Arm Systolic Blood Pressure Research Articles

The Unilateral Measurement of Blood Pressure May Mask the Diagnosis or Delay the Effective Treatment of Hypertension

Several studies have indicated the presence of significant interarm blood pressure (BP) differences; this could result in misclassification of BP status. Nevertheless, the findings of these studies were not consistent. This prospective, observational study investigated the presence and magnitude of interarm BP differences and determined the influence of age, gender, arm circumference, smoking, being hypertensive or diabetic, or having a previous history of cardiovascular disease in these differences. The study included 384 subjects, who were patients, ward visitors, and members of the nursing staff of this Department. BP measurements were recorded simultaneously in both arms by using 2 validated, fully automated oscillometric electronic devices. There were significant differences between the right arm and left arm systolic BP (p < 0.0005), between right arm and left arm diastolic BP (p < 0.05), and between right arm and left arm pulse pressure (p = 0.006). The mean interarm differences in systolic and diastolic BP measurements were 1.2 +/-5.0 mm Hg and 0.4 +/-4.2 mm Hg, respectively. There were 13 subjects (3.4%) and 4 subjects (1.04%) with an interarm systolic and diastolic BP difference of > 10 mm Hg, respectively, and a single patient with both interarm systolic and diastolic BP differences of > 10 mm Hg (0.26%). None of the studied demographic or clinical characteristics was a significant predictor of interarm systolic and diastolic BP differences. The authors conclude that significant interarm systolic and diastolic BP differences are frequently present. Therefore, the unilateral measurement of BP may mask the diagnosis or delay the effective treatment of hypertension. It is thus recommended that BP should be simultaneously measured in both arms at the initial consultation and the higher of the 2 readings should be used to guide further management decisions.

High prevalence of peripheral arterial disease in hypertension

The study aimed to test the prevalence of peripheral arterial disease (PAD) in general practice and to relate this to possible risk markers. The ankle/arm index (AAI), i.e. the ratio between the ankle systolic blood pressure and arm (brachial) systolic blood pressure, was employed, as it is a useful non-invasive tool for the early detection of atherosclerosis. The participants were selected from 20 general practices, each measuring 50 consecutive patients over the age of 60 years. The study included 1044 consecutive patients (591 women, 453 men) with a mean age of 71 years (range 60–94 years). The female was significant, but slightly, older than the male 71.1 (7.8) vs. 69.9(7.1) years. The ankle and arm blood pressures were measured using a regular automated oscillometric unit (Omron HEM-705CP). Patients with an AAI less than or equal to 0.9 were referred to the local hospital where the ankle pressures were measured with a standard plethysmographic technique. An AAI less than or equal to 0.9 measured with this technique was considered to be indicative of significant PAD. With the standard method, arm blood pressure varied between 91 and 238 mmHg and ankle blood pressure between 60 and 256 mmHg. The AAI measured by the general practitioner was less than or equal to 0.9 in 11.2% of the patients and this could be confirmed in 2/3 of the cases in the laboratory resulting in an overall prevalence of 7.2%. In hypertensive patients, the prevalence of PAD was considerably higher than in normotensive subjects (10.5 versus 6.2%; p<0.0002. The prevalence did not differ with respect to the presence or absence of diabetes. The prevalence was highest in current and previous smokers (14.5 and 8.4%, respectively) compared to people who had never smoked (3.2%; p<0,01). Hypertension and smoking showed considerable interaction with a prevalence of PAD on 28.7%. There was no difference in prevalence between male and female. PAD occurs with a high prevalence in elderly patients attending their general practitioners. The prevalence is significantly increased by the presence of hypertension and in current orp revious smokers. PAD was found to present in more than one fourth of all patients with hypertension who were current smokers. There was the same prevalence of PAD in male and female.

Isometric arm counter-pressure maneuvers to abort impending vasovagal syncope

ObjectivesWe hypothesized that isometric arm exercises were able to increase blood pressure (BP) during the phase of impending vasovagal syncope and allow the patient to avoid losing consciousness. BackgroundHypotension is always present during the prodromal phase of vasovagal syncope. MethodsWe evaluated the effect of handgrip (HG) and arm-tensing in 19 patients affected by tilt-induced vasovagal syncope. The study consisted of an acute single-blind, placebo-controlled, randomized, cross-over tilt-table efficacy study and a clinical follow-up feasibility study. ResultsIn the acute tilt study, HG was administered for 2 min, starting at the time of onset of symptoms of impending syncope. In the active arm, HG caused an increase in systolic blood pressure (SBP) from 92 ± 10 mm Hg to 105 ± 38 mm Hg, whereas in the placebo arm SBP decreased from 91 ± 11 mm Hg to 73 ± 21 mm Hg (p = 0.008). Heart rate behavior was similar in the two arms. In the active arm, 63% of patients became asymptomatic, versus 11% in the control arm (p = 0.02); conversely, only 5% of patients developed syncope, versus 47% in the control arm (p = 0.01). The patients were trained to self-administer arm-tensing treatment as soon as symptoms of impending syncope occurred. During 9 ± 3 months of follow-up, the treatment was actually performed in 95/97 episodes of impending syncope (98%) and was successful in 94/95 (99%). No patients suffered injury or other adverse morbidity related to the relapses. ConclusionsIsometric arm contraction is able to abort impending vasovagal syncope by increasing systemic BP. Arm counter-pressure maneuvers can be proposed as a new, feasible, safe, and well accepted first-line treatment for vasovagal syncope.

Inter-arm differences in blood pressure: when are they clinically significant?

To determine whether there is significant disparity in blood pressure between the two arms. Prospective, observational study. One general hospital in Birmingham, England. Four hundred participants [age 56.3 +/- 19.7 years (mean +/- SD), 50% male] were recruited from staff and patients. Simultaneous bilateral blood pressure measurements were obtained using Omron HEM-705CP automated oscillatory devices; with two measurements taken in each arm. Mean inter-arm blood pressure differences and frequency of clinically important disparities. Mean +/- SD inter-arm differences in systolic and diastolic blood pressure were 1.81 +/- 8.6 mmHg and -0.23 +/- 8.3 mmHg, respectively. The analogous figures for mean +/- SD absolute differences were 6.32 +/- 6.12 mmHg and 5.06 +/- 6.57 mmHg, respectively. Significant differences were present between the mean right and left arm systolic blood pressure [t(399) = 4.20, P < 0.0001], and the mean absolute difference for both systolic [t(399) = 20.65; P < 0.0001] and diastolic [t(399) = 15.39; P < 0.0001] blood pressure. The variation in mean inter-arm blood pressure was unrelated to age, sex, ethnicity, arm circumference, handedness, being hypertensive, diabetic, or previous history of cardiovascular disease. Clinically significant inter-arm differences in systolic blood pressure of > 10 and > 20 mmHg were found in 20 and 3.5%, respectively; diastolic differences of > 10 and > 20 mmHg were present in 11 and 3.5%, respectively. Age was the only significant predictor of clinically significant variations in inter-arm blood pressures and mean absolute blood pressure differences. Significant differences in mean inter-arm systolic blood pressure, and mean absolute inter-arm systolic and diastolic blood pressure are present. This emphasizes the importance of measuring blood pressure in both arms initially to prevent this misdiagnosis of hypertension, due to normal differences in blood pressure between the arms.

The Normal Difference in Bilateral Indirect Blood Pressure Recordings in Normotensive Individuals

If there is a significant dichotomy between bilateral blood pressure determinations in both arms, it is often taken as a sign of some type of underlying pathology. We wished to evaluate what the normal variation might be for significant differences between blood pressures in both arms. Significant difference was arbitrarily chosen as a systolic blood pressure value greater than 10 mm Hg. Bilateral indirect blood pressure determinations were obtained in 100 subjects with no known history of hypertension in the sitting position. The blood pressure was obtained by 2 observers, one who recorded the systolic and diastolic blood pressure as announced by the person taking the blood pressures who was blinded to the actual values taken. The coefficient of variation in obtaining the blood pressures in each arm was determined in 5 of the 100 subjects. The age, sex, and handedness of each individual were recorded as demographic variables. The average left and right systolic blood pressures were 112.1 +/- 16.5 and 112.7 +/- 16.3 mm Hg, respectively. The average left and right diastolic pressures were 64.4 +/- 11.6 and 63.5 +/- 9.9 mm Hg, respectively. There was no significant difference between left minus right systolic or diastolic differences (Student's paired t-test). There were no significant differences in systolic or diastolic blood pressure between gender or between right and left handed individuals (non-paired t-test). The average coefficients of variation for right and left arm systolic blood pressures were 5.41% and 5.81%, respectively. Fifteen subjects had differences in systolic blood pressure between both arms exceeding 10 mm Hg (7% to 22%, 95% confidence interval). Differences of more than 10 mm Hg in indirect bilateral blood pressure recordings are frequent in normotensive individuals and probably do not per se indicate any abnormal pathology. In the right clinical situation, differences that are noted should probably be repeated and should be added to the total clinical picture when used to determine whether a pathologic condition is present.

Percutaneous revascularization of atherosclerotic obstruction of aortic arch vessels

OBJECTIVESTo compare stenting of aortic arch vessel obstruction with surgical therapy and to establish recommendations for treatment.BACKGROUNDThough surgery has been considered to be the procedure of choice for subclavian and brachiocephalic obstruction, little work has been done to compare it with stenting.METHODSEighteen patients with symptomatic aortic arch vessel stenosis or occlusion were treated with stenting, followed by periodic clinical follow-up and noninvasive arterial Doppler studies. Data were compared with the results as shown in a systematic review of a published series of surgery and stenting procedures which included comparison of technical success, complications, mortality and patency.RESULTSPrimary success in our series was 100% with improvement in mean stenosis from 84 ± 11% to 1 ± 5% and mean arm systolic blood pressure difference from 44 ± 16 mm Hg to 3 ± 3 mm Hg. There were no major complications (death, stroke, TIA, stent thrombosis or myocardial infarction). At follow-up (mean 17 months), all patients were asymptomatic with 100% primary patency. Literature review demonstrates equivalent patency and complications in the other published series of stenting. In contrast, there was a similar patency but overall incidence of stroke of 3 ± 4% and death of 2 ± 2% in the published surgical series.CONCLUSIONSSubclavian or brachiocephalic artery obstruction can be effectively treated by primary stenting or surgery. Comparison of stenting and the surgical experience demonstrates equal effectiveness but fewer complications and suggests that stenting should be considered as first line therapy for subclavian or brachiocephalic obstruction.

Comparison of forearm and upper arm blood pressures

Objective. In the prehospital setting it is not always feasible to obtain blood pressure (BP) readings from the upper arm. This study was performed to compare BPs obtained from subjects' forearms and upper arms in order to assess the utility of forearm BP as a surrogate for standard BP. Methods. The authors performed a prospective, cross-sectional, convenience study in a sample of ambulatory university ED patients, where each subject had sequential determinations of left upper arm and forearm BPs with an automated monitor at ED triage. The order of measurement was determined by the day of the week. Demographic and clinical data were also recorded. The main outcome measure was the correlation between upper arm and forearm systolic and diastolic BPs. Pearson's correlation coefficient and Student's t-test were used to analyze the data. Results. 151 patients were enrolled. The mean age was 35.3 ± 15.7 years; 40% were female and 78% were white. The mean forearm and upper arm systolic BPs were 129.8 ± 20.7 mm Hg and 126.2 ± 17.6 mm Hg (p = 0.002). The mean forearm and upper arm diastolic BPs were 80.7 ± 14.5 mm Hg and 76.8 ± 13.4 mm Hg (p < 0.001). The correlations between forearm and upper arm systolic and diastolic BPs were 0.75 (p < 0.001) and 0.72 (p < 0.001). The differences between forearm and upper arm systolic and diastolic BPs were within 20 mm Hg in 86% and 94% of patients, respectively. Conclusion. Forearm BP is a fairly good predictor of standard upper arm BP in most patients. Forearm BP may be used when measurement of upper arm BP is not feasible.

Oxidation of LDL and extent of peripheral atherosclerosis

Evidence has accumulated for oxidative modification of low-density lipoproteins (LDL) to play an important role in the atherogenic process. Therefore, we investigated the relation between susceptibility of LDL to oxidation and risk of peripheral atherosclerosis among 249 men between 45 and 80 years of age. The ankle-arm index was calculated for both legs as the ratio of systolic blood pressure in the leg divided by the arm systolic blood pressure. The lowest of both ankle-arm indices was used to categorize subjects. Thirty-nine men with an ankle-arm index <1.00 (20% cut-off point of distribution) were classified as subjects with peripheral atherosclerosis.Subjects with peripheral atherosclerosis reported more often the use of a special diet and the use of antihypertensive medication, aspirin and coumarin derivatives. No significant differences in total, LDL and HDL cholesterol and triglycerides were present between groups. Resistance time and maximum rate of oxidation were measured ex vivo using copper-induced LDL oxidation. Subjects with peripheral atherosclerosis had a significantly lower resistance time, whereas the maximum rate of oxidation tended to be increased in subjects with peripheral atherosclerosis. Odds ratios (ORs, and 95% confidence interval) for the successive tertiles of resistance time were 1.00 (reference), 0.37 (0.15–0.89) and 0.37 (0.16–0.86) (ptrend < 0.01). ORs for the successive tertiles of maximum rate of oxidation were 1.00 (reference), 1.34 (0.47–3.82) and 1.50 (0.55–4.15). This inverse association was borderline significant (ptrend = 0.07).These results support an association between LDL oxidation and the development of peripheral atherosclerosis.

Homocysteine, atherosclerosis and prevalent cardiovascular disease in the elderly: The Rotterdam Study.

Elevated homocysteine increases the risk of vascular disease, in particular amongst younger subjects (< 60 years). Very few studies have been performed amongst older subjects. We evaluated the relation of plasma total homocysteine (tHcy) to atherosclerosis and symptomatic cardiovascular disease amongst older men and women. A cross-sectional study. General population. A random sample of 630 men and women, participating in the Rotterdam Study, a prospective population-based cohort study amongst 7983 subjects aged 55 years and over residing in the Ommoord district of Rotterdam, the Netherlands. Carotid atherosclerosis (carotid plaques and common carotid intima-media thickness) assessed by ultrasonography; lower extremity (peripheral) artery atherosclerosis measured by the ratio of the ankle to arm systolic blood pressure; prevalent cardiovascular disease assessed as a history of myocardial infarction or stroke. Subjects, 55-74 years of age, with elevated tHcy levels (+/- 18.6 mumol L-1) had a thicker common carotid intima-media (difference 0.037 mm; 95% CI 0.001, 0.073), a lower ankle-arm index (-0.054; -0.104, -0.004), and an increased risk of cardiovascular disease (odds ratio 3.0; 1.5, 6.1), after adjusting for sex and age. There was no appreciable association of tHcy levels to atherosclerosis and cardiovascular disease in subjects aged 75 years and older. In subjects aged 55-74 years elevated tHcy is associated with an increased risk of atherosclerosis and cardiovascular disease. The lack of association in those aged > or = 75 years most probably reflect selective mortality.

Isolated Aortic Coarctation in Neonates and Infants: Results of Resection and End-to-End Anastomosis

Operative resection is the treatment of choice for native aortic coarctation in most institutions. The ideal timing for elective repair is still a matter of debate. This study evaluated one institution's results with resection and end-to-end anastomosis in the first year of life. Between January 1987 and December 1993, 46 neonates and infants with functionally isolated aortic coarctation underwent operative resection and end-to-end anastomosis. For the patients included in the study, all hospital records, catheterization data, and operative protocols were evaluated for retrospective analysis. To obtain valid follow-up information, all patients were systematically seen on an outpatient basis during 1994. After a mean follow-up of 49 +/- 24 months (range, 13 to 95 months), recoarctation (arm-leg blood pressure gradient > 20 mm Hg) occurred in 5 of 26 patients with neonatal operations (19%) and in 1 of 20 patients with operations in infancy (5%, p = not significant). Four of these 6 children with recoarctation needed reintervention. The other 2 patients had only mild recoarctation (gradients of 22 and 30 mm Hg, respectively) and were not treated. In all 6 patients, recoarctation was diagnosed within the first 6 months postoperatively. During the whole follow-up period, right arm systolic blood pressures slightly above the 90th percentile of normal developed in 11 of the patients (24%) (7 in the group with neonatal operation and 4 after operation in infancy; p = not significant). Resection with end-to-end anastomosis was shown to be an adequate therapeutic strategy for isolated aortic coarctation in neonates and infants. The results indicate that already beyond the neonatal age, there is a relatively low incidence of recoarctation.

Ankle-arm blood pressure index as a predictor of mortality in hemodialysis patients

The ankle-arm blood pressure index (AAI, ratio of ankle to arm systolic blood pressure), a simple, noninvasive, and inexpensive screening test, has recently been found to be highly predictive of subsequent mortality in several populations. The purpose of this study was to evaluate the relationship of the AAI to cardiovascular and all-cause mortality in hemodialysis patients. A cohort of 132 patients was followed for 1 year. The primary outcome measures were cardiovascular and all-cause mortality. An AAI of <0.9 was associated with a relative risk (RR) of cardiovascular mortality of 7.5, (95% CI, 2.3 to 24.8). Other predictive variables included diabetes mellitus RR 3.0, (95% CI, 1.2 to 7.3), and a history of any vascular disease RR 2.6 (95% CI, 1.0 to 7.0). An AAI of <0.9 was also predictive of all-cause mortality, RR 2.4 (95% CI, 1.2 to 4.7). Other predictive variables for all-cause mortality included older age, RR 1.4 per 10 years (95% CI, 1.0 to 2.1), decreased serum albumin RR 0.9 per 0.1 mg/dL (95% Cl, 0.8 to 1.0), and diabetes mellitus RR 2.0 (95% CI, 1.0 to 3.7). Multivariate analysis showed an AAI of <0.9 and diabetes mellitus to be the only independent predictors of cardiovascular mortality, and an AAI of <0.9, older age, and a decreased serum albumin were independent predictors of all-cause mortality. In conclusion, we have found an AAI of <0.9 to be a powerful, independent predictor of mortality in hemodialysis patients.

Lipoprotein(a) and peripheral atherosclerosis in older adults

As part of an ancillary study to the Systolic Hypertension in the Elderly Program, carotid and lower extremity arterial disease (LEAD) were evaluated in 369 subjects, 186 with a systolic blood pressure (SBP) ≥ 160 mmHg, and 183 with SBP < 160 mmHg. Both groups had a diastolic blood pressure (DBP) < 90 mmHg. Internal carotid stenosis was identified by Doppler and LEAD was assessed using the ankle to arm systolic blood pressure ratio, commonly called the ankle/arm index (AAI). Lp(a) values were obtained from frozen sera and values ≥ 20 mg/dl were considered elevated. Rates of carotid stenosis were 24% among those with an Lp(a) ≥ 20 mg/dl and 14% among those with an Lp(a) level < 20 mg/dl ( P = 0.020). The relationship between Lp(a) and LEAD was even stronger. Those with an Lp(a) ≥ 20 mg/dl had a 36% prevalence of a low AAI vs 14% among those with a Lp(a) level < 20 mg/dl ( P < 0.001). Lp(a) values were also associated with the severity of LEAD. Controlling for other risk factors did not reduce the association between either LEAD or carotid stenosis and an Lp(a) ≥ 20 mg/dl. Thus, Lp(a) appears to be independently associated with peripheral atherosclerosis in older adults, both men and women. The relationship is particularly strong for atherosclerotic disease of the lower extremities.

Hemodynamics of Stenotic Infrainguinal Vein Grafts: Theoretic Considerations

We developed a theoretic model of arterial stenosis to study the relationship between perfusion pressure and regional hemodynamics in stenotic infrainguinal vein grafts in an attempt to identify grafts at high risk for failure. Our model was based on the concept of energy and mass conservation of the flowing blood. We used the modified Bernoulli equation (delta P = 4 delta V2) to calculate the maximum possible intrastenotic peak systolic velocity (PSV) from the systolic blood pressure. PSV was measured by means of duplex ultrasonography in infrainguinal bypasses up to the time of revision (nine grafts) or spontaneous thrombosis (two grafts). We related arm systolic blood pressure, intrastenotic PSV, and prestenotic PSV obtained from duplex examinations conducted prior to graft thrombosis or revision and applied our model to these stenotic vein grafts. Intrastenotic PSV was consistently lower than maximum PSV predicted from the Bernoulli equation. The highest measured intrastenotic PSV of 600 cm/sec would require a minimum perfusion pressure of 144 mm Hg. The lowest measured PSV (20 cm/sec) was considered the minimum "thrombotic threshold velocity." This model predicts that for parabolic profile flow in an 80% diameter-reducing axisymmetric stenosis (96% cross-sectional area reduction), a prestenotic PSV of 20 cm/sec would produce an intrastenotic PSV of 500 cm/sec requiring the equivalent potential energy of 100 mm Hg systolic blood pressure. Our theory implies that in patients with nocturnal hypotension thrombosis of stenotic vein grafts may occur.

Coronary-Subclavian Steal Syndrome: Report of Five Cases

The internal mammary artery (IMA) is the conduit of choice for cardiac revascularization. The phenomenon of retrograde flow in this graft secondary to proximal subclavian artery stenosis is an infrequent but increasingly recognized clinical entity and has been termed the "coronary-subclavian steal syndrome." We report on five patients with this syndrome. All were men. The average age was 65 years (range 56 to 68 years). The mean interval from coronary bypass to presentation was 7.8 years (range 1 month to 18 years). Three patients presented with unstable angina and one with congestive heart failure. One patient was asymptomatic from a cardiac standpoint. The mean arm systolic blood pressure differential was 45 mm Hg (range 30 to 60 mm Hg). Each patient underwent cardiac catheterization, and retrograde IMA flow was demonstrated in 100%. Arteriography confirmed the presence of a proximal high-grade (> 75%) subclavian stenosis in all patients. Stress thallium scanning was performed in two patients and demonstrated anterolateral ischemia in both. Operative intervention in four patients consisted of a left carotid-subclavian bypass using an 8 mm synthetic graft. There was no perioperative morbidity or mortality. Postoperative thallium scanning revealed resolution of the ischemic process. The average length of follow-up was 20 months (range 12 to 25 months) with all patients remaining asymptomatic. The one patient who refused surgery died at 12 months. When IMA grafting is contemplated, proximal subclavian stenosis should be suspected if there is > 20 mm Hg systolic pressure differential between the arms.(ABSTRACT TRUNCATED AT 250 WORDS)

Morbidity and Mortality in Hypertensive Adults With a Low Ankle/Arm Blood Pressure Index

To evaluate the relationship between the ankle/arm blood pressure index (AAI, the ratio of ankle to arm systolic blood pressure, a measure of peripheral arterial disease) and short-term cardiovascular morbidity and mortality in older adults with systolic hypertension. Prospective cohort study, 1- to 2-year follow-up (mean, 16 months). Eleven of 16 field centers from the Systolic Hypertension in the Elderly Program. 1537 older men and women with systolic hypertension. All-cause mortality, coronary heart disease (CHD) mortality, cardiovascular disease (CVD) mortality, and CHD and CVD morbidity and mortality. The AAI was measured at the 1989-1990 clinic examination and was 0.9 or less in 25.5% of 1537 participants. A low AAI was associated with most major CHD and CVD risk factors. In those with a low AAI (< or = 0.9) compared with those with an AAI of more than 0.9, age- and sex-adjusted relative risks for mortality end points at follow-up were as follows: total mortality, 3.8 (95% confidence interval [CI], 2.1 to 6.9); CHD mortality, 3.24 (95% CI, 1.4 to 7.5); and CVD mortality, 3.7 (95% CI, 1.8 to 7.7). For CVD morbidity and mortality, the age- and sex-adjusted relative risk was 2.5 (95% CI, 1.5 to 4.3). After adjustment for baseline CVD and other cardiovascular risk factors, the relative risk for total mortality was 4.1 (95% CI, 2.0 to 8.3) and for CVD morbidity and mortality, 2.4 (95% CI, 1.3 to 4.4). Results were similar when participants with clinical CVD at baseline were excluded. A low AAI appears to be an important predictor of morbidity and mortality among older adults with systolic hypertension.

Cerebral white matter lesions and atherosclerosis in the Rotterdam Study

Cerebral white matter lesions (WML) seen on magnetic resonance imaging scans are associated with cardiovascular disease and vascular risk factors. To assess the association between WML and atherosclerosis, we studied 111 people, aged 65 to 85 years, randomly sampled, and stratified by age and sex, from participants in the Rotterdam Study.Cerebral T2-weighted magnetic resonance images in the axial plane were obtained for all subjects. Carotid atherosclerosis was ultrasonographically assessed by the presence of stenosis, measurement of intima to media wall thickness (IMT), and the presence of atherosclerotic plaques. A possible or definite myocardial infarction on an electrocardiogram was used as an indicator of coronary atherosclerosis. The ankle to arm systolic blood pressure ratio (ABI) was determined, and peripheral arterial disease was defined as an ABI lower than 0·90 in at least one side.Carotid atherosclerosis was significantly more pronounced in people with WML. The difference in common carotid IMT was 0·13 mm (95% confidence interval [Cl] 0·04-0·21), whereas the odds ratio of WML associated with plaques in the carotid bifurcation was 3·9. The degree of internal carotid artery stenosis was not, however, associated with WML. The mean ABI was significantly lower in people with WM L than in those without lesions with a difference of -0·11 (95% Cl -0·21 to -0·01). The odds ratio of WML associated with peripheral arterial disease and a possible or definite myocardial infarction was 2·4 and 3·1, respectively. We conclude that atherosclerosis, indicated by increased common carotid IMT, carotid plaques, and a lower ABI, is related to WML.

Increased stiffness and persistent narrowing of the aorta after successful repair of coarctation of the aorta: Relationship to left ventricular mass and blood pressure at rest and with exercise

Fifteen children and adolescents who had repair of coarctation of the aorta before age 15, who were not hypertensive at rest, and who had resting arm-leg blood pressure gradients of <20 mm Hg underwent noninvasive evaluation of left ventricular structure and function, aortic stiffness, and residual coarctation as well as bicycle exercise testing. These results were compared with those in 15 age- and sex-matched control subjects. The mean resting age-related systolic blood pressure percentiles (63% versus 46%), transverse aortic stiffness measured by the elastic modulus (Ep) (42.1 versus 23.2 kPa), stiffness index beta (β) (3.66 versus 2.17), echocardiographic left ventricular fractional shortening (0.42 versus 0.36), left ventricular mass index (99.3 versus 81.0 gm/m 2), maximum exercise right arm systolic blood pressure (173 versus 156 mm Hg), and exercise arm-leg blood pressure gradient (35 versus 6 mm Hg) were significantly increased in the coarctectomy patients compared with controls. Univariate correlations in the coarctectomy group showed significant relationships of residual aortic narrowing with left ventricular mass index ( r = 0.68, p < 0.01) and resting systolic blood pressure percentile for age ( r = 0.55, p < 0.05). Residual aortic narrowing did not significantly correlate with aortic stiffness, resting blood pressure gradient, or exercise blood pressure gradient. Neither left ventricular mass index nor resting systolic blood pressure percentile significantly correlated with age of repair or years after repair. These results demonstrate persistent abnormalities in aortic stiffness and left ventricular mass and function after successful repair of coarctation of the aorta in childhood and adolescence. Mild degrees of residual aortic narrowing may affect resting blood pressure and left ventricular mass. Elevated blood pressure and blood pressure gradients between upper and lower extremities during exercise may be a reflection of increased arterial stiffness in the upper body as well as mild persistent coarctation.

Progression of Peripheral Occlusive Arterial Disease in Diabetes Mellitus

The clinical, biochemical, and vascular laboratory measurements potentially associated with the development and/or progression of peripheral occlusive arterial disease (POAD) were assessed during a 4-year period in 110 normal control subjects, 112 patients with POAD without diabetes mellitus, 240 patients with diabetes mellitus without POAD, and 100 patients with diabetes mellitus and POAD. Age, history of hypertension or coronary heart disease, history of cigarette smoking, presence of POAD, systolic blood pressure, and beta-thromboglobulin level were associated with progression of POAD. A multivariate logistic regression model indicated that the presence of diabetes mellitus or POAD or both at baseline, decreased postexercise ankle-brachial index, increased arm systolic blood pressure, and current smoking were independently associated with progression of POAD. This study suggests that cessation of smoking and control of hypertension are essential treatment modifications to decrease the risk of progression of peripheral vascular disease in diabetic patients.

Effect of Arterial Revascularization on Transcutaneous Oxygen Tension of the Ischemic Extremity

In 20 patients (24 limbs) with peripheral occlusive arterial disease involving the lower extremities, foot and chest transcutaneous oxygen tension (tcPO2) and ankle and arm systolic blood pressures were measured, with the patient's legs horizontal and with them in an elevated position, before and after revascularization procedures. Eighteen of the procedures were unilateral and were performed to alleviate severe ischemia; the three bilateral procedures were done to relieve intermittent claudication. Regional perfusion index (RPI) was calculated for each foot (RPI = tcPO2 foot/tcPO2 chest) with the legs horizontal and with the legs elevated for 3 minutes (RPI3). The ankle/brachial index was calculated from ankle and arm systolic blood pressures. Limbs with severe ischemia had considerably decreased RPI and RPI3 before revascularization, whereas limbs affected by claudication had only a modest decrease in RPI but a pronounced decrease in RPI3. The tcPO2, RPI, and RPI3 increased substantially after revascularization.

Carotid and lower extremity arterial disease in elderly adults with isolated systolic hypertension.

The prevalence of carotid and lower extremity arterial disease was assessed in a healthy population of 56 elderly adults with isolated systolic hypertension. Duplex scans were performed to determine the extent of carotid disease, and postexercise ratios of ankle to arm systolic blood pressure were measured to assess lower extremity arterial disease. Internal carotid stenosis was found in 38% (21 of 56) of subjects and lower extremity arterial disease in 42% (23 of 55). The strongest predictor of internal carotid stenosis was lower extremity arterial disease. Independent risk factors for lower extremity arterial disease were smoking, internal carotid stenosis, and age. A measure of extent of carotid plaque was found to correlate with age, carotid stenosis, male sex, history of smoking, and total cholesterol. The high prevalence of peripheral vascular disease in this population may be related to their age and blood pressure. The high correlation between carotid stenosis and lower extremity arterial disease suggests that persons with peripheral vascular disease should be assessed and treated for atherosclerotic disease in general.