Does “Hidden Undercuffing” Occur Among Obese Patients? Effect of Arm Sizes and Other Predictors of the Difference Between Wrist and Upper Arm Blood Pressures

Abstract

J Clin Hypertens (Greenwich). 2010;12:82–88. ©2009 Wiley Periodicals, Inc. Arm size can affect the accuracy of blood pressure (BP) measurement, and “undercuffing” of large upper arms is likely to be a growing problem. Therefore, the authors investigated the relationship between upper arm and wrist readings. Upper arm and wrist circumferences and BP were measured in 261 consecutive patients. Upper arm auscultation and wrist BP was measured in triplicate, rotating measurements every 30 seconds between sites. Upper arm BP was 131.9±20.6/71.6±12.6 mm Hg in an obese population (body mass index, 30.6±6.6 kg/m2) with mean upper arm size of 30.7±5.1 cm. Wrist BP was higher (2.6±9.2 mm Hg and 4.9±6.6 mm Hg, respectively, P<.001); however, there was moderate concordance for the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) strata (κ value=0.27–0.71), and the difference was ≥5 mm Hg in 72% of the patients. The authors conclude that there was poor concordance between arm and wrist BP measurement and found no evidence that “hidden undercuffing” was associated with obesity; therefore, they do not support routine use of wrist BP measurements.

Preliminary Blood Pressure Screening in a Representative Sample of Extremely Obese Kuwaiti Adolescents

“…There has been much debate in recent years over the clinical accuracy of wrist BP monitors. A recent study led by Doshi et al [26] have shown that even when a validated wrist device was used for BP measurement in a standardized protocol, there were significant differences for systolic BP and diastolic BP measured at the arm and wrist. In their study on obese patients, they found higher wrist values, with the majority of patients having systolic BP or diastolic BP absolute differences of ≥5 mm Hg between the two methods, and approximately one third having a difference of ≥10 mm Hg in systolic BP and diastolic BP.…”

Hypertension Canada’s 2018 Guidelines for Diagnosis, Risk Assessment, Prevention, and Treatment of Hypertension in Adults and Children

“…accurate measurement of BP can be challenging in patients with increased upper arm size, particularly in obese patients with a body mass index > 35. 2,39,40 In these patients, there is a concern of hidden undercuffing (ie, the cuff bladder is too small or narrow for the arm size) leading to falsely elevated BP values. 39 A 2016 systematic review and meta-analysis examined the diagnostic accuracy of BP measurements of the forearm, wrist, and fingertip compared with correctly fitting upper arm cuff in obese individuals.…”

Which cuff should I use? Indirect blood pressure measurement for the diagnosis of hypertension in patients with obesity: a diagnostic accuracy review

“…*Doshi et al 3 not included in pooled result as no individual patient data available. The figure presented is taken from the Bland-Altman analysis provided in the paper.…”

“…2 As a result, healthcare professionals are increasingly faced with situations where blood pressure (BP) measurement with a standard (or even large sized upper arm cuff) is not possible 2. This is important because errors in BP measurement are greater when the cuff used is too small relative to the patient's arm circumference 3. In the USA, over 30% of the population have a large arm circumference as a consequence of obesity, a figure which can rise to over 60% in some clinics 4…”