Abstract
A blood pressure (BP) difference between arms was first reported over 100 years ago. Knowledge of its prevalence and relevance to the accurate measurement of BP remains poor. Current hypertension guidelines do not emphasise it. The objectives of this study were to establish the best estimate of prevalence of the inter-arm difference (IAD) in the population, to consider its implications for accurate BP measurement and treatment, and to discuss its aetiology and potential as a risk marker for cardiovascular disease. Systematic literature review was carried out. The data sources were Medline EMBASE and CINAHL databases, and Index of Theses. Studies reporting prevalence rates of IAD were retrieved and considered for inclusion against explicit methodological criteria. Point prevalence rates were extracted and weighted mean prevalence rates calculated. The main outcome measures were weighted mean prevalences of systolic IAD⩾10 and ⩾20 mm Hg and of diastolic IAD⩾10 mm Hg. Thirty-one studies were identified. Most had methodological weaknesses; only four met the inclusion criteria. Pooled prevalences of the IAD from these four studies were 19.6% systolic ⩾10 mm Hg (95% CI 18.0–21.3%), 4.2% systolic ⩾20 mm Hg (95% CI 3.4–5.1%) and 8.1% diastolic ⩾10 mm Hg (95%CI 6.9–9.2%). In conclusion, an IAD is present in a substantial number of patients and should be looked for whenever diagnosis and treatment depend on accurate measurements of BP. The importance of an IAD should be better emphasised in current hypertension management guidelines. There is evidence associating an IAD with peripheral vascular disease, raising the possibility that its presence may predict cardiovascular events.
This is a preview of subscription content, access via your institution
Access options
Subscribe to this journal
Receive 12 digital issues and online access to articles
$119.00 per year
only $9.92 per issue
Buy this article
- Purchase on Springer Link
- Instant access to full article PDF
Prices may be subject to local taxes which are calculated during checkout
Similar content being viewed by others
References
Riva-Rocci S . Un Sfigmomanometro nuovo. Gaz med Torino 1896; 47: 981–996, 1001–1017 (translated in Ruskin A. Classics in Arterial Hypertension. CC Thomas: Springfield, IL, 1956).
Cyriax EF . Unilateral alterations in blood-pressure caused by unilateral pathological conditions: the differential blood pressure sign. Q J Med 1920; 13: 148–164.
Ezzati M, Lopez AD, Rodgers A, Vander Hoom S, Murray CJL, the Comparative Risk Assessment Collaborating Group. Selected major risk factors and global and regional burden of disease. Lancet 2002; 360: 1347–1360.
Williams B, Poulter NR, Brown MJ, Davis M, McInnes GT, Potter JF et al. British Hypertension Society guidelines for hypertension management 2004 (BHS-IV): summary. BMJ 2004; 328 (7440): 634–640.
O’Brien E . General principles of blood pressure measurement. In: O’Brien E, Beevers DG, Marshall HJ (eds). ABC of Hypertension. British Medical Journal Publishing Group: London, 1995, pp 3–8.
Primatesta P, Brookes M, Poulter NR . Improved hypertension management and control: results from the Health Survey for England 1998. Hypertension 2001; 38 (4): 827–832.
Reeves RA . Does this patient have hypertension? How to measure blood pressure. JAMA 1995; 273 (15): 1211–1218.
O’Brien E, Coats A, Owens P, Petrie J, Padfield PL, Littler WA et al. Use and interpretation of ambulatory blood pressure monitoring: recommendations of the British Hypertension Society. BMJ 2000; 320 (7242): 1128–1134.
Williams B, Poulter NR, Brown MJ, Davis M, McInnes GT, Potter JF et al. Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004-BHS IV. J Hum Hypertens 2004; 18 (3): 139–185.
Kirkendall WM, Burton AC, Epstein FH, Freis ED . Recommendations for human blood pressure determination by sphygmomanometers. Circulation 1967; 36: 980–988.
Petrie JC, O’Brien ET, Littler WA, de Swiet M . Recommendations on blood pressure measurement. BMJ 1986; 293 (6547): 611–615.
Perloff D, Grim C, Flack J, Frohlich ED, Hill M, McDonald M et al. Human blood pressure determination by sphygmomanometry. Circulation 1993; 88 (5): 2460–2470.
O’Brien ET, Petrie JC, Littler WA, de Swiet M, Padfield PL, Dillon MJ . Blood Pressure Measurement: Recommendations of the British Hypertension Society, 3rd edn. BMJ Publishing Group: London, 1997.
Ramsay L, Williams B, Johnston G, MacGregor G, Poston L, Potter J et al. Guidelines for management of hypertension: report of the third working party of the British Hypertension Society. J Hum Hypertens 1999; 13 (9): 569–592.
American Heart Association, Cardiac Society of Great Britain and Ireland, Committee of Standardisation of Blood Pressure Readings. Standard methods for taking blood pressure readings. JAMA 1939; 113: 294.
Beevers G, Lip GYH, O’Brien E . ABC of hypertension: blood pressure measurement. BMJ 2001; 322 (7292): 981–985.
Cushman WC . A century of indirect blood pressure measurement. Back to basics. Arch Intern Med 1996; 156 (17): 1922–1923.
Wingfield D, Pierce M, Feher M . Blood pressure measurement in the community: do guidelines help? J Hum Hypertens 1996; 10 (12): 805–809.
Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo Jr JL et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003; 42 (6): 1206–1252.
Clark CE, Powell RJ . The differential blood pressure sign in general practice: prevalence and prognostic value. Family Pract 2002; 19 (5): 439–441.
Newman AB, Sutton-Tyrrell K, Vogt MT, Kuller LH . Morbidity and mortality in hypertensive adults with a low ankle/arm blood pressure index. JAMA 1993; 270 (4): 487–489.
Newman AB, Shemanski L, Manolio TA, Cushman M, Mittelmark M, Polak JF et al. Ankle-arm index as a predictor of cardiovascular disease and mortality in the Cardiovascular Health Study. The Cardiovascular Health Study Group. Arterioscler Thromb Vasc Biol 1999; 19 (3): 538–545.
Violi F, Criqui M, Longoni A, Castiglioni C . Relation between risk factors and cardiovascular complications in patients with peripheral vascular disease. Results from the A.D.E.P. study. Atherosclerosis 1996; 120 (1–2): 25–35.
Vogt MT, Cauley JA, Newman AB, Kuller LH, Hulley SB . Decreased ankle/arm blood pressure index and mortality in elderly women. JAMA 1993; 270 (4): 465–469.
Zheng ZJ, Sharrett AR, Chambless LE, Rosamond WD, Nieto FJ, Sheps DS et al. Associations of ankle-brachial index with clinical coronary heart disease, stroke and preclinical carotid and popliteal atherosclerosis: the Atherosclerosis Risk in Communities (ARIC) Study. Atherosclerosis 1997; 131 (1): 115–125.
McDermott MM, Feinglass J, Slavensky R, Pearce WH . The ankle-brachial index as a predictor of survival in patients with peripheral vascular disease. J Gen Intern Med 1994; 9 (8): 445–449.
Applegate WB . Ankle/arm blood pressure index. A useful test for clinical practice? JAMA 1993; 270 (4): 497–498.
Thompson JF, Kinsella DC . Vascular disorders of the upper limb. In: Beard JD, Gaines PA (eds). Vascular and Endovascular Surgery. WB Saunders: London, 2001, pp 199–216.
Shadman R, Criqui MH, Bundens WP, Fronek A, Denenberg JO, Gamst AC et al. Subclavian artery stenosis: prevalence, risk factors, and association with cardiovascular diseases. J Am Coll Cardiol 2004; 44 (3): 618–623.
Coronary Heart Disease. National Service Framework. Department of Health: London, 2000.
Korns KM, Guinand PH . Inequality of blood pressure in the brachial arteries, with especial reference to disease of the arch of the aorta. J Clin Invest 1933; 12: 143.
Altman DG . Practical Statistics for Medical Research. Chapman & Hall: London, 1991.
Cyriax EF . Unilateral alterations in blood pressure: the differential blood pressure sign (second communication). Q J Med 1921; 14: 309–313.
Phipps C . Blood Pressure. Boston M & S J 1915; 173: 476.
Cyriax EF . Blood pressure in war traumatisms. BMJ 1918; 3: 132.
Frank SM, Norris EJ, Christopherson R, Beattie C . Right and left arm blood pressure discrepancies in vascular surgery patients. Anesthesiology 1991; 75: 457–463.
Harrison EG, Roth GM, Hines EA . Bilateral indirect and direct arterial pressures. Circulation 1960; 22: 419–436.
Kay WE, Gardner KD . Comparative blood pressures in the two arms. Calif Western Med 1930; 33: 578–579.
Israel E . Differences in blood pressure in both arms. Acta Med Orientalia 1944; 3: 86–89.
MacLaren JP . Medical Insurance Examination: Modern Methods and Rating of Lives, for Medical Practitioners, and Insurance Officials. London: Bailliere, Tindall and Cox, 1927.
Fotherby MD, Panayiotou B, Potter JF . Age-related differences in simultaneous interarm blood pressure measurements. Postgrad Med J 1993; 69 (809): 194–196.
Hashimoto F, Hunt WC, Hardy L . Differences between right and left arm blood pressures in the elderly. West J Med 1984; 141: 189–192.
Kristensen BO, Kornerup HJ . Which arm to measure the blood pressure? Acta Med Scand 1982; 670 (Suppl): 69–73.
Pesola GR, Pesola HR, Nelson MJ, Westfal RE . The normal difference in bilateral indirect blood pressure recordings in normotensive individuals. Am J Emerg Med 2001; 19 (1): 43–45.
Yagi S, Ichikawa S, Sakamaki T, Takayama Y, Murata K . Blood pressure in the paretic arms of patients with stroke. N Engl J Med 1986; 315 (13): 836.
Gould BA, Hornung RS, Kieso HA, Altman DG, Raftery EB . Is the blood pressure the same in both arms? Clin Cardiol 1985; 8 (8): 423–426.
Goldhill DR . Bilateral simultaneous indirect systolic blood pressure measurements. Cardiovasc Res 1986; 20 (10): 774–777.
Panayiotou BN, Harper GD, Fotherby MD, Potter JF, Castleden CM . Interarm blood pressure difference in acute hemiplegia. J Am Geriatr Soc 1993; 41 (4): 422–423.
O’Shea JC, Murphy MB . Ambulatory blood pressure monitoring: which arm? J Hum Hypertens 2000; 14 (4): 227–230.
Swallow RA . Hypertension: which arm? BMJ 1975; 3: 370.
Lane D, Beevers M, Barnes N, Bourne J, John A, Malins S et al. Inter-arm differences in blood pressure: when are they clinically significant? J Hypertens 2002; 20 (6): 1089–1095.
Orme S, Ralph SG, Birchall A, Lawson-Matthew P, McLean K, Channer KS . The normal range for inter-arm differences in blood pressure. Age Ageing 1999; 28 (6): 537–542.
Southby R . Some clinical observations on blood pressure and their practical application, with special reference to variation of blood pressure readings in the two arms. M J Australia 1935; 2 (569): 580.
Rueger MJ . Blood pressure variations in the two arms. Ann Int Med 1951; 35: 1023.
Singer AJ, Hollander JE . Blood pressure. Assessment of interarm differences. Arch Intern Med 1996; 156 (17): 2005–2008.
Cassidy P, Jones K . A study of inter-arm blood pressure differences in primary care. J Hum Hypertens 2001; 15 (8): 519–522.
Pesola GR, Pesola HR, Lin M, Nelson MJ, Westfal RE . The normal difference in bilateral indirect blood pressure recordings in hypertensive individuals. Acad Emerg Med 2002; 9 (4): 342–345.
Arnett DK, Tang W, Province MA, Oberman A, Ellison RC, Morgan D et al. Interarm differences in seated systolic and diastolic blood pressure: the Hypertension Genetic Epidemiology Network study. J Hypertens 2005; 23 (6): 1141–1147.
Clark CE . Difference in blood pressure between arms might reflect peripheral vascular disease. BMJ 2001; 323 (7309): 399–400.
Amsterdam B, Amsterdam AL . Disparity in blood pressures in both arms in normals and hypertensives and its clinical significance. NY State J Med 1943; 43: 2294–2300.
Hensen H . Beitrage zur Physiologie und pathologie des Blutdrucks. Deutsches Arch f klin Med 1900; 67: 436.
Van Balen GF . Bloeddrukmetingen aan beide armen. Nederlandsch Tijdschr v Geneesk 1929; 73: 932.
Banks MJ, Erb N, George P, Pace A, Kitas GD . Hypertension is not a disease of the left arm: a difficult diagnosis of hypertension in Takayasu's arteritis. J Hum Hypertens 2001; 15 (8): 573–575.
Phillips LS, Branch WT, Cook CB, Doyle JP, El Kebbi IM, Gallina DL et al. Clinical inertia. Ann Intern Med 2001; 135 (9): 825–834.
Janeway T . The Clinical Study of Blood Pressure; A Guide to the Use of the Sphygmomanometer. D. Appleton & Co: New York & London, 1904.
Shock NW, Ogden E . The differences between blood pressure measurements obtained simultaneously on the two arms. Q J Exp Physiol 1940; 30: 155.
Osler W . Modern Medicine. Lea & Febiger: Philadelphia, 1915.
Geisbock F . Die Bedeutung der Blutdruckmessung fur die praxis. Deutsches Arch f klin Med 1905; 83: 363 (quoted from Korns and Guinand (32)).
Norris GW . Blood Pressure: Its Clinical Applications 1917.
Bing HJ . Ueber die Blutdruckrnessung bei Menschen. Berl Klin Wchnschr 1906; 43: 1650.
Bodenstab WH . Blood pressure – difference of readings in the two arms. Journal Lancet 1925; 45 (15): 360–361.
Sutton-Tyrrell K, Wildman R, Newman A, Kuller LH . Extent of cardiovascular risk reduction associated with treatment of isolated systolic hypertension. Arch Intern Med 2003; 163 (22): 2728–2731.
Moll F, Six J, Mutsaerts D . Misleading upper extremity blood pressure measurements in vascular occlusive disease. Bruit 1983; 8: 18–19.
Hennerici M, Klemm C, Rautenberg W . The subclavian steal phenomenon: a common vascular disorder with rare neurologic deficits. Neurology 1988; 38 (5): 669–673.
Lawson JD, Petracek MR, Buckspan GS, Dean RH . Subclavian steal: review of the clinical manifestations. South Med J 1979; 72 (11): 1369–1373.
Tan TY, Schminke U, Lien LM, Tegeler CH . Subclavian steal syndrome: can the blood pressure difference between arms predict the severity of steal? J Neuroimaging 2002; 12 (2): 131–135.
English JA, Carell ES, Guidera SA, Tripp HF . Angiographic prevalence and clinical predictors of left subclavian stenosis in patients undergoing diagnostic cardiac catheterization. Catheterization Cardiovasc Interv 2001; 54 (1): 8–11.
Gutierrez GR, Mahrer P, Aharonian V, Mansukhani P, Bruss J . Prevalence of subclavian artery stenosis in patients with peripheral vascular disease. Angiology 2001; 52 (3): 189–194.
Leng GC, Lee AJ, Fowkes FG, Whiteman M, Dunbar J, Housley E et al. Incidence, natural history and cardiovascular events in symptomatic and asymptomatic peripheral arterial disease in the general population. Int J Epidemiol 1996; 25 (6): 1172–1181.
Moher D, Cook DJ, Eastwood S, Olkin I, Rennie D, Stroup DF . Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Quality of reporting of meta-analyses. Lancet 1999; 354 (9193): 1896–1900.
Acknowledgements
CEC was supported by a Clinical Academic Fellowship from Plymouth tPCT and a grant from Mid Devon Research Group. We owe thanks to Ginny Newton and her colleagues at Exeter Medical Library for their persistence in obtaining so many historic papers and books for this review.
Author information
Authors and Affiliations
Corresponding author
Additional information
Conflict of interests
None to declare.
Appendix A
Appendix A
Rights and permissions
About this article
Cite this article
Clark, C., Campbell, J., Evans, P. et al. Prevalence and clinical implications of the inter-arm blood pressure difference: a systematic review. J Hum Hypertens 20, 923–931 (2006). https://doi.org/10.1038/sj.jhh.1002093
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1038/sj.jhh.1002093
Keywords
This article is cited by
-
Inter-Arm Blood Pressure Difference an Indicator of Coronary Artery Disease
High Blood Pressure & Cardiovascular Prevention (2023)
-
Perioperative non-invasive versus semi-invasive cardiac index monitoring in patients with bariatric surgery – a prospective observational study
BMC Anesthesiology (2020)
-
Between-visit reproducibility of inter-arm systolic blood pressure differences in treated hypertensive patients: the coconet study
Hypertension Research (2017)
-
Association of Inter-arm Blood Pressure Difference with Asymptomatic Intracranial and Extracranial Arterial Stenosis in Hypertension Patients
Scientific Reports (2016)
-
A relative difference in systolic blood pressure between arms by synchronal measurement and conventional cardiovascular risk factors are associated with the severity of coronary atherosclerosis
Heart and Vessels (2016)