Вы находитесь на странице: 1из 9

Journal of Human Hypertension (2006) 20, 923931

& 2006 Nature Publishing Group All rights reserved 0950-9240/06 $30.00


Prevalence and clinical implications of the

inter-arm blood pressure difference:
a systematic review
CE Clark1, JL Campbell1, PH Evans1 and A Millward2

Primary Care Research Group, Institute of Health & Social Care Research, Peninsula Medical School,
Exeter, Devon, UK and 2Institute of Biomedical and Clinical Science, Peninsula Medical School,
Derriford, Plymouth, Devon, UK

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 interarm 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 preva-

lences of systolic IADX10 and X20 mm Hg and of

diastolic IADX10 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 X10 mm Hg
(95% CI 18.021.3%), 4.2% systolic X20 mm Hg (95% CI
3.45.1%) and 8.1% diastolic X10 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.
Journal of Human Hypertension (2006) 20, 923931.
doi:10.1038/sj.jhh.1002093; published online 12 October 2006

Keywords: blood pressure measurement; interarm difference

Patients are regularly encountered in the clinical
setting with a different systolic or diastolic
blood pressure (BP) in each arm. Comparisons
of arm pressures have been made ever since the
modern sphygmomanometer was introduced,1
yet the significance of this finding, which Cyriax
named the differential BP sign,2 is still poorly
appreciated today.
Hypertension is one of the major causes of
premature morbidity and mortality throughout the
developed and developing worlds.3 The vast majority of patients with hypertension are managed in
primary care4 and measurement of BP is the most
common investigation performed in this setting.5
Correspondence: Dr CE Clark, Primary Care Research Group,
Institute of Health & Social Care Research, Peninsula Medical
School, Smeall Building, St Lukes Campus, Magdalen Rd, Exeter,
Devon EX1 2LU, UK.
E-mail: christopher.clark@pms.ac.uk
Received 10 May 2006; revised 21 August 2006; accepted 25
August 2006; published online 12 October 2006

The management of hypertension is known to be

suboptimal;6 therefore, knowledge of the latest
guidelines, and the many factors known to influence
readings, is crucial.7 The prevalence of a systolic
(sIAD) or a diastolic (dIAD) inter-arm difference, its
importance for the management of hypertension, its
significance as a potential marker of peripheral
vascular disease (PVD) and predictor of cardiovascular disease (CVD) in hypertensive patients are the
subjects of this review.
Although recent ambulatory BP monitoring guidelines recommend routine bilateral assessment,8 the
latest British guidelines for the management of
hypertension merely state that BP should initially
be measured in both arms as patients may have large
differences (410 mm Hg) between arms. The arm
with the higher values should be used for subsequent measurements.9 This appears to be guidance
repeated almost verbatim through previous
versions1014 stretching back over 60 years.15 The
guidelines do not consider the prevalence of the IAD
and suggest that differences X20 mm Hg systolic
and/or 10 mm Hg diastolic warrant specialist

The inter-arm blood pressure difference

CE Clark et al

referral.16 As only one in three measurements of BP

in practice are made according to guidelines,17,18 it is
unlikely that even this passing reference to an IAD
is acted upon. The latest Joint National Committee
guidelines (JNC VII) merely suggest BP verification
in the contralateral arm.19
Appreciation of the presence and implications of
an IAD is clearly vital for accurate diagnosis and
consistent management of hypertension. Following
an earlier small study of a mixed normotensive
and hypertensive cohort of primary care patients,
we proposed that the IAD may be caused by PVD.20
As PVD is itself a strong predictor of CVD,2126 the
recognition of the IAD as a sign of PVD would
suggest that the IAD may also have prognostic value
as a marker for predicting cardiovascular events in a
similar manner to a reduced ankle-brachial pressure
index (ABPI). ABPI measurement has been proposed
as a screening test,27 but is not routinely undertaken
in the general practice assessment of hypertensive
patients in the United Kingdom. It is time consuming and requires specialised equipment and a
degree of training, whereas bilateral brachial BP
measurements are easily taken and are in any case
recommended in the assessment of new hypertensive patients.9 In symptomatic chronic upper
limb ischaemia, where the IAD is marked,28 the
predominant cause is atherosclerosis (Table 1), and
this is associated with PVD.29 It therefore seems
logical that the causes of an asymptomatic IAD
should be similar. Consequently, the recognition of
an IAD could have value in providing a simple
screening test to apply in routine consultations
to identify patients potentially at the highest
risk of cardiovascular events and therefore in
need of further assessment. This would facilitate
more appropriate targeting of limited resources
in primary prevention, as required by the National
Service Framework for Coronary Heart Disease


Table 1 Causes of chronic upper limb ischaemia




e.g. polyarteritis nodosa, giant cell arteritis, Buergers disease
Fibromuscular hyperplasia
Connective tissue disorders
e.g. scleroderma, mixed connective tissue disease, systemic
Radiation arteritis
Thoracic outlet compression

Adapted with permission from Thompson and Kinsella.28

Identification of studies

The principal investigator searched Medline (1966

2006), Old Medline (19501965), EMBASE (1974
2006) and CINAHL (19822006) databases in May
2006 using the following MeSH, and full text terms:
blood pressure (restricted to analysis, instrumentation, classification or physiology) or hypertension
or arm and difference or differential. The result
set was limited to human and English language
results. Further references were identified from
specialist cardiovascular and hypertension journal
collections. The Index of Theses (19702006) was
searched and authors recently active in the field
were contacted. Further citations were identified
by hand searching of reference lists in retrieved
papers. Only English language papers were
reviewed, but some findings from foreign language
papers quoted in a previous review31 have been
cited in the Discussion.
Selection and quality assessment of studies

Cross-sectional or cohort studies reporting a prevalence figure for sIAD or dIAD were retrieved for
assessment. Reports meeting the predefined quality
criteria based on sample selection, sample size and
method of measurement of the IAD (Box 1) were
included in the analysis.
Data collection and synthesis

The principal investigator extracted data on

prevalence rates, study population and methods of
measurement from all studies reporting prevalences
of the IAD. Where possible data were combined to
derive pooled estimates of prevalences and magnitudes of sIAD and dIAD using weighted means and
standard errors.32

Searches identified 357 citations, from which 18

articles were retrieved. Hand searching of references
identified a further 19 older papers. After exclusion
of papers without prevalence data, only four papers
met the inclusion criteria (Figure 1).
Description of studies

All potential studies for inclusion were crosssectional studies reporting point prevalences of

Box 1 Inclusion criteria for studies

Sample size
Selection of subjects

Defined primary or secondary care population not selected individuals

Method of measurement

Simultaneous using automated sphygmomanometers

Crossover design, repeated measurements
Controlled setting

Journal of Human Hypertension

The inter-arm blood pressure difference

CE Clark et al

Citations retrieved in search

Citations excluded from search
data (n=341)
Full text papers retrieved for potential
inclusion (n=18)
Additional papers identified from
references (n=19)
Full text papers considered for
inclusion (n=37)
Full text papers excluded: no
prevalence data (n=6)
Full text papers assessed against
inclusion criteria (n=31)
Papers not meeting inclusion
criteria (n=27)
Papers meeting inclusion criteria
Figure 1 QUORUM flow diagram (adapted from Moher et al

IADs. In total, 31 English language series published

between 1915 and 2005 were assessed against the
inclusion criteria. Many studies exhibited selection bias in reporting selective or opportunistic
samples, or had unclear selection criteria,2,31,3340
and older studies tended to report highly selected
series.34,36,4145 Others suffered from bias in the selection of results for analysis37,46 or reported small sample
sizes (defined as o100 subjects).2,34,3436,41,43,4550
Studies reported one or more pairs of BP readings
measured either simultaneously or sequentially.
Simultaneous techniques used either two observers37,46 or a pair of automated sphygmomanometers41,51,52 to record BP in both arms at the
same time. Sequential methods involved measurement of BP in one arm and then the
other.2,20,29,33,35,36,38,39,4244,49,5359 Excluded studies,
with reasons for exclusion, are summarised in
Appendix A.
Reported prevalences

Only four studies met the inclusion criteria37,51,52,60

(Table 2). The mean prevalences of sIAD in these
studies were 19.6%X10 mm Hg (95% CI 18.0
21.3%) and 4.2%X20 mm Hg (95% CI 3.45.1%)
and for dIAD 8.1%X10 mm Hg (95% CI 6.99.2%).
The mean prevalences for excluded studies were
significantly higher (Table 3). One study presented
data for normotensive and hypertensive subjects,60
the prevalences of sIADX20 mm Hg and

Table 2 Characteristics of studies included in the review

Study (country of

Study population

Method of measurement


Prevalence of systolic

Prevalence of diastolic

Amsterdam and
Amsterdam (1943)60


Repeated averaged


31.2%X10 mm Hg
8.4%420 mm Hg

9.3%410 mm Hg


51%420 mm Hg

27.2%410 mm Hg


26.6%X10 mm Hg
7.2%X20 mm Hg
5.3%X10 mm Hg
0.1%X20 mm Hg
10%X10 mm Hg
6%X10 mm Hg direct
(difference NS)

15%X10 mm Hg

Probably hospital, not
Harrison et al. (1960)37 Patients attending
Selected volunteers
with differences on
simultaneous indirect
Orme et al. (1999)52

Staff, visitors and day

case surgery patients
at one DGH

Lane et al. (2002)51


Staff and patients in

one general hospital

Single sequential pair of

Simultaneous three pairs
of measurementsa
Simultaneous direct

Automated simultaneous
2  2 crossover 4 pairs
readings averaged


4%X10 mm Hg
8%X10 mm Hg
1%X10 mm Hg direct
(difference NS)


8.2%X10 mm Hg
0X20 mm Hg

6.5%X10 mm Hg
0.4%X20 mm Hg


2.7%X10 mm Hg
0X20 mm Hg
19.4%X10 mm Hg
0X20 mm Hg

6.3%X10 mm
0.3%X20 mm
7.1%X10 mm
1.0%X20 mm

20%410 mm Hg
3.5%420 mm Hg

11.3%410 mm Hg
3.8%420 mm Hg

Simultaneous automated, 400
2 pairs of measurements


Abbreviation: CVD, cardiovascular disease.

Only this data set included in review.
Journal of Human Hypertension

The inter-arm blood pressure difference

CE Clark et al

Table 3 Comparison of weighted mean prevalences of inter-arm differences for studies included and excluded
Inter-arm difference

sIADX10 mm Hg
sIADX20 mm Hg
dIADX10 mm Hg

Included studies

Excluded studies

Mean (%)

95% CI

Mean (%)

95% CI







Abbreviations: CI, confidence interval; dIAD, diastolic inter-arm difference; sIAD, systolic inter-arm difference.

dIADX10 mm Hg were significantly higher in the

presence of hypertension (sIADX20 mm Hg 8.4 vs
51%; OR 11.40, 95% CI 8.1216.01; Po0.0001 and
dIADX10 mm Hg 9.3 vs 27.2%; OR 3.64, 95% CI
2.555.20; Po0.0001). One study reported data for
subjects with or without CVD,52 and showed a
significantly higher rate of sIADX10 mm Hg in
patients with CVD (19.4% with CVD vs 2.7% without
CVD; OR 4.34, 95% CI 2.099.04; Po0.0001).

The prevalence rates presented demonstrate that the
IAD is a common finding in clinical practice
whenever it is looked for. The majority of reports
and all included studies was from selected or
secondary care populations, the true general population or primary care prevalence is unknown.
Studies using sequential or single pair measurement
techniques appear to overestimate prevalence compared with studies meeting our inclusion criteria.
Strengths and weaknesses of the review

Published data on the prevalence of an IAD stretch

back to 1900.61 Thorough hand searching appears to
have yielded as full a set of papers as possible, but as
only English language papers were retrieved some
data may have been excluded. No foreign language
citations were identified after 1929;62 therefore, it
seems unlikely that our findings could have been
substantially altered by their inclusion. Data extraction was only carried out by one investigator but was
not a complex task, and the inclusion criteria were
clear and objective. The choices of inclusion criteria
were our own but based on a published critique32 of
the methodology of one of the studies.46
Implications for BP measurement in practice

Failure to recognise the IAD and to standardise

readings to the higher arm runs the risks of
inadequate treatment of hypertensive patients, false
diagnosis of hypotension due to over treatment
(pseudohypotension36), a delay in the diagnosis of
hypertension,63 or physician confusion creating the
potential for clinical inertia.64 The Health Survey
of England states that if systolic BP were lowered by
X10 mm Hg among the 71.5% of hypertensive
subjects uncontrolled (in the survey), we estimate
Journal of Human Hypertension

that 44000 fatal and nonfatal coronary events and

46000 fatal and nonfatal strokes could be prevented
each year in England.6 Given our estimate of the
prevalence of a sIADX10 mm Hg of 19.6%, there is
a one in 10 risk that a BP measurement could be
underestimated by this amount if the IAD has not
been excluded. We suggest that it is vital to undertake measurements of BP in a consistent manner in
both arms for all subjects, to record the findings
accurately, and to record measurements taken from
the higher arm to guide subsequent assessments.
This approach should be more clearly emphasised
in future hypertension guidelines, and given the
prevalence figures that we have presented, the
advice to refer subjects with a sIAD X20 mm Hg or
dIAD X10 mm Hg for specialist assessment is seen
to be impractical and should be revised.
Pathophysiology of the IAD

Although the ability of arteriosclerosis to affect BP

has long been recognised65 and the presence of an
IAD is used to help diagnose symptomatic upper
limb ischaemia,28 in health it has historically been
dismissed as a normal variant. Anatomical explanations have been proposed31,39,49,53,60,66 but there is
now evidence for an association with PVD, suggesting a pathological rather than a physiological
Initially the IAD was described as a sign of aortic
aneurysm67 or vascular disease,68,69 and the earliest
report dismissed its magnitude in health as negligible, with differences of 10 mm Hg being unusual.61
The earliest series of 36 patients reported a pressure
difference of 10 mm Hg or more in 20%, leading to
the conclusion that the difference between the right
and left brachial arteries is by no means diagnostic
of aneurysm.70 Another early series of 100 healthy
subjects found only 10% to have equal BPs71 and
the argument against arteriosclerosis as a cause
ever since has been that these differences are too
frequent,37 and therefore represent a spectrum of
normality. Consequently, anatomical explanations were advanced, which considered the angulation and anatomy of the aortic arch and its
branches.31,39,49,53,60,66 The high prevalence of an
IAD in war victims with unilateral injuries seemed
to support this explanation.35 But normal anatomy
alone cannot explain the higher left arm pressures
noted.36,51 It is our contention that the IAD may be due

The inter-arm blood pressure difference

CE Clark et al

to occult PVD59 and one recent study of subclavian

artery stenosis has shown such an association.29
If indeed such an observation was confirmed, one
would predict that factors associated with PVD
should have a higher prevalence in patients with an
IAD. CHD is one common condition strongly associated with PVD, as defined by a reduced ABPI.2125,72
No study has set out to compare the prevalence of an
IAD in patients with or without CHD; however, data
extracted from one study meeting our inclusion
criteria showed a significantly higher prevalence of
sIADX10 mm Hg in patients with CVD than without
(19.4 vs 2.7%; OR 4.34, 95% CI 2.099.04;
Po0.0001).52 Arteriosclerosis was also more common
in subjects with an IAD in Kay and Gardners study,38
whereas although Singer and Hollander found no
relationship between coronary risk factors and an
IAD, they did find the mean sIAD to be significantly
higher in patients with known coronary artery
disease than without (14.5 vs 10.4 mm Hg;
P 0.05).55 Another smaller study reported higher
prevalence of IAD in patients with PVD compared to
both CHD patients and controls.36 Thus, there is a
body of indirect evidence to support our hypothesis.
There is also direct evidence from vascular studies.
In one angiographic series, 83% of patients undergoing vascular surgery with a difference in systolic
BPs had evidence of innominate or subclavian artery
stenosis on the side with the lower BP.73 IAD
prevalence is also high (7888%) in subclavian steal
syndrome,74,75 and the severity of the stenosis has
been associated with the size of the BP difference.76
In another large series of patients presenting for coronary angiography, the non-simultaneously measured
IAD had a low sensitivity and positive predictive
value, but high specificity (85% for 410 mm Hg and
94% for X20 mm Hg) and negative predictive value
(99% for 410 mm Hg and 98% for X20 mm Hg) for
predicting subclavian stenosis,77 and aortic arch
angiography in a series of subjects with PVD showed
a measurable stenosis of at least one brachiocephalic
artery in 42% of 48 subjects studied.78
Thus, there is evidence of an association of the
IAD with symptomatic PVD. We propose that there
is a similar underlying aetiology of asymptomatic
arterial disease causing the IAD reported in these
studies. As the risk of cardiovascular events is
similarly high for subjects with symptomatic and
asymptomatic PVD in primary care,79 the recognition of the IAD, assuming our hypothesis to be
correct, could become an important part of the risk
assessment of hypertensive patients. This would
facilitate the focusing of finite resources for primary
prevention onto those at highest risk, as demanded
by the National Service Framework for Coronary
Heart Disease.30 To justify this approach, evidence
from prospective survival studies is needed. To date,
only the authors have reported a correlation of
reduced event-free survival with the IAD in a
general20 and hypertensive (Clark CE, MSc Dissertation, Peninsula Medical School, 2006) primary care

population. Larger studies using careful and standardised bilateral assessments of BP are needed to
confirm this important observation, and to examine
the additional contribution as a risk factor that
recognition of the IAD can make to cardiovascular
risk assessment. Thus, Cyriaxs words from 1921:
Neglect to exclude the presence of the differential
blood-pressure sign may easily lead to totally
erroneous conclusions as to the state of the circulation33 remain just as relevant now.

The IAD has been repeatedly shown to occur in
substantial numbers of patients studied in primary
and secondary care, and needs to be looked for in all
patients whose diagnosis and treatment depend on
accurate BP measurements. Many studies have
overestimated prevalence due to poor design, and
our estimate of prevalence from good quality studies
is 19.6% sIADX10 mm Hg, 4.3%X20 mm Hg and
8.1%X10 mm Hg dIAD. The prevalence in coronary
heart disease and hypertensive patients appears to
be much higher. This fact, and the importance of
measuring both arms during assessment, should be
better emphasised in current hypertension management guidelines.
There is a body of evidence associating the IAD with
PVD, suggesting a pathological rather than physiological cause. This raises the possibility that the
presence of the IAD may have a prognostic value in
predicting cardiovascular events. There is preliminary
evidence for this but further large, carefully controlled
studies are needed to confirm it, and to establish what
independent contribution to cardiovascular risk assessment the detection of an IAD may make.

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.
Conflict of interests
None to declare.

1 Riva-Rocci S. Un Sfigmomanometro nuovo. Gaz
med Torino 1896; 47: 981996, 10011017 (translated
in Ruskin A. Classics in Arterial Hypertension. CC
Thomas: Springfield, IL, 1956).
2 Cyriax EF. Unilateral alterations in blood-pressure
caused by unilateral pathological conditions: the differential blood pressure sign. Q J Med 1920; 13: 148164.
3 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: 13471360.
Journal of Human Hypertension

The inter-arm blood pressure difference

CE Clark et al

4 Williams B, Poulter NR, Brown MJ, Davis M, McInnes

GT, Potter JF et al. British Hypertension Society
guidelines for hypertension management 2004 (BHSIV): summary. BMJ 2004; 328(7440): 634640.
5 OBrien E. General principles of blood pressure
measurement. In: OBrien E, Beevers DG, Marshall HJ
(eds). ABC of Hypertension. British Medical Journal
Publishing Group: London, 1995, pp 38.
6 Primatesta P, Brookes M, Poulter NR. Improved
hypertension management and control: results from
the Health Survey for England 1998. Hypertension
2001; 38(4): 827832.
7 Reeves RA. Does this patient have hypertension?
How to measure blood pressure. JAMA 1995; 273(15):
8 OBrien 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):
9 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): 139185.
10 Kirkendall WM, Burton AC, Epstein FH, Freis ED.
Recommendations for human blood pressure determination by sphygmomanometers. Circulation 1967; 36:
11 Petrie JC, OBrien ET, Littler WA, de Swiet M.
Recommendations on blood pressure measurement.
BMJ 1986; 293(6547): 611615.
12 Perloff D, Grim C, Flack J, Frohlich ED, Hill M,
McDonald M et al. Human blood pressure determination by sphygmomanometry. Circulation 1993; 88(5):
13 OBrien 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.
14 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): 569592.
15 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.
16 Beevers G, Lip GYH, OBrien E. ABC of hypertension:
blood pressure measurement. BMJ 2001; 322(7292):
17 Cushman WC. A century of indirect blood pressure
measurement. Back to basics. Arch Intern Med 1996;
156(17): 19221923.
18 Wingfield D, Pierce M, Feher M. Blood pressure
measurement in the community: do guidelines help?
J Hum Hypertens 1996; 10(12): 805809.
19 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): 12061252.
20 Clark CE, Powell RJ. The differential blood pressure
sign in general practice: prevalence and prognostic
value. Family Pract 2002; 19(5): 439441.
Journal of Human Hypertension

21 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): 487489.
22 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): 538545.
23 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(12): 2535.
24 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):
25 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): 115125.
26 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): 445449.
27 Applegate WB. Ankle/arm blood pressure index. A
useful test for clinical practice? JAMA 1993; 270(4):
28 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 199216.
29 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):
30 Coronary Heart Disease. National Service Framework.
Department of Health: London, 2000.
31 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.
32 Altman DG. Practical Statistics for Medical Research.
Chapman & Hall: London, 1991.
33 Cyriax EF. Unilateral alterations in blood pressure: the
differential blood pressure sign (second communication). Q J Med 1921; 14: 309313.
34 Phipps C. Blood Pressure. Boston M & S J 1915; 173:
35 Cyriax EF. Blood pressure in war traumatisms. BMJ
1918; 3: 132.
36 Frank SM, Norris EJ, Christopherson R, Beattie C. Right
and left arm blood pressure discrepancies in vascular
surgery patients. Anesthesiology 1991; 75: 457463.
37 Harrison EG, Roth GM, Hines EA. Bilateral indirect
and direct arterial pressures. Circulation 1960; 22:
38 Kay WE, Gardner KD. Comparative blood pressures in
the two arms. Calif Western Med 1930; 33: 578579.
39 Israel E. Differences in blood pressure in both arms.
Acta Med Orientalia 1944; 3: 8689.
40 MacLaren JP. Medical Insurance Examination: Modern
Methods and Rating of Lives, for Medical Practitioners,

The inter-arm blood pressure difference

CE Clark et al









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): 194196.
Hashimoto F, Hunt WC, Hardy L. Differences between
right and left arm blood pressures in the elderly. West J
Med 1984; 141: 189192.
Kristensen BO, Kornerup HJ. Which arm to measure
the blood pressure? Acta Med Scand 1982; 670(Suppl):
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): 4345.
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): 423426.
Goldhill DR. Bilateral simultaneous indirect systolic
blood pressure measurements. Cardiovasc Res 1986;
20(10): 774777.
Panayiotou BN, Harper GD, Fotherby MD, Potter JF,
Castleden CM. Interarm blood pressure difference
in acute hemiplegia. J Am Geriatr Soc 1993; 41(4):
OShea JC, Murphy MB. Ambulatory blood pressure
monitoring: which arm? J Hum Hypertens 2000; 14(4):
Swallow RA. Hypertension: which arm? BMJ 1975; 3:
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):
Orme S, Ralph SG, Birchall A, Lawson-Matthew P,
McLean K, Channer KS. The normal range for interarm differences in blood pressure. Age Ageing 1999;
28(6): 537542.
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):
Cassidy P, Jones K. A study of inter-arm blood pressure
differences in primary care. J Hum Hypertens 2001;
15(8): 519522.
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): 342345.
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): 11411147.
Clark CE. Difference in blood pressure between arms
might reflect peripheral vascular disease. BMJ 2001;
323(7309): 399400.
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:

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 Takayasus arteritis.
J Hum Hypertens 2001; 15(8): 573575.
Phillips LS, Branch WT, Cook CB, Doyle JP, El Kebbi
IM, Gallina DL et al. Clinical inertia. Ann Intern Med
2001; 135(9): 825834.
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
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): 360361.
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): 27282731.
Moll F, Six J, Mutsaerts D. Misleading upper extremity
blood pressure measurements in vascular occlusive
disease. Bruit 1983; 8: 1819.
Hennerici M, Klemm C, Rautenberg W. The subclavian
steal phenomenon: a common vascular disorder
with rare neurologic deficits. Neurology 1988; 38(5):
Lawson JD, Petracek MR, Buckspan GS, Dean RH.
Subclavian steal: review of the clinical manifestations.
South Med J 1979; 72(11): 13691373.
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): 131135.
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): 811.
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): 189194.
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): 11721181.
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 metaanalyses. Lancet 1999; 354(9193): 18961900.
Journal of Human Hypertension


Journal of Human Hypertension

Appendix A
Summary of excluded studies
Study population

Reason for exclusion

Phipps (1915)34 (USA)

Mixed in-patients

Sequential measurements

Cyriax (1918)35 (UK)

War wounded

Cyriax (1920)2 (UK)

Cyriax (1921)33 (UK)


Prevalence of systolic differences

Prevalence of
diastolic differences


20%X10 mm Hg

Not stated

Sequential measurements


72%45 mm Hg

Not stated

Post-Surgical in-patients
Many war trauma.
Mainly with unilateral wounds

Sequential measurements


83%X10 mm Hg
20%X20 mm Hg

81%X10 mm Hg
12%X20 mm Hg

Private practice (93) and in-patients (35):

Unilateral or bilaterally unequal surgical
Bilaterally equal and constitutional

Sequential measurements


Confirmed previous findings

Kay and Gardner (1930)38 (USA)

General medical practice, opportunistic


Korns and Guinand (193l)31



35%X10 mm Hg
7%X20 mm Hg

Confirmed previous
45%X10 mm Hg
4%X20 mm Hg

Sequential measurements


12% 420 mm Hg

13% 410 mm Hg

Healthy University students, 73% male,

mean age 20

Simultaneous but single

pair of measurements


22.2%X10 mm Hg

21.7%X10 mm Hg

Southby (1935)53 (Australia)

Patients attending one general practice

Sequential measurements


Differences above 20 mm systolic or

10 mm diastolic in 60% of cases

Israel (1944)39

Hypertensives, population not defined

Sequential measurements


18.4% 420 mm Hg

2.4% 410 mm Hg

Office patients

Sequential measurements


50%410 mm Hg
13.6% 420 mm Hg

33.7% 410 mm Hg

Swallow (1975)(letter)50 (UK)

General practice, 5054 year old males

Measurement technique
not stated


76%X10 mm Hg

Kristensen and Kornerup

(1982)43 (Denmark)

Highly selected normotensive patients

without signs of CVD
Unselected normotensive in-patients

Sequential measurements


34.5%X10 mm Hg
3.4%X20 mm Hg
60.9%X10 mm Hg
26.1%X20 mm Hg
49.1%X10 mm Hg
15.8%X20 mm Hg
5.2%X30 mm Hg
59.7%X10 mm Hg
25.8%X20 mm Hg
8.1%X30 mm Hg

14.5%X10 mm Hg

20%X10 mm Hg
3.4%X20 mm Hg

9.7%X10 mm Hg

Rueger (1951)




Hypertensive out-patients


Hypertensive out-patients


Hashimoto et al. (1984)42 (USA)

Elderly residential home residents attending Sequential measurements

for BP checks. 50% were hypertensive

Gould et al. (1985)46 (UK)


Simultaneous random zero

measurements with two


Dismissed differences over 20 mm as

erroneous, found no apparent mean
differences over 10 mm systolic or
diastolic. Individual measured

43.5%X10 mm Hg
8.7%X20 mm Hg
29.8%X10 mm Hg
5.2%X20 mm Hg
1.8%X30 mm Hg
37.1%X10 mm Hg
12.9%X20 mm Hg
1.6%X30 mm Hg

The inter-arm blood pressure difference

CE Clark et al

Reference (country of origin)

differences were 8% readings 410 mm

Hg systolic and 3% diastolic. Concluded
that no bias is introduced by making
measurements in different arms
Goldhill (1986)47 (USA)

Not stated

One observer listening to

bilateral dopplers
Review of recordings of
dopplers and pressures


37%X6 mm Hg
13%X11 mm Hg
6%X6 mm Hg
None49 mm Hg

Yagi et al. (1986)45 (Japan)

Convalescent stroke in-patients

Simultaneous automated


Mean 131/83 in paretic arms, 129/78 in

intact arms, Po0.01/Po0.001

Frank et al. (1991)36 (USA)

Peripheral vascular disease in-patients

Sequential measurements


21%X20 mm Hg
41%X10 mm Hg
16%X10 mm Hg
3%X20 mm Hg
13%X10 mm Hg
0%X20 mm Hg

31%X10 mm Hg
4%X15 mm Hg
5%X10 mm Hg
3%X15 mm Hg
5%X10 mm Hg
3%X15 mm Hg

Coronary heart disease in-patients

Controls: orthopaedic & urology in-patients


Fotherby et al. (1993)41 (UK)

Elderly in & out-patients

Young in & out-patients

Simultaneous automated


10%410 mm Hg

Panayiotou et al. (1993)48 (UK)

Hemiplegic in-patients following acute


Simultaneous automated


No correlation with side of paresis, mean

inter-arm difference 4.4/4.7 mm Hg

Singer and Hollander (1996)55


Ambulant patients over 5 years old

attending university hospital emergency

Sequential measurements
Single (not repeated)
simultaneous automated


OShea and Murphy (2000)49


Patients attending for ambulatory BP


Sequential measurements


33%X10 mm Hg

Clark (2001)59 (UK)

General practice

Sequential measurements


31%X10 mm Hg
4%X20 mm Hg

13%X10 mm Hg

Cassidy and Jones (2001)56 (UK)

General practice

Sequential measurements


23%X20 mm Hg

40%X10 mm Hg

Normotensive patients attending ER and

staff accepting BP screening

Sequential measurements


15%X10 mm Hg

Clark and Powell (2002)20 (UK)

General practice

Sequential measurements


40.7%X10 mm Hg
13.6%X20 mm Hg

Pesola et al. (2002)57 (USA)

Staff and visitors to an ER with history of

hypertension willing to be screened

Sequential measurements


18%X10 mm Hg

Shadman et al. (2004)29 (USA)

General population
Vascular patients

Sequential measurements


1.9%415 mm Hg
7.1%415 mm Hg

Not stated
Not stated

Arnett et al. (2005)58 (USA)

Random population sample

Hypertensive siblings

Sequential measurements


9.2%410 mm Hg
1.1%420 mm Hg
14.2%410 mm Hg
1.8%420 mm Hg

1.6%410 mm Hg
0420 mm Hg
2.8%410 mm Hg
0.1%420 mm Hg


23.2%X10 mm Hg


Journal of Human Hypertension


28%410 mm Hg
20.6% 410 mm Hg

The inter-arm blood pressure difference

CE Clark et al

Pesola et al. (2001)


13.3%420 mm Hg
11.6% 420 mm Hg