# Which Systolic Blood Pressure Measure Is Most Important for Determining Cardiovascular Risk: Seated or Supine Blood Pressure?

## TL;DR

This paper reviews how different blood pressure measurements, like seated and supine, affect cardiovascular risk prediction and suggests supine BP may offer additional insights.

## Contribution

The paper highlights the novel role of supine blood pressure in improving cardiovascular risk prediction beyond seated measurements.

## Key findings

- Supine-only hypertension is associated with comparable cardiovascular risk to hypertension in both seated and supine positions.
- Supine BP is a stronger predictor of CV risk in individuals under 65 years of age.
- Nocturnal hypertension and dipping patterns from ABPM are strong CV risk predictors, but supine nocturnal HBPM remains under-researched.

## Abstract

In clinical practice, the diagnosis of hypertension is based on non-invasive upper-arm cuff blood pressure (BP) measurement. Most measurements are performed seated, although evidence indicates that supine BP may provide additional information. This review summarises recent findings on the influence of body posture on BP readings and cardiovascular (CV) risk prediction across office, ambulatory, and home BP monitoring (OBPM, ABPM, HBPM), their clinical implications and future research directions.

In OBPM, patients with supine-only hypertension demonstrated CV risk comparable to patients with hypertensive BP in both positions, and a higher risk than seated-only hypertensives. Supine hypertension was particularly predictive in individuals under 65 years of age. In ABPM, the strongest predictors of CV events are nocturnal hypertension and abnormal dipping patterns, particularly when patients are truly asleep, whereas supine nocturnal HBPM has been less extensively investigated.

Current clinical practice remains primarily based on seated BP measurements. Recent trials have highlighted that supine OBPM may provide additional predictive power in the assessment of CV risk. These findings offer a partial explanation for the residual high predictive value of nocturnal BP values which can be derived from ABPM or specialised HBPM devices that goes beyond the correlation of breathing related sleep disorders Research should focus on homogenising supine risk data into composite risk scores combining seated and supine BP while new outcome studies should consider including supine BP measurement. Future guideline committees should consider recommending the structured clinical application of supine BP, given its demonstrated prognostic benefits.