The inter-arm systolic blood pressure difference and risk of cardiovascular mortality: A meta-analysis of cohort studies

Prevalence and factors associated with inter-arm systolic and diastolic blood pressure differences: results from the baseline Fasa Adult's Cohort Study (FACS)

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.

The predictive value of interarm systolic blood pressure differences in patients with vascular disease: Sub-analysis of the COMPASS trial

BACKGROUND AND AIMS

Systolic blood pressure interarm difference (IAD) predicts cardiovascular morbidity and mortality in primary prevention populations. We examined the predictive value of IAD and the effects of treatment with the combination of rivaroxaban 2.5 mg twice daily plus aspirin 100 mg once daily versus aspirin 100 mg once daily according to IAD in patients with chronic coronary artery disease or peripheral artery disease.

METHODS

COMPASS trial patients with IAD <15 mmHg and IAD >15 mmHg were compared with respect to thirty-month incidence risk of: 1) composite of stroke, myocardial infarction, or cardiovascular death (MACE), 2) composite of acute limb-ischemia or vascular amputation (MALE), 3) composite of MACE or MALE, and 4) effects of treatment with the combination versus aspirin alone on these outcomes.

RESULTS

24,539 patients had IAD<15 mmHg and 2,776 had IAD ≥15 mmHg. Relative to patients with IAD ≥15 mm Hg, those with IAD<15 mmHg had similar incidence rates for all measured outcomes including the composite of MACE or MALE (HR 1.12 [95% CI: 0.95 to 1.31], p = 0.19), with the exception of stroke (HR 1.38 [95% CI: 1.02 to 1.88], p = 0.04). Compared to aspirin alone, the combination consistently reduced the composite of MACE or MALE in both IAD <15 mmHg (HR 0.74 [95% CI: 0.65-0.85], p < 0.0001, ARR = -23.1) and IAD>15 mmHg (HR 0.65 [95% CI: 0.44-0.96], p = 0.03; ARR = -32.6, p interaction = 0.53) groups.

CONCLUSIONS

Unlike primary prevention populations, measuring IAD for risk stratification purposes does not appear to be useful in patients with established vascular disease.

[Interarm blood pressure difference: Concordance between two methods of automatic simultaneous measurement and between visits reproducibility]

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.

Combined effect of inter-arm systolic blood pressure difference and carotid artery plaque on cardiovascular diseases and mortality: A prospective cohort study

OBJECTIVES

Previous studies have confirmed the relations between inter-arm systolic blood pressure difference (IASBPD) and carotid artery plaque with the risk of cardiovascular diseases (CVD). But it is unclear whether the combined effect of IASBPD and carotid artery plaque further increases the risk of CVD and all-cause mortality.

MATERIALS AND METHODS

We enrolled 4,970 participants (≥40 years old) in the prospective Kailuan study. All participants underwent dual-arm blood pressure and carotid artery ultrasounds. IASBPD was the absolute value of the difference between dual-arm blood pressure. All the participants were divided into four groups according to their IASBPD levels and the presence or absence of carotid artery plaque and Cox proportional hazards models were used to calculate the hazard ratios (HRs) and 95% confidence interval (CI) for incident CVD and all-cause mortality.

RESULTS

During a median follow-up of 7 years, 179 CVD events and 266 deaths occurred. Multivariable Cox Regression showed that participants with IASBPD ≥ 10 mmHg and plaque had a significantly higher incidence of CVD, cerebral infarction (CI), and myocardial infarction (10, 7.27, and 1.36%, respectively). After adjusting for covariates, the IASBPD ≥ 10 mmHg and carotid plaque group significantly increased risks for CVD (HR 2.38; 95% CI, 1.40∼4.05), CI (HR, 2.47; 95% CI, 1.31∼4.67), and all-cause mortality (HR, 2.08; 95% CI, 1.20∼3.59).

CONCLUSION

Our study indicated that the combination of IASBPD and carotid artery plaque was associated with incident CVD and all-cause mortality.

Inter-arm difference in systolic blood pressure: Prevalence and associated factors in an African population

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.

Prevalence of inter-arm blood pressure difference among young healthy adults: Results from a large cross-sectional study on 3235 participants

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.

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Blood pressure should be measured in both arms due to differences in values between them to avoid under-diagnosis of hypertension.

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Accurate measurement of blood pressure is mandatory to prevent cardiovascular, cerebrovascular, and renal diseases.

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In this study, the prevalence of IAD among young, healthy adults was reported.

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Hand dominance is a significant consideration while measuring blood pressure.

Interarm blood pressure differences and 2-year mortality in acute coronary syndrome patients

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.

Elevated Interarm Systolic Blood Pressure Difference Is Positively Associated with Increased Likelihood of Coronary Artery Disease

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.

Association between inter-arm difference in SBP and central blood pressure in a Beijing community cohort

OBJECTIVE

The inter-arm SBP difference (IASBPD) can serve as a predictor of cardiovascular disease (CVD). In this study, we aimed to determine the relationship between IASBPD and central blood pressure (CBP).

METHODS

The study cohort comprised of 7842 eligible individuals. Their BPs were assessed simultaneously in both arms using an Omron BP-203RPEIII vascular profiler, and the IASBPD was measured as the absolute difference in these values (absolute value of left minus right). The CBP was noninvasively measured using an Omron HEM-9000AI device. Multivariate regression analysis was used to assess the association between the central SBP (cSBP) and the IASBPD.

RESULTS

An IASBPD of ≥10 mmHg was positively associated with the cSBP (β = 2.26; 95% confidence interval, 1.04-3.48; P < 0.001). The interaction test showed no significant interactions between the IASBPD and any of the assessed covariates (age group; sex; BMI; smoking status; heart rate group; the presence of hypertension, diabetes, or CVD; and antihypertensive drug use) when the cSBP was used as the outcome in the subgroup analysis.

CONCLUSION

The mechanism underlying the ability of the IASBPD to predict CVD may partly involve an increase in the CBP.

Inter-arm difference in blood pressure in patients referred to tertiary hypertension center: Prevalence, risk factors, and relevance to physicians

The prevalence of inter-arm BP difference is high in hypertension and is associated with adverse cardiovascular outcomes. We performed a retrospective chart review of prevalent patients in the Ottawa Hospital Hypertension Center to assess for prevalence, risk factors, and whether finding of inter-arm BP difference >10 mmHg leads to investigations of the aorta and aortic arch. Inter-arm BP difference among 493 patients was present in 16.2% (95% confidence interval [CI]13.3-19.9%), and it was associated with presence of peripheral arterial disease. Physicians did not investigate ascending aorta and aortic arch for causes of the clinically significant inter-arm BP difference.

Characterization of resting and exercise inter-arm differences in SBP to isometric handgrip exercise in males and females

A large inter-arm difference (IAD; ≥10 mmHg) in SBP is linked to cardiovascular and peripheral vascular disease, hypertension, and premature mortality. Exercise-induced IAD (eIAD) is related to resting IAD, and acute aerobic activity alters eIAD and reduces IAD in recovery. Isometric handgrip exercise (IHE) affects blood pressure (BP), though the eIAD response to IHE is unknown. Further, the eIAD response may differ between males and females.

OBJECTIVES

To characterize the eIAD response to IHE in males and females.

METHODS

On visit 1, participants (16 females and 15 males, aged 18-35 years) completed three maximal voluntary isometric contractions (MVIC) per arm. On visit 2, before IHE, a series of three simultaneous, bilateral BP measures were averaged at rest. During IHE, participants maintained handgrip at 20% of MVIC for 2 minutes (arm randomly assigned), at which time bilateral BP was measured (IHE) during exercise and subsequent recovery (REC1 and REC2). Repeated-measures analysis of variance assessed eIAD and SBP (time × sex).

RESULTS

IHE increased absolute eIAD (4 mmHg). Differences in relative eIAD were observed at IHE and REC2 based on resting IAD status (P < 0.05). Females only had an exaggerated SBP and pulse pressure response in the working arm.

CONCLUSION

Acute IHE was shown to augment eIAD. Further eIAD and resting IAD were related. Acute IHE induced different bilateral responses between males and females, though the impact of sex on eIAD warrants further investigation. Future studies should address the effects of repeated bouts of IHE, which may benefit individuals with a large resting IAD.

Association between an elevated inter-arm systolic blood pressure difference, the ankle-brachial index, and mortality in patients with diabetes mellitus

OBJECTIVES

To estimate the prevalence of an inter-arm blood pressure difference greater than 10mmHg in patients with type 2 diabetes, and the association of this measurement with the presence of a low ankle-brachial index and mortality at 5-year follow-up.

METHOD

A validated blood pressure measurement protocol was used. The blood pressure was calculated for each arm to obtain mean systolic differences. Peripheral arterial disease was confirmed by an ankle-arm index less than 0.9. The medical history of the patient was reviewed in the computerized clinical notes after 5 years of follow-up.

RESULTS

The study included 139 patients with a mean age of 70.1 years (49% male), and a mean duration of diabetes mellitus of 10.8 years. A total of 50 (36%) patients had an inter-arm systolic blood pressure difference greater than 10mmHg. Patients with an inter-arm systolic blood pressure greater than 10mmHg had lower ankle-arm index (0.91±0.30 vs. 1.04±0.28, P=0.005), and higher mortality rates from all causes (48.0% vs. 28.9%; hazard ratio 1.64; 95% confidence interval: 1.06-2.53; P=0.03), compared with those with lower inter-arm systolic blood pressure difference.

CONCLUSION

A high proportion of patients with type 2 diabetes have an elevated systolic blood pressure difference between arms. A significant relationship was found between elevated inter-arm systolic blood pressure difference, lower ankle-brachial index and greater all-cause mortality.

Inter-Arm Blood Pressure Difference in Diabetes Mellitus and Its Preferential Association with Peripheral Artery Disease

Aim: Inter-arm blood pressure difference (IAD) is known to be associated with a composite of cardiovascular disease (CVD) and with CVD risk factors. However, only limited information is available regarding the contribution of diabetes mellitus to IAD and the association of IAD with individual CVDs, such as coronary artery disease (CAD), stroke, and peripheral artery disease (PAD).

Methods: We addressed these issues in this cross-sectional study of 2580 participants who had simultaneous blood pressure measurements in both arms using an automated device.

Results: Compared with 1,264 nondiabetic subjects, 1316 patients with diabetes mellitus had a greater IAD (P = 0.01) and a higher prevalence of IAD of ≥ 10 mmHg (8.4% vs. 5.4%, P = 0.002). However, such difference was not significant after the adjustment for potential confounders. Among CAD, stroke, and PAD, only PAD was significantly associated with IAD in a model adjusted for the CVD risk factors. Age was found to modify the association between IAD and PAD, with the association being more prominent in the younger subgroup.

Conclusion: Thus, diabetes mellitus itself was not an independent factor associated with IAD. A larger IAD was preferentially associated with the presence of PAD, and this association was modified by age.

Association of interarm blood pressure difference with cardio-cerebral vascular disease: A community-based, cross-sectional study

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.

Inter-arm systolic blood pressure dependence on hand dominance

Inter-arm systolic blood pressure differences (SBP-DIFF) ≥ 10 mmHg have been reported useful to predict future cardiovascular-related morbidities. Although well studied in patients, there is little information on healthy young adults and the role of hand-dominance as a factor affecting SBP-DIFF. As dominant arms (DOM) tend to have greater girth and muscle development than nondominant arms (NDOM) it was reasoned that cuff pressures needed to obtain SBP may be greater on DOM causing DOM SBP to be greater. To test this hypothesis and also provide typical values, SBP was measured in left and right-handers (29·4 ± 10·4 years) in whom handedness was clearly defined. Handedness was determined by a multi-question form in 90 young adults (45 male) and SBP-DIFF determined via simultaneous measurements done in triplicate on seated subjects. The percentage of left-handers in male and female sub-groups were equal at 37·8%. Results show that the absolute SBP-DIFF in left-handers (mean ± SD) was 4·4 ± 3·8 mmHg and for right-handers was 5·0 ± 4·2 mmHg (P = 0·362). There was also no statistically significant difference among 1st, 2nd and 3rd measured SBP-DIFF for either right or left-handers or differences between right and left-handers. Results show no evidence of a higher SBP in DOM and thus clarifies the hand-dominance issue as a factor not generally needing to be considered in clinical assessments. A potentially useful secondary outcome was the finding that 14·8% of this group had at least one measured SBP-DIFF ≥ 10 mmHg a fact that may have future relevance.