Inter-arm systolic blood pressure differences, relations with future vascular events and mortality in patients with and without manifest vascular disease
Introduction
Peripheral artery disease (PAD) significantly contributes to the total burden of vascular disease as it is related to high risks of vascular morbidity and mortality [1], [2]. Although PAD most often presents as an atherosclerotic disease of the leg arteries, atherosclerotic changes in the arteries of the upper limbs occur as well [3]. Inter-arm systolic blood pressure difference (SBPD) reflects subclavian stenosis which in most cases is caused by atherosclerosis in the upper limb arteries [4]. In rare cases there may be another origin such as arteritis, fibromuscular dysplasia, arterial injuries or arterial dissection [5], [6], [7]. International hypertension guidelines stress the importance of bilateral blood pressure measurement and state that large inter-arm SBPD is an indicator of elevated vascular risk [8], [9]. Indeed, high inter-arm SBPD (> 15 mm Hg) relates to an approximately 1.6-fold risk of cardiovascular mortality [4], [10]. Although the association of inter-arm SBPD with atherosclerotic stenosis of the upper arm arteries is generally acknowledged, little is known about the precise determinants of a large inter-arm SBPD.
Several epidemiological studies indicate that large inter-arm SBPD confers a higher risk for (cardiovascular) mortality and relates to the presence of cardiovascular risk factors, PAD of the lower extremities, and cerebrovascular disease [4], [10], [11], [12], [13], [14]. Previous studies mostly used cut off values (≥ 10, ≥ 15 or ≥ 20 mm Hg) to investigate the relation between inter-arm SBPD and prevalent vascular disease, while a continuous approach could provide more precise information [10], [11]. A small prospective cohort study of 230 patients with hypertension with a median follow-up of 9.8 years shows that each 1 mm Hg increase in inter-arm SBPD relates to future cardiovascular events (HR 1.04; 95% CI 1.02–1.07) [15]. Also, a larger community-based prospective cohort including 3390 participants shows that each standard deviation increase in inter-arm SBPD relates to cardiovascular events (HR 1.07; 95% CI 1.00–1.14) [14]. Nevertheless, evidence on the relation in patients with manifestations of vascular disease is scarce [10], [11].
The presence of clinical manifest vascular disease might influence the relation between inter-arm SBPD and vascular events. Patients with clinical manifest vascular disease are at higher risk for vascular events than patients without clinical manifestations of vascular disease. Therefore the relation between inter-arm SBPD and vascular risk might be different in patients with and without clinical manifest vascular disease.
The aim of the present study is to identify determinants of high inter-arm SBPD and to investigate the relation between inter-arm SBPD and vascular events and all-cause mortality in patients with and without clinical manifest vascular disease.
Section snippets
Study population
Data of 7344 participants enrolled in the Second Manifestations of ARTerial disease (SMART) study after the first of January 2002 and before the first of March 2014 were used for this study. The SMART study is an ongoing prospective single-center cohort study in the University Medical Center Utrecht (UMCU), The Netherlands. Patients with manifest vascular disease (coronary artery disease, cerebrovascular disease, peripheral artery disease or abdominal aortic aneurysm) and patients without
Results
Table 1 summarizes the baseline characteristics. In patients with manifest vascular disease (n = 5293) the mean age was 60 years (± 10) and 73% of the participants were male. In patients without manifest vascular disease (n = 2051) the mean age was 50 years (± 13) and 52% of the participants were male.
Discussion
In our study in patients with and without clinical manifest vascular disease 16% had a large inter-arm SBPD (≥ 15 mm Hg). Determinants of large inter-arm differences were age, SBP, diabetes mellitus, carotid stenosis ≥ 70%, carotid intima-media thickness, and lower ankle-brachial indexes. In patients without clinical manifest vascular disease each 5 mm Hg increase in inter-arm SBPD is significantly related to a 12% higher risk of vascular events, whereas in patients with manifest vascular disease no
Conflict of interest statement
None.
Acknowledgements
We gratefully acknowledge the SMART research nurses; R. van Petersen (data-manager); B.G.F. Dinther (vascular manager) and the participants of the SMART Study Group: A. Algra MD, PhD; Y. van der Graaf, MD,PhD; D.E. Grobbee, MD, PhD; G.E.H.M. Rutten, MD, PhD, Julius Center for Health Sciences and Primary care; F.L.J. Visseren, MD, PhD, Department of Internal Medicine; G.J. de Borst, MD, PhD, Department of Vascular Surgery; L.J. Kappelle, MD, PhD, Department of Neurology; T. Leiner, MD, PhD,
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