Blood pressure trace: 6 patterns from AFib to orthostatic drop

A blood pressure monitor ends with two numbers. Between them lie forty, sixty or eighty heartbeats, and each one builds its own pressure. Most of the time these beats are so alike that the average hides nothing important.

With some heart rhythms and circulatory reactions it is the other way round: what matters happens between the numbers. This article shows six typical patterns as they look in a beat-to-beat trace – and what a single reading leaves of them.

About the charts: All animations in this article are schematic illustrations. They show typical shapes, not recordings of real patients, and the numbers are rounded example values. Only a doctor can make a diagnosis – for rhythm disorders, with an ECG.

How to read the charts

The red curve is the pressure in the artery. Each wave is one heartbeat: the peak is that beat's systolic value, the low point before it the diastolic value. The blue line below shows the pulse, the teal line the breathing. On the right you see the values of the current beat.

Even in a healthy rhythm no two beats are exactly alike. When you breathe in, the pulse gets slightly faster and the systolic value drops a few mmHg; when you breathe out, the opposite happens. This is normal and one of the reasons two readings taken back to back never match exactly. More on this in Why your blood pressure is different every time you measure it. This calm baseline is the reference for all the patterns that follow.

Atrial fibrillation: no two beats alike

In atrial fibrillation the atria no longer set an orderly beat, and the ventricles contract at irregular intervals. In the chart, short and long intervals alternate with no recognizable pattern – and the pressure changes with them. After a long interval the ventricle has filled more and the next beat is stronger; after a short one it is weaker. The gentle swing with breathing is lost.

Some people feel palpitations or a bumpy pulse; many feel nothing. The German Heart Foundation (Deutsche Herzstiftung) describes atrial fibrillation as a rhythm disorder that often goes unnoticed and is found by chance. High blood pressure is among its most important causes – more on this in Atrial fibrillation and smartwatches: what the sensor really picks up.

For blood pressure measurement this pattern is difficult. When the pressure differs strongly from beat to beat, the result of a single reading depends on which beats happened to be captured. Experts point out that the diastolic value in particular becomes unreliable and that most automatic monitors were never specifically validated in atrial fibrillation. Their advice, explicitly labelled as expert opinion: average several readings. Why many monitors show a heart symbol in this situation is explained in our article Blood pressure monitor: what the heart symbol really means.

Premature beats: one beat too early, then a strong one

A premature beat (extrasystole, in the ventricles often called PVC) is a heartbeat that starts before the next regular beat is due. In the chart it comes so early that the ventricle has barely filled: the wave stays small (marked “PVC”), and its systolic value is far below that of its neighbours. A pause follows, during which the pressure keeps falling. Because the ventricle fills for longer during that pause, the next regular beat is noticeably stronger.

This is exactly the sequence many people describe as a skipped beat: a gap, then a beat you can feel. According to the German Heart Foundation, premature beats are a common cause of this sensation, and single premature beats are usually harmless in the absence of other heart disease. A skipping heart should still be checked, because atrial fibrillation can feel similar.

On a monitor, premature beats often go unnoticed. Frequent extra beats can, however, trigger the same heart symbol as atrial fibrillation – the device reports an irregularity, not its type.

Pauses: when the pressure keeps falling

During a pause the heartbeat stops for a moment. In the chart the heart is already beating slowly, around 54 beats per minute, and every few beats the next one is missing for 2.6 seconds. No new pressure pulse arrives in that time; the pressure keeps falling, below the usual diastolic level. The first beat afterwards is stronger again. The pulse display shows only a dash during the pause.

Such pauses can be caused by disorders of the sinus node, the heart’s natural pacemaker, or of the conduction system. Short pauses like the 2.6 seconds in the chart often go unnoticed. According to the German Heart Foundation’s guide, it is pauses of more than five seconds that cause symptoms such as dizziness or reduced exercise tolerance, and longer ones can cause brief loss of consciousness.

A single home reading catches such a pause only by chance – and even then it shows up at most as a slightly lower pulse.

Pressure spike: up high and quickly gone

This pattern plays out on a different time scale. The chart is a time-lapse: one second equals about one minute. Within a few minutes the systolic value rises from around 134 to 185 mmHg, the diastolic from 84 to 106, the pulse from 70 to 88. After a while everything returns to where it started.

Some people notice a flushed face, headache or dizziness – signs that the patient information of the German National Care Guideline (NVL) on hypertension also lists. Many feel nothing.

What counts is how long it lasts. The guideline speaks of a hypertensive derailment when the systolic value is above 180 and the diastolic above 110 mmHg, and advises: stay calm and measure again after half an hour. The spike in the chart reaches 185 systolic but stays at 106 diastolic – and it is long over after half an hour. The follow-up reading tells you whether your pressure is persistently too high. It does not tell you how high a short spike went in between.

Orthostatic drop: you stand up, and the pressure sags

When you stand up, blood pools in the legs. For a few seconds it is missing from the circulation until the vessels constrict and the pulse rises. In the chart the dashed line marks the moment of standing: within two seconds the systolic value falls from 126 to about 96 mmHg, the diastolic from 80 to 68, and the pulse rises from 64 to around 98. Both then settle again within six to seven seconds.

A certain drop in the first seconds is normal; in studies of young adults it averaged roughly 20 to 26 mmHg systolic. Specialists distinguish two forms. Initial orthostatic hypotension is a transient drop of at least 40 mmHg systolic or 20 mmHg diastolic within 15 seconds. Classic orthostatic hypotension is a sustained drop of at least 20/10 mmHg within three minutes. The chart shows a pronounced initial reaction that meets neither threshold.

Typical symptoms are dizziness, vision going dark and feeling unsteady, easing within seconds. A cuff measurement takes longer than the whole event. A review of the diagnostic criteria therefore states that beat-to-beat recordings are needed to capture the first seconds after standing reliably.

What a trace can show – and what it cannot

All six patterns have one thing in common: they unfold within seconds or a few minutes. A single reading, by contrast, gives you two numbers at one point in time.

Pattern	Visible in the trace	What you may feel	What a single reading shows
Normal rhythm	even waves, slight swing with breathing	nothing	a reliable value
Atrial fibrillation	irregular intervals, changing pressure	palpitations, often nothing	fluctuating values, unreliable diastolic, often heart symbol
Premature beats	early weak beat – pause – strong beat	skipped beat	usually nothing, heart symbol if frequent
Pauses	seconds without a beat, pressure keeps falling	often nothing, dizziness with long pauses	caught only by chance
Pressure spike	rise over minutes, then decline	headache, flushed face, often nothing	a normal value if measured afterwards
Orthostatic drop	drop within seconds of standing, pulse rises	dizziness, vision going dark	nothing, because readings are taken seated

The limit matters just as much. A pressure trace shows how the circulation behaves; it does not show the electrical cause of a rhythm disorder. Whether an irregular trace reflects atrial fibrillation, premature beats or something else is clarified by an ECG. A conspicuous trace is a reason to talk to your doctor, not a diagnosis. How to get reliable values at home is covered in Measuring blood pressure correctly: 7 mistakes that distort your readings.

When to seek medical advice

• If your monitor repeatedly reports an irregular pulse, or you notice a skipping heart that is new or frequent.
• If you feel persistent irregular palpitations.
• If you experience dizziness, vision going dark or fainting – even if it only happens when you stand up.
• If your blood pressure is above 180/110 mmHg and a follow-up reading after 30 minutes of rest is not clearly lower.
• Call 112 immediately for chest pain, shortness of breath, paralysis, visual or speech disturbances, or loss of consciousness. A blood pressure reading does not replace emergency care in this situation.

Bring your readings with date and time to your appointment, and note what you felt at the moment of each one.

See your own trace instead of two numbers: the BPER blood pressure event recorder records pressure, pulse and rhythm over 60 seconds – beat by beat.