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Delucchi A, Fernández D, Sorini M, Reisin P, Scarabino M, Rodríguez P. [Inter-arm blood pressure difference: Consecutive versus simultaneous measurements in treated and controlled hypertense patients]. HIPERTENSION Y RIESGO VASCULAR 2024:S1889-1837(24)00084-9. [PMID: 39043554 DOI: 10.1016/j.hipert.2024.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 06/22/2024] [Accepted: 06/25/2024] [Indexed: 07/25/2024]
Abstract
The inter-arm difference (IAD) of systolic blood pressure (SBP) is associated with higher cardiovascular risk. We compared simultaneous and consecutive recordings in measuring IAD of SBP, and evaluated reproducibility between visits. 143 hypertensive patients (63.8±9.5 years, 51.7% women) treated and controlled with stable antihypertensive medication for a period of ≥3 months were included. Blood pressure (BP) in both arms was measured simultaneously and consecutively with an automatic oscillometric device, in two visits. The IAD of the simultaneous SBP was significantly lower compared to the consecutive one, both in the first (3.51±4.1 vs. 4.40±3.7mmHg; P<.01) and in the second visit (3.62±3.5 vs. 5.69±5.1mmHg; P<.001). When the IAD of SBP was categorized as ≥10 or <10mmHg, the reproducibility between visits was insignificant in both simultaneous measurements and consecutive measurements. The frequency of initial dominance was similar between the left and right arm in simultaneous ones (46.2 vs. 43.3%), and greater in the right arm in consecutive ones (55.2 vs. 38.5). The persistence of dominance between both visits was significantly higher when SBP was measured simultaneously (54.4% vs. 45.5%; P<.01). Our study shows that to define the arm with the highest BP, simultaneous measurements are preferable. In treated and controlled hypertensive patients, the poor persistence of initial dominance between visits requires us to review the recommendation of recording, during follow-up, the BP in the arm where it was highest on the first visit.
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Affiliation(s)
- A Delucchi
- Sección Hipertensión Arterial, Sanatorio Municipal «Dr. Julio Méndez», Ciudad Autónoma de Buenos Aires, Argentina.
| | - D Fernández
- Sección Hipertensión Arterial, Sanatorio Municipal «Dr. Julio Méndez», Ciudad Autónoma de Buenos Aires, Argentina
| | - M Sorini
- Sección Hipertensión Arterial, Sanatorio Municipal «Dr. Julio Méndez», Ciudad Autónoma de Buenos Aires, Argentina
| | - P Reisin
- Sección Hipertensión Arterial, Sanatorio Municipal «Dr. Julio Méndez», Ciudad Autónoma de Buenos Aires, Argentina
| | - M Scarabino
- Sección Hipertensión Arterial, Sanatorio Municipal «Dr. Julio Méndez», Ciudad Autónoma de Buenos Aires, Argentina
| | - P Rodríguez
- Sección Hipertensión Arterial, Sanatorio Municipal «Dr. Julio Méndez», Ciudad Autónoma de Buenos Aires, Argentina
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Dahl M, Andersen JW, Lindholt J, Krarup NT, Borregaard B, Uberg N, Høgh A. Prevalence of interarm blood pressure difference is notably higher in women; the Viborg population-based screening program (VISP). BMC Public Health 2024; 24:1868. [PMID: 38997668 PMCID: PMC11245839 DOI: 10.1186/s12889-024-19388-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 07/05/2024] [Indexed: 07/14/2024] Open
Abstract
BACKGROUND Bilateral blood pressure (BP) measurement is important in cardiovascular prevention for identifying systolic interarm BP difference (IAD) and hypertension. We investigated sex-stratified IAD prevalence and its associations and coexistence with screen-detected peripheral atherosclerosis and hypertension. Furthermore, we determined the proportion misclassified as non-hypertensive when using the lower versus the higher reading arm. METHODS This sub-study formed part of the Viborg Screening Program (VISP), a cross-sectorial population-based cardiovascular screening programme targeting 67-year-old Danes. VISP includes screening for peripheral atherosclerosis (lower extremity arterial disease and carotid plaque), abdominal aortic aneurysm, hypertension, diabetes mellitus, and cardiac disease. Self-reported comorbidities, risk factors, and medication use were also collected. Among 4,602 attendees, 4,517 (82.1%) had eligible bilateral and repeated BP measurements. IAD was defined as a systolic BP difference ≥ 10 mmHg. IAD-associated factors (screening results and risk factors) were estimated by logistic regression; proportional coexistence was displayed by Venn diagrams (screening results). RESULTS We included 2,220 women (49.2%) and 2,297 men (50.8%). IAD was more predominant in women (26.8%) than men (21.0%) (p < 0.001). This disparity persisted after adjustment [odds ratio (OR) 1.53; 95% confidence interval (CI) 1.32-1.77]. No other association was recorded with the conditions screened for, barring potential hypertension: BP 140-159/90-99 mmHg (OR 1.68, 95% CI 1.44-1.97) and BP ≥ 160/100 mmHg (OR 1.82, 95% CI 1.49-2.23). Overall, IAD and BP ≥ 160/100 mmHg coexistence was 4% in women and 5% in men; for BP ≥ 140/90 mmHg, 13% and 14%, respectively. Among those recording a mean BP ≥ 140/90 mmHg in the higher reading arm, 14.5% of women and 15.3% of men would be misclassified as non-hypertensive compared with the lowest reading arm. CONCLUSION Female sex was an independent factor of IAD prevalence but not associated with other arterial lesions. Approximately 15% needed reclassification according to BP ≥ 140/90 mmHg when the lower rather than the higher reading arm was used; verifying bilateral BP measurements improved detection of potential hypertension. In future, the predictive value of sex-stratified IAD should be assessed for cardiovascular events and death to verify its potential as a screening tool in population-based cardiovascular screening. TRIAL REGISTRATION FOR VISP NCT03395509:10/12/2018.
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Affiliation(s)
- Marie Dahl
- Vascular Research Unit, Department of Surgery, Viborg Regional Hospital, Toldbodgade 12, Viborg, 8800, Denmark.
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Blvd. 82, Aarhus, 8200, Denmark.
- Department of Cardiac, Thoracic and Vascular Surgery, Odense University Hospital, JB Winsløwsvej 4, Odense, 5000, Denmark.
- Department of Clinical Research, University of Southern Denmark, Campusvej 55, Odense, 5230, Denmark.
| | - Jesper Winkler Andersen
- Vascular Research Unit, Department of Surgery, Viborg Regional Hospital, Toldbodgade 12, Viborg, 8800, Denmark
| | - Jes Lindholt
- Vascular Research Unit, Department of Surgery, Viborg Regional Hospital, Toldbodgade 12, Viborg, 8800, Denmark
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Blvd. 82, Aarhus, 8200, Denmark
- Department of Cardiac, Thoracic and Vascular Surgery, Odense University Hospital, JB Winsløwsvej 4, Odense, 5000, Denmark
- Department of Clinical Research, University of Southern Denmark, Campusvej 55, Odense, 5230, Denmark
- Department of Cardiothoracic and Vascular Surgery, Elite Centre of Individualized Treatment of Arterial Diseases (CIMA), Clinical Institute, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Nikolaj Thure Krarup
- Department of Cardiology, Viborg Regional Hospital, Heibergs Alle 5A, Viborg, 8800, Denmark
| | - Britt Borregaard
- Department of Cardiac, Thoracic and Vascular Surgery, Odense University Hospital, JB Winsløwsvej 4, Odense, 5000, Denmark
- Department of Clinical Research, University of Southern Denmark, Campusvej 55, Odense, 5230, Denmark
- Department of Cardiology, Odense University Hospital, JB Winsløwsvej 4, Odense, 5000, Denmark
| | - Nikolai Uberg
- Vascular Research Unit, Department of Surgery, Viborg Regional Hospital, Toldbodgade 12, Viborg, 8800, Denmark
| | - Annette Høgh
- Vascular Research Unit, Department of Surgery, Viborg Regional Hospital, Toldbodgade 12, Viborg, 8800, Denmark
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Blvd. 82, Aarhus, 8200, Denmark
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Ishigami J, Appel LJ, Brady TM. Pitfalls of Cuff Size and Blood Pressure Measurement-Reply. JAMA Intern Med 2024; 184:449-450. [PMID: 38372969 DOI: 10.1001/jamainternmed.2023.6340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Affiliation(s)
- Junichi Ishigami
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Lawrence J Appel
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tammy M Brady
- Johns Hopkins University School of Medicine, Baltimore, Maryland
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Mthethwa WS, Ramoshaba NE, Mampofu ZM. Association of interarm blood pressure difference with selected body circumferences among Walter Sisulu University community. BMC Public Health 2024; 24:644. [PMID: 38424532 PMCID: PMC10902929 DOI: 10.1186/s12889-024-18117-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 02/15/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND A high interarm blood pressure difference (IAD) has been identified as a precursor of vascular diseases. Anthropometric measures for obesity such as body circumferences including waist circumference (WC), mid-upper arm circumference (MUAC) and neck circumference (NC) have been associated with a high IAD in Western countries. However, the prevalence of IAD and its association with body circumferences in South African communities such as universities is not well established. Therefore, this study aimed at investigating the correlation of IAD with selected body circumferences among the Walter Sisulu University (WSU) community. METHODS A total of 230 participants, 117 males and 113 females, consisting of 185 students and 45 staff members from WSU, aged 18-27 and 18-63 years respectively, participated in this cross-sectional study. The selected body circumferences: WC, MUAC, and NC were measured using standard procedures. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured in both arms simultaneously using automated machines. IAD was achieved by calculating differences in SBP and DBP between the left (L) and right (R) arms, (R -L), and getting the absolute value, L-R (|L-R|). RESULTS 14.78% of the participants had an interarm SBP difference (IASBPD) ≥ 10 mmHg, and 4.35% of participants had an interarm DBP difference (IADBPD) ≥ 10 mmHg. In a Pearson's correlation analysis, IASBPD was positively correlated with the selected body circumferences (WC, r = 0.29; P < 0.001; MUAC, r = 0.35; P < 0.001; NC, r = 0.27; P < 0.001) and mean arterial pressure (MAP) (r = 0.30; P < 0.001). In the multivariable-adjusted regression analyses, IASBPD was positively associated with MUAC (adjusted R2 = 0.128, β = 0.271 (95% CI = 0.09; 0.60), P = 0.008), and NC (adjusted R2 = 0.119, β = 0.190 (95% CI = 0.01; 0.32), P = 0.032) only, adjusted for MAP, age, gender, body mass index, smoking, and alcohol. There was no association of body circumferences with IADBPD. CONCLUSION A high IAD is common among students and staff members of the WSU community. Furthermore, IAD showed a positive correlation with MUAC and NC. These body circumferences can serve as indicators of high IAD, aiding in the early detection and prevention of vascular diseases.
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Affiliation(s)
- Wenzile S Mthethwa
- Department of Human Biology, Walter Sisulu University, Nelson Mandela Drive, Mthatha, 5117, South Africa
| | - Nthai E Ramoshaba
- Department of Human Biology, Walter Sisulu University, Nelson Mandela Drive, Mthatha, 5117, South Africa.
| | - Zuqaqambe M Mampofu
- Department of Human Biology, Walter Sisulu University, Nelson Mandela Drive, Mthatha, 5117, South Africa
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Mouseli A, Sharafi M, Amiri Z, Dehghan A, Haghjoo E, Mohsenpour MA, Eftekhari MH, Fatemian H, Keshavarzian O. Prevalence and factors associated with inter-arm systolic and diastolic blood pressure differences: results from the baseline Fasa Adult's Cohort Study (FACS). BMC Public Health 2024; 24:345. [PMID: 38302901 PMCID: PMC10835907 DOI: 10.1186/s12889-024-17857-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 01/23/2024] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND One of the modifiable risk factors for cardiovascular diseases is the inter-arm blood pressure difference (IAD), which can be easily measured. This study aimed to determine the prevalence and factors related to the Iranian population's inter-arm differences in systolic and diastolic blood pressure. METHOD This cross-sectional study was conducted on the baseline data of participants who had Iranian nationality, were at least 1 year of residence in the area, aged within the age range of 35-70 years, and willed to participate from the Fasa Persian Adult Cohort Study (FACS). IAD for systolic and diastolic blood pressure was measured and categorized into two groups of difference < 10 and ≥ 10 mmHg. Logistic regression was used to model the association between independent variables and IAD. RESULTS The prevalence of systolic and diastolic IAD ≥ 10 mmHg was 16.34% and 10.2%, respectively, among 10,124 participants. According to the multivariable logistic regression models, age (adjusted odds ratio (aOR): 1.019 [95% CI: 1.013, 1.025]), body mass index (BMI) (aOR: 1.112 [95% CI: 1.016, 1.229]), having type 2 diabetes (aOR Yes/No: 1.172 [95% CI: 1.015, 1.368]), having chronic headaches (aOR Yes/No: 1.182 [95% CI: 1.024, 1.365]), and pulse rate (aOR: 1.019 [95% CI: 1.014, 1.024]) significantly increased the odds of systolic IAD ≥ 10 mmHg. Additionally, high socio-economic status decreased the odds of systolic IAD ≥ 10 mmHg (aOR High/Low: 0.854 [95% CI: 0.744, 0.979]). For diastolic IAD, age (aOR: 1.112 [95% CI: 1.015, 1.210]) and pulse rate (aOR: 1.021 [95% CI: 1.015, 1.027]) significantly increased the odds of diastolic IAD ≥ 10 mmHg. Moreover, high socioeconomic status decreased the odds of diastolic IAD ≥ 10 mmHg (aOR High/Low: 0.820 [95% CI: 0.698, 0.963]). CONCLUSION The noticeable prevalence of systolic and diastolic IAD in general population exhibits health implications due to its' association with the risk of cardiovascular events. Sociodemographic and medical history assessments have potentials to be incorporated in IAD risk stratification and preventing programs.
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Affiliation(s)
- Ali Mouseli
- Social Determinants in Health Promotion Research Center, Hormozgan Health Institute, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Mehdi Sharafi
- Social Determinants in Health Promotion Research Center, Hormozgan Health Institute, Hormozgan University of Medical Sciences, Bandar Abbas, Iran.
- Noncommunicable Disease Research Center, Fasa University of Medical Sciences, Fasa, Iran.
| | - Zahra Amiri
- Social Determinants in Health Promotion Research Center, Health Institute, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Azizallah Dehghan
- Noncommunicable Disease Research Center, Fasa University of Medical Sciences, Fasa, Iran
| | - Elham Haghjoo
- Department of Persian Medicine, Fasa University of Medical Sciences, Fasa, Iran
| | - Mohammad Ali Mohsenpour
- Department of Clinical Nutrition, School of Nutrition and Food Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Hassan Eftekhari
- Department of Clinical Nutrition, School of Nutrition and Food Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hossein Fatemian
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Omid Keshavarzian
- School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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Li M, Fan F, Qiu L, Ma W, Zhang Y. Association of an inter-arm systolic blood pressure difference with all-cause and cardiovascular mortality: A meta-analysis of cohort studies. J Clin Hypertens (Greenwich) 2023; 25:1069-1078. [PMID: 37946576 PMCID: PMC10710559 DOI: 10.1111/jch.14746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 10/22/2023] [Accepted: 10/24/2023] [Indexed: 11/12/2023]
Abstract
This meta-analysis evaluated the potential association of a simultaneously measured inter-arm systolic blood pressure difference (IASBPD) and all-cause mortality and cardiovascular mortality. The Medline, Cochrane Library, Embase, and PubMed databases were searched through to April 14, 2023 for relevant literature. The outcomes were the associations of IASBPD with all-cause and cardiovascular mortality. Finally, 10 cohort studies that included 15 320 individuals were included. An IASBPD of ≥15 mm Hg was associated with increased all-cause mortality (pooled hazard ratio [HR] 1.28, 95% confidence interval [CI] 1.02-1.61) but an IASBPD of ≥10 mm Hg was not (pooled HR 1.28, 95% CI 0.89-1.85). The pooled HR for cardiovascular mortality was 1.88 (95% CI 1.31-2.71) for an IASBPD of ≥10 mm Hg and 1.93 (95% CI 1.24-2.99) for an IASBPD of ≥15 mm Hg. Subgroup analysis showed that younger patients (HR 9.03, 95% CI 2.00-40.82, p = .004) with an IASBPD ≥15 mm Hg were at higher risk of cardiovascular mortality than older patients (HR 1.67, 95% CI 1.06-2.64, p = .03); the difference between groups was statistically significant (p = .04). In conclusions, our findings show that a simultaneously measured IASBPD ≥15 mm Hg predicts increased all-cause mortality and an IASBPD of ≥15 mm Hg or ≥10 mm Hg predicts increased cardiovascular mortality. An IASBPD ≥15 mm Hg appears to be more correlated with cardiovascular mortality in younger patients than in older patients.
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Affiliation(s)
- Min Li
- Department of Cardiovascular DiseasePeking University First HospitalBeijingChina
| | - Fangfang Fan
- Department of Cardiovascular DiseasePeking University First HospitalBeijingChina
| | - Lin Qiu
- Department of Cardiovascular DiseasePeking University First HospitalBeijingChina
| | - Wei Ma
- Department of Cardiovascular DiseasePeking University First HospitalBeijingChina
- Echocardiography Core LabInstitute of Cardiovascular Disease at Peking University First HospitalBeijingChina
- Hypertension Precision Diagnosis and Treatment Research CenterPeking University First HospitalBeijingChina
| | - Yan Zhang
- Department of Cardiovascular DiseasePeking University First HospitalBeijingChina
- Key Laboratory of Molecular Cardiovascular Sciences (Peking University)Ministry of EducationBeijingChina
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Sweity R, Fanoun K, Jarrar T, Alqtishat BF, Abdelhafez M, Ereqat S. Systolic inter-arm blood pressure difference and estimated glomerular filtration rate in type 2 diabetic patients in Palestine: a cross-sectional study. Ann Med 2023; 55:2259927. [PMID: 37748114 PMCID: PMC10521340 DOI: 10.1080/07853890.2023.2259927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 09/12/2023] [Indexed: 09/27/2023] Open
Abstract
OBJECTIVES This study aimed to investigate the association between systolic inter-arm blood pressure difference (IABPD) and the estimated glomerular filtration rate (eGFR), as well as chronic kidney disease (CKD), in patients with type 2 diabetes mellitus (T2DM). PATIENTS AND METHODS This cross-sectional study included 189 Palestinians diagnosed with T2DM. Data were collected through personal interviews, medical records and three separate blood pressure measurements from both arms. Patients were stratified in two ways: based on systolic IABPD ≥15 mmHg and the presence of CKD, indicated by an eGFR of <60 mL/min/1.73 m2 over a three months period. We used simple and multiple linear regression analyses to clarify the association between systolic IABPD (mmHg) and eGFR and to identify independent predictors for eGFR. RESULTS The mean age was 61.3 years, with a female percentage of 57.7%. The prevalence of systolic IABPD ≥15 mmHg and CKD was 27.5% and 30.2%, respectively. Among patients with eGFR <60 mL/min/1.73 m2, the median systolic IABPD was 12.5 mmHg (interquartile range (IQR), 13.5 mmHg), whereas in patients with eGFR ≥60 mL/min/1.73 m2, it was 7.5 mmHg (IQR, 9.8 mmHg) with a significant difference (p = .021). The results of the multiple linear regression model did not reveal an independent association between systolic IABPD and eGFR, with an unstandardized coefficient (B) of -0.257 (95% confidence interval (CI), -0.623 to 0.109; p = .167). However, older age (B, -0.886; 95% CI, -1.281 to -0.49; p < .001), hypertension (B, -12.715; 95% CI, -22.553 to -2.878; p = .012) and a longer duration of DM (B, -0.642; 95% CI, -1.10 to -0.174; p = .007) were significantly and negatively associated with eGFR. CONCLUSIONS Systolic IABPD did not exhibit an independent association with eGFR in T2DM patients. However, older age, a previous history of hypertension, and a longer duration of DM were all significantly associated with lower eGFR.
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Affiliation(s)
- Raghad Sweity
- Medical Research Club, Faculty of Medicine, Al-Quds University, Jerusalem, Palestine
| | - Khadeeja Fanoun
- Medical Research Club, Faculty of Medicine, Al-Quds University, Jerusalem, Palestine
| | - Tareq Jarrar
- Medical Research Club, Faculty of Medicine, Al-Quds University, Jerusalem, Palestine
| | - Bayan F. Alqtishat
- Medical Research Club, Faculty of Medicine, Al-Quds University, Jerusalem, Palestine
| | - Mohammad Abdelhafez
- Department of Internal Medicine, Faculty of Medicine, Al-Quds University, Abu Dis, Jerusalem, Palestine
| | - Suheir Ereqat
- Biochemistry and Molecular Biology Department, Faculty of Medicine, Al-Quds University, Abu Dis, Jerusalem, Palestine
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Al-Makhamreh HK, Sadalla AA, Alhawari H, Bedros AW, Kahlous MM, Amer MA, Al-Mubarak BA, Hussein M, Toubasi AA, Chichan HT. Inter-Arm Blood Pressure Difference an Indicator of Coronary Artery Disease. High Blood Press Cardiovasc Prev 2023:10.1007/s40292-023-00591-4. [PMID: 37418105 DOI: 10.1007/s40292-023-00591-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 06/20/2023] [Indexed: 07/08/2023] Open
Abstract
INTRODUCTION Considering the scarcity of the literature on the association between inter-arms blood pressure difference (IABPD) and coronary artery disease (CAD). AIM We performed this study to investigate the prevalence of IABPD within the Jordanian population and to assess if it has an association with CAD. METHODS We sampled patients visiting the cardiology clinics at the Jordan University Hospital between October, 2019 and October 2021 into two groups. Participants were divided into two groups; patients with severe CAD and control group who had no evidence of CAD. RESULTS We measured the blood pressure for a total of 520 patients. Of the included patients, 289 (55.6 %) had CAD while 231 (44.4%) were labeled as controls who were normal. A total of 221 (42.5%) participants had systolic IABPD above 10 mmHg, while 140 (26.9%) had a diastolic IABPD above 10 mmHg. Univariate analysis demonstrated that patients with CAD were significantly more likely to be older (p < 0.001), of the male gender (p < 0.001), hypertensive (p < 0.001), and having dyslipidemia (p < 0.001). Moreover, they had significantly higher IABPD differences in terms of both systolic and diastolic blood pressure (p < 0.001 and p = 0.022, respectively). Multivariate analysis showed that CAD was a positive predictor of abnormal systolic IABPD. CONCLUSION In our study, elevated systolic IABPD was associated with a higher prevalence of severe CAD. Patients with abnormal IABPD might be subjected to more specialist investigation as IABPD consistently predicts coronary artery disease, peripheral arterial disease or other vasculopathy throughout the literature.
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Affiliation(s)
- Hanna K Al-Makhamreh
- Cardiology Section, Department of Internal Medicine, Faculty of Medicine, University of Jordan, Amman, Jordan
| | | | - Hussein Alhawari
- Nephrology Section, Department of Internal Medicine, Faculty of Medicine, University of Jordan, Amman, Jordan
| | - Adees W Bedros
- Al-Essra Hospital, Amman, 11941, Jordan
- Faculty of Medicine, School of Medicine, The University of Jordan, Amman, 11942, Jordan
| | - Maher M Kahlous
- Al-Bashir Hospital, Amman, 11151, Jordan
- Faculty of Medicine, School of Medicine, The University of Jordan, Amman, 11942, Jordan
| | - Mohammed A Amer
- Department of Internal Medicine, Hamad Medical Corporation, Doha, 3050, Qatar
- Faculty of Medicine, School of Medicine, The University of Jordan, Amman, 11942, Jordan
| | - Baraa A Al-Mubarak
- Faculty of Medicine, School of Medicine, The University of Jordan, Amman, 11942, Jordan
| | - Moaiad Hussein
- Faculty of Medicine, School of Medicine, The University of Jordan, Amman, 11942, Jordan
| | - Ahmad A Toubasi
- Faculty of Medicine, School of Medicine, The University of Jordan, Amman, 11942, Jordan.
| | - Hayder T Chichan
- Faculty of Medicine, School of Medicine, The University of Jordan, Amman, 11942, Jordan
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Bonifant G, Weir MR. The role of blood pressure control in the prevention of cardiorenal disease in patients with chronic kidney disease. Nephrol Dial Transplant 2023; 38:264-270. [PMID: 36449690 DOI: 10.1093/ndt/gfac313] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Indexed: 12/05/2022] Open
Affiliation(s)
- George Bonifant
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Matthew R Weir
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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Song X, Liu Y, Wang S, Zhang H, Qiao A, Wang X. Non-invasive hemodynamic diagnosis based on non-linear pulse wave theory applied to four limbs. Front Bioeng Biotechnol 2023; 11:1081447. [PMID: 36970627 PMCID: PMC10033961 DOI: 10.3389/fbioe.2023.1081447] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 02/28/2023] [Indexed: 03/29/2023] Open
Abstract
Introduction: Hemodynamic diagnosis indexes (HDIs) can comprehensively evaluate the health status of the cardiovascular system (CVS), particularly for people older than 50 years and prone to cardiovascular disease (CVDs). However, the accuracy of non-invasive detection remains unsatisfactory. We propose a non-invasive HDIs model based on the non-linear pulse wave theory (NonPWT) applied to four limbs. Methods: This algorithm establishes mathematical models, including pulse wave velocity and pressure information of the brachial and ankle arteries, pressure gradient, and blood flow. Blood flow is key to calculating HDIs. Herein, we derive blood flow equation for different times of the cardiac cycle considering the four different distributions of blood pressure and pulse wave of four limbs, then obtain the average blood flow in a cardiac cycle, and finally calculate the HDIs. Results: The results of the blood flow calculations reveal that the average blood flow in the upper extremity arteries is 10.78 ml/s (clinically: 2.5-12.67 ml/s), and the blood flow in the lower extremity arteries is higher than that in the upper extremity. To verify model accuracy, the consistency between the clinical and calculated values is verified with no statistically significant differences (p < 0.05). Model IV or higher-order fitting is the closest. To verify the model generalizability, considering the risk factors of cardiovascular diseases, the HDIs are recalculated using model IV, and thus, consistency is verified (p < 0.05 and Bland-Altman plot). Conclusion: We conclude our proposed algorithmic model based on NonPWT can facilitate the non-invasive hemodynamic diagnosis with simpler operational procedures and reduced medical costs.
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Affiliation(s)
- Xiaorui Song
- School of Radiology, Shandong First Medical University and Shandong Academy of Medical Sciences, Tai’an, China
| | - Yi Liu
- Department of Ultrasound, Taian Maternity and Child Health Care Hospital, Tai’an, China
| | - Sirui Wang
- Graduate School of Engineering, Chiba University, Chiba, Japan
| | - Honghui Zhang
- College of Engineering, Inner Mongolia Minzu University, Tongliao, China
| | - Aike Qiao
- Faculty of Environment and Life, Beijing University of Technology, Beijing, China
| | - Xuezheng Wang
- School of Radiology, Shandong First Medical University and Shandong Academy of Medical Sciences, Tai’an, China
- Department of Medical Image, The Second Affiliated Hospital of Shandong First Medical University, Tai’an, China
- *Correspondence: Xuezheng Wang,
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11
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Wei L, Hu S, Gong X, Ahemaiti Y, Zhao T. Diagnosis of covert coarctation of the aorta in adolescents. Front Pediatr 2023; 11:1101607. [PMID: 37025297 PMCID: PMC10070858 DOI: 10.3389/fped.2023.1101607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 03/03/2023] [Indexed: 04/08/2023] Open
Abstract
Objectives By reviewing the diagnostic process for adolescents with coarctation of the aorta (CoA) in our institution, we analyzed the reasons for delayed diagnosis of CoA. We also proposed a diagnostic protocol to improve the detection rate of CoA. Methods In this retrospective study, we included 48 patients aged 12-18 years who were diagnosed with CoA in our hospital from January 2000 to November 2022. Clinical data from involved cases in local hospitals and our institution were collected. Results All patients had blood pressure (BP) measurements in upper and lower extremities in our institution. They all had hypertension, 29 (60.4%) of whom had known histories of the same. BP in the upper limbs of 47 (97.9%) patients was ≥20 mmHg higher than that in the lower limbs, and BP in the upper limb of 1 (2.1%) patient was greater than 0 and less than 20 mmHg than that in the lower limb. Echocardiography (ECHO) was performed in all patients, computed tomography (CT) or magnetic resonance imaging (MRI) was performed in 44 patients (91.7%). There were 38 (79.2%) patients who visited local hospitals. Among them, a total of 20 (52.6%) patients had their right upper extremity BP measured, 18 (47.4%) only had their left upper extremity BP measured, and 16 (42.1%) had their lower extremity BP measured. ECHO was performed in 27 (56.2%) patients and CT/MRI was performed in 18 (37.5%) patients. The detection rate for CT/MRI was 100%, and those of ECHO were 72.9% and 18.5% at our institution and a local hospital, respectively. Forty-eight (100%) and 23 (60.5%) patients were detected in our institution and local hospitals (P < 0.0001). Conclusion We recommend measuring BP in the bilateral upper extremities. Measurement of BP in the lower extremities is recommended if hypertension is diagnosed. MRI/CT is recommended when BP in the upper extremity is greater than that in the lower extremity.
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12
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Martínez-Sánchez N, Palasí A, Pera G, Martínez LM, Albaladejo R, Torán P. [Interarm blood pressure difference: Concordance between two methods of automatic simultaneous measurement and between visits reproducibility]. Aten Primaria 2022; 54:102514. [PMID: 36423568 PMCID: PMC9681639 DOI: 10.1016/j.aprim.2022.102514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 10/14/2022] [Accepted: 10/18/2022] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE An increased interarm blood pressure difference (IAD) (≥10mmHg) has been associated with increased cardiovascular morbidity and mortality. There are few studies determining how IAD has to be measured and its reliability between visits. The objectives of our study were twofold. First, to evaluate the concordance between two automatic oscillometric devices for IAD measurement (two OMRON devices and one Microlife WatchBP™ device (WBP™)) and to analyse the reproducibility of IAD between visits in the general population attending a primary care centre. DESIGN Descriptive cross-sectional study of concordance between the two methods and reproducibility of IAD between two visits separated by one week. SITE: Parets del Vallès primary care centre (Barcelona). PARTICIPANTS General population aged 35-74 years. INTERVENTIONS AND MAIN MEASUREMENTS One hundred and forty-nine patients completed the two visits. At each visit, IAD was measured three times with both methods and the mean of the three determinations was considered. Other variables such as sociodemographic and anthropometric variables, pathological antecedents and pharmacological treatment were collected through a review of the medical history and an interview with the patient. Concordance between the two devices and between visits reproducibility were calculated using the Lin concordance coefficient (CCL) for IAD expressed continuously and kappa(k) indices for IAD categorised as normal or pathological. RESULTS Concordance for IAD expressed continuously was low: CCL=0.13 (0.02-0.24). Concordance was also low for IAD categorised as normal or pathological (k=-0.03 (-0.05-0.00)). Reproducibility between visits was low for both methods and for both continuous and categorised IAD: with OMRON™ CCL=0.19 (0.03-0.34) and k=-0.02 (-0.16-0.12) and for WBP™ CCL=0.14 (-0.01-0.29) and k=0.49 (0.33-0.64). CONCLUSIONS Concordance between two automatic oscillometers in the simultaneous IAD measurement was low. Reproducibility between visits was also low for both methods.
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Affiliation(s)
- Nuria Martínez-Sánchez
- Centro de Atención Primaria Parets, Institut Català de la Salut, Parets del Vallès, Barcelona, España,Autor para correspondencia.
| | - Antonio Palasí
- Servicio de Neurología, Hospital Universitario Vall d́Hebron, Barcelona, España
| | - Guillem Pera
- Unitat de Suport a la Recerca Metropolitana Nord, Fundació Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Mataró, Barcelona, España
| | | | - Raquel Albaladejo
- Centro de Atención Primaria Pinetons, Institut Català de la Salut, Ripollet, Barcelona, España
| | - Pere Torán
- Unitat de Suport a la Recerca Metropolitana Nord, Fundació Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Mataró, Barcelona, España
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13
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Nolde JM, Lugo-Gavidia LM, Kannenkeril D, Chan J, Robinson S, Jose A, Joyson A, Schlaich L, Carnagarin R, Azzam O, Kiuchi MG, Schlaich MP. Simultaneously measured inter-arm blood pressure difference is not associated with pulse wave velocity in a clinical dataset of at-risk hypertensive patients. J Hum Hypertens 2022; 36:811-818. [PMID: 34354250 DOI: 10.1038/s41371-021-00588-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 07/22/2021] [Accepted: 07/26/2021] [Indexed: 11/09/2022]
Abstract
Recent analysis of systolic inter-arm differences in blood pressure from the INTERPRESS-IPD Collaboration suggest an association with increased all-cause mortality, cardiovascular mortality and cardiovascular events. Previous studies have demonstrated associations with other risk parameters. We aimed to reproduce these associations in a cohort of 199 treated, at-risk hypertensive patients with pulse wave velocity (PWV) as a surrogate marker of cardiovascular (CV) damage. Simultaneously measured inter-arm blood pressure (BP) differences, 24 hour ambulatory BP and PWV were measured in 199 treated patients from a tertiary hospital hypertension outpatient clinic. Associations between systolic inter-arm BP difference and PWV were analyzed with uni- and multi-variate regression models. Out of 199 participants, 90 showed an inter-arm BP difference of more than 5 mmHg. The inter-arm difference was not associated with PWV. Furthermore, neither observed single BP measurements nor 24 hour ambulatory BP was associated with inter-arm BP differences. In our clinical patient cohort we failed to observe an association between inter-arm BP differences and PWV. Mode of assessment, study design and the sample characteristics of this treated, hypertensive cohort may have contributed to the negative findings. The limited sample size of the study poses a challenge to the detection of smaller effects in our study.
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Affiliation(s)
- Janis M Nolde
- Dobney Hypertension Centre, School of Medicine-Royal Perth Hospital Research Foundation, Faculty of Medicine, Dentistry & Health Sciences, The University of Western Australia, Perth, WA, Australia
| | - Leslie Marisol Lugo-Gavidia
- Dobney Hypertension Centre, School of Medicine-Royal Perth Hospital Research Foundation, Faculty of Medicine, Dentistry & Health Sciences, The University of Western Australia, Perth, WA, Australia
| | - Dennis Kannenkeril
- Dobney Hypertension Centre, School of Medicine-Royal Perth Hospital Research Foundation, Faculty of Medicine, Dentistry & Health Sciences, The University of Western Australia, Perth, WA, Australia.,Department of Nephrology and Hypertension, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Justine Chan
- Dobney Hypertension Centre, School of Medicine-Royal Perth Hospital Research Foundation, Faculty of Medicine, Dentistry & Health Sciences, The University of Western Australia, Perth, WA, Australia
| | - Sandi Robinson
- Dobney Hypertension Centre, School of Medicine-Royal Perth Hospital Research Foundation, Faculty of Medicine, Dentistry & Health Sciences, The University of Western Australia, Perth, WA, Australia
| | - Ancy Jose
- Dobney Hypertension Centre, School of Medicine-Royal Perth Hospital Research Foundation, Faculty of Medicine, Dentistry & Health Sciences, The University of Western Australia, Perth, WA, Australia
| | - Anu Joyson
- Dobney Hypertension Centre, School of Medicine-Royal Perth Hospital Research Foundation, Faculty of Medicine, Dentistry & Health Sciences, The University of Western Australia, Perth, WA, Australia
| | - Luca Schlaich
- Dobney Hypertension Centre, School of Medicine-Royal Perth Hospital Research Foundation, Faculty of Medicine, Dentistry & Health Sciences, The University of Western Australia, Perth, WA, Australia
| | - Revathy Carnagarin
- Dobney Hypertension Centre, School of Medicine-Royal Perth Hospital Research Foundation, Faculty of Medicine, Dentistry & Health Sciences, The University of Western Australia, Perth, WA, Australia
| | - Omar Azzam
- Dobney Hypertension Centre, School of Medicine-Royal Perth Hospital Research Foundation, Faculty of Medicine, Dentistry & Health Sciences, The University of Western Australia, Perth, WA, Australia
| | - Márcio Galindo Kiuchi
- Dobney Hypertension Centre, School of Medicine-Royal Perth Hospital Research Foundation, Faculty of Medicine, Dentistry & Health Sciences, The University of Western Australia, Perth, WA, Australia
| | - Markus P Schlaich
- Dobney Hypertension Centre, School of Medicine-Royal Perth Hospital Research Foundation, Faculty of Medicine, Dentistry & Health Sciences, The University of Western Australia, Perth, WA, Australia. .,Departments of Cardiology and Nephrology, Royal Perth Hospital, Perth, WA, Australia. .,Neurovascular Hypertension & Kidney Disease Laboratory, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia.
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14
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Inter-arm difference in systolic blood pressure: Prevalence and associated factors in an African population. PLoS One 2022; 17:e0272619. [PMID: 36044475 PMCID: PMC9432703 DOI: 10.1371/journal.pone.0272619] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 07/24/2022] [Indexed: 11/30/2022] Open
Abstract
Objectives Inter-arm blood pressure difference (IABPD) can lead to underdiagnosis and poor management of hypertension, when not recognized and are associated with increased cardiovascular mortality and morbidity. However, the prevalence and associated risk factors of IABPD in sub-Saharan Africa are unknown. This study aims to determine the prevalence and associated risk factors of IABPD among Tanve Health Study (TAHES) participants, a cohort about cardiovascular diseases in a rural area in Benin. Methods The cohort was conducted since 2015 among adults aged 25 years and over in Tanve village. Data were collected from February to March, 2020. Brachial blood pressure were recorded at rest on both arm with an electronic device. Systolic IABPD (sIABPD) was defined as the absolute value of the difference in systolic blood pressure between left and right arms ≥ 10 mmHg. A multivariate logistic regression models identified factors associated with sIABPD. Results A total of 1,505 participants (women 59%) were included. The mean age was 45.08 ±15.65 years. The prevalence of sIABPD ≥ 10 mmHg was 19% (95%CI: 17–21). It was 19% (95%CI: 16–22) in men and 20% (95%CI: 17–22) in women. In final multivariable model, the probability of sIABPD ≥ 10 mmHg increased significantly with age (adjusted OR (aOR) = 1.1; 95%CI: 1.02–1.20 per 10-years), hypertension (aOR = 2.33; 95%CI: 1.77–3.07) and diabetes (aOR = 1.96; 95%CI: 1.09–3.53). Conclusion Almost quarter of sample have a sIABPD ≥ 10 mmHg, with an increased risk with older age and hypertension and diabetes.
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15
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Das S, Iktidar MA, Das J, Chowdhury F, Roy S. Inter-arm blood pressure difference as a tool for predicting coronary artery disease severity. Open Heart 2022; 9:openhrt-2022-002063. [PMID: 35961695 PMCID: PMC9379529 DOI: 10.1136/openhrt-2022-002063] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 07/06/2022] [Indexed: 12/15/2022] Open
Abstract
Background Patients with severe atherosclerosis have been found to exhibit considerable changes in blood pressure (BP) between arms. The objective of our study was to investigate the predictive value of interarm blood pressure difference (IABPD) for coronary artery disease (CAD) severity. Methods It was a cross-sectional study conducted in the Department of Cardiology, Chittagong Medical College Hospital, Chattogram from May 2020 to November 2020. The study conveniently selected 110 individuals who visited the department for a coronary angiography during the study period. The BP of both arms were synchronously measured 1–2 days before the coronary angiography and IABPD were calculated. After coronary angiography, two blinded interventional cardiologists visually estimated the amount of coronary artery obstruction and determined the Gensini score. Results Among the participants, more than three-fourths of the patients were above 50 years of age (64.66%), and the majority were male (86.67%). 14.7% of participants had no occlusion in their coronary artery, 38.0% of participants had insignificant occlusion, 26.7% participants had mild occlusion, 10.3% participants had moderate occlusion, 3.3% participants had significant occlusion and 6.0% participants had total occlusion. Corrected pulse IABPD (cIABPDpulse) showed the greatest area under the receiver operating characteristic curve (0.73) for predicting a high Gensini score (>median). Multiple regression analysis revealed a significant relationship between corrected systolic IABPD (cIABPDsys) and the Gensini score (B=0.057, p<0.001). Conclusion The differences in BP between the arms were found to be having a strong positive correlation with CAD severity.
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Affiliation(s)
- Somen Das
- Department of Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh
| | - Mohammad Azmain Iktidar
- Department of Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh .,Department of Public Health, North South University, Dhaka, Bangladesh
| | - Joyanti Das
- Department of Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh
| | - Faisal Chowdhury
- Department of Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh
| | - Simanta Roy
- Department of Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh.,Department of Public Health, North South University, Dhaka, Bangladesh
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16
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Wander GS, McDonagh STJ, Rao MS, Alagesan R, Mohan JC, Bhagwat A, Pancholia AK, Viswanathan M, Chopda MB, Purnanand A, Kapardhi PLN, Vadavi AR, Selvaraj R, Aneja P, Hardas S, Bordoloi N, Sivakadaksham N, Goswami N, Clark CE, Verberk WJ. Clinical relevance of double-arm blood pressure measurement and prevalence of clinically important inter-arm blood pressure differences in Indian primary care. J Clin Hypertens (Greenwich) 2022; 24:993-1002. [PMID: 35811439 PMCID: PMC9380175 DOI: 10.1111/jch.14497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/22/2022] [Accepted: 04/23/2022] [Indexed: 11/29/2022]
Abstract
Hypertension guidelines recommend measuring blood pressure (BP) in both arms at least once. However, this is seldom done due to uncertainties regarding measurement procedure and the implications of finding a clinically important inter‐arm BP difference (IAD). This study aimed to provide insight into the prevalence of clinically important IADs in a large Indian primary care cohort. A number of 134 678 (37% female) unselected Indian primary care participants, mean age 45.2 (SD 11.9) years, had BP measured in both arms using a standardized, triplicate, automated simultaneous measurement method (Microlife WatchBP Office Afib). On average, there were clinically minor differences in right and left arm BP values: systolic BP 134.4 vs 134.2 mmHg (p < .01) and diastolic BP 82.7 vs 82.6 mmHg (p < .01), respectively. Prevalence of significant mean systolic IAD between 10 and 15 mmHg was 7,813 (5.8%). Systolic IAD ≥ 15 mmHg 2,980 (2.2%) and diastolic IAD ≥ 10 mmHg 7,151 (5.3%). In total, there were 7,595 (5.6%) and 8,548 (6.3%) participants with BP above the 140/90 mmHg threshold in only the left or right arm, respectively. Prevalence of participants with elevated BP on one arm only was highest in patients with a systolic IAD ≥ 15 mmHg; 19.1% and 13.7%, for left and right arm, respectively. This study shows that a substantial prevalence of IAD exists in Indian primary care patients. BP is above the diagnostic threshold for hypertension in one arm only for 6% of participants. These findings emphasize the importance of undertaking bilateral BP measurement in routine clinical practice.
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Affiliation(s)
- Gurpreet S Wander
- Department of Cardiology, Hero DMC Heart Institute, Dayanand Medical College & Hospital, Ludhiana, Punjab, India
| | - Sinead T J McDonagh
- Primary care research group, College of Medicine and Health, University of Exeter, UK
| | | | - R Alagesan
- G. A. Vasant Compu Cardiac Scan Centre, Chennai, India
| | - J C Mohan
- Jaipur Golden Hospital Rohini, Delhi, India
| | | | | | | | | | | | | | | | - R Selvaraj
- Preetham Cardiac Care, Coimbatore, India
| | | | - Suhas Hardas
- Poona Hospital and Research Center, Pune & Clinic: Hardas Heart Care, Pune, India
| | | | | | | | - Christopher E Clark
- Primary care research group, College of Medicine and Health, University of Exeter, UK
| | - Willem J Verberk
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherlands
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17
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Essa RA, Ahmed SK. Prevalence of inter-arm blood pressure difference among young healthy adults: Results from a large cross-sectional study on 3235 participants. Ann Med Surg (Lond) 2022; 77:103631. [PMID: 35638020 PMCID: PMC9142544 DOI: 10.1016/j.amsu.2022.103631] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 04/11/2022] [Accepted: 04/11/2022] [Indexed: 11/25/2022] Open
Abstract
More than 100 years ago, the difference in blood pressure (BP) between arms was first reported. Recent studies have shown that different blood pressure between the right and left arm leads to cardiovascular events. Three thousand and thirty volunteers participated in our cross-sectional study. The sIABP was equal in 163 of 3030 persons (5.37%), dIABP was equal in 222 out of 3030 persons (7.32%), from a total of 792/3030 persons (26.1%) sIAD >10 mmHg, and dIAD > or = 10 mmHg was found in 927 out of 3030 persons (33.5%) in the right arm, and 32.4% in the left arm. In 2692 of 3030 volunteers BP, initially recorded in the dominant hand (right arm), showing sIAD > or = 10 mmHg was found in 943 (37.1%) volunteers, and when the first measurement was done in 338 left-handed volunteers it showed sIAD > or = 10 mmHg in 112 of 338 (34.1%), P < .001; 95% confidence interval for systolic right hand were (115.73: 116.73), and for systolic left hand 95% confidence interval were (113.17:114.15). Furthermore, height, residential area, and heart rate above 90 bpm had a significant effect on IAD (P = . 041, 0.002, <001, respectively). In conclusion, significant inter-arm systolic and diastolic BP differences above (10 mm Hg) is common in the young, healthy population. Hand dominance is a significant consideration while measuring blood pressure. It is mandatory to measure blood pressure in both arms in a sitting position with a stable condition. Blood pressure should be measured in both arms due to differences in values between them to avoid under-diagnosis of hypertension. Accurate measurement of blood pressure is mandatory to prevent cardiovascular, cerebrovascular, and renal diseases. In this study, the prevalence of IAD among young, healthy adults was reported. Hand dominance is a significant consideration while measuring blood pressure.
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18
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Inter-arm blood pressure difference and cardiovascular risk estimation in primary care. BJGP Open 2022; 6:BJGPO.2021.0242. [PMID: 35387763 DOI: 10.3399/bjgpo.2021.0242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 03/15/2022] [Accepted: 04/04/2022] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Systolic inter-arm differences (IAD) in blood pressure (BP) contribute independently to cardiovascular risk estimates; this can be used to refine predicted risk and guide personalised interventions. AIM To model the effect of accounting for IAD in cardiovascular risk estimation in a primary care population free of pre-existing cardiovascular disease. DESIGN AND SETTING Cross-sectional analysis of people aged 40-75 years attending National Health Service (NHS) Health Checks in one general practice in England. METHOD Simultaneous bilateral BP measurements were made during Health Checks. QRISK2, ASCVD and Framingham cardiovascular risk scores were calculated before and after adjustment for IAD using previously published hazard ratios. Reclassification across guideline-recommended intervention thresholds was analysed. RESULTS Data for 334 participants were analysed. Mean (standard deviation) QRISK2, ASCVD and Framingham scores were 8.0 (6.9), 6.9 (6.5) and 10.7 (8.1) respectively rising to 8.9 (7.7), 7.1 (6.7) and 11.2 (8.5) after adjustment for IAD. 13 (3.9%) participants were reclassified from below to above the 10% QRISK2 threshold, 3 (0.9%) for the ASCVD 10% threshold and 9 (2.7%) for the Framingham 15% threshold. CONCLUSION Knowledge of IAD can be used to refine cardiovascular risk estimates in primary care. By accounting for IAD, recommendations of interventions for primary prevention of cardiovascular disease can be personalised and treatment offered to those at greater than average risk. When assessing elevated clinic BP readings, both arms should be measured to allow fuller estimation of cardiovascular risk.
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Yang W, Sun L, He Y, Xu X, Gan L, Guo T, Yang L. Association between four-limb blood pressure differences and arterial stiffness: a cross-sectional study. Postgrad Med 2022; 134:309-315. [PMID: 35274579 DOI: 10.1080/00325481.2022.2046415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Although inter-arm blood pressure difference (IAD) and inter-ankle blood pressure difference (IAND) have been shown to be associated with cardiovascular disease, controversy remains. In this study, we investigated the prevalence of IAD and IAND as well as the correlation with arterial stiffness and systolic blood pressure in a large number of the Chinese population. METHODS The four-limb blood pressure, IAD, IAND, brachial-ankle pulse wave velocity (baPWV) and ankle-brachial index (ABI) of 12,176 participants have been measured. Multivariate logistic regression analysis was used to analyze the relationship of the increase in IAD/IAND with arterial stiffness and blood pressure. Reporting adheres to the STROBE guidelines. RESULTS In 12,176 participants, 1832 (15%) subjects had an IAD≥10 mmHg, 663 (5%) had an IAD≥15 mmHg, and 291 (2%) had an IAD≥20 mmHg. Correspondingly, 4548 (37%) had an IAND≥10 mmHg, 2706 (22%) had an IAND≥15 mmHg, and 1706 (14%) had an IAND≥20 mmHg. baPWV was significantly higher in those with an IAD≥10 mmHg (1881 ± 487 cm/s vs. 1943 ± 508 cm/s, P = 0.036) and IAND≥10 mmHg (1850 ± 476 cm/s vs. 1955 ± 509 cm/s, P = 0.000). Compared to others, those with IAD or IAND≥10 mmHg had higher systolic blood pressure (SBP), higher prevalence of hypertension, larger male gender ratio, bigger body mass index, higher pulse rate and lower ABI (P < 0.001 for all). A significant association with baPWV was observed for IAND≥10 mmHg (OR = 1.117; 95%CI: 1.039-1.201; P = 0.003) not for IAD≥10 mmHg (OR = 0.771; 95%CI: 0.699-0.851; P = 0.000) in multivariate logistic regression analysis. CONCLUSIONS Limb blood pressure differences were closely related to arterial stiffness and systolic blood pressure, allowing for a more comprehensive assessment of cardiovascular risk.
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Affiliation(s)
- Wenhui Yang
- Department of Cardiology, Fuwai Yunnan Cardiovascular Hospital, Cardiovascular Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Lin Sun
- Department of Cardiology, Fuwai Yunnan Cardiovascular Hospital, Cardiovascular Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Yan He
- Department of Geriatric Cardiology, Yan'an Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Xiaocui Xu
- Department of Cardiology, Fuwai Yunnan Cardiovascular Hospital, Cardiovascular Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Lulu Gan
- Department of Geriatric Cardiology, Yan'an Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Tao Guo
- Department of Cardiology, Fuwai Yunnan Cardiovascular Hospital, Cardiovascular Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Li Yang
- Department of Geriatric Cardiology, Yan'an Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
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20
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Lee SJ, Kim H, Oh BK, Choi HI, Lee JY, Lee SH, Kim BJ, Kim BS, Kang JH, Kang J, Kim SH, Sung KC. Association of inter-arm systolic blood pressure differences with arteriosclerosis and atherosclerosis: A cohort study of 117,407 people. Atherosclerosis 2022; 342:19-24. [DOI: 10.1016/j.atherosclerosis.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/27/2021] [Accepted: 12/09/2021] [Indexed: 11/02/2022]
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21
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Clark CE. Inter-arm blood pressure difference, when is it a useful risk marker for cardiovascular events? J Hum Hypertens 2022; 36:117-119. [PMID: 34741123 PMCID: PMC8850189 DOI: 10.1038/s41371-021-00629-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 10/12/2021] [Accepted: 10/18/2021] [Indexed: 02/06/2023]
Affiliation(s)
- Christopher E. Clark
- grid.8391.30000 0004 1936 8024Primary Care Research Group, Institute of Health Services Research, University of Exeter Medical School, College of Medicine & Health, Smeall Building, St Luke’s Campus, Magdalen Road, Exeter, Devon, EX1 2LU England
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22
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Kilic ID, Kilci H, Sevgican CI, Kilinc M, Ozden Tok O, Oguz I, Ghilencea L, Senol H, Kilickesmez Orta K. Interarm blood pressure differences and 2-year mortality in acute coronary syndrome patients. Blood Press Monit 2021; 26:245-250. [PMID: 33734120 DOI: 10.1097/mbp.0000000000000526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND AIMS Interarm blood pressure difference (IABPD) was associated with increased cardiovascular and all-cause mortality in various cohorts previously. In this study, we planned to explore the association between the IABPD obtained with simultaneous measurements in both arms and the risk of mortality over a 2-year follow-up of patients with acute coronary syndrome (ACS). METHODS Simultaneous blood pressure (BP) measurements were performed during initial admission in patients with ACS. Systolic ≥10 mmHg and diastolic ≥5 mmHg absolute IABPD was defined as cutoff values in this study. The relationship of IABPD and all-cause mortality was assessed using Kaplan-Meier curves and Cox analysis. RESULTS A total of 532 patients with ACS were included in the study. Mean age of the study participants was 60.1 ± 12.6. Patients included in the study were followed for 23.2 ± 7.2 months (median 25.3, min: 0, max: 28.7 months). Survival was assessed using Kaplan-Meier curves. Patients with systolic IABPD ≥ 10 mmHg and systolic IABPD < 10 mmHg had an average survival time of 25.94 ± 0.84 and 25.92 ± 0.38 months (P = 0.925), respectively. Survival times of diastolic IABPD ≥5 mmHg and diastolic IABPD <5 mmHg were 26.44 ± 0.62 and 25.71 ± 0.41 (P = 0.251) months, respectively. CONCLUSIONS In the current study, we did not find a significant association between IABPD and all-cause mortality in patients with ACS in 2-years follow-up. Future studies may be required for further evaluation of the prognostic importance of IABPD in patients with ACS.
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Affiliation(s)
| | - Hakan Kilci
- Department of Cardiology, Hamidiye Sisli Etfal Training and Research Hospital, Istanbul
| | | | - Mehmet Kilinc
- Department of Cardiology, Pamukkale University, Denizli
- Department of Cardiology, Ceylanpinar State Hospital, Sanliurfa
| | - Ozge Ozden Tok
- Department of Cardiology, Memorial Bahcelievler Hospital, Istanbul
| | - Ibrahim Oguz
- Department of Cardiology, Denizli State Hospital, Turkey
| | - Liviu Ghilencea
- Department of Cardiology, Elias University Hospital
- Department of Cardiology, Carol Davila University of Medicine, Bucharest, Romania
| | - Hande Senol
- Department of Biostatistics, Pamukkale University, Denizli, Turkey
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Elevated Interarm Systolic Blood Pressure Difference Is Positively Associated with Increased Likelihood of Coronary Artery Disease. Int J Hypertens 2021; 2021:5577957. [PMID: 34336266 DOI: 10.1155/2021/5577957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 06/29/2021] [Indexed: 11/17/2022] Open
Abstract
Background Systolic interarm differences in blood pressure have been associated with all-cause mortality and cardiovascular disease. We investigated the relationship between interarm systolic blood pressure difference and coronary artery disease. Methods We retrospectively analyzed data for patients undergoing coronary angiography and brachial-ankle pulse wave velocity examination during hospitalization from 2013 to 2018. Patients underwent simultaneous upper arm blood pressure measurement. Interarm systolic blood pressure difference (IASBPD) was defined as the absolute value of the difference between the right and left upper limb systolic blood pressure. Patients with IASBPD ≥10 mmHg constituted the high group, and those with IASBPD <10 mmHg constituted the normal group. We also recorded data for cardiovascular risk factors. Coronary artery disease was defined as ≥50% vessel stenosis or having undergone interventional therapy according to coronary angiography results. Results Compared with the normal group, the number of patients with coronary artery disease was higher in the high group (86.1% vs. 74.6%, P=0.029). Multiple logistic regression showed that IASBPD ≥10 mmHg were positively correlated with coronary artery disease (odds ratio, 2.313; 95% confidence interval, 1.086-4.509; P=0.029), and as the IASBPD value increased, the correlation also gradually increased. Conclusions IASBPD ≥10 mmHg was positively related to coronary artery disease and increased IASBPD values were correlated with coronary artery disease severity.
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Abstract
OBJECTIVES To investigate whether the blood pressure (BP) levels are similar between the paralyzed and unaffected arms or legs. METHODS This study enrolled 236 post-stroke patients with hemiplegic paralysis. Simultaneous four-limb BP was measured using four automatic BP devices for three times, and the average was used as final value. The inter-arm difference (IAD) and inter-ankle difference (IAND) were the BP difference between the arms or ankles, respectively. The difference between maximal BP reading and minimal BP reading was calculated as △BP to reflect the variation of three BP readings. RESULTS The paralyzed arm had similar mean SBP (134.8 ± 18.7 vs. 135.1 ± 19.0 mmHg, NS) and DBP (79.5 ± 11.3 vs 78.1 ± 10.4 mmHg, NS) levels as compared with the unaffected arm. Similarly, the mean ankle SBP (143.6 ± 19.1 vs. 143.7 ± 18.6 mmHg, NS) and DBP (77.9 ± 17.7 vs. 75.8 ± 11.1 mmHg, NS) in the paralyzed legs were also similar to those in the unaffected legs. The detection rate of systolic IAD ≥10 mmHg was 5.9% and that for systolic IAND ≥15 mmHg was 20.3%. Meanwhile, △SBP levels were similar between two arms or ankles. CONCLUSION In the post-stroke patients with hemiplegic paralysis, the SBP and DBP levels of the paralyzed and unaffected arms or ankles were similar.
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Essa R, Ahmed SK, Abdul-Sahib SH, Qadir RM, Miire ZK. The Future Alert of Inter-Arm Blood Pressure Difference Among Young Healthy Population: A Cross-Sectional Study. (Preprint). J Med Internet Res 2020. [DOI: 10.2196/24195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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26
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Han M, Kim YD, Choi JK, Choi J, Ha J, Park E, Kim J, Song TJ, Heo JH, Nam HS. Predicting Stroke Outcomes Using Ankle-Brachial Index and Inter-Ankle Blood Pressure Difference. J Clin Med 2020; 9:jcm9041125. [PMID: 32326413 PMCID: PMC7231112 DOI: 10.3390/jcm9041125] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 04/12/2020] [Accepted: 04/13/2020] [Indexed: 02/04/2023] Open
Abstract
Background: This study investigated the association of high ankle-brachial index difference (ABID) and systolic inter-ankle blood pressure difference (IAND) with short- and long-term outcomes in acute ischemic stroke patients without peripheral artery disease (PAD). Methods: Consecutive patients with acute ischemic stroke who underwent ankle-brachial index (ABI) measurement were enrolled. ABID was calculated as |right ABI-left ABI|. IAND and systolic inter-arm blood pressure difference (IAD) were calculated as |right systolic blood pressure – left systolic blood pressure|. Poor functional outcome was defined as modified Rankin Scale score ≥3 at 3 months. Major adverse cardiovascular events (MACEs) were defined as stroke recurrence, myocardial infarction, or death. Results: A total of 2901 patients were enrolled and followed up for a median of 3.1 (interquartile range, 1.6–4.7) years. Among them, 2643 (84.9%) patients did not have PAD. In the logistic regression analysis, ABID ≥ 0.15 and IAND ≥ 15 mmHg were independently associated with poor functional outcome (odds ratio (OR), 1.970, 95% confidence interval (CI), 1.175‒3.302; OR, 1.665, 95% CI, 1.188‒2.334, respectively). In Cox regression analysis, ABID ≥0.15 and IAND ≥ 15 mmHg were independently associated with MACEs (hazard ratio (HR), 1.514, 95% CI, 1.058‒2.166; HR, 1.343, 95% CI, 1.051‒1.716, respectively) and all-cause mortality (HR, 1.524, 95% CI, 1.039‒2.235; HR, 1.516, 95% CI, 1.164‒1.973, respectively) in patients without PAD. Conclusion: High ABID and IAND are associated with poor short-term outcomes, long-term MACE occurrence, and all-cause mortality in acute ischemic stroke without PAD.
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Affiliation(s)
- Minho Han
- Department of Neurology, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul 03722, Korea
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Seoul 03722, Korea
| | - Jin Kyo Choi
- Department of Neurology, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Junghye Choi
- Department of Neurology, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Jimin Ha
- Department of Neurology, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Eunjeong Park
- Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Jinkwon Kim
- Department of Neurology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin-si 16995, Korea
| | - Tae-Jin Song
- Department of Neurology, Seoul Hospital, Ewha Womans University College of Medicine, Seoul 07804, Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul 03722, Korea
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Seoul 03722, Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul 03722, Korea
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Seoul 03722, Korea
- Correspondence: ; Tel.: +82-2-2228-1617; Fax: +82-2-393-0705
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Park SJ, Son JW, Hong KS, Choi HH. Effect of inter-arm blood pressure differences on outcomes after percutaneous coronary intervention. J Cardiol 2020; 75:648-653. [PMID: 32037252 DOI: 10.1016/j.jjcc.2019.12.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 12/01/2019] [Accepted: 12/19/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND We investigated the effect of inter-arm blood pressure differences (IABPD) on the percutaneous coronary intervention (PCI) outcomes of patients with coronary artery diseases. METHODS We retrospectively reviewed the data of blood pressures measured simultaneously in the bilateral arms of 855 patients (560 males) who underwent PCI with drug-eluting stents for coronary artery diseases. IABPD was defined as the difference of blood pressure in both arms. The primary outcome was the presence of major adverse cardiac events (MACE) consisting of cardiovascular death, myocardial infarction, stroke, and ischemia-driven target vessel revascularization. RESULTS The mean age of the included patients was 66.2 ± 11.6 years, with a mean follow-up period of 44.5 ± 26.4 months. MACE occurred in 15.2% of patients, showing a higher rate in the higher IABPD group (≥10 mmHg) than in the lower IABPD group (<10 mmHg) (22.5% vs 14.5%, p = 0.081). The difference was induced by a higher rate of ischemia-driven target vessel revascularization (17.5% vs 8.3%, p = 0.011). The Kaplan-Meier survival analysis revealed a greater incidence of MACE in patients with a higher IABPD (log rank p = 0.054). The Cox proportional hazard analysis showed that IABPD was an independent predictor of long-term MACE (hazard ratio, 1.028; 95% confidence interval, 1.002-1.055; p = 0.037), along with age, diabetes mellitus, and number of implanted stents. CONCLUSION Among patients treated with PCI, the incidence of MACE was significantly higher in those with a higher IABPD (≥10 mmHg) than in those with a lower IABPD (<10 mmHg), which was mainly driven by ischemia-driven target vessel revascularization.
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Affiliation(s)
- Se-Jun Park
- Division of Cardiology, Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Republic of Korea
| | - Jung-Woo Son
- Department of Cardiology, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Kyung-Soon Hong
- Division of Cardiology, Cardiovascular Center, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Republic of Korea
| | - Hyun-Hee Choi
- Division of Cardiology, Cardiovascular Center, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Republic of Korea.
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Hsu PC, Lee WH, Tsai WC, Chu CY, Lee CS, Yen HW, Lin TH, Voon WC, Lai WT, Sheu SH, Su HM. Usefulness of four-limb blood pressure measurement in prediction of overall and cardiovascular mortality in acute myocardial infarction. Int J Med Sci 2020; 17:1300-1306. [PMID: 32624684 PMCID: PMC7330671 DOI: 10.7150/ijms.44735] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 05/12/2020] [Indexed: 12/11/2022] Open
Abstract
Four-limb blood pressure measurement could improve mortality prediction in the elderly. However, there was no study to evaluate whether such measurement was still useful in predicting overall and cardiovascular (CV) mortality in acute myocardial infarction (AMI). Two hundred AMI patients admitted to cardiac care unit were enrolled. The 4-limb blood pressures, inter-limb blood pressure differences, and ankle brachial index (ABI) were measured using an ABI-form device. The median follow-up to mortality was 64 months (25th-75th percentile: 5-174 months). There were 40 and 138 patients documented as CV and overall mortality, respectively. After multivariable adjustment, the ankle diastolic blood pressure (DBP) on the lower side, ABI value, ABI < 0.9, interarm DBP difference, interankle systolic blood pressure (SBP) and DBP differences, interankle SBP difference ≥ 15 mmHg, and interankle DBP difference ≥ 10 mmHg could predict overall mortality (P ≤ 0.025). The ankle DBP on the lower side, interankle DBP difference, and interankle DBP difference ≥ 10 mmHg could predict CV mortality (P ≤ 0.031). In addition, in the Nested Cox model, the model including the ankle DBP on the lower side and the model including interankle DBP difference had the best value for overall and CV mortality prediction, respectively (P ≤ 0.031). In AMI patients, 4-limb blood pressure measurement could generate several useful parameters in predicting overall and CV mortality. Furthermore, ankle DBP on the lower side and interankle DBP difference were the most powerful parameters in prediction of overall and CV mortality, respectively.
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Affiliation(s)
- Po-Chao Hsu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wen-Hsien Lee
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wei-Chung Tsai
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chun-Yuan Chu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Chee-Siong Lee
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsueh-Wei Yen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tsung-Hsien Lin
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wen-Chol Voon
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wen-Ter Lai
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Sheng-Hsiung Sheu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ho-Ming Su
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung, Taiwan.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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Chang CT, Lee WH, Hsu PC, Chen YC, Lee MK, Tsai WC, Chu CY, Lee CS, Lin TH, Voon WC, Su HM. Association of 4-limb systolic blood pressure heterogeneity with peripheral artery disease and left ventricular mass index. Medicine (Baltimore) 2020; 99:e18598. [PMID: 32011439 PMCID: PMC7220312 DOI: 10.1097/md.0000000000018598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
A large interarm and interleg systolic blood pressure (SBP) difference and ankle-brachial index (ABI) <0.9 were associated with peripheral artery disease and left ventricular hypertrophy. These 3 parameters were derived from 4-limb SBP data. However, there is no study to assess clinical significance of SBP heterogeneity in 4 limbs. The aim of this study was to evaluate the association of 4-limb SBP standard deviation (SD) with peripheral vascular parameters and echocardiographic data in patients with or without clinical findings of peripheral artery disease.A total of 1240 patients were included, of whom 1020 had no clinical evidence of overt peripheral artery disease. The 4-limb blood pressures, brachial-ankle pulse wave velocity, and ABI were measured simultaneously by an ABI-form device.In the multivariable linear regression analysis, increased left ventricular mass index (LVMI), ABI < 0.9, interarm SBP difference >10 mm Hg, and interleg SBP difference >15 mm Hg (P ≤ .030) were associated with increased 4-limb SBP SD. Additionally, a subgroup multivariable linear regression analysis in 1020 patients without ABI < 0.9, interarm SBP difference >10 mm Hg, and interleg SBP difference >15 mm Hg found 4-limb SBP SD still had a positive correlation with LVMI (P < .001).In addition to significant association with ABI < 0.9, interarm SBP difference >10 mm Hg, and interleg SBP difference >15 mm Hg, 4-limb SBP SD was positively correlated with LVMI in the multivariable linear regression analysis in all study patients. Furthermore, in the subgroup of patients without clinical evidence of peripheral artery disease, 4-limb SBP SD still had a positive correlation with LVMI. Hence, assessment of 4-limb SBP heterogeneity is useful in identification of high-risk group of peripheral artery disease and/or increased LVMI, irrespective of the presence of overt peripheral artery disease.
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Affiliation(s)
- Ching-Tang Chang
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University
- Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital
| | - Wen-Hsien Lee
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University
- Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital
- Faculty of Medicine, College of Medicine
| | - Po-Chao Hsu
- Faculty of Medicine, College of Medicine
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Ying-Chih Chen
- Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital
| | - Meng-Kuang Lee
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Wei-Chung Tsai
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University
- Faculty of Medicine, College of Medicine
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Chun-Yuan Chu
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University
- Faculty of Medicine, College of Medicine
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Chee-Siong Lee
- Faculty of Medicine, College of Medicine
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Tsung-Hsien Lin
- Faculty of Medicine, College of Medicine
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Wen-Chol Voon
- Faculty of Medicine, College of Medicine
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Ho-Ming Su
- Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital
- Faculty of Medicine, College of Medicine
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Inter-arm Blood Pressure Difference is Associated with Recurrent Stroke in Non-cardioembolic Stroke Patients. Sci Rep 2019; 9:12758. [PMID: 31484982 PMCID: PMC6726617 DOI: 10.1038/s41598-019-49294-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 08/22/2019] [Indexed: 01/15/2023] Open
Abstract
Recurrent stroke increases mortality and aggravates the disability of stroke patients. We hypothesized that increased inter-arm systolic blood pressure difference and inter-arm diastolic blood pressure difference would be related to recurrent stroke in non-cardioembolic stroke patients. A total of 1226 consecutive non-cardioembolic first-ever ischemic stroke patients, in whom bilateral brachial blood pressures were measured by an automated ankle-brachial index measuring device, were included in our study. Recurrent stroke was defined as newly developed neurologic symptoms with relevant lesions on brain CT and/or MRI after 7 days or hospital discharge. Inter-arm systolic and diastolic blood pressure differences ≥10 mmHg were noted in 9.7% (120/1226) and 5.0% (62/1226) of patients, respectively. During a median 24 months of follow-up, 105 (8.5%) patients experienced recurrent stroke. Patients who had inter-arm systolic blood pressure difference ≥10 mmHg showed increased risk of recurrent stroke (hazard ratio:1.77, 95% confidence interval: 1.04–3.00, p = 0.033). Moreover, inter-arm diastolic blood pressure difference ≥10 mmHg was also independently associated with increased risk of recurrent stroke (hazard ratio:2.92, 95% confidence interval: 1.59–5.34, p = 0.001). In conclusion, inter-arm blood pressure difference ≥10 mmHg may be associated with increased risk recurrent stroke in non-cardioembolic stroke patients.
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Yu S, Zhou Y, Wu K, Zhou X, Yang Y, Qiu H, Liu X, Ke J, Wang X, Li Z, Chen X, Ruan X. Association of interarm blood pressure difference with cardio-cerebral vascular disease: A community-based, cross-sectional study. J Clin Hypertens (Greenwich) 2019; 21:1115-1123. [PMID: 31304684 DOI: 10.1111/jch.13604] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 05/08/2019] [Accepted: 05/25/2019] [Indexed: 01/03/2023]
Abstract
Interarm blood pressure difference (IAD) is a risk factor for peripheral artery disease and cardio-cerebral vascular disease (CCVD). The current study examines the association of IAD with stroke and coronary heart disease in a Chinese community. A cross-sectional study was conducted in Pudong New Area in Shanghai, China. A total of 10 657 residents aged 15 years and older were randomly selected through three-stage sampling. Volunteers had systolic and diastolic blood pressure (BP) measured in both arms at recruitment, and IAD was defined in both arms as the absolute difference in BP. Medical records of study participants were reviewed by investigators to confirm measurements. Logistic regression models were used to assess the association between systolic interarm blood pressure difference (sIAD) and diastolic interarm blood pressure difference (dIAD) with stroke and coronary heart disease. Compared with dIAD <5 mm Hg, the multivariate adjusted odds ratio (OR) of stroke prevalence was 1.357 (95% CI 0.725-2.542, P = 0.034) for dIAD ≥20 mm Hg and 1.702 (95% CI1.025-2.828, P = 0.040) for dIAD between 15 and 19 mm Hg, and the multivariate adjusted OR of coronary heart disease prevalence was 1.726 (95% CI 1.093-2.726, P = 0.019) for dIAD ≥20 mm Hg and 1.498 (95% CI 0.993-2.261, P = 0.044) for dIAD between 15 and 19 mm Hg. The relationship between cardio-cerebral vascular disease and dIAD was significant in a Chinese community population. Further cohort studies are needed to investigate the association of different levels of IAD with the incidence of cardiovascular and cerebrovascular diseases and subsequent mortality.
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Affiliation(s)
- Siyu Yu
- Department of Chronic Disease, Shanghai Pudong New Area Center for Disease Control and Prevention, Pudong Institute of Preventive Medicine, Fudan University, Pudong New Area, Shanghai, China
| | - Yi Zhou
- Department of Chronic Disease, Shanghai Pudong New Area Center for Disease Control and Prevention, Pudong Institute of Preventive Medicine, Fudan University, Pudong New Area, Shanghai, China
| | - Kang Wu
- Department of Chronic Disease, Shanghai Pudong New Area Center for Disease Control and Prevention, Pudong Institute of Preventive Medicine, Fudan University, Pudong New Area, Shanghai, China
| | - Xianfeng Zhou
- Department of Chronic Disease, Shanghai Pudong New Area Center for Disease Control and Prevention, Pudong Institute of Preventive Medicine, Fudan University, Pudong New Area, Shanghai, China
| | - Yi Yang
- Department of Chronic Disease, Shanghai Pudong New Area Center for Disease Control and Prevention, Pudong Institute of Preventive Medicine, Fudan University, Pudong New Area, Shanghai, China
| | - Hua Qiu
- Department of Chronic Disease, Shanghai Pudong New Area Center for Disease Control and Prevention, Pudong Institute of Preventive Medicine, Fudan University, Pudong New Area, Shanghai, China
| | - Xiaolin Liu
- Department of Chronic Disease, Shanghai Pudong New Area Center for Disease Control and Prevention, Pudong Institute of Preventive Medicine, Fudan University, Pudong New Area, Shanghai, China
| | - Juzhong Ke
- Department of Chronic Disease, Shanghai Pudong New Area Center for Disease Control and Prevention, Pudong Institute of Preventive Medicine, Fudan University, Pudong New Area, Shanghai, China
| | - Xiaonan Wang
- Department of Chronic Disease, Shanghai Pudong New Area Center for Disease Control and Prevention, Pudong Institute of Preventive Medicine, Fudan University, Pudong New Area, Shanghai, China
| | - Zhitao Li
- Department of Chronic Disease, Shanghai Pudong New Area Center for Disease Control and Prevention, Pudong Institute of Preventive Medicine, Fudan University, Pudong New Area, Shanghai, China
| | - Xiaodan Chen
- Department of Chronic Disease, Shanghai Pudong New Area Center for Disease Control and Prevention, Pudong Institute of Preventive Medicine, Fudan University, Pudong New Area, Shanghai, China
| | - Xiaonan Ruan
- Department of Chronic Disease, Shanghai Pudong New Area Center for Disease Control and Prevention, Pudong Institute of Preventive Medicine, Fudan University, Pudong New Area, Shanghai, China
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32
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Chang Y, Lee SA, Lee SH, Lee EH, Kim YJ, Song TJ. Interarm Blood Pressure Difference has Various Associations with the Presence and Burden of Cerebral Small-Vessel Diseases in Noncardioembolic Stroke Patients. J Clin Neurol 2019; 15:159-167. [PMID: 30877693 PMCID: PMC6444144 DOI: 10.3988/jcn.2019.15.2.159] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 10/22/2018] [Accepted: 10/22/2018] [Indexed: 12/12/2022] Open
Abstract
Background and Purpose An interarm blood pressure difference (IABD) is independently related to the occurrence of cardiovascular disease and mortality. Cerebral small-vessel diseases (SVDs) are important risk factors for stroke, cognitive dysfunction, and mortality. We aimed to determine whether IABD is related to cerebral SVDs. Methods This study included 1,205 consecutive noncardioembolic ischemic stroke patients as confirmed by brain MRI and simultaneously measured the bilateral brachial blood pressures. We investigated cerebral SVDs based on high-grade white-matter hyperintensities (HWHs), presence of cerebral microbleeds (CMBs), high-grade perivascular spaces (HPVSs), and asymptomatic lacunar infarctions (ALIs) on brain MRI. Results In multivariate logistic regression, an interarm systolic blood pressure difference (IASBD) ≥10 mm Hg was independently related to the existence of HWHs [odds ratio (OR)=1.94, 95% CI=1.32–2.84, p=0.011] and had a tendency to be associated with the presence of HPVSs (OR=1.45, 95% CI=0.49–2.23, p=0.089) and ALIs (OR=1.42, 95% CI=0.96–2.11, p=0.052), but not with the presence of CMBs (OR=1.09, 95% CI=0.73–1.61, p=0.634). In multivariate linear regression adjusted for age, sex, and variables with p<0.1 in the univariate analysis, IASBD ≥10 mm Hg and interarm diastolic blood pressure difference ≥10 mm Hg were significantly correlated with an increased total burden of SVDs (β=0.080 and p=0.006, and β=0.065 and p=0.023, respectively). Conclusions This study found that IABD ≥10 mm Hg was associated with the presence and increased burden of cerebral SVDs in noncardioembolic stroke patients. This suggests that IABD ≥10 mm Hg could be a useful indicator of the presence and burden of cerebral SVDs in stroke patients.
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Affiliation(s)
- Yoonkyung Chang
- Department of Neurology, College of Medicine, Ewha Womans University, Seoul, Korea.,Departent of Neurology, College of Medicine, Korea University Guro Hostpital, Seoul, Korea
| | - Seung Ah Lee
- Department of Neurology, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Sue Hyun Lee
- Department of Neurology, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Eun Hye Lee
- Department of Neurology, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Yong Jae Kim
- Department of Neurology, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Tae Jin Song
- Department of Neurology, College of Medicine, Ewha Womans University, Seoul, Korea.
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Liu S, Li P, Su H. Four-Limb Blood Pressure Measurement with an Oscillometric Device: a Tool for Diagnosing Peripheral Vascular Disease. Curr Hypertens Rep 2019; 21:15. [PMID: 30747289 DOI: 10.1007/s11906-019-0917-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Traditionally, the term peripheral vascular disease (PAD) is restricted to the occlusive arterial disease in the leg, but now, the connotation of PAD is more widespread as it encompasses all extracoronary and extracerebral vascular disease. The incidence of PAD is increasing worldwide; therefore, it is necessary to diagnose PAD at an early stage. RECENT FINDINGS Oscillometric BP device is widely used for four-limb measurement in clinical practice and provides several parameters for evaluating inter-limb BP difference, such as ankle-brachial index (OS-ABI), inter-arm BP differences (IAD), and inter-ankle BP difference (IAND). Using angiographic results as reference, the ABI, IAD, and IAND from an oscillometric BP device have been demonstrated having high accuracy for diagnosis of PAD. Meanwhile, combination of these parameters could further improve the accuracy of PAD, including the occlusive artery disease in the arm, leg, and aorta. For example, some patients with severe PAD in the leg have normal ABI; in this situation, an increased sIAND could confirm the diagnosis of PAD in the leg. Because ABI, IAD, and IAND from inter-limb oscillometric BP measurement can also predict adverse prognosis, we encourage the use of an oscillometric device to measure four-limb BP and to evaluate the inter-limb BP difference.
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Affiliation(s)
- Songtao Liu
- Department of Cardiovascular Medicine, the Second Affiliated Hospital of Nanchang University, 330006, NO 1 Mingde Road, Nanchang, Jiangxi, China
| | - Ping Li
- Department of Cardiovascular Medicine, the Second Affiliated Hospital of Nanchang University, 330006, NO 1 Mingde Road, Nanchang, Jiangxi, China
| | - Hai Su
- Department of Cardiovascular Medicine, the Second Affiliated Hospital of Nanchang University, 330006, NO 1 Mingde Road, Nanchang, Jiangxi, China.
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Song BM, Kim HC, Shim JS, Kang DR. Comparison between Right and Left Upper Arms in Detection of Hypertension. Korean Circ J 2018; 49:267-277. [PMID: 30468034 PMCID: PMC6393325 DOI: 10.4070/kcj.2018.0147] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 08/09/2018] [Accepted: 10/02/2018] [Indexed: 11/11/2022] Open
Abstract
Background and Objectives This study aimed to investigate the right-left arm difference in detection of hypertension in the general Korean population. Methods This study analyzed data from the Cardiovascular and Metabolic Disease Etiology Research Center cohort. Study population was 2,103 people who were aged 30 to 64 years old, without history of major cardiovascular diseases, and did not use antihypertensive medication. Brachial blood pressures (BPs) were measured for both arms using an automated oscillometric device equipped with 2 cuffs for simultaneous double-arm measurements. Systolic and diastolic blood pressures (SBP and DBP) were measured 3 times, and the average value was used in the analysis. Overall hypertension was defined as elevated blood pressure (SBP/DBP ≥140/90 mmHg) at the arm with higher value, while right-arm or left-arm hypertension was defined as elevated BP at each arm. Sensitivity was calculated as the number of each-arm hypertension divided by the number of overall hypertension. Results Overall 8.6% of the population had hypertension at either arm, while 7.8% had right-arm hypertension, 7.2% had left-arm hypertension, and 6.4% had both arms hypertension. The sensitivity for the detection of hypertension was 90.6% when BP was measured only at right arm, and 83.4% when measured only at left arm. Corresponding sensitivity were 87.9% and 87.1% in men, and 95.4% and 76.9% in women. Conclusions Single-arm measurements, compared to double-arm measurements, may underestimate the prevalence of hypertension. However, if double-arm measurements are unavailable, right arm is preferred for measurement of BP, especially in women.
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Affiliation(s)
- Bo Mi Song
- Cardiovascular and Metabolic Disease Etiology Research Center, Yonsei University College of Medicine, Seoul, Korea
| | - Hyeon Chang Kim
- Cardiovascular and Metabolic Disease Etiology Research Center, Yonsei University College of Medicine, Seoul, Korea.,Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jee Seon Shim
- Cardiovascular and Metabolic Disease Etiology Research Center, Yonsei University College of Medicine, Seoul, Korea
| | - Dae Ryong Kang
- Center of Biomedical Data Science, Yonsei University Wonju College of Medicine, Wonju, Korea.
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Omboni S, Verberk WJ. Simultaneous double arm automated blood pressure measurement for the screening of subjects with potential vascular disease: a community study. Blood Press 2018; 28:15-22. [DOI: 10.1080/08037051.2018.1539619] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Stefano Omboni
- Clinical Research Unit, Italian Institute of Telemedicine, Varese, Italy
- Scientific Research Department of Cardiology, Science and Technology Park for Biomedicine, Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Willem J. Verberk
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Microlife AG, Widnau, Switzerland
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Abstract
Background Brachial–ankle pulse wave velocity (baPWV) and cardio-ankle vascular index (CAVI) are indices of arterial stiffness, and several studies have used these indices. However, there is no comprehensive review of these parameters in the prognostic significance. Methods The aim of this study was to review the articles exploring the prognostic significance of these parameters. Articles demonstrating independent significance after multivariate analysis on the Cox proportional hazards model were defined as “successful.” The success rate was compared using Fisher’s exact test. In addition, multivariate logistic regression analysis was performed to explore the independent determinants of the success of prognostic prediction. Results The success rate of the baPWV articles (65.7% [46/70]) tended to be higher than that of the CAVI articles (40.0% [6/15]; P=0.083). Multivariate analysis demonstrated that log (number of patients) (OR 11.20, 95% CI 2.45–51.70, P=0.002) and dialysis population (OR 0.28, 95% CI 0.08–0.94, P=0.039) were positive and negative independent determinants of the success of prognostic prediction, respectively. In addition, after redefining two studies as the absence of arteriosclerosis obliterans (ASO) exclusion, baPWV (OR 3.36, 95% CI 0.86–13.20, P=0.083) and the existence of exclusion criteria of ASO (OR 3.08, 95% CI 0.96–9.93, P=0.060) exhibited statistical tendency in the multivariate analysis. Conclusion This study demonstrated that the number of study participants and dialysis population were the independent determinants of the success of prognostic prediction. This study also showed the importance of exclusion criteria of ASO when using these indices. In addition, a prospective large-scale study to confirm the superiority in the prognostic prediction of these indices is warranted.
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Affiliation(s)
- Dai Ato
- Gakujutsu Shien Co., Ltd, Tokyo, Japan,
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37
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The Relationship between Inter-Arm Blood Pressure Difference and Coronary Artery Disease Severity Calculated by the SYNTAX Score. Int J Hypertens 2018; 2018:9370417. [PMID: 30302286 PMCID: PMC6158967 DOI: 10.1155/2018/9370417] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 07/28/2018] [Accepted: 08/28/2018] [Indexed: 12/22/2022] Open
Abstract
Objectives The inter-arm systolic blood pressure difference (IASBPD) is closely related to cardiovascular mortality and morbidity. The SYNTAX score indicates the extent and complexity of coronary artery disease, which are determined by coronary angiography. The aim of our study is to examine the relationship between the IASBPD (which is easily calculated in routine practice) and the SYNTAX score. Methods 104 patients were included in this cross-sectional study. The IASBPD was calculated by blood pressure measurements obtained simultaneously from both arms. The SYNTAX score was calculated by coronary angiography. Results Patients were divided into two groups: those with a high SYNTAX score (≥20) and those with a low SYNTAX score (<20). The mean IASBPD values were significantly higher in the group with a high SYNTAX score (≥20) (p<0.001). The patients with IASBPD≥10 were more likely to have a high SYNTAX score compared to the patients with IASBPD<10 (p<0.001). Multiple logistic regression analysis revealed that only the IASBPD values were found to be independently associated with high SYNTAX score (OR: 1.717 (CI: 1.307-2.257), p<0.001). Conclusion The IASBPD values obtained by only blood pressure measurements are closely related to the extent of coronary artery disease.
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Inter-arm Systolic Blood Pressure Difference in Physically Active, Adult Subjects. High Blood Press Cardiovasc Prev 2018; 25:303-307. [DOI: 10.1007/s40292-018-0269-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 07/01/2018] [Indexed: 10/28/2022] Open
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Abstract
Background The ankle-brachial index (ABI) and pulse wave velocity (PWV) are indices of atherosclerosis and arterial stiffness. The Japan-made measuring devices of those indices have spread widely because of their convenience and the significance of the parameters. However, studies that comprehensively discuss the various pitfalls in using these indices are not available. Methods This study presents several representative pitfalls in using the ABI and brachial-ankle PWV (baPWV) by showing the result sheets of the device, “the Vascular Profiler”. Furthermore, some considerations when utilizing these indices in the future are also discussed. Results Several diseases such as arteriosclerosis obliterans (ASO), arterial calcification in the lower limb, arterial stenosis in the right upper-limb, aortic valve diseases, arterial stenosis in the upper-limb of the contralateral side of the hemodialysis access, are the representative pitfalls when evaluating ABI and baPWV. Moreover, a measurement error is found to actually exist. Furthermore, same phenomena are considered most likely to occur when using other similar indices and devices. Conclusion The ABI and baPWV are the useful and significant biomarkers. Nevertheless, caution is sometimes necessary when interpreting them. Moreover, rigorous patient exclusion criteria should be considered when using those indices in the severely conditioned patient population. And the results of this study can be applied to enhance the literacy using other indices, such as the cardio-ankle vascular index and other similar devices.
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Affiliation(s)
- Dai Ato
- Gakujutsu Shien Co., Ltd., Tokyo, Japan
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40
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Chang Y, Kim J, Kim MH, Kim YJ, Song TJ. Interarm Blood Pressure Difference is Associated with Early Neurological Deterioration, Poor Short-Term Functional Outcome, and Mortality in Noncardioembolic Stroke Patients. J Clin Neurol 2018; 14:555-565. [PMID: 30284767 PMCID: PMC6172494 DOI: 10.3988/jcn.2018.14.4.555] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 07/16/2018] [Accepted: 07/18/2018] [Indexed: 02/07/2023] Open
Abstract
Background and Purpose Interarm differences in the systolic and diastolic blood pressures (IASBD and IADBD, respectively) are found in various populations, including stroke patients, but their significance for stroke outcomes has rarely been reported. We aimed to determine the associations of IASBD and IADBD with early neurological deterioration (END), functional outcome, and mortality. Methods This study included 1,008 consecutive noncardioembolic cerebral infarction patients who were admitted within 24 hours of onset and had automatic measurements of blood pressures in the bilateral arms. END was assessed within 72 hours of stroke onset according to predefined criteria. A poor functional outcome was defined as a score on the modified Rankin Scale ≥3 at 3 months after the index stroke. All-cause mortality was also investigated during a median follow-up of 24 months. The absolute difference of blood pressure measurements in both arms were used to define IASBD and IADBD. Results END occurred in 15.3% (155/1,008) of the patients. A multivariate analysis including sex, age, and variables for which the p value was <0.1 in a univariate analysis revealed that IASBD ≥10 mm Hg was significantly associated with END [odds ratio (OR)=1.75, 95% CI=1.02–3.01]. IADBD ≥10 mm Hg was also related to END (OR=3.11, 95% CI=1.61–5.99). Moreover, having both IASBD ≥10 mm Hg and IADBD ≥10 mm Hg was related to a poor functional outcome (OR=2.67, 95% CI=1.36–5.35) and mortality (hazard ratio=7.67, 95% CI=3.76–12.83) even after adjusting for END. Conclusions This study suggests that an interarm blood pressure difference of ≥10 mm Hg could be a useful indicator for the risks of END, poor functional outcome, and mortality.
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Affiliation(s)
- Yoonkyung Chang
- Department of Neurology, College of Medicine, Ewha Woman's University, Seoul, Korea.,Department of Neurology, College of Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Jinkwon Kim
- Department of Neurology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Min Ho Kim
- Department of Biostatistics, Ewha Institute of Convergency Medicine, Seoul, Korea
| | - Yong Jae Kim
- Department of Neurology, College of Medicine, Ewha Woman's University, Seoul, Korea
| | - Tae Jin Song
- Department of Neurology, College of Medicine, Ewha Woman's University, Seoul, Korea.
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Rosenberger J, McCrudden S, McCullough C, Wang L, Kime J, Albert NM. Factors associated with inter-arm blood pressure differences in patients admitted to critical care units. Heart Lung 2017; 47:100-106. [PMID: 29248156 DOI: 10.1016/j.hrtlng.2017.11.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Revised: 11/09/2017] [Accepted: 11/12/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Experts recommend obtaining one-time dual- (inter)-arm blood pressure (BP) measurements to predict cardiovascular morbidity risk. OBJECTIVES To determine differences in inter-arm systolic (S)/diastolic (D) BPs obtained simultaneously and sequentially and examine associations between patient factors and clinical outcomes and inter-arm BP differences. METHOD A comparative study of adults treated in intensive care; multivariable logistic models were created to determine the extent that inter-arm BP differences predicted outcomes. RESULTS Of 427 adults in intensive care units, 31.8% had differences of >10 mmHg on simultaneous measurement and 35.1% had differences of >10 mmHg on sequential measurement; differences >15 mmHg were 17.9% and 19.8%, respectively. After controlling for patient factors, simultaneous inter-arm DBP differences >15 mmHg were associated with shorter hospital and longer intensive care length of stay (p = 0.031 and 0.029, respectively) and a 79% reduction in the likelihood of discharge to home (p = 0.009). CONCLUSIONS Simultaneous inter-arm DBP differences >15 mmHg were associated with clinical outcomes.
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Affiliation(s)
| | | | | | - Lu Wang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Joni Kime
- Cleveland Clinic Hillcrest Hospital, Mayfield Heights, Ohio
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Chang Y, Choi GS, Lim SM, Kim YJ, Song TJ. Interarm Systolic and Diastolic Blood Pressure Difference Is Diversely Associated With Cerebral Atherosclerosis in Noncardioembolic Stroke Patients. Am J Hypertens 2017; 31:35-42. [PMID: 28985258 DOI: 10.1093/ajh/hpx126] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 07/11/2017] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Interarm systolic and diastolic blood pressure differences (IASBD, IADBD) are not infrequent in various populations. Cerebral atherosclerosis, including extracranial cerebral atherosclerosis (ECAS) and intracranial cerebral atherosclerosis (ICAS), is an important risk factor for stroke. In this study, we aimed to investigate the relationship of IASBD, IADBD with presence and burden of ICAS and ECAS. METHODS This was a retrospective hospital-based cross-sectional study. In total, 1,063 consecutive noncardioembolic ischemic stroke patients, who were checked for bi-brachial blood pressures from ankle-brachial index and brain magnetic resonance angiographic images of cerebral arteries, were included. The IASBD and IADBD were defined as absolute value of the blood pressure difference in both arms. RESULTS In all included patients, patients with IASBD ≥10 and IADBD ≥10 were noted in 9.4% (100/1,063) and 5.3% (56/1,063). The patients with IASBD ≥10 mm Hg were more frequently burdened with ICAS (P = 0.001) and ECAS (P = 0.027) and patients with IADBD ≥10 mm Hg were more frequently burdened with ICAS (P = 0.042) but not ECAS (P = 0.187). Multivariate analysis after adjusting gender, age, and a P value <0.1 in univariate analysis showed IASBD ≥10 mm Hg was associated with the presence of both ECAS and ICAS [odds ratio (OR): 2.96, 95% confidence interval (CI): 1.65-5.31]. The IADBD ≥10 mm Hg was related with presence of ICAS only (OR: 1.87, 95% CI: 1.05-3.37) but not with ECAS only (OR: 1.50, 95% CI: 0.73-3.06). CONCLUSIONS Our study showed IASBD and IADBD were diversely associated with cerebral atherosclerosis. In noncardioembolic stroke patients with IASBD ≥10 or IADBD ≥10, the possibility of accompanying cerebral atherosclerosis should be considered.
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Affiliation(s)
- Yoonkyung Chang
- Department of Neurology, College of Medicine, Ewha Womans University, Korea
| | - Gyeong Seon Choi
- Department of Neurology, College of Medicine, Ewha Womans University, Korea
| | - Soo Mee Lim
- Department of Radiology, College of Medicine, Ewha Womans University, Korea
| | - Yong-Jae Kim
- Department of Neurology, College of Medicine, Ewha Womans University, Korea
| | - Tae-Jin Song
- Department of Neurology, College of Medicine, Ewha Womans University, Korea
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Herráiz-Adillo Á, Soriano-Cano A, Martínez-Hortelano JA, Garrido-Miguel M, Mariana-Herráiz JÁ, Martínez-Vizcaíno V, Notario-Pacheco B. Simultaneous inter-arm and inter-leg systolic blood pressure differences to diagnose peripheral artery disease: a diagnostic accuracy study. Blood Press 2017; 27:112-119. [DOI: 10.1080/08037051.2017.1400903] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Ángel Herráiz-Adillo
- Department of Primary Care, Health Service of Castilla-La Mancha (SESCAM), Tragacete, Spain
- Health and Social Research Center, Universidad de Castilla-La Mancha, Cuenca, Spain
| | - Alba Soriano-Cano
- Health and Social Research Center, Universidad de Castilla-La Mancha, Cuenca, Spain
| | | | | | | | - Vicente Martínez-Vizcaíno
- Health and Social Research Center, Universidad de Castilla-La Mancha, Cuenca, Spain
- Facultad de Ciencias de la Salud, Universidad Autónoma de Chile, Talca, Chile
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Kranenburg G, Spiering W, de Jong PA, Kappelle LJ, de Borst GJ, Cramer MJ, Visseren FL, Aboyans V, Westerink J. Inter-arm systolic blood pressure differences, relations with future vascular events and mortality in patients with and without manifest vascular disease. Int J Cardiol 2017. [DOI: 10.1016/j.ijcard.2017.06.044] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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45
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Schwartz CL, Clark C, Koshiaris C, Gill PS, Greenfield SM, Haque SM, Heer G, Johal A, Kaur R, Mant J, Martin U, Mohammed MA, Wood S, McManus RJ. Interarm Difference in Systolic Blood Pressure in Different Ethnic Groups and Relationship to the "White Coat Effect": A Cross-Sectional Study. Am J Hypertens 2017; 30:884-891. [PMID: 28475667 PMCID: PMC5861584 DOI: 10.1093/ajh/hpx073] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 04/05/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Interarm differences (IADs) ≥10 mm Hg in systolic blood pressure (BP) are associated with greater incidence of cardiovascular disease. The effect of ethnicity and the white coat effect (WCE) on significant systolic IADs (ssIADs) are not well understood. METHODS Differences in BP by ethnicity for different methods of BP measurement were examined in 770 people (300 White British, 241 South Asian, 229 African-Caribbean). Repeated clinic measurements were obtained simultaneously in the right and left arm using 2 BPTru monitors and comparisons made between the first reading, mean of second and third and mean of second to sixth readings for patients with, and without known hypertension. All patients had ambulatory BP monitoring (ABPM). WCE was defined as systolic clinic BP ≥10 mm Hg higher than daytime ABPM. RESULTS No significant differences were seen in the prevalence of ssIAD between ethnicities whichever combinations of BP measurement were used and regardless of hypertensive status. ssIADs fell between the 1st measurement (161, 22%), 2nd/3rd (113, 16%), and 2nd–6th (78, 11%) (1st vs. 2nd/3rd and 2nd–6th, P < 0.001). Hypertensives with a WCE were more likely to have ssIADs on 1st, (odds ratio [OR] 1.73 (95% confidence interval 1.04–2.86); 2nd/3rd, (OR 3.05 (1.68–5.53); and 2nd–6th measurements, (OR 2.58 (1.22–5.44). Nonhypertensive participants with a WCE were more likely to have a ssIAD on their first measurement (OR 3.82 (1.77 to −8.25) only. CONCLUSIONS ssIAD prevalence does not vary with ethnicity regardless of hypertensive status but is affected by the number of readings, suggesting the influence of WCE. Multiple readings should be used to confirm ssIADs.
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Affiliation(s)
- Claire Lorraine Schwartz
- Nuffield Department of Primary Care Health Sciences, NIHR School for Primary Care Research, University of Oxford, Radcliffe Observatory Quarter, Oxford, UK
| | - Christopher Clark
- Primary Care Research Group, University of Exeter Medical School, Smeall Building, St Luke’s Campus, Exeter, UK
| | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, NIHR School for Primary Care Research, University of Oxford, Radcliffe Observatory Quarter, Oxford, UK
| | - Paramjit S Gill
- WMS—Social Science and Systems in Health, University of Warwick, Coventry, Birmingham, UK
| | - Shelia M Greenfield
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Sayeed M Haque
- Institute of Clinical Science, University of Birmingham, Edgbaston, Birmingham, UK
| | - Gurdip Heer
- Institute of Clinical Science, University of Birmingham, Edgbaston, Birmingham, UK
| | - Amanpreet Johal
- NIHR Clinical Research Network: West Midlands, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Ramandeep Kaur
- Institute of Clinical Science, University of Birmingham, Edgbaston, Birmingham, UK
| | - Jonathan Mant
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Wort’s Causeway, Cambridge, Cambridgeshire, UK
| | - Una Martin
- Institute of Clinical Science, University of Birmingham, Edgbaston, Birmingham, UK
| | | | - Sally Wood
- Nuffield Department of Primary Care Health Sciences, NIHR School for Primary Care Research, University of Oxford, Radcliffe Observatory Quarter, Oxford, UK
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, NIHR School for Primary Care Research, University of Oxford, Radcliffe Observatory Quarter, Oxford, UK
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Gaynor E, Brewer L, Mellon L, Hall P, Horgan F, Shelley E, Dolan E, Hickey A, Bennett K, Williams DJ. Interarm blood pressure difference in a post-stroke population. ACTA ACUST UNITED AC 2017; 11:565-572.e5. [DOI: 10.1016/j.jash.2017.06.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 06/02/2017] [Accepted: 06/20/2017] [Indexed: 02/01/2023]
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Sato K, Sugiura T, Ohte N, Dohi Y. Association of physical activity with a systolic blood pressure difference between arms in older people. Geriatr Gerontol Int 2017; 18:95-100. [PMID: 28786517 DOI: 10.1111/ggi.13147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 05/31/2017] [Accepted: 06/27/2017] [Indexed: 11/29/2022]
Abstract
AIM A increase in interarm systolic blood pressure difference (IASBPD) is believed to lead to increased risk of cardiovascular disease and to be a predictor of future cardiovascular events. The purpose of the present study was to test the hypothesis that an increased IASBPD is associated with reduced physical activity in older people. METHODS Older people who used a geriatric health services facility (n = 147, mean age 83.3 years) were enrolled. The prevalence of IASBPD in individuals with different levels of physical activity and factors that have a crucial effect on IASBPD were investigated. The study participants were divided into three groups according to their physical activity; ambulant persons (group A), wheelchair users (group B) and bedridden persons (group C). Blood pressure around the both brachiums was simultaneously measured using two automated devices. An IASBPD of ≥10 mmHg was considered to be significant IASBPD. RESULTS The median IASBPD was 4.5 mmHg in the present study participants, and 28 participants (19.0%) had an IASBPD ≥10 mmHg. The IASBPD in group C was greater than that in group A or B. Multivariate linear regression analysis showed that physical activity was the independent predictor of IASBPD after adjustment for possible factors. Furthermore, a logistic regression analysis with the end-point of significant IASBPD showed that physical activity is an independent predictor of significant IASBPD. CONCLUSIONS Physical activity simply assessed by moving ability can predict IASBPD in older individuals. In older people, reduced physical activity might indicate the progression of silent or clinical atherosclerosis and an increased risk of cardiovascular disease. Geriatr Gerontol Int 2018; 18: 95-100.
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Affiliation(s)
- Koichi Sato
- Geriatric health services facility, Komakinomori, Komaki, Japan
| | - Tomonori Sugiura
- Cardio-Renal Medicine and Hypertension, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Nobuyuki Ohte
- Cardio-Renal Medicine and Hypertension, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Yasuaki Dohi
- Faculty of Rehabilitation Science, Nagoya Gakuin University, Seto, Japan
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Park SJ, Son JW, Park SM, Choi HH, Hong KS. Relationship between inter-arm blood pressure difference and severity of coronary atherosclerosis. Atherosclerosis 2017. [DOI: 10.1016/j.atherosclerosis.2017.06.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Hwang HJ, Sohn IS, Kim DH, Park CB, Cho JM, Kim CJ. Increased interarm blood pressure difference is associated with autonomic dysfunction and atherosclerosis in patients with chest pain and no history of coronary artery disease. Int J Cardiol 2017; 241:25-29. [DOI: 10.1016/j.ijcard.2017.03.084] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 02/10/2017] [Accepted: 03/13/2017] [Indexed: 11/26/2022]
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Evaluation of interarm blood pressure differences using the Microlife WatchBP Office in a clinical setting. Blood Press Monit 2017; 22:161-165. [DOI: 10.1097/mbp.0000000000000246] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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