Hypertension is not a disease of the left arm: a difficult diagnosis of hypertension in Takayasu’s arteritis

Banks, MJ; Erb, N; George, Paul V; Pace, Annalisa; Kitas, George D.

doi:10.1038/sj.jhh.1001247

Cited by 9 publications

(7 citation statements)

References 16 publications

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“…For example, with a prevalence of 10%, a systolic blood pressure might be underestimated by ≥10 mmHg through the chance selection of the lower reading arm once in every 20 assessments, leading to false reassurance about, or undertreatment of, high blood pressure. 5,10,17,67 This study's findings quantify the prevalence of inter-arm differences that may be expected in primary care populations, suggesting that an interarm blood pressure difference occurs in a significant minority of these patients. Historically, inter-arm difference has not been routinely checked for in primary care, 27 although uptake seems to be increasing (CE Clark, unpublished data, 2016) and guideline recommendations are due for review.…”

Section: Comparison With Existing Literaturementioning

confidence: 68%

Prevalence of systolic inter-arm differences in blood pressure for different primary care populations: systematic review and meta-analysis

et al. 2016

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Section: Comparison With Existing Literaturementioning

confidence: 68%

Prevalence of systolic inter-arm differences in blood pressure for different primary care populations: systematic review and meta-analysis

et al. 2016

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“…The choices of inclusion criteria were our own but based on a published critique 32 of the methodology of one of the studies. 46 Implications for BP measurement in practice Failure to recognise the IAD and to standardise readings to the higher arm runs the risks of inadequate treatment of hypertensive patients, false diagnosis of hypotension due to over treatment (pseudohypotension 36 ), a delay in the diagnosis of hypertension, 63 or physician confusion creating the potential for 'clinical inertia'. 64 The Health Survey of England states that 'if systolic BP were lowered by X10 mm Hg among the 71.5% of hypertensive subjects uncontrolled (in the survey), we estimate that 44000 fatal and nonfatal coronary events and 46000 fatal and nonfatal strokes could be prevented each year in England.'…”

Section: Strengths and Weaknesses Of The Reviewmentioning

confidence: 99%

Prevalence and clinical implications of the inter-arm blood pressure difference: a systematic review

et al. 2006

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A blood pressure (BP) difference between arms was first reported over 100 years ago. Knowledge of its prevalence and relevance to the accurate measurement of BP remains poor. Current hypertension guidelines do not emphasise it. The objectives of this study were to establish the best estimate of prevalence of the interarm difference (IAD) in the population, to consider its implications for accurate BP measurement and treatment, and to discuss its aetiology and potential as a risk marker for cardiovascular disease. Systematic literature review was carried out. The data sources were Medline EMBASE and CINAHL databases, and Index of Theses. Studies reporting prevalence rates of IAD were retrieved and considered for inclusion against explicit methodological criteria. Point prevalence rates were extracted and weighted mean prevalence rates calculated. The main outcome measures were weighted mean prevalences of systolic IADX10 and X20 mm Hg and of diastolic IADX10 mm Hg. Thirty-one studies were identified. Most had methodological weaknesses; only four met the inclusion criteria. Pooled prevalences of the IAD from these four studies were 19.6% systolic X10 mm Hg (95% CI 18.0-21.3%), 4.2% systolic X20 mm Hg (95% CI 3.4-5.1%) and 8.1% diastolic X10 mm Hg (95%CI 6.9-9.2%). In conclusion, an IAD is present in a substantial number of patients and should be looked for whenever diagnosis and treatment depend on accurate measurements of BP. The importance of an IAD should be better emphasised in current hypertension management guidelines. There is evidence associating an IAD with peripheral vascular disease, raising the possibility that its presence may predict cardiovascular events. IntroductionPatients are regularly encountered in the clinical setting with a different systolic or diastolic blood pressure (BP) in each arm. Comparisons of arm pressures have been made ever since the modern sphygmomanometer was introduced, 1 yet the significance of this finding, which Cyriax named the 'differential BP sign', 2 is still poorly appreciated today.Hypertension is one of the major causes of premature morbidity and mortality throughout the developed and developing worlds. 3 The vast majority of patients with hypertension are managed in primary care 4 and measurement of BP is the most common investigation performed in this setting. 5 The management of hypertension is known to be suboptimal; 6 therefore, knowledge of the latest guidelines, and the many factors known to influence readings, is crucial. 7 The prevalence of a systolic (sIAD) or a diastolic (dIAD) inter-arm difference, its importance for the management of hypertension, its significance as a potential marker of peripheral vascular disease (PVD) and predictor of cardiovascular disease (CVD) in hypertensive patients are the subjects of this review.Although recent ambulatory BP monitoring guidelines recommend routine bilateral assessment, 8 the latest British guidelines for the management of hypertension merely state that 'BP should initially be measured in both arms as patient...

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“…A difference in blood pressure readings between arms can be observed in various general populations,1 2 healthy women during the antenatal period,3 4 and populations with an increased risk of cardiovascular disease, such as people with hypertension,5 diabetes,6 7 chronic renal disease,8 or peripheral vascular disease 9. The presence of a difference between arm measurements has been implicated in a delayed diagnosis of hypertension10 and is associated with a higher prevalence of poor control in hypertension,9 as failure to standardise measurement to the arm with the highest reading can mislead decisions about management. Current guidelines recognise the need to check blood pressure in both arms11 12 but this practice has not been followed by many clinicians,13 14 including general practitioners in the United Kingdom,15 and continues to be undertaken selectively in primary care settings 16.…”

Section: Introductionmentioning

confidence: 99%

The difference in blood pressure readings between arms and survival: primary care cohort study

Clark

Taylor

Shore

et al. 2012

BMJ

131

153

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Objective To determine whether a difference in systolic blood pressure readings between arms can predict a reduced event free survival after 10 years. Design Cohort study.Setting Rural general practice in Devon, United Kingdom.Participants 230 people receiving treatment for hypertension in primary care.Intervention Bilateral blood pressure measurements recorded at three successive surgery attendances.Main outcome measures Cardiovascular events and deaths from all causes during a median follow-up of 9.8 years.Results At recruitment 24% (55/230) of participants had a mean interarm difference in systolic blood pressure of 10 mm Hg or more and 9% (21/230) of 15 mm Hg or more; these differences were associated with an increased risk of all cause mortality (adjusted hazard ratio 3.6, 95% confidence interval 2.0 to 6.5 and 3.1, 1.6 to 6.0, respectively). The risk of death was also increased in 183 participants without pre-existing cardiovascular disease with an interarm difference in systolic blood pressure of 10 mm Hg or more or 15 mm Hg or more (2.6, 1.4 to 4.8 and 2.7, 1.3 to 5.4). An interarm difference in diastolic blood pressure of 10 mm Hg or more was weakly associated with an increased risk of cardiovascular events or death.Conclusions Differences in systolic blood pressure between arms can predict an increased risk of cardiovascular events and all cause mortality over 10 years in people with hypertension. This difference could be a valuable indicator of increased cardiovascular risk. Bilateral blood pressure measurements should become a routine part of cardiovascular assessment in primary care. IntroductionA difference in blood pressure readings between arms can be observed in various general populations, 1 2 healthy women during the antenatal period, 3 4 and populations with an increased risk of cardiovascular disease, such as people with hypertension, 5 diabetes, 6 7 chronic renal disease, 8 or peripheral vascular disease. 9The presence of a difference between arm measurements has been implicated in a delayed diagnosis of hypertension 10 and is associated with a higher prevalence of poor control in hypertension, 9 as failure to standardise measurement to the arm with the highest reading can mislead decisions about management. Current guidelines recognise the need to check blood pressure in both arms 11 12 but this practice has not been followed by many clinicians, 13 14 including general practitioners in the United Kingdom, 15 and continues to be undertaken selectively in primary care settings. 16 This poor uptake may in part result from a lack of clearly presented supporting evidence for this intervention that is relevant to primary care practitioners. 17The new clinical guideline for hypertension from the National Institute for Health and clinical Excellence considers an interarm difference of less than 10 mm Hg to be normal and attributes a difference of more than 20 mm Hg to underlying vascular disease. 18 An evidence review for interarm differences in blood pressure was outside the remit of this...

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Hypertension is not a disease of the left arm: a difficult diagnosis of hypertension in Takayasu’s arteritis

Abstract: Hypertension and its cause may be missed by failure to measure blood pressure in both arms. We report a case of Takayasu's arteritis where diagnostic confusion

Cited by 9 publications

References 16 publications

Prevalence of systolic inter-arm differences in blood pressure for different primary care populations: systematic review and meta-analysis

Prevalence of systolic inter-arm differences in blood pressure for different primary care populations: systematic review and meta-analysis

Prevalence and clinical implications of the inter-arm blood pressure difference: a systematic review

The difference in blood pressure readings between arms and survival: primary care cohort study

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