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Updates in Hypertension and Cardiovascular Protection
Series Editors: Giuseppe Mancia · Enrico Agabiti Rosei

George S. Stergiou
Gianfranco Parati
Giuseppe Mancia Editors

Home Blood
Pressure
Monitoring
Updates in Hypertension and
Cardiovascular Protection

Series Editors
Giuseppe Mancia
Milano, Italy
Enrico Agabiti Rosei
Brescia, Italy
The aim of this series is to provide informative updates on both the knowledge and
the clinical management of a disease that, if uncontrolled, can very seriously damage
the human body and is still among the leading causes of death worldwide. Although
hypertension is associated mainly with cardiovascular, endocrine, and renal
disorders, it is highly relevant to a wide range of medical specialties and fields –
from family medicine to physiology, genetics, and pharmacology. The topics
addressed by volumes in the series Updates in Hypertension and Cardiovascular
Protection have been selected for their broad significance and will be of interest to
all who are involved with this disease, whether residents, fellows, practitioners, or
researchers.

More information about this series at http://www.springer.com/series/15049

George S. Stergiou
Gianfranco Parati • Giuseppe Mancia
Editors

Home Blood Pressure

Monitoring
Editors
George S. Stergiou Gianfranco Parati
Hypertension Center STRIDE-7 Department of Medicine and Surgery
National and Kapodistrian University of Milano-Bicocca
University of Athens Milano
School of Medicine Italy
Third Department of Medicine
Istituto Auxologico Italiano, IRCCS,
Sotiria Hospital
Department of Cardiovascular
Athens
Neural and Metabolic Sciences
Greece
Milano
Italy
Giuseppe Mancia
University of Milano-Bicocca
Milano
Italy

ISSN 2366-4606     ISSN 2366-4614 (electronic)

Updates in Hypertension and Cardiovascular Protection
ISBN 978-3-030-23064-7    ISBN 978-3-030-23065-4 (eBook)
https://doi.org/10.1007/978-3-030-23065-4

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland
AG 2020
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether
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The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Preface

Self-monitoring of blood pressure at home is widely used by patients with hyperten-

sion in several countries [1]. Indeed, the clinical application of home blood pressure
monitoring by patients has preceded the publication of strong research evidence from
outcome studies, which are necessary to support its clinical utility in the management
of hypertension [2]. Thus, despite its wide availability, scientific organizations around
the world have initially hesitated to endorse the use of home blood pressure monitor-
ing for decision-making in hypertension in clinical practice. However, in the last 20
years, the publication of several outcome studies reporting the superiority of home
blood pressure monitoring compared to the conventional office measurements has
now supported a major role of home monitoring in hypertension management [1–6].
Home blood pressure monitoring has unique advantages for clinical practice, par-
ticularly for repeated and long-term use, as it is widely available in most countries, is
well accepted by hypertensive patients, and has relatively low cost [1, 3–6]. Thus,
although ambulatory blood pressure monitoring, which is the alternative method for out-
of-office blood pressure evaluation, is regarded as the gold standard method for hyper-
tension diagnosis as it has stronger research evidence and additional unique advantages
[5, 6], a pragmatic approach for most scientific societies and healthcare organizations is
to promote home blood pressure monitoring as much as ambulatory monitoring, aiming
to increase the number of people having their blood pressure status confirmed by out-of-
office readings. When home blood pressure monitoring is applied according to the cur-
rent recommendations [3–6], it can play a primary role for treatment initiation and
titration in subjects with suspected or treated hypertension [7, 8]. These advantages
strongly call for reimbursement of home blood pressure monitoring by healthcare sys-
tems, as done for glucose monitors in patients with diabetes [9].
The 2017 American College of Cardiology/American Heart Association guide-
lines for hypertension [5] and the 2018 guidelines by the European Society of
Cardiology/European Society of Hypertension [6] highlighted the primary role of
home blood pressure monitoring as well as of ambulatory monitoring in the diagnosis
and management of hypertension. These statements on both sides of the Atlantic have
started a new era in hypertension management by endorsing out-of-office blood pres-
sure measurement as mandatory for most diagnostic and treatment decisions.
Time has come to take this method seriously [2]. As home blood pressure monitor-
ing is already widely used, its appropriate implementation according to the current
recommendations [3–6] can optimize the management of hypertension in clinical

v
vi Preface

practice. This book endorsed by the European Society of Hypertension presents the
current knowledge on all the aspects of home blood pressure monitoring, including
the technology of devices, the clinical relevance of the method, the optimal protocol
and clinical application, the clinical indications for general and special populations,
the application in clinical research, and the international consensus on clinical imple-
mentation. A total of 39 international experts in blood pressure measurement research
have contributed in preparing 16 chapters in this book, which aim to guide clinicians
in the optimal application of home blood pressure monitoring and to stimulate
researchers in filling the gaps in knowledge by performing further trials.

References

1. Stergiou GS, Kario K, Kollias A, McManus RJ, Ohkubo T, Parati G, et al. Home
blood pressure monitoring in the 21st century. J Clin Hypertens.
2018;20:1116–21.
2. Stergiou GS, Siontis KC, Ioannidis JP. Home blood pressure as a cardiovascular
outcome predictor: it’s time to take this method seriously. Hypertension.
2010;55:1301–3.
3. Parati G, Stergiou GS, Asmar R, Bilo G, de Leeuw P, Imai Y, et al. European
Society of Hypertension guidelines for blood pressure monitoring at home: a
summary report of the Second International Consensus Conference on Home
Blood Pressure Monitoring. J Hypertens. 2008;26:1505–26.
4. Parati G, Stergiou GS, Asmar R, Bilo G, de Leeuw P, Imai Y, et al. ESH Working
Group on Blood Pressure Monitoring. European Society of Hypertension prac-
tice guidelines for home blood pressure monitoring. J Hum Hypertens.
2010;24:779–85.
5. Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison
Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/
ASPC/NMA/PCNA guideline for the prevention, detection, evaluation and man-
agement of high blood pressure in adults: a report of the American College of
Cardiology/American Heart Association Task Force on clinical practice guide-
lines. Hypertension. 2018;71:e13–e115.
6. Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, et al.
ESC/ESH Guidelines for the management of arterial hypertension: The Task Force
for the management of arterial hypertension of the European Society of Cardiology
and the European Society of Hypertension. J Hypertens. 2018;36:1953–2041.
7. Stergiou GS, Kollias A, Zeniodi M, Karpettas N, Ntineri A. Home blood pres-
sure monitoring: primary role in hypertension management. Curr Hypertens
Rep. 2014;16:462.
8. Stergiou GS, Parati G. Home blood pressure monitoring may make office mea-
surements obsolete. J Hypertens. 2012;30:463–5.
9. Pickering TG, Miller NH, Ogedegbe G, Krakoff LR, Artinian NT, Goff D. Call
to action on use and reimbursement for home blood pressure monitoring: execu-
tive summary: a joint scientific statement from the American Heart Association,
American Society of Hypertension, and Preventive Cardiovascular Nurses
Association. Hypertension. 2008;52:1–9.
Contents

1 Devices for Home Blood Pressure Monitoring����������������������������������������   1

Roland Asmar, Anastasios Kollias, Paolo Palatini, Gianfranco Parati,
Andrew Shennan, George S. Stergiou, Jirar Topouchian,
Ji-Guang Wang, William White, and Eoin O’Brien
2 Cuff Design for Home Blood Pressure Monitors������������������������������������ 13
Paolo Palatini, Roland Asmar, Grzegorz Bilo, and Gianfranco Parati
3 Home Blood Pressure and Preclinical Organ Damage�������������������������� 23
Takayoshi Ohkubo, Kazuomi Kario, Teemu J. Niiranen,
Daichi Shimbo, and Giuseppe Mancia
4 Home Blood Pressure as Predictor of Adverse Health Outcomes �������� 33
Kei Asayama, Teemu J. Niiranen, Takayoshi Ohkubo,
George S. Stergiou, Lutgarde Thijs, Yutaka Imai,
and Jan A. Staessen
5 Diagnostic Value of Home Blood Pressure���������������������������������������������� 45
Kazuomi Kario, Yutaka Imai, Anastasios Kollias, Teemu J. Niiranen,
Takayoshi Ohkubo, Richard J. McManus, and George S. Stergiou
6 Home Blood Pressure Monitoring Schedule�������������������������������������������� 55
Teemu J. Niiranen, Richard J. McManus, Takayoshi Ohkubo,
and George S. Stergiou
7 Home Blood Pressure Monitoring for Treatment Titration������������������ 63
Richard J. McManus, Jonathan Mant, Takayoshi Ohkubo,
Yutaka Imai, and Kazuomi Kario
8 Home Blood Pressure Monitoring, Treatment Adherence and
Hypertension Control�������������������������������������������������������������������������������� 73
Alejandro de la Sierra, Anastasia Mihailidou, Ji-Guang Wang,
Daichi Shimbo, and Richard J. McManus

vii
viii Contents

9 Home Blood Pressure Monitoring: Cost-­Effectiveness, Patients’

Preference and Barriers for Clinical Use������������������������������������������������ 79
Paul Muntner, Richard J. McManus, Daichi Shimbo,
Alejandro de la Sierra, and Martin G. Myers
10 Home Blood Pressure Monitoring in Clinical Research������������������������ 89
Angeliki Ntineri, Kazuomi Kario, Ji-Guang Wang, William White,
and George S. Stergiou
11 Home Blood Pressure Telemonitoring: Conventional Approach
and Perspectives from Mobile Health Technology���������������������������������� 103
Gianfranco Parati, Juan Eugenio Ochoa, Nicolas Postel-­Vinay,
Dario Pellegrini, Camilla Torlasco, Stefano Omboni,
and Richard J. McManus
12 Nocturnal Home Blood Pressure Monitoring������������������������������������������ 121
George S. Stergiou, Emmanuel Andreadis, Kei Asayama,
Kazuomi Kario, Anastasios Kollias, Takayoshi Ohkubo,
Gianfranco Parati, Michael A. Weber, and Yutaka Imai
13 Home Blood Pressure Monitoring in Children, Pregnancy,
and Chronic Kidney Disease �������������������������������������������������������������������� 131
Anastasios Kollias, Andrew Shennan, Rajiv Agarwal,
Angeliki Ntineri, and George S. Stergiou
14 Home Blood Pressure Variability ������������������������������������������������������������ 143
Gianfranco Parati, Juan Eugenio Ochoa, Yutaka Imai,
Anastasios Kollias, Efstathios Manios, Takayoshi Ohkubo,
Kazuomi Kario, George S. Stergiou, and Grzegorz Bilo
15 Home Versus Ambulatory Blood Pressure Monitoring�������������������������� 155
Eoin O’Brien, Alex de la Sierra, Richard J. McManus,
Anastasia Mihailidou, Paul Muntner, Martin G. Myers,
George S. Stergiou, Gianfranco Parati, and Efstathios Manios
16 Guidelines for Home Blood Pressure Monitoring���������������������������������� 165
George S. Stergiou, Gianfranco Parati, Yutaka Imai,
Richard J. McManus, Geoff A. Head, Kazuomi Kario, Paul Muntner,
Martin G. Myers, James Sharman, Eoin O’Brien, Michael A. Weber,
Paul K. Whelton, and Giuseppe Mancia

Index�������������������������������������������������������������������������������������������������������������������� 171
Devices for Home Blood
Pressure Monitoring 1
Roland Asmar, Anastasios Kollias, Paolo Palatini,
Gianfranco Parati, Andrew Shennan, George S. Stergiou,
Jirar Topouchian, Ji-Guang Wang, William White,
and Eoin O’Brien

R. Asmar (*)
Foundation-Medical Research Institutes (F-MRI®), Geneva, Switzerland
e-mail: [email protected]
A. Kollias
Hypertension Center STRIDE-7, National and Kapodistrian University of Athens,
School of Medicine, Third Department of Medicine, Sotiria Hospital, Athens, Greece
G. S. Stergiou
Hypertension Center STRIDE-7, National and Kapodistrian University of Athens, School of
Medicine, Third Department of Medicine, Sotiria Hospital, Athens, Greece
e-mail: [email protected]
P. Palatini
Department of Medicine, University of Padova, Padova, Italy
e-mail: [email protected]
G. Parati
Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
Istituto Auxologico Italiano, IRCCS, Department of Cardiovascular, Neural and Metabolic
Sciences, Milan, Italy
e-mail: [email protected]
A. Shennan
Department of Women and Children’s Health, School of Life Course Sciences, FoLSM,
King’s College London, London, UK
e-mail: [email protected]
J. Topouchian
Diagnosis and Therapeutic Center, Hôtel Dieu Hospital, Paris, France
e-mail: [email protected]
J.-G. Wang
The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University
School of Medicine, Shanghai, China

© The Editor(s), under exclusive license to Springer Nature Switzerland AG 2020 1

G. S. Stergiou et al. (eds.), Home Blood Pressure Monitoring,
Updates in Hypertension and Cardiovascular Protection,
https://doi.org/10.1007/978-3-030-23065-4_1
2 R. Asmar et al.

W. White
Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington, CT, USA
e-mail: [email protected]
E. O’Brien
The Conway Institute, University College Dublin, Dublin, Ireland

1.1 Introduction

The use of home blood pressure (BP) monitoring (HBPM) for hypertension manage-
ment is recommended by most of the international guidelines [1–4]. While these
recommendations provide information on HBPM indications, procedures, and
thresholds of BP values, they provide very few, or no, indications on device choice.
In fact, the hypertension guidelines of the European Society of Hypertension (ESH)
and the European society of cardiology (ESC) simply indicate: “HBPM …performed
with semiautomatic validated BP monitors…; use of Apps as a cuff-­independent
means of measuring BP is not recommended; Telemonitoring and smartphone appli-
cations may offer additional advantages [4].” No other information on the device
choice is indicated. The other guidelines [1–3] do not provide more indications
(Table 1.1). Given the worldwide increasing dissemination of HBPM, more detailed
indications on choice and use of HBPM devices are therefore necessary to guide
physicians, patients, and users towards an adequate choice of suitable equipment.
In the absence of guidance on how to choose a reliable HBPM device and con-
sidering the great popularity of HBPM which is now widely available in most coun-
tries, the device market has evolved into an uncontrolled one with about 80% of
marketed devices either not validated or with questionable accuracy [5]. This global
BP monitoring market reached US$ 16.9 billion in 2015 and is expected to reach
US$ 23.8 billion in 2020, thus being one of the most lucrative markets in the field
of cardiovascular health [5, 6].

Table 1.1 Indications on HBPM devices from current hypertension guidelines

ESH/ESC AHA/ACC CHEP
• Semiautomatic validated BP • Use of automated • Use only BPM devices that are
monitor. validated device appropriate for the individual and
• Memory to store and review • BP device validated have met the standards (AAMI,
BP data with an internationally ISO, BHS, ESH-IP)
• Use of Apps as cuff-­ accepted protocol • Encourage devices with data
independent means of • Use of auscultatory recording capabilities or automatic
measuring BP is not devices is not generally data transmission
recommended useful for HBPM
• Tele monitoring and • Monitors with data
smartphone Apps may offer storage in memory are
advantages preferred
• Use of appropriate cuff
size to fit the arm
ESH/ESC European Guidelines [4], AHA/ACC American Guidelines [1], CHEP Canadian
guidelines [3]
1 Devices for Home Blood Pressure Monitoring 3

The widespread use of HBPM, the scientific recommendations of its use, and the
large financial potential of the device market emphasize the need of device accuracy
and certification and the necessity of providing clear guidance to this market by giv-
ing strict indications for the choice of HBPM devices. Publication of lists of validated
home BP devices has been successfully conducted. Updated lists of the validated
devices are available at several non-profit (www.bihsoc.org, https://hypertension.ca)
or for-profit organizations: www.medaval.ie, www.dableducational.org [3, 7–9].
Despite the establishment of such lists, they are currently accessed only by small
groups of scientists and experts and thus do not reach most of the concerned public,
including physicians, pharmacists, and patients [5]. The purpose of this chapter is to
describe the main characteristics of the most widely used HBPM devices and to help
prescribers, consumers, and users in choosing the most reliable and suitable device.

1.2  lood Pressure Measurement Techniques

B
Used For HBPM

Several techniques for measuring BP are used by HBPM devices. These devices are
either manual, semiautomated, or automated. Semiautomated are characterized by
automatic inflation and manual cuff deflation; automated devices are characterized
by automatic cuff inflation and deflation. The most widely used techniques are
described below.

1.2.1 Manual Auscultatory Method

The manual auscultatory method to detect the Korotkoff sounds using either aneroid
or mercury devices—where mercury manometers remain available —are not rec-
ommended for HBPM as they require substantial patient training and regular cali-
bration [1–4].

1.2.2 Automatic Auscultatory Method

Very few devices incorporate microphones or specific sensors to perform automatic

auscultatory (microphonic) measurement of BP with less user interference. Some of
these devices offer automatic BP measurement using dual methods (auscultatory
and/or oscillometry). Their use remains limited to exceptional cases where auto-
matic BP measurement is problematic. Overall, the auscultatory method is not cur-
rently recommended for HBPM by clinical guidelines.

1.2.3 Oscillometric Method

Most automatic or semiautomatic electronic devices for BP measurements are using

the oscillometric method [10]. Each device has its specific algorithm to calculate BP
4 R. Asmar et al.

and pulse rate from the collected oscillometric signal. Most of these devices acquire
data for measurements during cuff deflation whereas others do this during cuff infla-
tion. Since each device has its own specific proprietary algorithm and technical
characteristics, the measurement accuracy of one device cannot be extrapolated to
another even if produced by the same manufacturer. Moreover, since the cuff in the
oscillometric method is used not only to obtain arterial occlusion but also as a sen-
sor to collect the oscillometric signal, experts agree that each oscillometric device
must be used only with its own specific cuff(s) as provided by the manufacturer.
Therefore, HBPM devices must be considered as the combination of a device and
its accompanying cuff(s), whereas the cuff size and type used in the auscultatory
method may not be applicable.
Electronic oscillometric devices require little to no training and are user-friendly,
relatively inexpensive, and generally not affected by observer bias if used correctly.
These devices, as well as all the other BP measurements devices, must meet the
requirements of national and international regulatory bodies for medical devices such
as the Food and Drug Administration (FDA) in the United States (US), and the CE
(Conformité Européene) labeling according to the medical device Directives and
Regulations in Europe. Since these regulations are mainly focused on safety rather
than accuracy, it is recommended to use only devices that have undergone independent
validation and passed the criteria of established validation protocols (CF. Accuracy).
Automatic oscillometric devices have been designed to measure BP at different
arterial sites. The most popular (and recommended) ones are those measuring BP at
the upper-arm (brachial artery) level and to a lesser extent those measuring BP at the
wrist (radial artery) level. Even though several automated wrist devices have suc-
cessfully passed recommended validation protocols, they are considered less accu-
rate than the upper-arm devices. Oscillometric wrist device accuracy can be affected
by wrist anatomy and position (with reference to the heart level), as well as by the
wrist cuff characteristics (soft or pre-shaped). The pre-shaped cuffs are easier for
patients to use but they conform less well than the soft one to the wrist.
Many of the electronic oscillometric devices include additional features such as
memory, connectivity (PC, smartphone, or telemonitoring), and position sensor (CF
Features), which may facilitate the HBPM procedures and improve its impact for
hypertension management.
Taking into consideration all these aspects, current guidelines recommend the
use of automated electronic oscillometric upper-arm cuff devices which meet regu-
latory authority requirements and have been validated according to established pro-
tocols. Moreover, some of these guidelines also do support wrist devices if used
correctly in certain clinical circumstances. Indeed, wrist measurements can be help-
ful when the upper-arm cuff cannot be correctly fitted or is structurally impossible,
such as in obese subjects with a very large upper-arm circumference.

1.2.4 Hybrid Devices

Hybrid devices have two BP measuring methods—the manual auscultatory method

and the oscillometric method (CF). Even though these devices, originally developed
1 Devices for Home Blood Pressure Monitoring 5

for office BP measurement, are accurate and require less maintenance than the aner-
oid device, their use for HBPM is not recommended. Additionally, the use of the
auscultatory method remains affected by observer bias and other disadvantages of
this method; moreover, they are more expensive than most of the other digital oscil-
lometric HBPM devices. If a hybrid device is used for HBPM, then the automatic
oscillometric method would be preferable.

1.2.5 Plethysmography: Cuffless Method

For many years, many device manufacturers have been attempting to develop cuff-
less BP measurement devices as these would avoid many of the inconveniences
associated with cuff measurements. Among these techniques such as tonometry,
pulse wave velocity, pulse transit time, and plethysmography, the plethysmographic
approach appears to be the most likely method to succeed [11]. Briefly, plethysmog-
raphy measures volume changes. When applied to an arterial segment, the measured
changes of volume are transformed into changes of pressure with calculation of
systolic and diastolic BP and pulse rate values according to specific algorithms. To
date, most of the cuffless devices used at the finger or at the wrist level (watches,
bracelets), or even those applied at the earlobe level, are based on the plethysmo-
graphic method. These use an infrared (or other) photoelectric sensor to record
changes in pulsatile blood flow by calculating the light absorption changes, which
are then translated into BP values. Cuffless BP values are derived through various
methods including calculation of pulse transit time, analysis of the signal using the
Fast Fourier Transform (FFT) and Generalized Transfer Function (GTF), or rela-
tionships between BP and the arterial radial volume changes.
Accuracy of most plethysmography-based cuffless devices for BP measurements
which may be used for HBPM remains controversial. In fact, to our knowledge,
none of these very popular devices (watches, bracelets, smartphone Apps) satisfy
regulatory requirements or has been validated according to currently established
protocols. Therefore, despite their large distribution, mainly as multiple parameters
monitoring bracelets or watches, the use of these devices is not presently recom-
mended for HBPM as their accuracy and reliability remains highly questionable. It
should be mentioned, however, that established validation standards have not been
developed to assess cuffless devices and a new ISO standard for such devices is cur-
rently under development.

1.2.6 Tonometry

Principles of tonometry for measuring radial BP and performing pulse wave analysis
using the transfer function has been reported and described in detail previously else-
where [12]. Briefly, tonometry means “measuring of pressure” whereas applanation
means “to flatten” the arterial wall. Applanation tonometry is performed by placing
one or several tonometers (strain gauge pressure sensor) over the radial artery and
applying soft pressure to obtain an assumed flattened arterial wall. This method was
6 R. Asmar et al.

designed particularly for clinical use by researchers to measure the radial BP and
calculate aortic (central) BP by performing the pulse wave analysis and using algo-
rithms such as the Transfer Function. Considering the importance of aortic BP, man-
ufacturers have tried to extrapolate the use of this technique for HBPM, but this
approach is still under development and at this time remains reserved for research.

1.2.7 Other Techniques

Several other techniques to measure BP have been proposed for HBPM. The most
current methods include:

–– Pulse transit time: this technique is based on the assessment of pulse wave veloc-
ity and on use of its reciprocal variable, the pulse transit time, to calculate beat-­
by-­beat BP values through a dedicated algorithm [13].
–– Smartphone Apps turning the smartphone into a cuffless device. Most of these
Apps use the light absorption changes from a finger to estimate changes in blood
volume and to calculate finger BP values by considering the relationships
between changes of blood volume and the corresponding changes in BP.

None of these techniques can be currently recommended as reliable methods for

performing HBPM.

1.3 Arterial Sites: Which Are Most Suitable for HBPM?

HBPM devices measuring or calculating BP at different arterial sites are now avail-
able: upper-arm, wrist, finger, or even aortic. The choice of the arterial site is impor-
tant, not only because most, if not all, of the hypertension studies have been
performed using brachial BP measurements but also because BP values are not
identical at the different arterial sites due to an “amplification” phenomenon.

1.3.1 Brachial Artery

Most HBPM devices measure BP at the upper-arm level (brachial artery). This mea-
surement is currently recommended by all guidelines.

1.3.2 Radial Artery

–– Oscillometric devices: several HBPM devices measuring BP at the wrist level

(radial artery) are available. These devices are very popular because they are user-
friendly for patients. To limit observer bias and the BP variations between bra-
chial and radial arteries or those due to the wrist position in relation to the heart
level, several wrist devices incorporate interesting features such as a position
Other documents randomly have
different content
 To the south of the chapter house is a large apartment, 50 feet in length by
23 feet wide. It has been vaulted at a late period, and the vaulting shafts still
remain attached to the east, west, and south walls. Their details are of the
third pointed period. There is a fireplace in the centre of the west wall, and
an outer doorway at the south end of the same wall. The apartment was
lighted by three plain round arched windows in the east wall, one of which
has had tracery inserted in after times. At the north-west angle, opening from
the level of the cloister, there is a round-headed doorway, and traces of a
staircase, which doubtless served as the day access to the dormitory. The
large apartment just described was probably the fratery or monks’ day room.
This is the more likely from its having a fireplace, where the monks might
warm themselves

Fig. 417.—Dryburgh Abbey. Arms of John Stewart, 1555.

in cold weather. At the south-east angle of the room, and in the thickness of
the wall, a narrow staircase leads up to where the dormitories were situated.
South of the fratery is the slype or passage 10 feet in width, with arched
openings to the east and west. It has also a doorway to the fratery, and
another to the apartment on the south side. The latter now only exists in part,
the south end of the range having been destroyed.
The range of buildings above described still retains its eastern wall to the
full height of two stories (see Fig. 411.), the upper story being, doubtless, the
dormitory. The wall is all built in a simple early style, with flat buttresses
between the windows, and the latter are plain round-headed openings, with a
single recessed order. The hood mould is in some cases carved with a notch
ornament.
On the south side of the cloister, where the refectory once stood, there
 Fig. 418.—Dryburgh Abbey. West End of Nave—Interior.

are now only the ruins of the vaulted basement on which it stood. At the east
end of this range there is a doorway from the cloister giving access to a
staircase, which led down to the lower level of the fratery, &c. The
remainder of the south side was probably all occupied by the refectory,
Fig. 419.—Dryburgh Abbey. Western Doorway.
which would thus be about 77 feet in length by 27 feet in width. The west
wall is almost all that survives. It is ivy clad, and contains a picturesque
circular window, with radiating tracery (Fig. 416). Adjoining

Fig. 420.—Dryburgh Abbey. North and South Ends of Transept.

this wall in the south-west angle of the cloister there is an arched recess in
the west wall, apparently intended for a tomb and monument; but it is empty.
Over the doorway in this angle is a large shield (Fig. 417),
Fig. 421.—Dryburgh Abbey. North Transept and Choir.
which contains the arms of John Stewart, who was commendator in 1555.
On the shield are the initials “J. S.,” with the crozier in the centre. He was
brother of the Earl of Lennox, and uncle to Lord Darnley, who married
Queen Mary. The arms are those of the Stewarts of Lennox.
The cloister occupies a space of 93 feet by 91 feet. It has been surrounded
by a vaulted walk, which has entirely disappeared. It is evident that the
cloister walk was at least partly vaulted from the small remains of the
springing of the vaults which are visible in the eastern wall on each side of
the doorway to the chapter house (see Fig. 413.). From the way in which
these springings die away to nothing against the wall, without corbel or
support of any kind, it is apparent that the vaulting must have been of a late
date. The corbels which supported the top of the wooden roof over the
vaulting are also still visible in the east wall.
The south wall of the nave of the church extends along the north side of
the cloister. At the north-east angle is the doorway which led from the
cloister into the nave. It is a handsome specimen of the transition style,
having a circular arched head deeply recessed in four or five orders,
springing from three shafts, and two moulded members in the jambs. It is
noteworthy regarding this doorway that the two inner orders of the jambs
and arch had been removed and erected in private grounds, and, after many
years’ absence, were restored to their original position only a short time ago.
The nave of the church is entered through this handsome doorway by ten
steps up from the cloister. It presents a scene of terrible destruction. All the
piers of the nave are demolished, and only slight traces of the north wall
remain; of the south wall, more is preserved. The west end wall (Fig. 418),
however, has to some extent escaped destruction, and shows by the responds
attached to it the form of the nave piers, with their caps and bases. The
position of the piers along the nave is now roughly indicated by a collection
of fragments arranged, as nearly as possible, in the original position and
form. The mouldings indicate a late date, and were, doubtless, restorations;
but the responds, which were not so liable to destruction, are of first pointed
date. The responds which form part of the west wall show that there was a
central nave 28 feet wide and side aisles, each about 13 feet 6 inches wide,
making a total width of 55 feet. There have been side chapels in the nave,
apparently divided by walls, some portions of which remain, with ambries in
the chapels.
 The western doorway (Fig. 419) has a round arched head, but its details
show that it is of late design. This part of the edifice has apparently been
restored in the fifteenth century, after the destruction of the abbey by
Richard II. in the end of the fourteenth century.
The transept has a slight projection to the north and south. It is 80 feet in
length internally from north to south and 37 feet in width, including an
eastern aisle.
This part of the building and all to the east of it are evidently of
Fig. 422.—Dryburgh Abbey. Choir-Aisle and North Transept.
thirteenth century work, but, unfortunately, only a few detached portions
remain. These include (see Fig. 412.) the very picturesque gable of the south
transept, with its large window filled with simple pointed tracery, rising in
steps above the roof of the dormitory (Fig. 420). The arch through which the
stair to the dormitory passed is visible in this wall. (See Fig. 420.)
To the east of the transept is a choir of two bays, with aisles, beyond
which is an aisleless presbytery, 42 feet long by 24 feet wide, now almost
reduced to foundations. The buttresses and base course are traceable, and a
doorway in the north-east angle, which probably led to a small staircase. The
portion of the structure still preserved to the north is a part of the north
transept wall, with the eastern aisle of the transept and the two north bays of
the choir (Fig. 421).
These portions are of very beautiful design, both internally and externally.
The exterior (Fig. 422) is of very simple, but elegant, first pointed work,
while the interior shows symptoms of somewhat more advanced design. The
angle pier of the crossing and the piers of the choir consist of round shafts
with fillets, divided by square angles. These are surmounted by moulded
caps, with round abacus and first pointed mouldings. From these spring the
pier arches, composed of three orders of plain splays, with hood moulding.
Over the main arches is a low triforium marked by string courses above and
below. It has flat arched openings filled in with circles having six cusps.
The clerestory is of beautiful design. Each bay contains an arcade of three
arches, the central one, which is opposite the window, being larger than the
side arches. The arches are supported on detached piers, behind which runs a
gallery. These piers each consist of two shafts, with central fillet. They have
first pointed round caps, over which a round block receives the arch
mouldings as they descend.
A small portion of the north end of the transept adjoins the above, which
shows that the structure has been carried up in two stories of richly moulded
windows (see Fig. 420.), all in the same style as the adjoining portion of the
choir. The remaining portion of the aisle is vaulted with moulded ribs
springing from responds and corbels corresponding in style with the choir.
The whole of this part of the church is of very fine design and
workmanship, but it is, unfortunately, a mere fragment. Additional interest
attaches to it from its forming the last resting-place of Sir Walter Scott and
members of his family.
 AIRTH CHURCH.[197]
This ruined church adjoins the old Castle of Airth, which lies half a mile
from the Forth and eight miles south-east of Stirling. The church is in part a
building of considerable antiquity, dating from the transition period about
the end of the twelfth or the beginning of the thirteenth century, but it has
undergone many alterations, and only a small part of the early structure
remains. The building as it now stands (Fig. 423) consists of a

Fig. 423.—Airth Church. Plan.

nave and chancel, having a south wing or aisle, containing the Airth vault,
and forming a transept, with a tower at the re-entering angle of the Airth
aisle, and with indications of an aisle on the north side of the choir. There are
also two burial vaults attached to the building, one on the north side and the
other at the south-west angle, called respectively the Bruce and Elphinstone
aisles. The internal length of the church is 79 feet 3 inches by about 19 feet 9
inches in breadth. The most ancient part of the church (Fig. 424) is on the
north side of the nave, and consists of a bay of what has been a nave arcade,
opening into a north aisle. One pillar and respond (tinted black on the Plan),
with the connecting round arch, still
Fig. 424.—Airth Church. North Arcade.
stand. The original arcade probably consisted of three bays extending to near
the west gable, where there are indications, at the ground level, of what
appears to have been the western respond. Whether there was originally a
south arcade or not cannot now be determined, as this part has been entirely
rebuilt, and all traces of the north and south aisles of the nave, if there was a
south aisle, have perished. The existing north bay is 11 feet 3 inches wide,
and the pillar, which is circular, is about 17 inches in diameter. It has a
capital, carved with simple foliage (Fig. 425), and has a square abacus. The
arch has a double set of plain arch stones, with plain soffit.
The few details which survive are extremely interesting, and show this to
have been a building of some importance. Behind the above bay now stands
the burial aisle of the Bruces of Powfoulis. It bears over the doorway the
initials of Sir James Bruce and his wife, Dame Margaret Rollox, of Duncrub,
and on another part the date 1614. It seems probable that this, as well as the
other aisles shown on Plan, contained, on the upper floor, the family seats or
galleries of the respective houses whose arms they bear, and a burial vault
beneath.

Fig. 425.—Airth Church. Cap of Pillar.

 Judging from the few details left, the Airth aisle is a structure of the
fifteenth century. It measures about 24 feet 3 inches long by 13 feet 3 inches
wide, and has contained a large traceried south window, which is now
destroyed, and brought to the condition shown in Fig. 426. The external
hood moulding of the window remains with nicely carved terminations (Fig.
427). Beneath this window is seen the top of an arched tomb, in which
probably the recumbent effigy (Fig. 428) once lay. There is a small square-
headed window in the east wall, divided by a mullion; but, as appears from
its mouldings, it is an insertion of perhaps the seventeenth century.
Adjoining this is the usual ambry. Beneath this aisle is the burial vault
(indicated by dotted lines on the Plan), which is reached by the stair shown.
On the outside of the east wall there is a niche for a statue (Fig. 429). It has
the usual canopy and bracket so frequent on the churches of this late period.
The bracket (Fig. 430) contains the Bruce arms—viz., the chief and saltier;
the chief being charged with two incised cinquefoils, which may point to an
alliance with the Livingstone family. The same arms, but without the
cinquefoils,
 Fig. 426.—Airth Church. The Airth Aisle, looking South.

appear beneath each of the first crow steps of the gable. This aisle was
probably erected by Alexander Bruce of Stenhous and first of Airth (1452 to
1483), who was a son of Sir Robert Bruce of Clackmannan,[198] and is stated
to have married (first) Janet, daughter of the first Lord Livingstone, by
whom he had no issue. It was probably “our Ladie Aisle, founded and
situated on the south side of the Kirk of Airth,” the chaplainrie of which was
presented by Sir Alexander Bruce of
Airth, the patron, to Robert
Bruce, younger, his son, on 30th
October 1572.
 Fig. 427.—Airth Church. Terminations.

Fig. 428.—Airth Church. Effigy.

The effigy (see Fig. 428.), which, as already stated, probably occupied the
tomb in the Airth aisle, lies at present in a mutilated state in the
 Fig. 429.—Niche for Fig. 430.— Fig. 431.—Stone in
Statue. Bracket. Airth Castle.

eastern portion of the church. There is no certainty whom the recumbent

figure represents, but it is in all likelihood an effigy of one of the ladies of
either the family of Erth or of the Bruces of Airth. It has been stated that
another effigy lies beside the one referred to, but we understand from a
person who has examined the ground that nothing of the kind is to be found.
This effigy, which is 6 feet 3 inches long by 1 foot 10 inches in breadth, is
greatly mutilated; but the coverlet extending from the waist downwards is
well preserved, and is very finely carved, and, so far as we know, is unique
amongst Scottish figures.
In Airth Castle is preserved the stone shown in Fig. 431. It appears to
have been taken from the church and to have formed a part of a piscina or
ambry. The fragment measures about 2 feet high, with an opening about 12½
inches wide. It doubtless belonged to the Airth aisle.
 Fig. 432.—Airth Church. Stone in South Gable of Elphinstone Aisle.

The Elphinstone aisle, which is separated from the nave by a semicircular

arch, presents no architectural features of note; but on the exterior of the
gable towards the south there is a well-preserved stone (Fig. 432), with
shield bearing the Elphinstone arms, parted per pale with those of
Livingstone and Calendar quarterly, with the motto “Cavis Cavis” (Caus
Caus), the date 1593, and at either side the letters M A ♢ E and I ♢ L ME,
the initials of Alexander, fourth Lord Elphinstone, and his wife Jane, eldest
daughter of William, sixth Lord Livingstone.
The tower contains, on the lintel of the doorway, the inscription I V L Y +
THE + 15 + 1647, doubtless the date of its erection. The other parts of the
church appear to be of late seventeenth century work, and need not be
further referred to.

LASSWADE CHURCH, Mid-Lothian.

Lasswade is a village on the south bank of the river Esk, about six miles
south from Edinburgh. The old Parish Church stood, till 1866, in the ancient
churchyard, on a height above the south side of the river. “It became a
mensal church of the Bishopric of St. Andrews in the twelfth century,
forming a prebend of St. Salvator’s Church; but was annexed to the
Collegiate Church of Restalrig, in the reign of King James III.”[199]

Fig. 433.—Lasswade Church. Plan.

The old structure having become unsuitable, a new church was erected in
1793, and the old building was allowed to fall into ruins. Some portions,
however, were preserved, and converted into mausoleums. In one of these
aisles lie the remains of Henry Dundas, first Lord Melville; in another is
buried the poet Drummond of Hawthornden.
The old church (Fig. 433) consisted of a single oblong chamber 20 feet in
width, with a tower 16 feet square at the west end. The aisles, or
 Fig. 434.—Lasswade Church. East, West, and North Elevations.

mausoleums, above referred to, are projected from the north side. The
westmost is roofed with stone slabs, and has a picturesque appearance.
The tower and a portion of the church were of considerable age, and may
be classed as Transition work. In 1866 the tower had become much crushed
and dangerous. While steps were being taken by the heritors
Fig. 435.—Lasswade Church. South Elevation.
to have it strengthened the tower fell. The accompanying drawings were
made before that event.
The tower (Fig. 434) was three stories in height, besides the gables of the
saddle roof which crowned it. The entrance to the tower was from the inside
of the church by a round-headed doorway (see East Elevation), with simple
impost and plain arch with hood moulding. Above this was a large round-
arched opening into the roof of the church. The two lower stories had narrow
pointed windows. The top story had double-pointed lights, with central
mullion in each face. This story had an enriched cornice, above which rose
the east and west gables, each with a small round-headed window. A door
had been knocked into the tower on the south side (Fig. 435), which,
doubtless, helped to weaken it.
In a portion of the south wall of the church, near the tower, there was
preserved an original doorway (see Fig. 435.) about 5 feet 6 inches wide. It
resembled that to the tower in design, having plain jambs, with a string
course forming the imposts, and a plain round arch above, enclosed with a
hood moulding. All the above features seem to point to the structure being
one of the first half of the thirteenth century.
Annexed is a sketch of the effigy of a knight in armour (Fig. 436), which
is lying in the churchyard. There is no record of the knight’s name.

Fig. 436.—Effigy in Churchyard.

BATHGATE CHURCH, Linlithgowshire.

About one mile east from the town of Bathgate stands the old ruined
church, surrounded by an ancient burial-ground. It is a long, narrow,
 Fig. 437.—Bathgate Church. Plan.

ivy-covered building (Fig. 437), measuring internally about 91 feet 2 inches

from east to west by 19 feet 5 inches from north to south, with walls from 3
to 4 feet in thickness. The doorway, which was probably round arched, is
almost the only feature of its architecture left. The opening is unusually
wide, showing 7 feet of daylight (see Fig. 437.), and, judging from its
details, the church belonged to the transitional period. The doorway was
decorated with shafts placed in square nooks or recesses, with carved
capitals having the square abacus, a certain feature of early work. (Fig. 438.)
Both inside and outside the walls are so entirely covered either with ivy or
tombstones that almost no part of the masonry can be seen; only one small
window on the north side, about six inches wide, being partly visible.
 Fig. 438.—Bathgate Church. Caps.

The grave slab (Fig. 439) has lately been fixed into the south wall. Some
time ago it was lying on the floor. It measures 6 feet 2 inches long by 2 feet
3 inches wide, and bears a beautifully lettered inscription to the memory of
Andreas Crichton. In the centre of the slab there is a cross, with the Calvary
steps, and beneath the cross limb a shield with the Crichton arms (a lion
rampant), and on the dexter side a long sword.
In the Exchequer Rolls for the year 1497, Andrew Crichton of Drumcorse
(the name of the estate adjoining the church on the north) first comes into
view. On the 1st May 1502, Crichton entered office as the Chamberlain of
the Lordship of Linlithgowshire. He presents his accounts yearly, his last
being rendered from July 1513 to July 1514, when he presumably died. His
monumental slab was, doubtless, carved shortly after that date.
There is a very beautiful recumbent statue (Fig. 440) lying in the church.
It appears to be an early work, but no record exists to tell whose memory it
commemorates.
 Fig. 439.—Bathgate Church. Slab in Church to Andreas Crichton.

Malcolm IV. (1153 to 1165) granted the church of “Bathket,” with certain
lands, to Holyrood.[200] Robert, Bishop of St. Andrews, who died about
1159, confirmed those grants. There was, further, a Papal confirmation in
1164. In 1251, by a taxation of churches in the diocese of St. Andrews, the
vicar of the Church of Bathgate was to receive 12 merks of the altar dues, to
be assigned him at the sight of William, Archdeacon of Lothian, and Master
Alexander, of Edinburgh. This was confirmed by Bishop Gamelin.

Fig. 440.—Bathgate Church. Effigy.

 The church and lands were afterwards given by the monks of Holyrood to
Newbotle, in payment of arrears of rent for lands and salt works in the Carse
of Callender, and this was confirmed by Bishop Landels, of St. Andrews, in
1327.[201] The church remained with Newbotle, and was served by a vicar
till the Reformation.
The old church was probably abandoned in 1739, when a new church was
erected in the town of Bathgate.
From Dryburgh Abbey.
 INDEX.
A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, P, R, S, T, U, V, W.
Abb’s, St., Chapel, 437.
Abercorn Church, description, 346.
Aberdeen Cathedral, 47.
—— St. Nicholas, description, 426.
Abernethy Tower, 11, 15, 26;
description, 175.
Adamnan, 11.
Aidan, St., 11.
Airth Church, description, 465.
Alexander I., 29.
—— II. and III., 50.
Allen, J. Romilly, 2.
Alnwick, 47.
Anchorites, 1.
Anderson, Dr. Joseph, 2, 3, 66.
Antiquaries of Scotland, 101.
Arbroath Abbey, 38, 47, 48, 49.
Arched style of building, 32.
Architecture, Scottish, of Fourteenth to Sixteenth Centuries, 50.
—— Division of, 53.
—— Ceases to be like English, 52.
—— Connection with French, 52.
Ardoilean, 8.
Armstrong, R. B., 465.
Augustine, St., 12.
Aula, St., Gress, Lewis, 83.

Bangor Monastery, 5.
Bathgate Church, description, 474.
Bede, 12.
Beehive Cells, 7, 24, 68.
Benedict Biscop, 12.
Beverley Minster, 54.
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