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Inter-arm blood pressure differences

Measuring blood pressure in both arms is recommended for initial patient evaluation. A large inter- arm blood pressure (BP) difference (IAD) (≥10 mm Hg systolic) may be a manifestation of peripheral vascular disease, congenital heart disease, musculoskeletal abnormality, or aortic dissection. In patients with hypertension, its importance lies primarily in indicating that repeated BP determinations should be consistently performed in the arm with the higher reading. Moreover, in hypertensive patients it has been shown that a wide IAD is associated with increased cardiovascular mortality, and in patients with chronic kidney disease it has been associated with shortened survival. Despite such findings, it has been suggested that BP measurement in both arms is part of the assessment of fewer than one-quarter of all patients.

In this issue, Willem Verberk and colleagues from the Netherlands present their analysis of 46 studies (culled from nearly 700 reports), involving 14,540 subjects, that systematically tested BP difference between arms. Although the studies were heterogeneous, the authors contend that the large numbers involved, and the focus of the question, justified a meta-analysis to address their question. The principal variables explored were numbers of measurements, whether an automatic or a manual device was used to measure BP, and whether the comparison was sequential or simultaneous. Overall, the mean BP difference between arms was 5.4/3.6 mm Hg. However, 14% of subjects had a systolic difference ≥10 mm Hg, and in 4% it was ≥20 mm Hg; 7% had a diastolic IAD of ≥10 mm Hg. There was no correlation of wide IAD with handedness, age, gender, or blood pressure. Further analyses revealed that the prevalence of wide IAD was reduced when two or more measurements were made simultaneously using an automatic device. The clinical efficacy, if any, of IAD in contributing to detection of underlying pathology is unknown. Thus, to determine whether routine use of the most precise (and costly) method-an automatic device with dual cuffs-is always worthwhile requires further study. However, given the frequency of a clinically significant disparity between arms, more frequent assessment of IAD might lead both to improved estimation of cardiovascular risk, particularly in patients without other risk factors, and ensure accuracy in assessing BP response to treatment. See page 1201

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