To define the relationship between arm and leg blood pressure to inform the interpretation of leg blood pressure readings in routine clinical practice where arm readings are not available. Methods: Systematic review of all existing studies comparing arm and leg blood pressure measurements. A search strategy was designed in MEDLINE and adapted to be run across six further databases. Articles were deemed eligible for inclusion if they measured and reported arm and leg blood pressure taken in the supine position and/or the difference between the two. Mean values for arm-leg blood pressure difference and measures of precision (95% confidence intervals [CI] or standard deviation) were extracted and entered into a random-effects meta-analysis. Results: A total of 887 articles were screened and 44 were included in the descriptive analyses, including 9,771 patients. In the general population, ankle systolic blood pressure was 17.0 mmHg (95%CI 15.4 to 21.3 mmHg) higher than arm blood pressure in the supine position. For diastolic blood pressure, there was no difference between arm and ankle blood pressure (-0.3 mmHg, 95%CI-1.5 to 1.0 mmHg). In patients with vascular disease, systolic blood pressure was-33.3 mmHg (95%CI-59.1 to-7.6 mmHg) lower in the ankle compared to the arm. Conclusions: This is the first review to provide empirical data defining the difference between blood pressure in the arm and leg in the general population. Findings suggest a diagnostic threshold of 155/90 mmHg could be used for diagnosing hypertension when only ankle measurements are available in routine practice.

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Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are effective and widely used antihypertensive drugs. Exposure to these agents is known to be harmful to the fetus in the second and third trimesters of pregnancy. Concerns have also been raised about the risk of congenital malformations if ACEIs or ARBs are taken during the first trimester of pregnancy. The evidence to date, however, is conflicting and observed malformations may be due to confounders such as undiagnosed diabetes or maternal obesity, other antihypertensive medications or the hypertension itself. Nonetheless, in women who become pregnant while taking an ACEI or ARB, the drug should be stopped as soon as possible. In women with chronic kidney disease and proteinuria, it may be appropriate to continue taking an ACEI or ARB until the pregnancy is confirmed because of the significant benefit to their kidney function and the lower fertility rate in these patients.

Poor adherence with pharmacotherapy is well recognised as one of the main barriers to achieving satisfactory blood pressure control, although accurately measuring patient adherence has historically been very challenging. Urine analysis by high-performance liquid chromatography-tandem mass spectrometry has recently become routinely available as a method of screening for non-adherence. In addition to measuring rates of adherence in hypertensive patients, this study aimed to investigate the reasons for non-adherence given by patients and how patients react when they are informed of their results. This was a retrospective observational study looking at results from the routine use of this assay in a specialist hypertension clinic in Birmingham, UK, in patients with uncontrolled hypertension and those under consideration for renal denervation. Out of the 131 patients analysed, only 67 (51%) were taking all their medications as prescribed. Forty-three patients (33%) were taking some of their medications, whilst 21 patients (16%) were completely non-adherent. The most common reasons cited for non-adherence were adverse effects of medication and forgetfulness. Adherence rates for thiazide/thiazide-like diuretics and spironolactone were lower than for other classes of antihypertensive drug. Despite the objective nature and high sensitivity of the test, 36% of non-adherent patients disputed the results. A minority of patients did not attend follow-up. Further research investigating the implications of a 'non-adherence' result on the patient-clinician relationship is required.