of the 2024 Expert Consensus on Blood Pressure Measurement and Assessment of Arterial Structure and Function

YI Shanye¹, YANG Rong¹,², LIAO Xiaoyang¹,², ZHOU Yiheng¹, LIU Lidi¹, YANG Ziyu¹,², BAI Jiaxin¹, JIA Yu¹,², ZHANG Xin³

¹General Practice Medical Center and General Practice Research Institute, West China Hospital, Sichuan University, Chengdu 610041, China
²General Practice Ward/International Medical Center Ward, General Practice Medical Center, West China Hospital, Sichuan University, Chengdu 610041, China
³Center for Integrated Traditional Chinese and Western Medicine, Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu 610041, China

Corresponding authors: JIA Yu, Attending physician; E-mail: 453986149@qq.com
ZHANG Xin, Attending physician; E-mail: zhangxinwch@126.com

Abstract

Assessment of arterial pressure, structure, and function forms an essential part of cardiovascular health management. In recent years, multiple non-invasive assessment techniques have been adopted in clinical practice; however, specific implementation details, advantages, and limitations of these techniques remain unclear. To address this, an international panel of cardiovascular experts developed the Expert Consensus on Assessment of Arterial Pressure, Structure, and Function in September 2024. This consensus reviews the most widely utilized arterial assessment techniques, detailing reference ranges for each method and their clinical utility. This article provides an interpretive analysis of the consensus document, aiming to synthesize and propose arterial evaluation approaches suitable for China's current healthcare landscape. The objective is to deliver clinical recommendations for comprehensive cardiovascular health management in China.

Keywords: Cardiovascular diseases; Arterial pressure; Arterial structure; Arterial function; Expert consensus; Interpretation

Cardiovascular disease remains the leading cause of death globally, with health assessment and prevention representing the most cost-effective management strategies. Assessment of arterial pressure, structure, and function is fundamental for predicting cardiovascular events and managing cardiovascular health. However, existing arterial pressure measurement methods have various limitations, and inappropriate measurement locations or timing may lead to missed diagnoses and misdiagnoses. Furthermore, techniques for evaluating arterial structure and function lack standardization, including ankle-brachial index, cardio-ankle vascular index (CAVI), and intima-media thickness. To clarify the application conditions and limitations of these technologies, the Expert Consensus on Blood Pressure Measurement and Assessment of Arterial Structure and Function (hereinafter referred to as "the Consensus") was published in the Journal of Hypertension on September 9, 2024. This consensus integrates the latest evidence to clarify appropriate scenarios for arterial pressure measurement and standardize methods for assessing arterial structure and function, with particular emphasis on advantages, limitations, indications, normal values, and practical clinical applications to improve the accuracy of vascular health evaluation and risk prediction. Currently, China lacks corresponding guidelines or consensus systematically exploring the standardization and applicability of arterial pressure, structure, and function assessment. Given the consensus's important role in standardizing arterial evaluation in China, our research team provides this interpretation for peer scholars' reference. Our team comprises clinical physicians specializing in cardiovascular medicine and general practice cardiology, evidence-based medicine methodology experts, and guideline development methodology specialists, with no conflicts of interest with the original consensus development team.

1. Main Content of the Consensus: Arterial Pressure Assessment

1.1 Office Blood Pressure, Home Blood Pressure Monitoring, and Ambulatory Blood Pressure Monitoring

Office blood pressure measurement is the most commonly used method for screening, diagnosing, treating, and following up hypertensive patients, with the most extensive research and evidence base. Hypertension classification, treatment initiation thresholds, and therapeutic targets are all based on this approach. However, relying solely on office blood pressure often leads to "white coat hypertension" and "masked hypertension" issues, and errors are common when using manual auscultation devices, resulting in overtreatment or undertreatment of hypertension. Office blood pressure measurement methods include manual auscultation, electronic blood pressure monitors, and unattended automated office blood pressure measurement. Office blood pressure also has significant limitations because values measured only in specific environments differ substantially from real-life conditions. Additionally, office blood pressure cannot identify blood pressure variations occurring outside the clinic during waking or sleeping periods. Unattended automated office blood pressure refers to patients self-measuring blood pressure in a room without staff present, typically yielding lower results than traditional measurements (closer to daytime ambulatory blood pressure), reducing but not eliminating white coat and masked hypertension phenomena, though the threshold for defining office hypertension remains unclear. Furthermore, unattended automated office blood pressure measurement is not feasible in many clinical settings. Beyond seated measurements, hypertensive patients should also have standing blood pressure measured when orthostatic hypotension symptoms are present, particularly in elderly individuals and those with neurodegenerative diseases (such as Parkinson's disease, dementia) or diabetes.

Compared with office blood pressure measurement, out-of-office blood pressure measurement better captures individuals' true blood pressure status during daily activities, including 24-hour ambulatory blood pressure monitoring or home blood pressure monitoring. Home blood pressure monitoring or 24-hour ambulatory blood pressure monitoring demonstrates stronger reproducibility, and their values show stronger correlations with hypertension-mediated organ damage and better predictive value for cardiovascular events and mortality. The combination of these three methods can be used to diagnose white coat hypertension and masked hypertension. Twenty-four-hour ambulatory blood pressure monitoring can identify nocturnal hypertension, daytime hypertension, and abnormal blood pressure variability, with recommended repeat cycles of at least 2-3 months, or 1 year for those with stable blood pressure.

1.2 Central Arterial Blood Pressure

Due to the structural and functional characteristics of arterial vessels, pressure pulses generated by left ventricular ejection in the proximal aorta typically increase in amplitude as they propagate peripherally. Invasive measurements reveal that central and peripheral arterial diastolic pressures are nearly identical, so waveform changes primarily relate to differences between central and peripheral arterial systolic pressure, ranging from 0-30 mmHg (1 mmHg = 0.133 kPa), with an average difference of 12 mmHg. In clinical settings, central arterial blood pressure is typically estimated using pulse wave conduction velocity and morphology.

Current blood pressure reduction strategies are based on office brachial artery blood pressure measurements, which can reduce cardiovascular risk but cannot completely reverse the incidence risk caused by hypertension. Simply assessing brachial artery blood pressure without considering the impact of central blood pressure on cardiovascular events may lead to overtreatment or undertreatment. Numerous studies have focused on central arterial pressure as a stronger predictor of hypertension-related end-organ damage, cardiovascular events, and cardiovascular mortality. Central arterial pressure-based antihypertensive therapy may represent a future direction for antihypertensive strategies. However, due to inconsistent diagnostic and prognostic data and lack of clear clinical thresholds to distinguish normal from high central arterial pressure values in broader populations, central arterial pressure measurement is not recommended as a fundamental indicator for hypertension clinical management. Current clinical applications target young patients with isolated systolic hypertension, where peripheral blood pressure is disproportionately elevated compared to central blood pressure. On the other hand, central arterial pressure and other parameters such as augmentation index and wave reflection index are used in research to describe pathophysiological mechanisms of many diseases and related therapeutic approaches. Therefore, central arterial pressure measurement is currently essentially limited to clinical research and specialized centers.

2. Arterial Structure Assessment

2.1 Carotid Artery Intima-Media Thickness (CIMT) and Plaque

CIMT can be quantified through carotid ultrasound. The 2023 European Society of Hypertension (ESH) guidelines state that increased CIMT at the carotid bifurcation can be considered a marker of early-stage atherosclerosis. CIMT can predict cardiovascular disease risk, with CIMT > 0.9 mm considered abnormal; CIMT > 1.5 mm, local thickness increase of 0.5 mm, or local thickness increase exceeding 50% of surrounding levels suggests carotid plaque. The 2021 European Society of Cardiology (ESC) clinical practice guidelines for cardiovascular disease prevention state that due to lack of methodological standardization and lack of additional predictive value for cardiovascular disease, intima-media thickness is not recommended for risk assessment. Compared with CIMT, carotid plaque carries more important prognostic significance for cardiovascular events. The 2018 and 2023 ESH guidelines recommend carotid ultrasound examination for patients with carotid bruits, history of transient ischemic attack, cerebrovascular disease, or other vascular disease evidence to screen for severe carotid stenosis and asymptomatic plaque or stenosis in patients with confirmed vascular disease in other locations.

2.2 Retinal Microcirculation

The eye is an ideal window for observing microvascular changes in the pathophysiology and treatment of cardiovascular and metabolic diseases. Retinal vascular assessment primarily involves fundoscopy for patients with risk factors such as diabetes or hypertension. Fundoscopic examination can detect hemorrhages, microaneurysms, exudates, and cotton wool spots (grade 3), papilledema or macular edema (grade 4); these changes are reproducible and predictive of mortality. Grade 1 and 2 lesions such as arteriolar narrowing or arteriovenous nicking have lower reproducibility and predictive value. Retinal microcirculation examination is an excellent marker and prognostic tool for hypertension and other cardiovascular and metabolic diseases, applicable for large-scale population cohort studies or clinical trials aimed at evaluating the impact of drug or nutritional interventions on cardiometabolic diseases.

3. Arterial Function Assessment

3.1 Blood Pressure Variability

Research shows that blood pressure variability includes short-term variations within 24 hours (through 24-hour ambulatory blood pressure monitoring), medium-term fluctuations in home blood pressure measurements (self-home blood pressure monitoring), or long-term variability in office blood pressure changes. Increased blood pressure variability may predict the development, progression, and severity of cardiac, vascular, and renal organ damage, as well as cardiovascular events and mortality. Blood pressure variability indicators include frequency, dispersion, sequence, and instability. However, which blood pressure variability methods, parameters, and indicators are most effective and reproducible for risk prediction remains controversial, and there is no consensus on whether blood pressure variability should be incorporated into clinical practice. Currently, it is limited to research and specialized hypertension centers but can be used to evaluate patients with specific characteristics.

3.2 Ankle-Brachial Index

The ankle-brachial index is the ratio of systolic pressure measured at the ankle to systolic pressure measured at the brachial artery. Ankle-brachial index measurement is simple, non-invasive, time-efficient, and low-cost; it is used for diagnosis and monitoring of lower extremity artery disease (LEAD) and assessment of systemic atherosclerosis progression and cardiovascular risk.

Ankle-brachial index measurement is suitable for patients with suspected LEAD and asymptomatic patients at risk for LEAD. Patients with the following symptoms should be suspected of having LEAD: presence of LEAD symptoms (intermittent claudication), other symptoms (rest/exercise lower limb ischemia), non-healing lower limb wounds, signs suggesting LEAD (absent pulses, arterial bruits). Asymptomatic patients at risk for LEAD include those with: cardiovascular disease or other atherosclerosis, age > 65 years, high cardiovascular risk, diabetes, chronic kidney disease, heart failure, aortic aneurysm. Measurement results with ankle-brachial index ≤ 0.90 diagnose LEAD, while ankle-brachial index > 1.40 suggests increased arterial stiffness. Ankle-brachial index < 0.90 or > 1.40 is an independent predictor of other cardiovascular and mortality risks.

3.3 Pulse Wave Velocity (PWV)

PWV is the propagation speed of waves (pressure) over arterial segments. Currently, multiple devices can calculate PWV through single-point measurement using arterial pulse wave analysis. Arterial wall properties vary considerably from the aortic root to smaller peripheral arteries, and PWV containing aortic segments is a strong predictor of cardiovascular risk. Elevated carotid-femoral pulse wave velocity (cfPWV) and brachial-ankle arterial segment (baPWV) are independent risk factors for cardiovascular disease.

Following the release of the arterial stiffness consensus, Western countries have adopted cfPWV as the gold standard for assessing arterial stiffness. cfPWV research has primarily been conducted in Western countries, using simultaneous (Compilor device) or continuous (SphygmoCor CVMS device) application sensors at carotid and femoral artery sites, with operators recording pulse pressure. However, high-quality pulse pressure requires strong operator expertise, making it difficult to use. Asian countries prefer using baPWV. Studies have found that in patients without peripheral arterial disease, baPWV is associated with premature aging and cardiovascular risk. baPWV may slightly diminish the aortic contribution to PWV values, but its advantage lies in greatly simplifying measurement operations. Measurement devices can typically also measure ankle-brachial index to assess peripheral arterial disease, providing a two-in-one examination such as Omron VP1000 and MESI mTABLET ABI systems.

Since accurate cfPWV measurement requires expertise, it limits large-scale clinical application, while baPWV measurement is simple, rapid, and easy to use, also including ankle-brachial index and/or blood pressure measurements, which helps better manage cardiovascular risk patients. Increased PWV may occur in early stages of hypertension, with arterial stiffness increasing before hypertension development. Furthermore, compared with traditional risk-based scores, cfPWV or baPWV can more accurately classify cardiovascular risk, an advantage particularly important for low- or medium-risk young patients. According to the 2023 ESH Hypertension Guidelines, PWV is included as a basic screening tool for assessing hypertension-mediated organ damage. baPWV ≥ 18 m/s and cfPWV ≥ 10 m/s are recommended as thresholds for determining hypertension-related target organ damage. However, factors such as lack of equipment, high costs (reaching 100,000-350,000 RMB), and limited medical conditions may restrict implementation scope.

3.4 Cardio-Ankle Vascular Index (CAVI)

CAVI is a non-invasive indicator developed in Japan for assessing structural and functional stiffness of the arterial tree from the aortic origin to the ankle. Its characteristic is independence from immediate blood pressure values, more stably reflecting structural arterial stiffness. CAVI is influenced by multiple factors, such as arteriosclerotic disease, cardiovascular risk factors, and arterial smooth muscle contraction and relaxation. CAVI uses the automated VaSera device (Fukuda Denshi, Japan) to record electrocardiograms, phonocardiograms, pulse waveforms of brachial and ankle arteries, and brachial artery systolic and diastolic pressure, calculating PWV through formulas and finally computing CAVI values based on electrocardiogram, phonocardiogram, pulse waveform, and blood pressure data. The VaSera device's built-in algorithm automatically completes calculations and directly displays CAVI values.

The prospective CAVI-J study for Asian populations showed that populations with CAVI ≥ 9.5 had increased risk of cardiovascular events and all-cause mortality. The multicenter prospective TRIPLE-A study for European populations showed that in subjects ≥ 60 years old, the optimal CAVI threshold for predicting increased cardiovascular morbidity was 9.25. CAVI is an indicator of overall arterial stiffness, independent of blood pressure levels at the time of measurement, easy to measure, almost operator-independent, and a reproducible method for assessing arterial structure and function that can serve as an indicator for predicting and evaluating cardiovascular disease and risk factors in daily clinical practice. However, currently, CAVI is mainly used for cardiovascular prevention and clinical disease in Asia, and its clinical application in Western countries requires more data support.

4. Advantages and Limitations of the Consensus

The consensus's advantage lies in its comprehensive evaluation methodology, covering multiple methods for assessing blood pressure, arterial structure, and function, including office blood pressure measurement, home blood pressure monitoring, ambulatory blood pressure monitoring, blood pressure variability, ankle-brachial index, PWV, CIMT, and retinal microcirculation, providing clinicians and researchers with a comprehensive perspective for evaluating cardiovascular health status. Additionally, some recommended techniques such as home blood pressure monitoring and ankle-brachial index screening are low-cost, high-benefit, simple to operate, and well-supported by evidence, making them suitable for clinical practice.

The consensus's limitations include that some technologies (such as central arterial pressure, cfPWV, CAVI) have high equipment costs and require professional operation, making them difficult to popularize in medical institutions in developing countries with limited clinical applicability. Some indicators, such as blood pressure variability, although clearly associated with target organ damage, lack high-quality evidence for intervention thresholds. Emerging technologies such as CAVI show potential in early diagnosis of cardiovascular disease, but their clinical application still requires more support from randomized controlled trials. Future efforts need to reduce costs and simplify operations through technological innovation and conduct multi-population studies to strengthen evidence and enhance clinical utility.

5. Significance of the Consensus for Chinese Clinical Practice and Guideline Development

China currently lacks corresponding guidelines or consensus systematically discussing commonly used techniques for blood pressure measurement and arterial structure and function assessment. This consensus comprehensively standardizes blood pressure measurement techniques and arterial structure and function assessment methods, providing precise and individualized cardiovascular risk management tools for Chinese clinical practice while offering multidimensional references for China's blood pressure measurement and arterial structure and function assessment decisions and guideline development.

Developing a set of well-adapted本土化 evaluation indicators is crucial. We recommend that when developing related guidelines, China should prioritize evaluation methods with high cost-effectiveness, low technical difficulty, and high-level evidence. For example, office blood pressure measurement and home blood pressure monitoring are suitable for widespread promotion in China's primary healthcare units due to their low cost and simple operation. This consensus interpretation team recommends constructing a standardized evaluation framework from three dimensions—arterial pressure, structure, and function—to provide a comprehensive and actionable evaluation system for clinical practice: for arterial pressure assessment, we recommend selecting office blood pressure, home blood pressure monitoring, or 24-hour ambulatory blood pressure monitoring based on the problems and timing that need to be addressed, using them synergistically to optimize hypertension screening, diagnosis, treatment, and follow-up. For arterial structure assessment, we recommend carotid color Doppler ultrasound and retinal microcirculation examination as early evaluation indicators for vascular health. For arterial function assessment, we recommend ankle-brachial index as an evaluation indicator for peripheral arterial disease and arterial stiffness.

This consensus provides a scientific framework for arterial pressure, structure, and function assessment by integrating global evidence and comprehensively discussing multiple assessment techniques, enabling clinicians to more fully understand patients' cardiovascular health status and achieve early intervention and personalized treatment. Future research should further optimize these assessment methods, requiring integration of localized research, policy support, and technology popularization, and explore their application effects in different populations to promote the standardization and precision development of cardiovascular health assessment and achieve comprehensive upgrading of cardiovascular disease prevention and control.

Author Contributions: YI Shanye was responsible for conceptualization and design, data collection and analysis, manuscript writing and revision, and overall responsibility for the article; YANG Rong, JIA Yu, ZHOU Yiheng, LIU Lidi, YANG Ziyu, and BAI Jiaxin contributed to manuscript revision; LIAO Xiaoyang and ZHANG Xin conducted feasibility analysis, participated in manuscript revision, and were responsible for supervision, quality control, and proofreading.

Conflict of Interest: None declared.

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(Received: April 10, 2025; Revised: June 20, 2025) (Edited by: MAO Yamin)