Inter-arm difference and orthostatic changes of brachial blood pressure in the very elderly patients under antihypertensive treatment

Background. Inter-arm difference in blood pressure (BP) and orthostatic BP response are significant prognostic factors in hypertensive patients, especially in the elderly ones. However, data on their prevalence, predictors and clinical associations remain contradictory.

The aim of our study was to investigate inter-arm difference and orthostatic response and to establish their clinical associations in the very elderly hypertensive patients.

Design and methods. We enrolled 67 hypertensive subjects older than 80 years (mean age 84,1 ± 3,1 years, 25,5 % male, mean clinic brachial systolic BP (SBP) 134,8 ± 23,2 mm Hg) in a cross-sectional study. Simultaneous bilateral brachial BP measurements were performed using oscillometric validated cuffbased device in sitting position and then 2 minutes after standing up. Central pulse waveform characteristics and arterial stiffness parameters were estimated by BPLab Vasotens system (Petr Telegin, Russia).

Results. The median of inter-arm difference in SBP (IADSBP) was 4,00 (2,50, 9,00) mm Hg. IADSBP was ≥ 10 mm Hg in 25,4 % participants. Compared to others, those with IADSBP ≥ 10 mmHg had significantly higher body mass index (31,39 ± 5,73 vs 28,48 ± 4,1 kg/m2 , p < 0,05), waist circumference (116,3 ± 13,6 vs 107,7 ± 11,2 cm, p < 0,05) and pulse wave velocity in aorta (11,65 ± 1,46 vs 10,75 ± 1,71 m/s, p < 0,05). A positive correlation between IADSBP and augmentation index was revealed (r = 0,277, p < 0,05). Patients with asymptomatic orthostatic hypotension (22,4 % participants) had higher levels of brachial SBP and pulse pressure while central BP and markers of arterial stiffness did not differ from those without orthostatic hypotension. Conclusions. Significant IADSBP is associated with increased arterial stiffness and abdominal obesity in the very elderly hypertensive patients, whereas there is no evidence of interrelation between orthostatic response and arterial stiffness in these patients.

1. Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A et al. 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J. 2013;34(28):2159–2219.

2. Clark CE, Taylor RS, Shore AC, Ukoumunne OC, Campbell JL. Association of a difference in systolic blood pressure between arms with vascular disease and mortality: a systematic review and meta-analysis. Lancet. 2012;379(9819):905–914.

3. Bouhanick B, Meliani S, Doucet J, Bauduceau B, Verny C, Chamontin B et al. Gerodiab Study group. Orthostatic hypotension is associated with more severe hypertension in elderly autonomous diabetic patients from the French Gerodiab study at inclusion. Ann Cardiol Angeiol (Paris). 2014;63(3):176–182.

4. Finucane C, O’Connell MD, Fan CW, Savva GM, SoraghanCJ, Nolan H et al. Age-related normative changesin phasic orthostatic blood pressure in a large population study: findings from the Irish Longitudinal Study on Ageing (TILDA). Circulation. 2014;130(20):1780–1789.

5. Fedorowski A, Stavenow L, Hedblad B, Berglund G, Nilsson PM, Melander O. Orthostatic hypotension predicts all-cause mortality and coronary events in middleaged individuals (The Malmo Preventive Project). Eur Heart J. 2010;31(1):85–91.

6. Fagard RH, De Cort P. Orthostatic hypotension is a more robust predictor of cardiovascular events than night-time reverse dipping in elderly. Hypertension. 2010;56(1):56–61.

7. Verwoert GC, Matace-Raso FU, Hofman A, Heeringa J, Stricker BH, Breteler MM et al. Orthostatic hypotension and risk of cardiovascular disease in elderly people: the Rotterdam study. J Am Geriatr Soc. 2008;56(10):1816–1820.

8. Kario K. Orthostatic hypertension — a new haemodynamic cardiovascular risk factor. Nat Rev Nephrol. 2013;9(12):726–738.

9. English JA, Carell ES, Guidera SA, Tripp HF.Angiographic prevalence and clinical predictors of left subclavian stenosisin patients undergoing diagnostic cardiac catheterization. Catheter Cardiovasc Interv. 2001;54(1):8–11.

10. Agarwal R, Bunaye Z, Bekele DM. Prognostic significance of between-arm blood pressure differences. Hypertension. 2008;51(3):657–662.

11. Verberk WJ, Kessels AG, Thien T. Blood pressure measurement method and inter-arm differences: a metaanalysis. Am J Hypertens. 2011;24(11):1201–1208.

12. Canepa M., Milaneschi Y, Ameri P, AlGhatrif M, Leoncini G, Spallarossa P et al. Relationship between interarm difference in systolic blood pressure and arterial stiffness in community-dwelling older adults. J Clin Hypertens (Greenwich). 2013;15(12):880–887.

13. Kimura A, Hashimoto J, Watabe D, Takahashi H, Ohkubo T, Kikuya M et al. Patient characteristics and factors associated with inter-arm difference of blood pressure measurements in a general population in Ohasama, Japan. J Hypertens. 2004;22(12):2277–83.

14. Khokhlov RA, Gaydashev AE, Akhmedzhanov NM. Predictors of atherosclerotic lesions of limb arteries according to cardioangiological screening of the adult population. Ratsional’naya Farmakoterapiya v Kardiologii = Rational Pharmacotherapy in Cardiology. 2015;11(5):470–476. In Russian.

15. Hu W, Li J, Su H, Wang J, Xu J, Liu Y et al. The interarm diastolic blood pressure difference induced by one arm ischemia: a new approach to assess vascular endothelia function. PLoS One. 2014;13(9): e84765.

16. Jacobs JM, Stessman J, Ein-Mor E, Byrsztun M. Hypertension and 5-year mortality among 85-years-olds: the Jerusalem Longitudinal Study. J Am Med Dir Assoc 2012;13(8):1–6.

17. Hoshide S, Parati G, Matsui Y, Shibazaki S, Eguchi K, Kario K. Orthostatic hypertension: home blood pressure monitoring for detection and assessment of treatment with doxazosin. Hypertens Res. 2012;35(1):100–106.

18. Avolio AP, Van Bortel LM, Boutouyrie P, CockcroftJR, McEniery CM, Protogerou AD et al. Role of pulse pressure amplification in arterial hypertension: experts’ opinion and review of the data. Hypertension. 2009;54(2):375–383.