Which cuff should I use? Indirect blood pressure measurement for the diagnosis of hypertension in patients with obesity: a diagnostic accuracy review.
To determine the diagnostic accuracy of different methods of blood pressure (BP) measurement compared with reference standards for the diagnosis of hypertension in patients with obesity with a large arm circumference.



Systematic review with meta-analysis with hierarchical summary receiver operating characteristic models. Bland-Altman analyses where individual patient data were available. Methodological quality appraised using Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS2) criteria.



MEDLINE, EMBASE, Cochrane, DARE, Medion and Trip databases were searched.



Cross-sectional, randomised and cohort studies of diagnostic test accuracy that compared any non-invasive BP tests (upper arm, forearm, wrist, finger) with an appropriate reference standard (invasive BP, correctly fitting upper arm cuff, ambulatory BP monitoring) in primary care were included.



4037 potentially relevant papers were identified. 20 studies involving 26 different comparisons met the inclusion criteria. Individual patient data were available from 4 studies. No studies satisfied all QUADAS2 criteria. Compared with the reference test of invasive BP, a correctly fitting upper arm BP cuff had a sensitivity of 0.87 (0.79 to 0.93) and a specificity of 0.85 (0.64 to 0.95); insufficient evidence was available for other comparisons to invasive BP. Compared with the reference test of a correctly fitting upper arm cuff, BP measurement at the wrist had a sensitivity of 0.92 (0.64 to 0.99) and a specificity of 0.92 (0.85 to 0.87). Measurement with an incorrectly fitting standard cuff had a sensitivity of 0.73 (0.67 to 0.78) and a specificity of 0.76 (0.69 to 0.82). Measurement at the forearm had a sensitivity of 0.84 (0.71 to 0.92) and a specificity 0.75 of (0.66 to 0.83). Bland-Altman analysis of individual patient data from 3 studies comparing wrist and upper arm BP showed a mean difference of 0.46 mm Hg for systolic BP measurement and 2.2 mm Hg for diastolic BP measurement.



BP measurement with a correctly fitting upper arm cuff is sufficiently sensitive and specific to diagnose hypertension in patients with obesity with a large upper arm circumference. If a correctly fitting upper arm cuff cannot be applied, an incorrectly fitting standard size cuff should not be used and BP measurement at the wrist should be considered.
Department of Primary Care, Institute of Public Health and Primary Care, University of Cambridge, Cambridge, UK.
Greg
0000-0002-9471-3700
G
Irving
Department of Garswood Surgery, Garswood, UK.
John
J
Holden
Nuffield Department of Primary Care Health Sciences, NIHR School for Primary Care Research, University of Oxford, Oxford, UK.
Richard
0000-0002-9258-4060
R
Stevens
Nuffield Department of Primary Care Health Sciences, NIHR School for Primary Care Research, University of Oxford, Oxford, UK.
Richard J
0000-0003-3638-028X
RJ
McManus
D000328:Adult; D000368:Aged; D001132:Arm; D001794:Blood Pressure; D001795:Blood Pressure Determination / Q000379:methods*; D018660:Blood Pressure Monitoring, Ambulatory / Q000295:instrumentation / Q000379:methods*; D049628:Body Size; D006801:Humans; D006973:Hypertension / Q000150:complications / Q000175:diagnosis*; D008875:Middle Aged; D009765:Obesity / Q000150:complications*; D012680:Sensitivity and Specificity; D014953:Wrist
Obesity; PRIMARY CARE