Inter-arm Blood Pressure Difference Research Articles

INTERARM SYSTOLIC BLOOD PRESSURE DIFFERENCE IS ASSOCIATED WITH A HIGH PREVALENCE OF CARDIO VASCULAR DISEASES- A CROSS-SECTIONAL STUDY IN POLICE WORKER

Background: Interarm systolic blood pressure difference more than 10 mm of Hg is predictor of cardiovascular and metabolic risk. Despite of sufficient physical activity there is high prevalence of obesity in police personal because of stressful working environment. No studies have addressed the significance of interarm pressure difference among them. Therefore, the present study conducted to access the relation of interarm blood pressure difference with obesity in police personnel. Aims and Objective: To estimate the interarm pressure difference in police personal to see its association with their obesity. Material and Method: This cross-sectional observational study done on 245 police workers in PAC, Sitapur, India. Subjects having more than ten years of working experience were included in study. Anthropometric measurements of subject recorded by following standard protocol. Measurement of systolic pressure in both arm recorded simultaneously by mercury sphygmomanometer. Available data analyze and expressed in percentage, mean with SD and chi square test to see the significance of association. Results: According to anthropometric results of subjects 77.14 prcent subjects were having generalised obesity and 82.04 percent of subjects having abdominal obesity. 34.29 percent of subjects showed abnormally high (?10 mmHg) inter-arm systolic blood pressure difference. Both type of obesity showed positive association with blood sugar level but no association with interarm pressure difference. Conclusion: Interarm blood pressure difference is greater in individual having obesity or prolong duration of service. Such subjects are more susceptible to develop coronary artery disease or peripheral arterial disease in future. Early screening can help to detect the vascular events likely to occur in the future Keywords: Body mass index, Waist circumference, Interarm pressure difference, Random blood sugar

Prevalence and associated factors of inter-arm blood pressure difference in Chinese community hypertensive population

ABSTRACT Objectives This study aimed to investigate the prevalence and associated factors of inter-arm blood pressure difference (IAD) in Chinese community hypertensive population. Methods The cross-sectional study included 7788 hypertensive patients (3673 male and 4115 female, aged 62.3 ± 13.6 years) in Guangdong, China. IAD was defined as the absolute value of blood pressure (BP) difference between left and right arms. Bilateral BP was measured simultaneously by automated devices. Results The mean IAD was 4.04 ± 4.33 mm Hg in systolic and 3.19 ± 3.43 mm Hg in diastolic. The prevalence rates of systolic IAD (sIAD)≥5 mm Hg and ≥10 mmHg were 28.9% (n = 2247) and 12.8% (n = 996), respectively. By univariate linear regression, higher sIAD correlated with aging, higher SBP, higher DBP, lower baseline estimated glomerular filtration rate (eGFR), and anti-hypertensive medication (p < 0.05). In multivariate linear regression analysis, higher sIAD was significantly associated with systolic BP (SBP, β = 0.033; 95%CI, 0.025–0.041; p < 0.001), triacylglycerol (β = 0.093; 95%CI, 0.017–0.169; p = 0.016), total cholesterol (β = −0.202; 95%CI, −0.396to −0.009; p = 0.04), and low-density lipoprotein cholesterol (LDL-C; β = 0.304; 95%CI, 0.027–0.582; p = 0.032). Conclusion The elevated prevalence of large IAD was shown in hypertensive population. Meanwhile, higher levels of SBP, triacylglycerol, total cholesterol, LDL-C, and lower eGFR were associated with higher sIAD.

Inter-Arm Blood Pressure Difference Among Nigerian Primary Care Patients— the Need for Dual Arm Blood Pressure Measurement

Background: For many decades, hypertension guidelines have recommended dual-arm blood pressure measurement. However, the practice is poor in Nigerian primary care and its significance largely unidentified. Hence, the need to determine the significance of detecting inter-arm blood pressure difference among primary care patients in our local population. This study was done to determine the point prevalence of inter-arm blood pressure difference and its relationship with hypertension and diabetes mellitus. Methods: A cross-sectional study was conducted among 214 respondents at the general outpatient clinic of a tertiary hospital in Nigeria. Demographic characteristics and anthropometric indices were obtained. Blood pressure readings were obtained through sequentially repeated measurements in respondents’ arms. Results: One hundred and eighty-six respondents had complete data given a completion rate of 86.9%. Systolic blood pressure was higher on the right and left arm in 102 (54.8%) and 56 (30.1%) of the respondents respectively. Diastolic blood pressure was higher on the right and left arm in 73 (39.2%) and 63 (33.9%) of the respondents respectively. The overall prevalence of significant systolic inter-arm difference (≥ 10 mmHg) and diastolic inter-arm difference (≥ 10 mmHg) were 24.2% and 18.8% respectively. Significant systolic inter-arm difference (p=0.033) and diastolic inter-arm difference (p=0.01) were significantly more among respondents with hypertension and/or diabetes mellitus. Conclusion: The blood pressure readings in both arms were different among majority of the respondents, being higher on the right arm in more of them. The prevalence of significant inter-arm difference was high in the unselected primary care patients studied especially among patients with hypertension and/or diabetes mellitus. Blood pressure measurement in both arms should become a routine practice during initial patients’ visits in primary care.

The Future Alert of Inter-Arm Blood Pressure Difference Among Young Healthy Population: A Cross-Sectional Study. (Preprint)

The Future Alert of Inter-Arm Blood Pressure Difference Among Young Healthy Population: A Cross-Sectional Study. (Preprint)

Correlation of interarm blood pressure difference with family history of hypertension, anthropometric parameters, and mean arterial blood pressure in normotensive people

Background: Blood pressure (BP) measurement is routinely done and often, the values obtained from the left and right arms of patients differ. Difference between left and right arm BP relates to delayed diagnosis of hypertension. Failure of considering higher value for diagnosis results in the delayed institution of treatment. Aim and Objective: The objective of the study was to determine the correlation of interarm difference (IAD) of BP with anthropometric parameters and mean arterial BP and its association with family history. Materials and Methods: A cross-sectional study was carried out in 300 healthy subjects in the age group of 18–60 years after approval of the ethical committee. Height, weight, body mass index (BMI), waist circumference (WC), and BP were measured after written informed consent. Results: Data were analyzed using Pearson’s coefficient of correlation analysis and Chi-square test. About 51.91% of people showed large IAD (≥10 mmHg) with 38.03% of systolic IAD (SIAD) and 13.88 % of diastolic IAD (DIAD) χ2 = 39.892 with 3 degrees of freedom; P = 0.000). SIAD showed significant and positive correlation with weight (r = 0.205**; P = 0.000), BMI (r = 0.184**; P = 0.001), WC (r = 0.127*; P = 0.03), and left arm mean (LAM) arterial pressure (r = 0.278**; P = 0.000). On the other hand, DIAD showed significant and positive correlation only with LAM (r = 0.181**; P = 0.002) and right arm mean arterial pressure (r = 0.244**; P = 0.000). Conclusion: Positive correlation of increased IAD in BP with adverse values of anthropometric parameters and mean arterial pressure was confirmed.

Efficacy of Diltiazem for the Control of Blood Pressure in Puerperal Patients with Severe Preeclampsia: A Randomized, Single-Blind, Controlled Trial.

Background Postpartum preeclampsia is a serious disease related to high blood pressure that occurs commonly within the first six days after delivery. Objective To evaluate if diltiazem improves blood pressure parameters in early puerperium patients with severe preeclampsia. Methodology. A randomized, single-blind longitudinal clinical trial of 42 puerperal patients with severe preeclampsia was carried out. Patients were randomized into two groups: the experimental group (n = 21) received diltiazem (60 mg) and the control group (n = 21) received nifedipine (10 mg). Both drugs were orally administered every 8 hours. Systolic, diastolic, and mean blood pressures as well as the heart rate were recorded and analyzed (two-way repeated measures ANOVA) at baseline and after 6, 12, 18, 24, 30, 36, 42, and 48 hours. Primary outcome measures were all the aforementioned blood pressure parameters. Secondary outcome measures included the number of hypertension and hypotension episodes along with the length of stay in the intensive care unit. Results No statistical differences were found between groups (diltiazem vs. nifedipine) regarding basal blood pressure parameters. Interarm differences in blood pressure (systolic, diastolic, and mean) and heart rate were statistically significant between treatment groups from 6 to 48 hours. Patients in the diltiazem group had lower blood pressure levels than patients in the nifedipine group. Significantly, patients who received diltiazem had fewer hypertension and hypotension episodes and stayed fewer days in the intensive care unit than those treated with nifedipine. Conclusions Diltiazem controlled arterial hypertension in a more effective and uniform manner in patients under study than nifedipine. Patients treated with diltiazem had fewer collateral effects and spent less time in the hospital. This trial is registered with NCT04222855.

Functional and Cardiovascular Parameters in Peripheral Artery Disease Patients with Interarm Blood Pressure Difference

To analyze the impact of interarm blood pressure difference (IAD) on functional and cardiovascular parameters in patients with peripheral artery disease (PAD). Ninety-eight patients with PAD were recruited in this cross-sectional study. Patients with differences between the right and left arms of systolic and/or diastolic blood pressure ≥10mm Hg were classified as IAD, whereas the remaining patients were classified as PAD control subjects. Functional parameters included were the 6-min walk test, short physical performance battery, walking impairment questionnaire (WIQ), and the walking estimated-limitation calculated by history. Systemic cardiovascular parameters included were arterial stiffness and heart rate variability. Local cardiovascular parameters assessed in both arms were brachial blood pressure and flow-mediated dilation. Patients with IAD presented higher systolic blood pressure and pulse pressure compared with control patients (P<0.01). The carotid femoral pulse wave velocity tended to be higher and flow-mediated dilation tended to be lower in PAD patients with IAD compared with control subjects (P<0.09). Patients with IAD presented lower scores in short physical performance battery (P=0.012), WIQ distance (P=0.003), WIQ speed (P=0.008), WIQ stair climbing (P=0.034), and walking estimated-limitation calculated by history (P=0.026) when compared with PAD control patients. In patients with PAD, IAD is associated with lower physical function and impairments in cardiovascular parameters compared with PAD patients without IAD.

Inter-arm blood pressure difference in healthy young adults: a cross-sectional study

Introduction: Inter-arm difference (IAD) in blood pressure is the difference in the systolic and the diastolic blood pressure between arms of an individual. Studies regarding IAD among elderly, pregnant women, patients with cardiovascular disease and diabetes have been conducted but there are very limited studies carried out among young healthy adults. Thus, this study aimed to investigate the inter-arm blood pressure difference and its association with age, sex, BMI and family history of hypertension among Nepalese healthy young adults.&#x0D; Materials and methods: A cross-sectional study was carried out among 230 students of Kantipur Dental College, Kathmandu, Nepal. Blood pressure was measured using a mercurial sphygmomanometer. Statistical analysis was done using paired t test, chi-square and Pearson’s correlation test using SPSS 16.&#x0D; Results: The absolute mean IAD for SBP was 5.03±3.88 mm Hg and for DBP was 3.84±3.77 mm Hg. There is significant inter-arm difference for SBP (t=4.882, p&lt;0.001) but not for DBP. Inter-arm SBP difference was significantly associated with family history of hypertension (χ2 = 6.41, p=0.01) and positive but weakly correlated with age (r = +0.135, p=0.04). There is no significant association of inter-arm SBP difference with sex and BMI. Meanwhile, there is no statistically significant association of sex, family history of hypertension, age and BMI with inter-arm DBP.&#x0D; Conclusions: There is a significant inter-arm systolic blood pressure difference among the healthy young Nepalese adults and it is associated with the positive family history of hypertension and age.

Systolic inter-arm blood pressure difference and risk of cognitive decline in older people: a cohort study.

Systolic inter-arm difference in blood pressure (IAD) and cognitive decline are both associated with cardiovascular disease; therefore, it was hypothesised that IAD may be predictive of cognitive decline. To examine associations of IAD with cognitive decline in a community population. A prospective study of older Italian adults enrolled in the InCHIANTI study. Univariable and multivariable associations of IAD were explored with declines in mini mental state examination (MMSE) scores, Trail Making Test A and B scores, and a composite outcome representing substantial decline in any of these scores. Backward stepwise regression was used to adjust observed associations of IAD with cognitive decline. The rate of decline for MMSE scores in 1133 participants was greater with IAD ≥5 mmHg or ≥10 mmHg. On univariable analyses continuous IAD was associated with the composite outcome (odds ratio [OR] 1.16 per 5 mmHg of IAD, 95% confidence interval [CI] = 1.02 to 1.31). Substantial decline in MMSE score was seen with IAD ≥5 mmHg (OR 1.41, 95% CI = 1.03 to 1.93), and in the composite outcome with IAD ≥5 mmHg (OR 1.44, 95% CI = 1.10 to 1.89) or ≥10 mmHg (OR 1.39, 95% CI = 1.03 to 1.88). After multivariable adjustment, an IAD ≥ 5 mmHg remained associated with reductions in the composite outcome, reflecting declining cognitive performance (OR 1.46, 95% CI = 1.05 to 2.03). An IAD ≥5 mmHg is associated with cognitive decline in a representative older population. Given that systolic inter-arm differences in blood pressure are easily measured, confirmation of these findings could inform individualised treatment for the prevention of cognitive decline and dementia.

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

ObjectivesTo 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. MethodA 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. ResultsThe 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. ConclusionA 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.

Predicting Stroke Outcomes Using Ankle-Brachial Index and Inter-Ankle Blood Pressure Difference.

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.

Effect of inter-arm blood pressure differences on outcomes after percutaneous coronary intervention

BackgroundWe investigated the effect of inter-arm blood pressure differences (IABPD) on the percutaneous coronary intervention (PCI) outcomes of patients with coronary artery diseases. MethodsWe 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. ResultsThe 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. ConclusionAmong 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.

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

ObjectivesTo 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. MethodA 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. ResultsThe 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. ConclusionA 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.

Relationship between Inter-Arm Blood Pressure Difference (IAD) and severity of Coronary Artery Disease

Relationship between Inter-Arm Blood Pressure Difference (IAD) and severity of Coronary Artery Disease

Observations of the Exercise-Induced Interarm Blood Pressure Difference

ABSTRACT Blood pressure (BP) is used to aid in appropriate clinical decision making and monitor safe exercise participation. A large interarm difference (IAD) in systolic BP (≥10 mm Hg between arms; IAD+) at rest is associated with premature morbidity and mortality. Moderate-intensity aerobic exercise is known to influence IAD. Purpose The aims of the present study were to examine the relationship between resting IAD and exercise IAD (eIAD), and to characterize eIAD during a prolonged steady-state bout of aerobic exercise in IAD− (&lt;10 mm Hg between arms at rest) and IAD+ individuals. Methods Sixty-two participants were studied on two separate occasions. On the initial visit, anthropometric measures and a V˙O2peak test were completed. On the subsequent visit, participants cycled at 50% V˙O2peak for 30 min. Heart rate and sequential bilateral BP were measured at rest; at 5, 10, 20, and 30 min of exercise; and during active recovery. Descriptive statistics are reported as mean and SEM. The value of eIAD in predicting IAD was determined using multiple linear regression analysis. Absolute values and the percent (%) change in eIAD, systolic BP (right and left arms), and heart rate during exercise were examined between both IAD− and IAD+ individuals using a repeated-measures ANOVA. Results The incidence of IAD+ at rest was 19%. Twenty-five percent of the variation in resting IAD was predicted by eIAD (P &lt; 0.05). There were significantly different absolute and relative eIAD, and SBP responses to exercise between IAD+ and IAD−. Conclusion There is a relationship between eIAD and resting IAD that warrants further attention. The eIAD response is inherently different between IAD− and IAD+ individuals. It may be important to measure BP bilaterally during aerobic exercise.

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.

Inter-arm Blood Pressure Difference as an Emergent Risk for Pre-hypertension

Objective: This study was aimed to determine the frequency of pre-hypertension and hypertension along with its association with inter-arm difference of blood pressure.Methodology: It was a cross sectional study conducted at Aziz Fatimah Medical and Dental College Faisalabad. Students of age ranged 19-21 years were enrolled by convenience sampling technique for screening of pre-hypertension and hypertension. Blood pressure was recorded from both arms by using sphygmomanometer and inter-arm differences were estimated. Mean±SD for continuous variables, frequency and percentages for categorical variables and chi square for association between pre-hypertension, hypertension and inter-arm difference was analyzed by SPSS 21.Results: Study comprised of 100 students with mean age 19.79±1.18 years. Of total 47% were females and 53% was male population. Mean systolic (p value =0.0002*) and diastolic (p value =0.000*) blood pressure of the two arms were significantly different. Of total population, 27% and 13% of population had pre-hypertension and hypertension respectively. Mean systolic inter-arm difference was significantly higher among the hypertensive subjects as compared to pre-hypertensive subjects, (p value =0.0001*). No significant difference was noted with respect to diastolic inter-arm difference (p value =0.93). Greater percentage of normotensive subjects have systolic inter-arm difference &lt;10mmHg as compared to this most of the subjects with hypertension and pre-hypertension have systolic inter-arm difference of &gt;15mmHg. Significant association between hypertension and systolic inter-arm difference was noted (p value =0.025)Conclusion: Pre-hypertension and hypertension is prevalent among young adults. High systolic inter-arm difference was significantly associated with pre-hypertension and hypertension.

Inter-leg systolic blood pressure difference predicts cardiovascular events and mortality in incident hemodialysis patients.

High inter-arm blood pressure difference, a marker of vascular disease, may be difficult to assess in hemodialysis patients with arm arteriovenous fistulae. We investigated if high inter-leg systolic blood pressure difference associates with cardiovascular events and increased mortality in hemodialysis patients. Among 118 incident Japanese dialysis patients, bilateral leg blood pressure, arm blood pressure, brachial-ankle pulse wave velocity, and ankle-brachial index were measured, and the relative risk associated with inter-leg systolic blood pressure difference and other indices of vascular status was analyzed. During follow-up (median, 46 months), 18 deaths and 75 cardiovascular events occurred in 38 patients. Kaplan-Meier curves showed that higher inter-leg systolic blood pressure difference was associated with overall (log-rank 9.35, p = 0.002) and cardiovascular (log-rank 5.81, p = 0.02) mortality. The period from the start of dialysis therapy to the first cardiovascular event was shorter as inter-leg systolic blood pressure difference increased (log-rank 23.7, p < 0.0001). In Cox hazard models, inter-leg systolic blood pressure difference greater than median independently predicted deaths (relative risk, 3.8; 95% confidence interval, 1.3-13.9) and cardiovascular events (relative risk, 3.9; 95% confidence interval, 1.9-9.21) after adjustments for age, sex, nutritional status, and diabetes, whereas other indices were not related to the risks. For well-nourished, moderately malnourished, and severely malnourished patients, the cumulative number of cardiovascular events in the high-inter-leg systolic blood pressure difference patients were 4.96, 31.44, and 55.18 events per 100 patient-years. Higher inter-leg systolic blood pressure difference associated with increased risk of mortality and cardiovascular events suggesting that wider application of inter-leg systolic blood pressure difference measurements may be warranted in hemodialysis patients.

Interarm blood pressure measurement and the reference-arm assignment variability

The arm with the higher blood pressure (BP) is assigned as the follow up arm for hypertensive patients (reference-arm). We evaluated the reproducibility of this assignment. BP was measured simultaneously on both arms with a double cuff validated device in two visits separated <10 days (two sets of three readings per visit). Two reference-arms were assigned in each visit (the arm with higher BP, at least ≥1 mmHg). The intravisit and intervisit agreements of this assignment were evaluated. We included 313 hypertensive patients. First visit mean right arm BP was 131.6 (16.6)/75.3 (9.4) mmHg and left arm BP was 132.4 (16.9)/75.7 (9.7) mmHg (P = 0.002). Intravisit concordance at the first and second visits were κ = 0.60 [95% confidence interval (CI), 0.516-0.696] and κ = 0.45 [95% CI, 0.356-0.555], respectively. Therefore, 21.8% of patients (at the first visit) and 29.1% (at the second visit) with the right arm as the reference-arm in the first round of readings changed to the left arm in the same visit in the second round of readings. The intervisit κ index was 0.25 [95% CI, 0.147-0.365]. After that, 36.8% of patients with the right arm as the reference-arm at the first visit changed to the left arm at the second visit. The subgroup (9.5%) with an interarm systolic BP difference ≥10 mmHg at the first visit did not differ significantly from the rest of patients. The reference-arm assignment agreement is weak to moderate. The assignment of the reference-arm should be individualized and not considered as definitive.

Longitudinal association between adiposity and inter-arm blood pressure difference.

This is the first longitudinal study evaluating whether adiposity is associated with inter-arm blood pressure difference. We evaluated 714 overweight/obese individuals aged 40-65years over a 3-year follow-up. Systolic and diastolic blood pressures were measured in both arms simultaneously using an automated machine. Linear regression assessed the associations of body mass index, fat %, waist, neck, thigh, and arm circumferences (cm), with absolute inter-arm differences in systolic (IAS) and diastolic (IAD) blood pressure (mmHg). Poisson regression was used for binary outcomes (IAS and IAD≥10mmHg). All models were adjusted for age, gender, smoking, physical activity, and HOMA-IR. Adiposity measures were associated with increased IAS and IAD (β range: 0.09-0.20 and 0.09-0.30). Neck circumference showed the strongest association with IAS (β=0.20, 95% CI: 0.03, 0.37) and IAD (β=0.30, 95% CI: 0.12, 0.47); arm circumference showed a similar association with IAS, but lower with IAD. Highest quartiles of BMI, thigh, and arm showed significant associations with IAS (IRR: 2.21, 2.46 and 2.70). Highest quartiles of BMI, waist, neck, and arm circumferences were significantly associated with IAD (IRR: 2.38, 2.68, 4.50 and 2.24). If the associations are corroborated in other populations, adiposity may be an important modifiable risk factor for inter-arm blood pressure difference with a large potential public health impact.