Skip to main content

Thank you for visiting You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

Assessment of diastolic blood pressure with the auscultatory method in children and adolescents under exercise conditions


Controversy surrounds whether to define resting diastolic blood pressure (DBP) as the onset of the fourth or fifth Korotkoff phase (K4, sound muffling, or K5, sound disappearance) in children and adolescents. Although undetectable in some children (due to sounds continuing to zero cuff pressure), K5 is currently recommended for consistency with adult practice and because K4 can be difficult to discern or undetectable. However, to our knowledge, no studies have specifically assessed the reliability of measuring DBP with K4 and K5 in children and adolescents under exercise conditions. We therefore measured DBP before and immediately after a Bruce protocol stress test in 90 children and adolescents aged 12.3 ± 3.5 years (mean ± SD) in a cardiology clinic setting. When detected, K4 and K5 were 63.5 ± 9.2 and 60.2 ± 12.6 mmHg, respectively, at rest and 59.2 ± 14.6 mmHg (p = 0.028 vs rest) and 52.9 ± 18.3 mmHg (p < 0.001), respectively, immediately post-exercise. K4 and K5 were not detected in 41% and 4% of participants at rest or in 29% and 37% post-exercise, respectively, while K5 resulted in unrealistic DBP values (<30 mmHg) in an additional 11%. Better exercise performance was associated with a more frequent absence of K5 post-exercise, and after excluding participants performing at <10th percentile for age, post-exercise K4 was absent in 23%, and plausible K5 values were not obtained in 59% (p < 0.001). Although neither K4 nor K5 alone were reliable measures of DBP immediately post-exercise, a novel hybrid approach using K4, if detected, or K5, if not, produced reasonable DBP measurements in 97% of participants.

Access options

Rent or Buy article

Get time limited or full article access on ReadCube.


All prices are NET prices.


  1. 1.

    Yang L, Magnussen CG, Yang L, Bovet P, Xi B. Elevated blood pressure in childhood or adolescence and cardiovascular outcomes in adulthood: a systematic review. Hypertension. 2020;948–55.

  2. 2.

    Theodore RF, Broadbent J, Nagin D, Ambler A, Hogan S, Ramrakha S. et al. Childhood to early mid-life systolic blood pressure trajectories: early life predictors, effect modifiers, and adult cardiovascular outcomes. Hypertension. 2015;66:1108–15.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  3. 3.

    Juonala M, Magnussen CG, Venn A, Dwyer T, Burns TL, Davis PH, et al. Influence of age on associations between childhood risk factors and carotid intima-media thickness in adulthood: The cardiovascular risk in young finns study, the childhood determinants of adult health study, the bogalusa heart study, and the muscatine st. Circulation. 2010;122:2514–20.

    Article  PubMed  Google Scholar 

  4. 4.

    Chen X, Wang Y. Tracking of blood pressure from childhood to adulthood: a systematic review and meta-regression analysis. Circulation. 2008;117:3171–80.

    Article  PubMed  PubMed Central  Google Scholar 

  5. 5.

    Hao G, Wang X, Treiber FA, Harshfield G, Kapuku G, Su S. Blood pressure trajectories from childhood to young adulthood associated with cardiovascular risk. Hypertension. 2017;69:435–42.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  6. 6.

    Sylvestre MP, Kâ K, Dugas EN, Zappitelli M, O’Loughlin J. Sex-specific trajectories of systolic and diastolic blood pressure in youth. J Hypertens. 2017;35:1416–23.

    CAS  Article  PubMed  Google Scholar 

  7. 7.

    Sundström J, Neovius M, Tynelius P, Rasmussen F. Association of blood pressure in late adolescence with subsequent mortality: cohort study of Swedish male conscripts. Br Med J. 2011;342:483

    Article  Google Scholar 

  8. 8.

    Mahoney LT, Schieken RM, Clarke WR, Lauer RM. Left ventricular mass and exercise responses predict future blood pressure. The muscatine study. Hypertension. 1988;12:206–13.

    CAS  Article  PubMed  Google Scholar 

  9. 9.

    Lurbe E, Cifkova R, Cruickshank JK, Dillon MJ, Ferreira I, Invitti C, et al. Management of high blood pressure in children and adolescents: recommendations of the european society of hypertension. J Hypertens. 2009;27:1719–42.

    CAS  Article  PubMed  Google Scholar 

  10. 10.

    Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140:1–72.

    Article  Google Scholar 

  11. 11.

    Biro FM, Darziels SX, Similo SL, Baton BA, Payne GH. Differential classification of blood pressure by fourth and fifth Korotkoff phases in school-aged girls. Am J Hypertens. 1996;9:242–7.

    CAS  Article  Google Scholar 

  12. 12.

    Elkasabany AM, Urbina EM, Daniels SR, Berenson GS. Prediction of adult hypertension by K4 and K5 diastolic blood pressure in children: the bogalusa heart study. J Pediatr. 1998;132:687–92.

    CAS  Article  PubMed  Google Scholar 

  13. 13.

    Butani L, Morgenstern BZ. Are pitfalls of oscillometric blood pressure measurements preventable in children? Pediatr Nephrol. 2003;18:313–8.

    Article  PubMed  Google Scholar 

  14. 14.

    Moss AJ. Criteria for diastolic pressure: revolution, counterrevolution, and now a compromise. Pediatrics. 1983;71:854–5.

    CAS  PubMed  Google Scholar 

  15. 15.

    Moss AJ, Adams FH. Index of indirect estimation of diastolic blood pressure. Am J Dis Child. 1963;106:364–7.

    CAS  Article  PubMed  Google Scholar 

  16. 16.

    Londe S. Fifth versus fourth Korotkoff phase. Pediatrics. 1985;76:460–1.

    CAS  PubMed  Google Scholar 

  17. 17.

    Rosner B, Polk BF. The implications of blood pressure variability for clinical and screening purposes. J Chronic Dis. 1979;32:451–61.

    CAS  Article  PubMed  Google Scholar 

  18. 18.

    O’Sullivan J, Allen J, Murray A. A clinical study of the Korotkoff phases of blood pressure in children. J Hum Hypertens. 2001;15:197–201.

    Article  PubMed  Google Scholar 

  19. 19.

    Londe S, Klitzner TS. Auscultatory blood pressure measurement - effect of pressure on the head of the stethoscope. West J Med. 1984;141:193–5.

    CAS  PubMed  PubMed Central  Google Scholar 

  20. 20.

    Uhari M, Nuutinen M, Turtinen J, Pokka T. Pulse sounds and measurement of diastolic blood pressure in children. Lancet. 1991;338:159–61.

    CAS  Article  PubMed  Google Scholar 

  21. 21.

    Sinaiko AR, Gomez-Marin O, Prineas RJ. Diastolic fourth and fifth phase blood pressure in 10—15-year-old children. Am J Epidemiol. 1990;132:647–55.

    CAS  Article  Google Scholar 

  22. 22.

    Freedman DS, Foltz JL, Berenson GS. Differences between the fourth and fifth Korotkoff phases among children and adolescents. Am J Hypertens. 2014;27:1495–502.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  23. 23.

    Hammond IW, Urbina EM, Wattigney WA, Bao W, Steinmann WC, Berenson GS. Comparison of fourth and fifth Korotkoff diastolic blood pressures in 5 to 30 year old individuals. Am J Hypertens. 1995;8:1083–9.

    CAS  Article  Google Scholar 

  24. 24.

    National High Blood Pressure Education Program Working Group on Hypertension Control in Children and Adolescents. Update on the 1987 task force report on high blood pressure in children and adolescents: a working group report from the National High Blood Pressure Education Program. Pediatrics. 1996;88:649–58.

    Google Scholar 

  25. 25.

    Allison TG, Cordeiro MAS, Miller TD, Daida H, Squires RW, Gau GT. Prognostic significance of exercise-induced systemic hypertension in healthy subjects. Am J Cardiol. 1999;83:371–5.

    CAS  Article  PubMed  Google Scholar 

  26. 26.

    Thanassoulis G, Lyass A, Benjamin EJ, Larson MG, Vita JA, Levy D, et al. Relations of exercise blood pressure response to cardiovascular risk factors and vascular function in the framingham heart study. Circulation. 2012;125:2836–43.

    Article  PubMed  PubMed Central  Google Scholar 

  27. 27.

    Yzaguirre I, Grazioli G, Domenech M, Vinuesa A, Pi R, Gutierrez J, et al. Exaggerated blood pressure response to exercise and late-onset hypertension in young adults. Blood Press Monit. 2017;22:339–44.

    Article  PubMed  Google Scholar 

  28. 28.

    Paridon SM, Alpert BS, Boas SR, Cabrera ME, Caldarera LL, Daniels SR, et al. Clinical stress testing in the pediatric age group: a statement from the American Heart Association council on cardiovascular disease in the young, committee on atherosclerosis, hypertension, and obesity in youth. Circulation. 2006;113:1905–20.

    Article  PubMed  Google Scholar 

  29. 29.

    Sharman JE, Lagerche A. Exercise blood pressure: clinical relevance and correct measurement. J Hum Hypertens. 2015;29:351–8.

    CAS  Article  PubMed  Google Scholar 

  30. 30.

    Washington RL, Bricker JT, Alpert BS, Daniels SR, Deckelbaum RJ, Fisher EA, et al. Guidelines for exercise testing in the pediatric age group: from the Committee on Atherosclerosis and Hypertension in Children, Council on Cardiovascular Disease in the Young, the American Heart Association. Circulation. 1994;90:2166–79.

    CAS  Article  PubMed  Google Scholar 

  31. 31.

    Alpert BS, Fox ME. Blood pressure response to dynamic exercise. In Rowland TW, editor, Pediatric laboratory exercise testing: clinical guidelines, 1st ed. Champaign, Illinois, USA: Human Kinetics; 1993. p. 67–90.

  32. 32.

    Møller NC, Grøntved A, Wedderkopp N, Ried-Larsen M, Kristensen PL, Andersen LB, et al. Cardiovascular disease risk factors and blood pressure response during exercise in healthy children and adolescents: the European youth heart study. J Appl Physiol. 2010;109:1125–32.

    Article  PubMed  Google Scholar 

  33. 33.

    Alpert BS, Dover EV, Booker DL, Martin AM, Strong WB. Blood pressure response to dynamic exercise in healthy children-black vs white. J Pediatr. 1981;99:556–60.

    CAS  Article  PubMed  Google Scholar 

  34. 34.

    Bruce R, Kusumi F, Hosmer D. Maximal oxygen intake and nomographic assessment of functional aerobic impairement in cardiovascular disease. Am Heart J. 1973;85:546–62.

    CAS  Article  Google Scholar 

  35. 35.

    Cumming GR, Everatt D, Hastman L. Bruce treadmill test in children: normal values in a clinic population. Am J Cardiol. 1978;41:69–75.

    CAS  Article  PubMed  Google Scholar 

  36. 36.

    Gardner MJ, Altman DG. Statistics with confidence: confidence intervals and statistical guidelines. 1st ed. London: BMJ Publishing; 1989.

  37. 37.

    Benmira A, Perez-Martin A, Schuster I, Veye F, Triboulet J, Berron N, et al. An ultrasound look at Korotkoff sounds: the role of pulse wave velocity and flow turbulence. Blood Press Monit. 2017;22:86–94.

    Article  PubMed  Google Scholar 

  38. 38.

    Drzewiecki GM, Melbin J, Noordergraaf A. The Korotkoff sound. Ann Biomed Eng. 1989;17:325–59.

    CAS  Article  PubMed  Google Scholar 

  39. 39.

    Park MK, Menard SW, Yuan C. Comparison of auscultatory and oscillometric blood pressures. Arch Pediatr Adolesc Med. 2001;155:50–53.

    CAS  Article  Google Scholar 

  40. 40.

    Flynn JT, Pierce CB, Miller ER, Charleston J, Samuels JA, Kupferman J, et al. Reliability of resting blood pressure measurement and classification using an oscillometric device in children with chronic kidney disease. J Pediatr. 2012;160:434–440.e1.

    Article  PubMed  Google Scholar 

  41. 41.

    Wong SN, Rita RY, Leung LCK. Validation of three oscillometric blood pressure devices against auscultatory mercury sphygmomanometer in children. Blood Press Monit. 2006;11:281–91.

    Article  PubMed  Google Scholar 

  42. 42.

    Mynard JP, Goldsmith G, Springall G, Eastaugh L, Lane GK, Zannino D, et al. Central aortic blood pressure estimation in children and adolescents. J Hypertens. 2020;38:821–8.

    CAS  Article  PubMed  Google Scholar 

  43. 43.

    Muntner P, Shimbo D, Carey RM, Charleston JB, Gaillard T, Misra S, et al. Measurement of blood pressure in humans: a scientific statement from the American Heart Association. Hypertension. 2019;73:E35–E66.

    CAS  Article  PubMed  Google Scholar 

Download references



This work was supported by a grant from the National Health and Medical Research Council of Australia (APP1128516). JPM is supported by a co-funded R.D. Wright Career Development Fellowship from the National Health and Medical Research Council of Australia (APP1143510) and Future Leader Fellowship from the National Heart Foundation of Australia (101866). The Heart Research Group is supported by the Victorian Government’s Operational Infrastructure Support Program, RCH 1000 and Big W.

Author information



Corresponding author

Correspondence to Jonathan P. Mynard.

Ethics declarations

Conflict of interest

JPM is a consultant for the Brain Protection Company, Tournicare, Masimo Corporation and Baxter Healthcare; none of these consultancies have any relation to the present work. All other authors declare no competing interests.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Glenning, J.P., Lam, K., Clarke, M.M. et al. Assessment of diastolic blood pressure with the auscultatory method in children and adolescents under exercise conditions. Hypertens Res (2021).

Download citation


  • Blood pressure measurement
  • Children
  • Diastolic blood pressure
  • Exercise stress test
  • Korotkoff sounds


Quick links