Left Arm Blood Pressure Research Articles

Validation of the ANDON KD-595 automated upper-arm blood pressure monitor according to the universal standard.

To validate the ANDON KD-595 automated upper-arm blood pressure monitor for clinical use and self-measurement blood pressure measurement according to the Association for the Advancement of Medical Instrumentation/European Society of Hypertension/International Organization for Standardization (AAMI/ESH/ISO) Universal Standard. Same left-arm blood pressure was sequentially measured in 90 qualified adult participants and compared with a standard mercury sphygmomanometer. A total of 270 comparison pairs were obtained and analyzed according to the universal standard. For the validation Criterion 1 of the universal standard, the mean ± SD of the differences between the test device and reference blood pressure readings was 0.96 ± 5.35 and 0.82 ± 5.08 mmHg for SBP and DBP, respectively. For Criterion 2, the SDs of the averaged blood pressure differences between the test device and reference blood pressure per subject were 4.84 and 4.64 mmHg (with maximum allowed SDs of 6.87 and 6.89 mmHg) for SBP and DBP, respectively. The ANDON KD-595 automated upper-arm blood pressure monitor passed all the validation requirements according to the AAMI/ESH/ISO Universal Standard and can be recommended for clinical use and self-measurement blood pressure measurement in the general population.

Clinical relevance of double-arm blood pressure measurement and prevalence of clinically important inter-arm blood pressure differences in Indian Primary Care.

Hypertension guidelines recommend measuring blood pressure (BP) in both arms at least once. However, this is seldom done due to uncertainties regarding measurement procedure and the implications of finding a clinically important inter-arm BP difference (IAD). This study aimed to provide insight into the prevalence of clinically important IADs in a large Indian primary care cohort. A number of 134678 (37% female) unselected Indian primary care participants, mean age 45.2 (SD 11.9) years, had BP measured in both arms using a standardized, triplicate, automated simultaneous measurement method (Microlife WatchBP Office Afib). On average, there were clinically minor differences in right and left arm BP values: systolic BP 134.4 vs. 134.2 mmHg (p<0.01) and diastolic BP 82.7 vs. 82.6 mmHg (p<0.01), respectively. Prevalence of significant mean systolic IAD between 10 and 15 mmHg was 7813 (5.8%). Systolic IAD ≥ 15 mmHg 2980 (2.2%) and diastolic IAD ≥ 10 mmHg 7151 (5.3%). In total, there were 7595 (5.6%) and 8548 (6.3%) participants with BP above the 140/90 mmHg threshold in only the left or right arm, respectively. Prevalence of participants with elevated BP on one arm only was highest in patients with a systolic IAD ≥ 15 mmHg; 19.1% and 13.7%, for left and right arm, respectively. This study shows that a substantial prevalence of IAD exist in Indian primary care patients. BP is above the diagnostic threshold for hypertension in one arm only for 6% of participants. These findings emphasise the importance of undertaking bilateral BP measurement in routine clinical practice. This article is protected by copyright. All rights reserved.

Clinical relevance of double-arm blood pressure measurement and prevalence of clinically important inter-arm blood pressure differences in Indian primary care.

Hypertension guidelines recommend measuring blood pressure (BP) in both arms at least once. However, this is seldom done due to uncertainties regarding measurement procedure and the implications of finding a clinically important inter‐arm BP difference (IAD). This study aimed to provide insight into the prevalence of clinically important IADs in a large Indian primary care cohort.A number of 134 678 (37% female) unselected Indian primary care participants, mean age 45.2 (SD 11.9) years, had BP measured in both arms using a standardized, triplicate, automated simultaneous measurement method (Microlife WatchBP Office Afib).On average, there were clinically minor differences in right and left arm BP values: systolic BP 134.4 vs 134.2 mmHg (p < .01) and diastolic BP 82.7 vs 82.6 mmHg (p < .01), respectively.Prevalence of significant mean systolic IAD between 10 and 15 mmHg was 7,813 (5.8%). Systolic IAD ≥ 15 mmHg 2,980 (2.2%) and diastolic IAD ≥ 10 mmHg 7,151 (5.3%). In total, there were 7,595 (5.6%) and 8,548 (6.3%) participants with BP above the 140/90 mmHg threshold in only the left or right arm, respectively. Prevalence of participants with elevated BP on one arm only was highest in patients with a systolic IAD ≥ 15 mmHg; 19.1% and 13.7%, for left and right arm, respectively.This study shows that a substantial prevalence of IAD exists in Indian primary care patients. BP is above the diagnostic threshold for hypertension in one arm only for 6% of participants. These findings emphasize the importance of undertaking bilateral BP measurement in routine clinical practice.

EFECTS OF LISINOPRIL AND AMLODIPIN IN COMBINATION FOR THE TREATMENT OF HYPERTENSION WITH PULSE WAVE VELOCITY VP PLUS 1000 METER

Aim: The aim of this study was to evaluate the antihypertensive efficacy of lisinopril and amlodipine in combination which were measured by the pulse wave velocity meter. Research objects and Methods: 40 patients with primary hypertension, mean age 69.18 ± 10.4 years. All patients had their blood pressure, pulse wave velocity (baWPV), ankle brachial index measured by pulse wave velocity VP Plus 1000 meter before receiving the treatment. All patients were then given the Lisonorm combination pill (lisinopril 10 mg and amlodipine 5 mg) for 4 weeks. After 4 weeks, the patients was measured again with the same device (the pulse wave velocity of VP Plus 1000 meter). Results: After 4 weeks, the values of the Right arm blood pressure decreased: 26.58 ± 9.51 mmHg/ 8.6 ± 4.47 mmHg; Left arm blood pressure decreased: 26.88 ± 11.27/13.55 ± 8.15mmHg; Right ankle blood pressure decreased: 23.75 ± 11.78/10.75 ± 6.64mmHg; Left ankle blood pressure decreased: 30.33 ± 16.64/13.6 ± 9.28mmHg; The rate of patients with the target blood pressure was 72.5% (29/40 patients). Right baPWV decreased 593.65 ± 416.59 cm/s; Left baPWV decreased 585.4 ± 447.19 cm/s. Conclusion: The combination of lisinopril 10mg and amlodipine 5mg effectively had decreased the blood pressure in both extremities and pulse wave velocity, and had reduced vessel wall stiffness when it was measured by the pulse wave velocity VP Plus 1000 meter.

Effects of Lisinopril and Amlodipine in Combination for the Treatment of Hypertension with Pulse Wave Velocity VP Plus 1000 Meter

<i>Aim: </i>The aim of this study was to evaluate the antihypertensive efficacy of lisinopril and amlodipine in combination which were measured by the pulse wave velocity meter. <i>Research objects and Methods: </i>40 patients with primary hypertension, mean age 69.18 ± 10.4 years. All patients had their blood pressure, pulse wave velocity (baWPV), ankle brachial index measured by pulse wave velocity VP Plus 1000 meter before receiving the treatment. All patients were then given the Lisonorm combination pill (lisinopril 10 mg and amlodipine 5 mg) for 4 weeks. After 4 weeks, the patients was measured again with the same device (the pulse wave velocity of VP Plus 1000 meter). <i>Results:</i> After 4 weeks, the values of the Right arm blood pressure decreased: 26.58 ± 9.51 mmHg/ 8.6 ± 4.47 mmHg; Left arm blood pressure decreased: 26.88 ± 11.27/13.55 ± 8.15mmHg; Right ankle blood pressure decreased: 23.75 ± 11.78/10.75 ± 6.64mmHg; Left ankle blood pressure decreased: 30.33 ± 16.64/13.6 ± 9.28mmHg; The rate of patients with the target blood pressure was 72.5% (29/40 patients). Right baPWV decreased 593.65 ± 416.59 cm/s; Left baPWV decreased 585.4 ± 447.19 cm/s. <i>Conclusion: </i>The combination of lisinopril 10mg and amlodipine 5mg effectively had decreased the blood pressure in both extremities and pulse wave velocity, and had reduced vessel wall stiffness when it was measured by the pulse wave velocity VP Plus 1000 meter.

The management of a patient with multiple infarcts with different etiologies

72 yo male, presents for abdominal pain and motor deficiency of the left upper limb. Clinical examination reveal severe general condition, left brachial hemiparesis, right arm blood pressure (BP) 240/120 mmHg, left arm BP 210/100 mmHg, heart rate (HR) 110 bpm, arrhythmic, abdominal pain at superficial palpation, without other abnormalities. Biological: negative hs troponin I, positive D-dimers, positive CRP, GFR 38 ml/min/m2, potassium 2.97 mmol/l. ECG: Atrial fibrillation. Abdominal ultrasound: abdominal dilated aorta, dissection flap. Abdominal and pelvic CT scan: right renal infarction, multiple splenic infarction, abdominal aortic aneurysm with dissection. Underwent interventional treatment of the abdominal aortic dissection (EVAR). Particularity of the case: concomitant diagnosis of multiple infarction with different etiologies, for which therapeutic decision was challenging.

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.

Evolution into Takayasu arteritis in a patient presenting with acute pulmonary oedema due to severe aortic regurgitation; a case report

BackgroundTakayasu arteritis is a rare large vessel vasculitis which predominantly affects young Asian females. Aortic regurgitation and heart failure are well described manifestations which are usually preceded by constitutional symptoms, limb claudication, pulse and blood pressure discrepancies, vascular bruits and features of organ ischaemia.Case presentationA 25-year- old Sri Lankan female presented with a three days history of acute shortness of breath, cough and orthopnoea. On examination she had severe aortic regurgitation resulting in high output cardiac failure. There was no evidence of acute coronary ischaemia or infective endocarditis. The only significant investigation finding was an elevated erythrocyte sedimentation rate (ESR) of 114 mm/first hour. The patient was treated for pulmonary oedema and empirically for infective endocarditis. Extensive evaluation for an underlying infection, large vessel vasculitis or malignancy did not reveal any abnormalities. Detailed periodic assessment identified reduced blood pressure in left arm (70/40 mmHg) compared to right (100/70 mmHg) and reduced pulse volume of left arm with left subclavian bruit more than one year after the initial presentation. Digital subtraction angiography revealed significant stenosis at first part of left subclavian and origin of left vertebral arteries. A diagnosis of Takayasu arteritis was made and patient was started on high dose glucocorticoids.ConclusionsTakayasu arteritis can present initially with isolated cardiac involvement even as acute cardiac manifestations and high degree of suspicion with close follow up would allow early detection of development of other classic features and timely diagnosis.

Inter‐Arm Blood Pressure Differences in Aviators: Is It Important?

We read the article “Inter-Arm Blood Pressure Differences in Young, Healthy Patients” written by Grossman and colleagues1 with great interest. They concluded that there were no significant differences between right and left arm blood pressure (BP) measurements but inter-arm BP difference (IAD) was correlated with systolic BP. According to their results, significant IAD (>10 mm Hg) is common in young, healthy patients and so BP should be measured in both arms. We thank the authors for their contributions. The results of studies about the effects of IAD in young, healthy patients and aviators might be controversial. Currently, coronary risk factors, eg, hypertension, obesity, and diabetes, are increasing in prevalence among the young population.2 Higher systolic and diastolic BPs may be one of the features of excessive cardiovascular risk not only for older pilots but also young ones. Although all patients were completely healthy in the present study, the prevalence of IAD >10 mm Hg was 12.6% for systolic BP and 8.8% for diastolic BP and IAD was not correlated with age, body mass index, or heart rate, but was correlated with systolic BP. The impact of IAD during BP measurements has been the subject of extensive research in recent years. There may be a relationship between IAD and increased risk of cardiovascular morbidity in older patients.3 We do not know whether it is important in young patients, particularly cadet aviators. Additionally, measurement of BP must be very sensitive. While some centers can do it automatically, measurements are usually made manually. Therefore, analysis of intraobserver and interobserver differences are important. On the other hand, differential diagnosis of white-coat hypertension is a major concern, especially in young patients. The best way of excluding white-coat hypertension is 24-hour ambulatory BP monitoring in patients with higher BP measurements in the doctor's office.4 The measurement of BP in both the arms and legs is very important in cases of vascular disease such as peripheral vascular disease, aortic coarctation, and subclavian artery disease. The differences that exist in the values measured in both arms provide us with a diagnosis.5 The patient is important and we need further studies to better evaluate and understand BP measurements in both arms to exclude vascular disease and detect IAD.

Unknown Complication of Arterial Switch Operation

A 17-year-old man with complete transposition of the great arteries who had undergone the arterial switch procedure was referred to our tertiary center to investigate systemic hypertension. High blood pressure (BP) was first documented at age 13 years and was controlled until age 16 years by enalapril (20 mg/d) and atenolol (100 mg/d). BP became uncontrolled despite the addition of 2 other antihypertensive drugs (amlodipine 10 mg/d and furosemide 20 mg/d). At admission, hypertension was still observed despite treatment. Left arm BP was 141/64 mm Hg, right arm BP was 149/63 mm Hg, left inferior limb BP was 153/58 mm Hg, and right inferior limb BP was 155/60 mm Hg. Twenty-four-hour ambulatory BP monitoring confirmed hypertension, with mean daytime BP at 159/78 mm Hg. Initial laboratory investigations, including measures of serum potassium and creatinine, quantitative proteinuria, renin, aldosterone, corticosteroids, and catecholamines in plasma and urine, were normal. Renal and adrenal ultrasound scans were also normal. Echocardiography showed moderate left ventricular (LV) hypertrophy. The aortic root was dilated, and aortic regurgitation was graded as mild (Table). An instantaneous gradient of 36 mm Hg was measured with a continuous-wave sample through the aortic isthmus. Cardiovascular magnetic resonance angiography performed with a 1.5-Telsa magnet showed a common origin of the left and right carotid arteries from the brachiocephalic artery, as well as a visible narrowing of the descending aorta (minimum diameter 14 mm) insufficient to define coarctation. A major finding was that the aortic arch had a Gothic …

A case of coronary-subclavian steal in patient with a history of coronary artery bypass grafting and carotid-subclavian bypass

Introduction: A coronary-subclavian steal phenomenon was described in patients who have undergone prior bypass surgery using the left internal mammary artery (LIMA). Case report description: A 74-year-old male with a prior 3-vessel coronary artery bypass grafting (CABG) in 2005 was admitted to the hospital with the deteriorating condition over the last four months. He had complaints of exertional chest pain which was usually gone upon taking nitroglycerin. He had a history of carotid-subclavian bypass in 1995. His prior CABG included LIMA graft to the left anterior descending artery (LAD), saphenous vein graft (SVG) to the obtuse marginal (OM), and SVG to posterior descending artery (PDA). On admission, right arm blood pressure (BP) was 130/80 mm Hg, left arm BP was 80/60 mm Hg. Initial echocardiogram showed left ventricle (LV) ejection fraction of 53%. Stress-echocardiography was positive and demonstrated wall motion abnormalities in septal, antero-septal and anterior segments of LV. Duplex ultrasound revealed bilateral carotid stenosis of 55%, left subclavian artery subocclusion and stenosis of carotid-subclavian graft with maximal linear flow velocity up to 3.5 m/sec. Nevertheless both vertebral arteries had antegrade flow. Using cardiac catheterization severe 3-vessel coronary artery disease was diagnosed but PDA and OM SVG grafts and LIMA graft were patent. Angiography showed a severe stenosis of 95% of proximal left subclavian artery, stenosis of 59% of carotid-subclavian graft. LIMA graft had retrograde flow to the left subclavian artery and the first segment of left vertebral artery. The patient underwent PTA and stent placement of the left subclavian artery. During one-year follow-up period, he was symptom free, ultrasound showed normal flow in left subclavian artery, and regional wall motion of LV appeared to be normal. Discussion: Clinical manifestation of a coronary-subclavian steal in this patient was unusual with the severe angina but without any symptoms of cerebral ischemia probably due to partly functioning carotid-subclavian graft. Percutaneous revascularization of the subclavian artery was the reasonable treatment option. That lesion was more significant than stenosis of carotid-subclavian graft, more favorable for PTA due to minimal calcification and relatively short stenosis. Conclusions: Coronary-subclavian steal syndrome is a diagnosis that should not be overlooked, especially in patients with known peripheral atherosclerosis. Percutaneous interventions due to their efficacy and low complication rates constitute the first choice treatment in patients with high surgical risk.

Blood pressure differences between arms and association of dominant hands with blood pressure differences and carotid atherosclerosis

Guidelines for the management of hypertension recommend that blood pressure (BP) should be measured twice at every visit; it should be measured in both arms at the first visit, and the right arm BP or higher BP should be recorded. Manufacturers of home BP monitors tend to design the device for measurement of left arm BP. The arm preferred for BP measurement differs according to the methods recommended by the society and according to the home BP monitors. The BP difference (ΔBP) is calculated by subtracting left arm BP from right arm BP. Here, we aim to first investigate which hand will give the most accurate reading by a sphygmomanometer in daily medical practice. Second, we wish to assess the association of the dominant hand with absolute BP difference (|ΔBP|) of at least 10 mmHg and with early atherosclerotic markers in a subanalysis. We found that 6.4% of outpatients were left handed, and the percentage of individuals with systolic |ΔBP| (|ΔSBP|) and diastolic |ΔBP| (|ΔDBP|) of at least 10 mmHg was 14.4 and 7.2%, respectively. The dominant hand was not significantly associated with |ΔBP| of at least 10 mmHg or early atherosclerotic markers. This study suggests that BP measured in one arm is substitutable with that of the other arm because of a lack of association of |ΔBP| with the dominant hand. However, BP of both arms should be actively measured in new outpatients with moderate fever, lifestyle-related diseases, vascular events, age 65 years and above, and smoking history, all of which are factors potentially associated with |ΔBP| of at least 10 mmHg, regardless of the dominant hand.

Inter-arm blood pressure differences compared with ambulatory monitoring: a manifestation of the ‘white-coat’ effect?

Inter-arm difference in blood pressure of >10 mmHg is associated with peripheral vascular disease, but it is unclear how much of the difference in sequential right and left arm blood pressure measurements might be due to a 'white-coat' effect. To use ambulatory blood pressure monitoring (ABPM) to better understand the clinical significance of inter-arm differences in blood pressure. Retrospective study in a teaching hospital in Birmingham. Anonymised clinical data collected from 784 patients attending a single hospital-based hypertension clinic were retrospectively analysed. Each participant had blood pressure measured sequentially in both arms, followed by ABPM over the subsequent 24 hours. Data were available for 710 (91%) patients, of whom 39.3% (279) had a blood pressure difference of 10 mmHg or more between each arm. Compared to daytime systolic ABPM, the difference was 25.1 mmHg using the arm with the highest reading, but only 15.5 mmHg if the lower reading was taken (mean difference 9.6 mmHg (95% confidence interval [CI] = 9.0 mmHg to 10.3 mmHg)). However, differences between mean right (20.7 mmHg) or left (19.9 mmHg) arm blood pressure and daytime systolic ABPM were very similar. Compared with ABPM, use of the higher of the left and right arm readings measured sequentially appears to overestimate true mean blood pressure. As there is no significant difference in the extent of disparity with ABPM by left or right arm, this is unlikely to be due to arm dominance and may be due to the 'white-coat' effect reducing blood pressure on repeated measurement. Where a large inter-arm blood pressure difference is detected with sequential measurement, healthcare professionals should re-measure the blood pressure in the original arm.

Arteritis Mimicking Aortic Coarctation and Review of the Literature

Arteritis is a chronic non-specific inflammation involving the aorta and its main branches, coronary and pulmonary arteries which lead to vascular stenosis or occlusion. Compared with coronary atherosclerosis, primary hypertension and other common cardiovascular disease, arteritis is relatively rare disease. The aortic isthmus arteritist is rarer. Because of a variety of clinical manifestations, there is a little difficulty in early diagnosis and treatment with little experience. An 18-year-old Chinese girl was sent to our hospital for blood pressure 180/70 mmHg in order to confirm the etiology of hypertension. One and a half years ago, she was diagnosed as “bronchiectasis” for hemoptysis and treated by using embolization intervention. Two months ago, she was again diagnosed as iron deficiency anaemia for fatigue. Physical examination discovered that right arm blood pressure was 180/70 mmHg and left arm blood pressure 165/60 mmHg, but double lower limb blood pressure was not measured. Murmur was heard easy in bilateral carotid, subclavian, the back and heart valve auscultation area. However, ultrasound showed normal vascellum in bilateral carotid, subclavian other than decrease of blood flow velocity in double lower limb arteries. The aorta computed tomography angiography scanning found that there was only about 0.45 cm wide in the aortic isthmus with thicker wall. The results of hemoglobin, globulin, C-reaction protein and erythrocyte sedimentation rate were abnormal. The aortic isthmus arteritist and secondary hypertension were clearly diagnosed and treated by using anti-inflammatory, corticosteroids, immunosuppressive agents and antihypertensive drugs until erythrocyte sedimentation rate returned to normal. Finally, artificial vascular was replaced successfully by surgery. Now the patient fells very fine and has already been working for more than two year. This case gives us the inspiration: A detailed examination to patient is very important, which avoid missed diagnosis or misdiagnosis and missed the best opportunity for treatment. As a doctor, we must have solid basic skills and do not underestimate the role of stethoscope in any time. J Med Cases. 2013;4(6):376-379 doi: https://doi.org/10.4021/jmc1251e

Inter-arm Differences in Simultaneous Blood Pressure Measurements in Ambulatory Patients without Cardiovascular Diseases

BackgroundIt has traditionally been known that there is normally a difference in blood pressure (BP) between the two arms; there is at least 20 mm Hg difference in the systolic blood pressure (SBP) and 10 mm Hg difference in the diastolic blood pressure (DBP). However, recent epidemiologic studies have shown that there are between-arm differences of < 5 mm Hg in simultaneous BP measurements. The purposes of this study is to examine whether there are between-arm differences in simultaneous BP measurements obtained from ambulatory patients without cardiovascular diseases and to identify the factors associated these differences.MethodsWe examined 464 patients who visited the outpatient clinic of Gangneung Asan Hospital clinical department. For the current analysis, we excluded patients with ischemic heart disease, stroke, arrhythmia, congestive heart failure, or hyperthyroidism. Simultaneous BP measurements were obtained using the Omron MX3 BP monitor in both arms. The inter-arm difference (IAD) in BP was expressed as the relative difference (right-arm BP [R] minus left-arm BP [L]: R - L) and the absolute difference (|R - L|).ResultsThe mean absolute IAD in SBP and DBP were 3.19 ± 2.38 and 2.41 ± 1.59 mm Hg, respectively, in men and 2.61 ± 2.18 and 2.25 ± 2.01 mm Hg, respectively, in women. In men, there were 83.8% of patients with the IAD in SBP of ≤ 6 mm Hg, 98.1% with the IAD in SBP of ≤ 10 mm Hg, 96.5% with the IAD in DBP of ≤ 6 mm Hg and 0% with the IAD in DBP of > 10 mm Hg. In women, 89.6% of patients had IAD in SBP of ≤ 6 mm Hg, 92.1% with IAD in DBP of ≤ 6 mm Hg, and 0% with IAD in SBP of > 10 mm Hg or IAD in DBP of > 10 mm Hg. Gangneung Asan Hospital clinical series of patients showed that the absolute IAD in SBP had a significant correlation with cardiovascular risk factors such as the 10-year Framingham cardiac risk scores and higher BP in men and higher BP in women. However, the absolute IAD in SBP and DBP had no significant correlation with the age, obesity, smoking, drinking, hyperlipidemia, diabetes, metabolic syndrome, and renal function.ConclusionOur results showed that there were no significant between-arm differences in simultaneous BP measurements. It was also shown that most of the ambulatory patients without cardiovascular diseases had an IAD in SBP of < 10 mm Hg and an IAD in DBP of < 6 mm Hg.

Blood pressure by age, gender, height, and socioeconomic level in school populations in Cali, Colombia

Introduction: Blood pressure (BP) is a vital sign that should be recorded in children and adolescents. Studies have shown that hypertension in children can lead to adult cardiovascular diseases, which are the leading cause of death in many countries, including Colombia. The aim of this paper was to show the blood pressure data in a school population, 7 to 18 years of age in the city of Cali. Methods: We performed a cross-sectional study to assess risk factors for chronic diseases in a school population of Cali, Colombia, which included anthropometry, blood chemistry, physical work capacity, oral health, diet, and BP. Two pediatricians registered BP by auscultatory method in both arms according to standard method. BP data, their relationship with age, gender, height, body mass index, socioeconomic status, and salt intake were reported for this student population. Results: A total of 2807 students from different Educational institutions in the urban area of Cali were evaluated. Some 92.2% of the school population had normal BP with values below the 90th percentile, 3.8% had blood pressure between 90 to 95th percentiles or prehypertension, and 3.2% were hypertensive with blood pressure above the 95th percentile for age, gender, and height percentiles according to standards. Systolic and diastolic blood pressure increases with age, height, and in males the values are slightly higher. No significant differences were found in systolic and diastolic BP regarding socioeconomic status. There was no difference between right and left arm BP. Higher sodium intake in diet and body mass index increase systolic BP levels. Conclusions: The data found agree with those reported in the literature. Socioeconomic level does not influence blood pressure values in the population studied.

Management of Takayasu Arteritis During Pregnancy

25-year-old woman who was at 24 weeks’gestation presented to our institution with a2-day history of worsening epigastric and midtho-racic back pain. The patient denied chest pain,shortness of breath, palpitations, nausea, andvomiting. Her medical history was significant fora history of 2 spontaneous abortions, hyperten-sion, and anemia. Her only medications wereprenatal vitamins and iron supplements. Onphysical examination, blood pressure (BP) of120⁄70 mm Hg was noted in the right arm and152⁄90 mm Hg in the left arm. Neck examina-tion revealed 1+ bilateral carotid pulsations withloud carotid and subclavicular bruits. There wasno jugular venous distension or thyromegaly.Normal first and second heart sounds were nor-mal intensity with II⁄VI diastolic murmur at theleft upper sternal border. Abdominal examinationrevealed positive bowel sounds, tender epigastri-um with no fundal tenderness, rebound, orguarding. Lower extremities revealed 2+ pittingedema. Right upper extremity (radial and bra-chial) pulses were absent with 1+ left brachialand radial pulses. Initial laboratory valuesincluded mild anemia with hemoglobin of11 g⁄dL. White blood cell and platelet counts,chemistries, liver function tests, urine toxicology,and pancreatic enzymes were within normallimits. Urinalysis revealing a 4+ proteinuria.Erythrocyte sedimentation rate was 41 mm⁄hrand C-reactive protein was 4.4, respectively. Elec-trocardiography results showed normal sinusrhythm at 84 beats per minute with no ST⁄T-wave changes. Chest x-ray showed a mildly ectat-ic thoracic aorta. Fetal heart tracing at baselinewas 140 to 150 seconds with minimal heart ratevariability.The patient was admitted to the obstetrics wardfor preeclampsia and fetal monitoring. Consideringthe vascular and cardiac examination findings, thecardiology service was consulted. Transthoracicechocardiography was performed and revealed nor-mal left and right systolic function with mild tomoderate aortic insuffici ency. No valvular or con-genital abnormalities were identified. A computedtomography (CT) scan of the chest without con-trast revealed circumferen tial wall thickening of thedescending aorta with no dissection. Limited mag-netic resonance imaging (MRI) of the abdomenwithout gadolinium showed irregular wall thicken-ing of the aorta and significant stenoses of theproximal celiac and superior mesenteric arteries.Based on American Society of Rheumatology classi-fication criteria, the patient was diagnosed withTakayasu arteritis and started on intravenous ste-roids. She later underwent duplex ultrasonographyof the neck, which showed absence of flow in theinnominate, common carotid, and right vertebralartery. Flow was maintained in the internal carotidartery through retrograde flow in the external caro-tid artery. The right subclavian artery was occludedwith minimal flow in the right axillary arterythrough collaterals, which was later confirmed byselective angiography after pregnancy.The following morning, the patient complainedof recurrent epigastric abdominal pain and had ele-vatedBP196⁄108 mm Hg measured from the leftarm BP cuff. The patient was started on labetololvia oral and intravenous routes as well as methyl-dopa. These measures only temporarily decreased

Acute Heart Failure Due to Midaortic Occlusion as the Initial Manifestation of Takayasu Arteritis

An afebrile 8-year-old Japanese girl was referred with hypotensive shock and respiratory distress. She presented with a cough of 1-week duration followed by lethargy, dyspnea, and anuria, with which she was admitted to a previous hospital. She was intubated and given intravenous catecholamines, which did not improve her symptoms. Then, she was transferred to our hospital. Physical examination revealed a right arm blood pressure of 128/64 mm Hg and a left arm blood pressure of 94/56 mm Hg while on 4.6 μg/kg per min of dopamine and dobutamine. However, no blood pressure was obtained in the lower limbs. The heart sounds were distant with no murmur audible. Coarse crackles were prominent in both lungs. Laboratory data showed the following values: creatine kinase of …

Left subclavian artery stenosis found by the interarm blood pressure difference during combined spinal-epidural anesthesia of patient with peripheral vascular disease - A case report -

In spite of the American Heart Association recommendations for blood pressure measurement, many physicians measure blood pressure in only one arm that is easy to access at the time of measurement. This practice can lead to incorrect management with significant interarm blood pressure difference. We report a case of a 51 years old man who was scheduled to undergo vascular bypass graft under combined spinal-epidural anesthesia . In 60 minutes after anesthesia, the blood pressure of left arm dropped from 110/65 mmHg to 74/45 mmHg. The blood pressure was still 80/50 mmHg after two injections of ephedrine. After checking radial pulse tone strength, we found significant interarm blood pressure difference. The blood pressure of right arm was 150/70 mmHg. Postoperative CT angiogram revealed significant stenotic portion in the left subclavian artery. This case emphasizes the importance of bilateral blood pressure measurement, especially in patients with peripheral vascular disease. (Korean J Anesthesiol 2008; 55: 229～32)

Patient characteristics and factors associated with inter-arm difference of blood pressure measurements in a general population in Ohasama, Japan

To assess whether there is a natural difference in blood pressure (BP) measurements between the right and left arms, and to identify what factors are associated with this difference in a general population. The study subjects were 1090 individuals who participated in a medical check-up in Ohasama, Japan. The BP was measured simultaneously in both arms, using an automated device. The inter-arm BP difference was expressed as the relative difference [right-arm BP (R) minus left-arm BP (L): R - L] and the absolute difference (|R - L|). The relationship between inter-arm difference and various factors was analyzed using univariate analysis. The characteristics of subjects in whom the absolute systolic BP (SBP) difference was greater than 10 mmHg were analyzed using multivariate logistic analysis. The relative differences in SBP and diastolic BP (DBP) were -0.6 +/- 6.6 (mean +/- SD) and 1.1 +/- 4.7 mmHg, while the absolute differences were 4.9 +/- 4.4 and 3.7 +/- 3.0 mmHg. The absolute SBP difference was found to correlate significantly with age, body mass index, ankle-brachial index (ABI), and hypertension. Subjects with hypertension, hypercholesterolemia, obesity, elevated hemoglobin A1c (HbA1c) and low ABI had a significant and independent increase in the risk of an absolute SBP difference greater than 10 mmHg. The results suggest that there is considerable difference in the measured BP in the right and left arms and that large differences in the absolute SBP are associated with risk factors for arteriosclerosis such as hypertension, hypercholesterolemia, obesity, metabolic abnormalities and low ABI.