Clinical research study
The Systolic Blood Pressure Difference Between Arms and Cardiovascular Disease in the Framingham Heart Study

https://doi.org/10.1016/j.amjmed.2013.10.027Get rights and content

Abstract

Background

An increased interarm systolic blood pressure difference is an easily determined physical examination finding. The relationship between interarm systolic blood pressure difference and risk of future cardiovascular disease is uncertain. We described the prevalence and risk factor correlates of interarm systolic blood pressure difference in the Framingham Heart Study (FHS) original and offspring cohorts and examined the association between interarm systolic blood pressure difference and incident cardiovascular disease and all-cause mortality.

Methods

An increased interarm systolic blood pressure difference was defined as ≥10 mm Hg using the average of initial and repeat blood pressure measurements obtained in both arms. Participants were followed through 2010 for incident cardiovascular disease events. Multivariable Cox proportional hazards regression analyses were performed to investigate the effect of interarm systolic blood pressure difference on incident cardiovascular disease.

Results

We examined 3390 (56.3% female) participants aged 40 years and older, free of cardiovascular disease at baseline, mean age of 61.1 years, who attended a FHS examination between 1991 and 1994 (original cohort) and from 1995 to 1998 (offspring cohort). The mean absolute interarm systolic blood pressure difference was 4.6 mm Hg (range 0-78). Increased interarm systolic blood pressure difference was present in 317 (9.4%) participants. The median follow-up time was 13.3 years, during which time 598 participants (17.6%) experienced a first cardiovascular event, including 83 (26.2%) participants with interarm systolic blood pressure difference ≥10 mm Hg. Compared with those with normal interarm systolic blood pressure difference, participants with an elevated interarm systolic blood pressure difference were older (63.0 years vs 60.9 years), had a greater prevalence of diabetes mellitus (13.3% vs 7.5%,), higher systolic blood pressure (136.3 mm Hg vs 129.3 mm Hg), and a higher total cholesterol level (212.1 mg/dL vs 206.5 mg/dL). Interarm systolic blood pressure difference was associated with a significantly increased hazard of incident cardiovascular events in the multivariable adjusted model (hazard ratio 1.38; 95% CI, 1.09-1.75). For each 1-SD-unit increase in absolute interarm systolic blood pressure difference, the hazard ratio for incident cardiovascular events was 1.07 (95% CI, 1.00-1.14) in the fully adjusted model. There was no such association with mortality (hazard ratio 1.02; 95% CI 0.76-1.38).

Conclusions

In this community-based cohort, an interarm systolic blood pressure difference is common and associated with a significant increased risk for future cardiovascular events, even when the absolute difference in arm systolic blood pressure is modest. These findings support research to expand clinical use of this simple measurement.

Section snippets

Study Participant Sample

Methods of recruitment have been described previously for participants from the original cohort and the offspring study cohort of the FHS.21, 22

From the original FHS cohort of 5209 that was recruited in 1948,23 1026 men and women attended an FHS examination between 1991 and 1994. There also were 3532 men and women from the offspring study cohort who attended the sixth offspring cycle examination from 1995 to 1998. Of the 4558 total original and offspring cohort participants, 494 were excluded

Results

Our final study sample included 3390 participants; mean age of 61.1 ± 11.3 years, 56.3% women, followed for an average of 13.3 years. The median ISBPD was 3 (interquartile range 2.6) mm Hg, and 317 (9.4%) participants had an ISBPD ≥10 mm Hg (Table 1). The distribution of systolic blood pressure difference between arms in the sample is shown in Figure 1. There were 3073, 246, and 71 participants with ISBPD of <10 mm Hg, 10 to <15 mm Hg and ≥15 mm Hg, respectively.

Overall, 598 participants

Discussion

In this large, prospective, community-based cohort of middle-age men and women free of cardiovascular disease, an increased ISBPD was found to be present in nearly 10% of individuals, and is associated with increased levels of traditional cardiovascular risk factors. Furthermore, an increased ISBPD is associated with an increased risk for incident cardiovascular events, independent of traditional cardiovascular risk factors. This association is consistent when ISBPD was examined as a binary and

Acknowledgements

The Framingham Heart Study is supported by the NHLBI Framingham Heart Study (contract N01-HC-25195). Analysis for this project was supported by the NHLBI Division of Intramural Research.

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    Funding: The Framingham Heart Study is supported by the National Heart, Lung and Blood Institute (NHLBI) Framingham Heart Study (contract N01-HC-25195). Analysis for this project was supported by the NHLBI Division of Intramural Research.

    Conflicts of Interest: JMM is a board member of Vascular Interventional Advances (VIVA) Physicians, a 501c3 nonprofit education and research organization; all other authors have no potential conflicts of interest to disclose.

    Authorship: All authors had access to the data; other author roles were as follows: IW, study design, literature search, data interpretation, writing; PG, study design, data analysis, writing; CJD, study design, data interpretation, editing; MRJ, study design, data interpretation, editing; JMM, study design, data interpretation, editing.

    1

    These authors contributed equally to the manuscript.

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