A review of 28 studies published online in the distinguished medical journal Lancet suggests that doctors should “measure blood pressure in both arms of the patient - and not just one”, as in most offices.
The reason for that is obtaining a different pressure measurement in the arms may indicate an increased risk of a serious medical condition called: “peripheral vascular disease”.
Peripheral vascular disease(PVD), commonly referred to as peripheral arterial disease (PAD) or peripheral artery occlusive disease (PAOD), refers to the obstruction of large arteries not within the coronary, aortic arch vasculature, or brain. PVD can result from atherosclerosis, inflammatory processes leading to stenosis, an embolism, or thrombus formation. It causes either acute or chronic ischemia (lack of blood supply). Often PAD is a term used to refer to atherosclerotic blockages found in the lower extremity.
PVD also includes a subset of diseases classified as microvascular diseases resulting from episodal narrowing of the arteries (Raynaud's phenomenon), or widening thereof (erythromelalgia), i.e. vascular spasms.
Measuring the pressure in both arms is already being recommended in the guidelines of the Brazilian Society of Hypertension and Cardiology - the last update was published in 2010.
The rule directs that on the “first visit”, doctors measure the pressure in all four limbs of the patient: in the two arms and two legs - which does not always happen. In the U.S. that rarely happens.
“We certainly don’t measure the blood pressure in both arms”, says Dr. John Cooper of Charlotte, a retired medical doctor. “It’s an excellent idea however. I wonder how they would bill that to private insurance companies?” he said.
Apart from billing issues, which is only a concern here in the U.S. - where healthcare is profit driven. “In Brazil we don’t look at this as a billing issue. That’s absured!”, says Hector Gonzales of San Palo Medical Clinic.
The review was conducted by the physician, Christopher Clark, University of Exeter (Great Britain), and demonstrated that a difference in systolic blood pressure above 15 millimeters of mercury (mm Hg) between the two arms is associated with increased risk of having one of the arteries partially obstructed.
Britain is among a number of nations that is recommending a higher standard to doctors to better treat patients.
It would be the case, for example, with a patient having a blood pressure of 120 mm Hg over 80 mm Hg (12 by 8) on one arm and 140 mm Hg over 80 mm Hg (14 by 8) on the other. The difference from 140 to 120 is 20.
According to the study, the patient should be referred for more specific tests.
These tests would further identify the patient’s specific conditions, which would lead to earlier diagnosis and treatment options.
The guidelines recommended in this case represent a much higher standard in Brazil than in the United States - further investigation only in cases that present a measurement of pressure difference greater than 20 mm Hg between the two arms.
For the cardiologist, Luiz Aparecido Bortolotto, director of Clinical Hypertension Unit at InCor, this is a point that may be reassessed in the country.
"One of the most important things in this study is that the pressure difference between the two arms is to be considered dangerous at 15, while in Brazil the figure is 20.We might have to revise the guidelines and also lower the number," he says.
The information was obtained from the newspaper O Estado de Sao Paulo.
The American Medical Association did not respond to emails asking if they would support a higher standard of care to patients by revising guide lines like they have in Brazil?
“We should have the highest standard of care for patients here in the United States. Sadly we do not. We do have the most expensive system, that puts profits ahead of patient care. That is a fatal flaw of our healthcare system in this country. It is why a 3rd world impoverished country like Brazil, which still practices real preventive medicine, will always offer a higher standard of care for patients than the US”, says Bob Smith of Charlotte.
A survey of 14 physicians in Charlotte, asking doctors whether they would consider measuring blood pressure in both arms indicated they would do so if billing guidelines would allow it. One doctor, who declined to be named said his “provider network would not allow this because insurance companies may not pay for it.” The doctor said if profit was not the primary motive and patient care was - such guidelines would be embraced here in the United States.
In the USA peripheral arterial disease affects 12–20 percent of Americans age 65 and older. Approximately 10 million Americans have PVD. Despite its prevalence and cardiovascular risk implications, only 25 percent of PAD patients are undergoing treatment.
Robert Tilford
Charlotte, N.C.
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