Results of a new meta-analysis showed that differences in systolic BP
between a patient’s left and right arm could indicate that the patient has
vascular disease and is at increased risk for death.
Researchers searched databases for studies published before 2011 that
showed differences in
systolic BP between arms. Their search yielded 28 eligible
studies, 20 of which were included in the meta-analysis.
Five invasive studies using angiography showed a mean between-arm
difference in systolic BP of 36.9 mm Hg (95% CI, 35.4-38.4) for proven
subclavian stenosis. A systolic BP difference of 10 mm Hg or more between arms
was strongly related with subclavian stenosis (RR=8.8; 95% CI, 3.6-21.2).
Pooled findings from noninvasive studies showed that a difference of 15 mm Hg
or more was associated with peripheral vascular disease (nine cohorts: RR=2.5;
95% CI, 1.6-3.8), pre-existing cerebrovascular disease (five cohorts: RR=1.6;
95% CI, 1.1-2.4), increased CV mortality (four cohorts: HR=1.7; 95% CI,
1.1-2.5) and all-cause mortality (HR=1.6; 95% CI, 1.1-2.3). A difference of 10
mm Hg or more between arms was associated with peripheral vascular disease
(five studies: RR=2.4; 95% CI, 1.5-3.9), the researchers found.
“Our findings suggest that a difference in systolic BP of 10 mm Hg
or more or 15 mm Hg or more between arms could identify patients at high risk
of asymptomatic peripheral vascular disease and mortality who might benefit
from further assessment,” Christopher Clark, MD, FRCP, of the
primary care research group at Peninsula College of Medicine and Dentistry,
Plymouth, United Kingdom, and colleagues wrote in The Lancet.
“Findings from our study should be incorporated into future guidelines for
hypertension and BP measurement to justify bilaterial
brachial measurement in the assessment of individuals and to promote targeted
screening for peripheral vascular disease and aggressive risk factor management
in subjects with a demonstrable systolic between-arm difference.”
In an accompanying editorial, Richard J. McManus, MSc, MBBS, of
the University of Oxford, United Kingdom, and Jonathan Mant, MD, of the
University of Cambridge, United Kingdom, said these results support existing
guidelines that state BP should be measured in both arms.
“Ascertainment of differences should become part of routine care,
as opposed to a guideline recommendation that is mostly ignored,” McManus
and Mant wrote. “Future research is needed to clarify whether substantial
differences between arms should prompt aggressive management of CV risk
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Disclosure: Drs. Clark, Mant and McManus report no relevant
[These data] should not be too much of a surprise. If you have peripheral vascular disease, it is an indicator that CAD is more severe. That has been in literature in a variety of forms for a few decades. All it means is that when physicians examine a patient for the first time, they should take care and measure BP in both arms.
– - Neil S. Kleiman, MD, FACC, FSCAI
Director, Cardiac Catheterization Laboratory
Professor of Medicine, Weill Cornell Medical College
Disclosure: Dr. Kleiman reports no relevant financial disclosures.