In Reply

Abstract

I thank Dr. Neurath for his comments on blood pressure measurement in the elderly. The term “pseudohypertension” has indeed become a diagnostic term that refers to artifactual hypertension in patients with Mönckeberg's medical calcification of large arteries.1 This process can be diagnosed by radiographic examination of the arms; vascular calcification will be evident. Pseudohypertension may be superimposed on existing hypertension, normotension, or even hypotension and must be diagnosed correctly in order to prevent potentially dangerous overtreatment. Unfortunately, the true prevalence of pseudohypertension remains unknown although it is relatively uncommon. The Osler maneuver has not proved to be reliable, and a high index of clinical suspicion remains the best screening measure.2 There are many other causes of erroneous blood pressure readings, several of which are listed by Dr. Neurath. One of the most common is use of a blood pressure cuff that is too small for the patient's arm. The need for correct blood pressure measuring technique cannot be overemphasized. This includes the palpation of the peripheral pulse (radial or brachial) to avoid the error of the “silent zone” with consequent underestimation of the true intraarterial pressure. The diagnosis of ISH clearly requires multiple measurements on separate visits. The physical examination, chest X-ray, and ECG greatly underestimate the true prevalence of left ventricular hypertrophy. Nevertheless, cardiac ultrasound should be reserved for patients for whom the results are expected to be critical for diagnostic and therapeutic decision making. It is not a routine test. I could not agree more regarding the dangers of too rapid reduction of elevated blood pressure, especially in elderly patients. Rapid reduction is rarely necessary and potentially dangerous. Patients who are anxious and/or in pain may have blood pressure levels truly elevated above their usual baseline. Often the best treatment is relief of the anxiety and/or pain and not direct treatment of the blood pressure numbers. Semantics aside, the most important point of my editorial was that there are now data on which to base the treatment of patients with ISH.3 It is, of course, crucial to determine that the patient does, in fact, have ISH in order to avoid the risks of treatment, however small, for an entity that the patient does not actually have.