title: Simultaneously measured inter-arm and inter-leg systolic blood pressure differences and cardiovascular risk stratification: a systemic review and meta-analysis.
abstract: Association of inter-arm systolic blood pressure difference (IASBPD) with cardiovascular (CV) morbidity and mortality remains controversial. We aimed to thoroughly examine all available evidence on inter-limb blood pressure (BP) difference and its association with CV risk and outcomes. We searched PubMed, EMBASE, CINAHL, Cochrane library, and Ovid for studies reporting bilateral simultaneous BP measurements in arms or legs and risk of peripheral arterial disease (PAD), coronary artery disease, cerebrovascular disease, subclavian stenosis, or mortality. Random-effect meta-analysis was performed to compare effect estimates. Twenty-seven studies met inclusion criteria, but only 17 studies (18 cohorts) were suitable for analysis. IASBPD of 10 mmHg or more was associated with PAD (risk ratios, 2.22; 1.41-3.5; P = .0006; sensitivity 16.6%; 6.7-35.4; specificity 91.9%; 83.1-96.3; 8 cohorts; 4774 subjects), left ventricular mass index (standardized mean difference 0.21; 0.03-0.39; P = .02; 2 cohort; 1604 subjects), and brachial-ankle pulse wave velocity (PWV) (one cohort). Association of PAD remained significant at cutoff of 15 mmHg (risk ratios, 1.91; 1.28-2.84; P = .001; 5 cohorts; 1914 subjects). We could not find statistically significant direct association of coronary artery disease, cerebrovascular disease, CV, and all-cause mortality in subjects with IASBPD of 10 mmHg or more, 15 mmHg or more, and inter-leg systolic BP difference of 15 mmHg or more. Inter-leg BP difference of 15 mmHg or more was strong predictor of PAD (P = .0001) and brachial-ankle PWV (P = .0001). Two invasive studies showed association of IASBPD and subclavian stenosis (estimates could not be combined). In conclusion, inter-arm and leg BP differences are strong predictors of PAD. IASBPD may be associated with subclavian stenosis, high left ventricular mass effect, and higher brachial-ankle PWVs. Inter-leg BP difference may also be associated with high left ventricular mass effect and higher brachial-ankle PWVs. Presence of inter-limb BP difference may indicate higher global CV risk.
authors.affiliation: Department of Hospital Medicine, Ingalls Memorial Hospital, Harvey, IL, USA; Department of Cardiovascular Medicine, Mount Sinai Hospital Medical Center, Chicago, IL, USA. Electronic address: s.singhmd@outlook.com.
authors.forename: Sukhchain
authors.initials: S
authors.lastname: Singh
authors.affiliation: Department of Cardiovascular Medicine, Mount Sinai Hospital Medical Center, Chicago, IL, USA.
authors.forename: Ankur
authors.initials: A
authors.lastname: Sethi
authors.affiliation: Department of Cardiovascular Medicine, Mount Sinai Hospital Medical Center, Chicago, IL, USA.
authors.forename: Mukesh
authors.initials: M
authors.lastname: Singh
authors.affiliation: Department of Science, Brown University, Providence, RI, USA.
authors.forename: Kavia
authors.initials: K
authors.lastname: Khosla
authors.affiliation: Department of Cardiovascular Medicine, Mount Sinai Hospital Medical Center, Chicago, IL, USA; School of Public Health, University of Illinois, Chicago, IL, USA.
authors.forename: Navsheen
authors.initials: N
authors.lastname: Grewal
authors.affiliation: Department of Cardiovascular Medicine, Mount Sinai Hospital Medical Center, Chicago, IL, USA; Department of Cardiovascular Medicine, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA.
authors.forename: Sandeep
authors.initials: S
authors.lastname: Khosla
mesh_terms: D055109:Ankle Brachial Index; D001132:Arm / Q000098:blood supply*; D001794:Blood Pressure / Q000502:physiology*; D001795:Blood Pressure Determination / Q000379:methods*; D002318:Cardiovascular Diseases / Q000453:epidemiology / Q000503:physiopathology*; D014943:Global Health; D006801:Humans; D007866:Leg / Q000098:blood supply*; D009017:Morbidity / Q000639:trends; D018570:Risk Assessment; D012307:Risk Factors; D013599:Systole
keywords: Inter-limb; peripheral arterial disease; risk assessment