Interarm Blood Pressure Difference in People With Diabetes: Measurement and Vascular and Mortality Implications

Abstract

OBJECTIVEDifferences in blood pressure between arms are associated with vascular disease and increased mortality; this has not been reported in diabetes. We explored these associations, and assessed reference standard and pragmatic measurement techniques, in people with diabetes and in nondiabetic controls. RESEARCH DESIGN AND METHODSA prospective cohort study in Devon, England, recruited 727 people with type 1 or type 2 diabetes and 285 nondiabetic controls. Simultaneous repeated measurements of bilateral blood pressure were made at recruitment. Data were used to inform a pragmatic measurement strategy. Interarm differences were examined for cross-sectional associations with target organ disease and prospective mortality associations (median follow-up 52 months). RESULTSWe found 8.6% of participants with diabetes and 2.9% of controls had systolic interarm differences ‡10 mmHg. Single pairs of blood pressure measurements had high negative predictive values (97-99%) for excluding interarm differences. Systolic interarm differences ‡10 mmHg in diabetes were associated with peripheral arterial disease (odds ratio [OR] 3.4 [95% CI 1.2-9.3]). Differences ‡15 mmHg were associated with diabetic retinopathy .6]) and chronic kidney disease ). Systolic interarm differences were associated prospectively with increased cardiovascular mortality: hazard ratios 3.5 (1.0-13.0) for ‡10 mmHg and 9.0 (2.0-41.0) for ‡15 mmHg. CONCLUSIONSBlood pressure should be measured in both arms during initial assessment in diabetes. Systolic interarm differences can be excluded with a single pair of measurements. In the population with diabetes, systolic differences may be associated with an increased risk of morbidity and mortality.

Inter-arm blood pressure difference and mortality: a cohort study in an asymptomatic primary care population at elevated cardiovascular risk

“…2 Some previous reports have demonstrated a clear gradient in HRs and magnitude of IADs, 4,6,9,12,36 whereas others have not. 5,8 There were relatively few events included in analyses at the higher cut-off of ≥15 mmHg difference.…”

“…23,24 Thus simultaneous, automated repeated measurements of IAD should be a reference standard for epidemiological study. 10 However, the authors have found that a single sequential pair of measurements can exclude confirmed IAD with a high negative predictive value, 11,12 and designed this study to investigate whether IADs detected by this simple method can also predict survival differences.…”

“…Multiple readings avoid over-estimation of IADs, 10,11 but a single pair of readings can screen out individuals without an IAD. 12 It was therefore hypothesised that an IAD assessed from a single pair of readings, although overestimating the true prevalence of any difference in the chosen population, would still predict reduced survival for the cohort of subjects with an apparent IAD, because that cohort will include the majority of subjects with a true difference.…”

Interarm systolic blood pressure difference is associated with myocardial injury after noncardiac surgery

“…Also, we found a significant correlation between IASBPD and mean right arm SBP and peak mean hscTnT. Clark et al [21] examined 727 patients with DM and found increased IASBPD was independently associated with peripheral artery disease, diabetic retinopathy, and chronic renal disease. Follow-up of these patients demonstrated increased cardiovascular mortality in patients with IASBPD ≥ 10 mm Hg.…”

Gender differences in the relationship between adiposity and systolic inter-arm blood pressure difference in Korea adults

“…The prevalence of high sIAD (sIAD ≥10 mmHg) varies across ethnic groups and countries, and it tends to be higher in patients with diabetes mellitus and hypertension [16,17]. Inaddition, sIAD levels have been found to be associated with a significantly increased risk of future cardiovascular events [18].…”