Skip to main content

Advertisement

SpringerLink
Log in

Four-Limb Blood Pressure Measurement with an Oscillometric Device: a Tool for Diagnosing Peripheral Vascular Disease

  • Device-Based Approaches for Hypertension (Markus Schlaich, Section Editor)
  • Published:
Current Hypertension Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Traditionally, the term peripheral vascular disease (PAD) is restricted to the occlusive arterial disease in the leg, but now, the connotation of PAD is more widespread as it encompasses all extracoronary and extracerebral vascular disease. The incidence of PAD is increasing worldwide; therefore, it is necessary to diagnose PAD at an early stage.

Recent Findings

Oscillometric BP device is widely used for four-limb measurement in clinical practice and provides several parameters for evaluating inter-limb BP difference, such as ankle-brachial index (OS-ABI), inter-arm BP differences (IAD), and inter-ankle BP difference (IAND). Using angiographic results as reference, the ABI, IAD, and IAND from an oscillometric BP device have been demonstrated having high accuracy for diagnosis of PAD. Meanwhile, combination of these parameters could further improve the accuracy of PAD, including the occlusive artery disease in the arm, leg, and aorta. For example, some patients with severe PAD in the leg have normal ABI; in this situation, an increased sIAND could confirm the diagnosis of PAD in the leg.

Summary

Because ABI, IAD, and IAND from inter-limb oscillometric BP measurement can also predict adverse prognosis, we encourage the use of an oscillometric device to measure four-limb BP and to evaluate the inter-limb BP difference.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Guijarro C, Mostaza JM, Hernández MA. Lower limb arterial disease and renal artery stenosis. Clin Investig Arterioscler. 2013;25:218–23.

  2. Leng GC, Fowkes FG. The Edinburgh Claudication Questionnaire: an improved version of the WHO/Rose Questionnaire for use in epidemiological surveys. J Clin Epidemiol. 1992;45:1101–9.

  3. Fowkes FG, Housley E, Cawood EH, Macintyre CC, Ruckley CV, Prescott RJ. Edinburgh Artery Study: prevalence of asymptomatic and symptomatic peripheral arterial disease in the general population. Int J Epidemiol. 2001;20:384–92.

  4. Verberk WJ, Kollias A. Automated oscillometric determination of the ankle-brachial index: a systematic review and meta-analysis. Hypertens Res. 2012;35:883–91.

    Article  Google Scholar 

  5. Criqui MH, Aboyans V. Epidemiology of peripheral artery disease. Circ Res. 2015;116:1509–26.

    Article  CAS  Google Scholar 

  6. Hajibandeh S, Shah S, Child E, Antoniou GA, Torella F. Prognostic significance of ankle brachial pressure index: a systematic review and meta-analysis. Vascular. 2016;25:208–24.

    Article  Google Scholar 

  7. Wilson TW, Quest DW, Wilson M, Buxton AC, Herman RJ, Boctor MA, et al. A cardiovascular risk factor reduction clinic. Can J Cardiol. 1999;15:887–91.

  8. Faghihimani E, Darakhshandeh A, Feizi A, Amini M. Evaluation of peripheral arterial disease in prediabetes. Int J Prev Med. 2014;5:1099–105.

  9. Jeevanantham V, Chehab B, Austria E, Shrivastava R, Wiley M, Tadros P, et al. Comparison of accuracy of two different methods to determine ankle-brachial index to predict peripheral arterial disease severity confirmed by angiography. Am J Cardiol. 2014;114:1105–10.

  10. Osler W. Modern medicine, Volume 4. Lea & Febiger: Philadelphia 1915, 498.

  11. Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2018;138:e426–e483.

  12. Ramsay L, Williams B, Johnston G, MacGregor G, Poston L, Potter J, et al. Guidelines for management of hypertension. J Hum Hypertens. 1999;13:569–92.

  13. Singh S, Sethi A, Singh M, Khosla K, Grewal N, Khosla S. Simultaneously measured inter-arm and inter-leg systolic blood pressure differences and cardiovascular risk stratification: a systemic review and meta-analysis. J Am Soc Hypertens. 2015;9:640–50.

  14. • Verberk WJ, Kessels AGH, Thien T. Blood pressure measurement method and inter-arm differences: a meta-analysis. Am J Hypertens. 2011;24:1201–8. This meta-analysis pointed out that different blood pressure measurement methods lead to different results, indicating that we should measure four-limb blood pressure at the same time.

  15. Singh S, Sethi A, Singh M, Khosla S. Prevalence of simultaneously measured interarm systolic blood pressure diference and its clinical and demographic predictors: a systemic review and meta-analysis. Blood Press Monit. 2015;20:178–85.

    Article  Google Scholar 

  16. 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;379:905–14.

    Article  Google Scholar 

  17. Calligaro KD, Ascer E, Veith FJ, Gupta SK, Wengerter KR, Franco CD, et al. Unsuspected inflow disease in candidates for axillofemoral bypass operations: a prospective study. J Vasc Surg. 1990;11:832–7.

  18. • English JA, Carell ES, Guidera SA, Tripp HF. Angiographic prevalence and clinical predictors of left subclavian stenosis in patients undergoing diagnostic cardiac catheterization. Catheter Cardiovasc Interv. 2001;54:8–11 Using angiography as the gold standard, this article indicated the IAD > 10 mmHg usually means left subclavian stenosis.

  19. Aboyans V, Criqui MH, McDermott MM, Allison MA, Denenberg JO, Shadman R, et al. The vital prognosis of subclavian stenosis. J Am Coll Cardiol. 2007;49:1540–5.

  20. Osborn LA, Vernon SM, Reynolds B, Timm TC, Allen K. Screening for subclavian artery stenosis in patients who are candidates for coronary bypass surgery. Catheter Cardiovasc Interv. 2002;56:162–5.

    Article  Google Scholar 

  21. Um SW, Ohle R. Bilateral blood pressure differential as a clinical marker for acute aortic dissection in the emergency department. Emerg Med J. 2018;35:556–8. https://doi.org/10.1136/emermed-2018-207499.

    Article  PubMed  Google Scholar 

  22. Tarumi T, Sugawara J, Tanaka H. Association between ankle blood pressure and central arterial wave reflection. J Hum Hypertens. 2011;25:539–44.

    Article  CAS  Google Scholar 

  23. Hietanen H, Pääkkönen R, Salomaa V. Ankle and exercise blood pressures as predictors of coronary morbidity and mortality in a prospective follow-up study. J Hum Hypertens. 2010;24:577–84.

    Article  CAS  Google Scholar 

  24. Hietanen HJ, Pääkkönen R, Salomaa V. Predictors of cerebrovascular morbidity and mortality in a prospective follow-up study. Stroke Res Treat. 2010:729391.

  25. Gemignani T, Matos-Souza JR, Franchini KG, Nadruz W Jr. Leg blood pressure measured in orthostatic posture is associated with left ventricular mass in normotensive subjects. Am J Hypertens. 2012;25:1083–7.

    Article  Google Scholar 

  26. Jones WS, Patel MR, Rockman CB, Guo Y, Adelman M, Riles T, et al. Association of the ankle-brachial index with history of myocardial infarction and stroke. Am Heart J. 2014;167:499–505.

  27. Jimenez M, Dorado L, Hernandez PM,Alzamora MT, Pera G, Torán P,et al. Ankle-brachial index in screening for asymptomatic carotid and intracranial atherosclerosis. Atherosclerosis. 2014;233:72–5.

  28. • Gong Y, CAO KW, XU JS, Li JX, Hong K, Cheng XS, et al. Valuation of normal range of ankle blood pressure in subjects with normal arm blood pressure. PLoS One. 2015;10:e0122248 This article established a normal range for ankle systolic blood pressure, which provides a basis for PAD diagnosis.

  29. Shearman CP. Ankle blood pressure measured by automatic oscillotonometry: a comparison with Doppler pressure measurements. Ann R Coll Surg Engl. 1988;70(4):257.

  30. Herraiz AA, Soriano CA,Martinez JA, Garrido MM, Mariana JÁ, Martínez VV. Simultaneous inter-arm and inter-leg systolic blood pressure differences to diagnose peripheral artery disease: a diagnostic accuracy study. Blood Press. 2018;27:112–9.

  31. Chen SC, Chang JM, Tsai YC, Tsai JC, Su HM, Hwang SJ, et al. Association of interleg BP difference with overall and cardiovascular mortality in hemodialysis. Clin J Am Soc Nephrol. 2012;7(10):1646–53.

  32. Su HM, Lin TH, Hsu PC, Lee WH, Chu CY, Chen SC, et al. Association of interankle systolic blood pressure difference with peripheral vascular disease and left ventricular mass index. Am J Hypertens. 2014;27:32–7.

  33. Hoschtitzky JA, Anderson RH, Elliott MJ. Aortic coarctation and interrupted aortic arch. In: Price G (ed). Paediatric cardiology, 3rd edn, Vol. 2010. Churchill Livingston/Elsevier Ltd: Philadelphia, PA, USA, 2009; 945–966.

  34. • Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss LK, et al. 2011 ACCF/AHA focused update of the guideline for the management of patients with peripheral artery disease (updating the 2005 guideline):a report of the American college of cardiology foundation/American heart association task force on practice guidelines. J Am Coll Cardiol. 2011;58:2020–45 This comprehensive guideline statement, which will have a major influence on the evaluation and management of PAD, emphasizes the importance of early diagnosis of PAD and in assessing the effects of therapy.

  35. Niazi K, Khan TH, Easley KA. Diagnostic utility of the two methods of ankle brachial index in the detection of peripheral arterial disease of lower extremities. Catheter Cardiovasc Interv. 2006;68:788–92.

  36. Kollias A, Xilomenos A, Protogerou A, Dimakakos E, Stergiou GS. Automated determination of the ankle-brachial index using an oscillometric blood pressure monitor: validation vs. Doppler measurement and cardiovascular risk factor. Hypertens Res. 2011;34:825–30.

    Article  Google Scholar 

  37. Beckman JA, Higgins CO, Gerhard HM. Automated oscillometric determination of the ankle-brachial index provides accuracy necessary for office practice. Hypertension. 2006;47:35–8.

  38. •• Herráiz AÁ,Martínez VV,Cavero RI, Álvarez BC, Garrido MM, Notario PB. Diagnostic accuracy study of an oscillometric ankle-brachial index in peripheral arterial disease: the influence of oscillometric errors and calcified legs. PLoS One. 2016;11:e0167408 This article proved that oscillometric ABI could be a useful tool for the diagnosis of PAD, particularly when considering calcified legs and oscillometric “errors” readings as peripheral arterial disease equivalents, playing a good guidance for this paper.

  39. Herráiz AÁ, Martínez VV, Cavero-RI, Pozuelo DP, Notario-PB The accuracy of an oscillometric ankle-brachial index in the diagnosis of lower limb peripheral arterial disease: a systematic review and meta-analysis. Int J Clin Pract. 2017;71.

  40. • Ichihashi S, Hashimoto T, Iwakoshi S. Validation study of automated oscillometric measurement of the ankle-brachial index for lower arterial occlusive disease by comparison with computed tomography angiography. Hypertens Res. 2014;37:591–4 This article proved that the oscillometric ABI had a high diagnostic accuracy to detect PAD using CTA as a gold standard.

    Article  Google Scholar 

  41. Guo X, Li J, Pang W, Zhao M, Luo Y, Sun Y,et al. Sensitivity and specificity of ankle-brachial index for detecting angiographic stenosis of peripheral arteries. Circ J. 2008;72:605–10.

  42. Clairotte C, Retout S, Potier L, Roussel R, Escoubet B. Automated ankle-brachial pressure index measurement by clinical staff for peripheral arterial disease diagnosis in nondiabetic and diabetic patients. Diabetes Care. 2009;32:1231–6.

    Article  Google Scholar 

  43. Emanuele MA, Buchanan BJ. Elevated leg systolic pressures and arterial calcification in diabetic occlusive vascular disease. Diabetes Care. 1981;4:289–92.

    Article  CAS  Google Scholar 

  44. Aboyans V, Criqui MH, Abraham P, Allison MA, Creager MA, Diehm C, et al. Measurement and interpretation of the ankle-brachial index: a scientific statement from the American Heart Association. Circulation. 2012;126:2890–909.

  45. Aday AW, Kinlay S. Comparison of different exercise ankle pressure indices in the diagnosis of peripheral artery disease. Vasc Med. 2018;23:541–8. https://doi.org/10.1177/1358863X18781723.

    Article  Google Scholar 

  46. Park MK, Lee DH. Normative arm and calf blood pressure values in the newborn. Pediatrics. 1989;83:240–3.

  47. Patankar N, Fernandes N, Kumar K, Manja V, Lakshminrusimha S. Does measurement of four-limb blood pressures at birth improve detection of aortic arch anomalies? J Perinatol. 2016;36:376–80.

    Article  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Cardiovascular Medicine, the Second Affiliated Hospital of Nanchang University, 330006, NO 1 Mingde Road, Nanchang, Jiangxi, China

    Songtao Liu, Ping Li & Hai Su

Authors
  1. Songtao Liu
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ping Li
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Hai Su
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Hai Su.

Ethics declarations

Conflict of Interest

The authors declare no conflicts of interest relevant to this manuscript.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Device-Based Approaches for Hypertension

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Liu, S., Li, P. & Su, H. Four-Limb Blood Pressure Measurement with an Oscillometric Device: a Tool for Diagnosing Peripheral Vascular Disease. Curr Hypertens Rep 21, 15 (2019). https://doi.org/10.1007/s11906-019-0917-z

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11906-019-0917-z

Keywords

Search

Navigation