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BMJ 2003; 327 doi: https://doi.org/10.1136/bmjusa.03020008 (Published 19 November 2003) Cite this as: BMJ 2003;327:E186

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Misleading measurements of blood pressure among the elderly

The currently ongoing debate over the exact definition of hypertension and
regarding the optimal blood pressure levels required to be treated among
the elderly however, does not undermine in anyway, the significance of
accurately recording the blood pressure in this highly vulnerable group
for the development of vascular events eg. stroke , acute coronary
syndromes etc.

Atherosclerotic and / or calcified arteries are the frequent findings
among elderly people; as a result compression of the brachial artery with
a sphygmanometer requires a cuff pressure greater than the one present
within the artery and the thickened vessel will also cease to pulsate more
quickly during diastole leading to more rapid deterioration of Korotkoff
sounds and a higher estimated diastolic blood pressure. So that the net
effect known as pseudohypertension is that the systolic and diastolic
pressures estimated from the sphygmanometer may be considerably higher
than the directly measured intraarterial pressures giving the impression
of hypertension though it is not in true sence.

Pseudohypertension should be suspected in an elderly patient with
marked hypertension in absence of end organ damage and induction of
symptoms compatible with cerebral hypoperfusion ( dizziness, confusion)
upon instituting antihypertensive drug treatment. In addition these
patients may reveal ‘ locomotor brachial’ ( visible pulsating tortuous
brachial artery on the medial side of the arm upon clinical examination of
the partly flexed elbow) and the ‘pipestem calcification’ on brachial
artery radiograph. The diagnosis of pseudohypertension can only be
confirmed by direct measurement of the intraarterial pressure bur Osler’s
maneuver might allow the diagnosis to be made clinically by inflating a
sphygmanometer to a level above systolic pressure, thereby collapsing the
radial artery [1]. In this condition the radial artery would only be
palpable if vascular wall is markedly thickened.

Cuff-inflation hypertension may also easily be confused with
pseudohypertension and may even be considered in the differential
diagnosis of of resistant hypertension if physicain is not aware of this
entity. Cuff-inflation hypertension is induced by the excess and the rapid
inflation of of cuff to a level far above the systolic blood pressure and
by the muscular activity associated with the inflating cuff, while blood
pressure is measured [2]. A neurogenic theory has also been postulated. It
can be diagnosed by comparing the directly measured intraarterial
diastolic pressure both before and after cuff inflation, and at the
korotkoff phase V.

References:

1.Tsaparsaris NP, Napolitana GT, Rotchild J. Osler’s maneuver in an
out-patients clinic setting. Arch Intern Med 1991; 151: 2209-12.

2.Veerman DP, Van Montfrans GA, Weilling W. Effects of cuff inflation
on self-recorded blood pressure. Lancet 1990; 335: 451.

Competing interests:  
None declared

Competing interests: No competing interests

13 June 2003
ANIL K SAXENA, MD; MRCP (Dublin)
Consultant Renal Physician, Division of Nephrology,
Wahid Uzzaman
Department of Medicine, King Fahad Hospital & Tertiary care Center, Hofuf, Al-Hasa, Saudi Arabia