Journal of Human Hypertension (2001) 15, 573–575
 2001 Nature Publishing Group All rights reserved 0950-9240/01 $15.00
CASE REPORT
Hypertension is not a disease of the left
arm: a difficult diagnosis of hypertension
in Takayasu’s arteritis
MJ Banks, N Erb, P George, A Pace and GD Kitas
Department of Rheumatology, The Guest Hospital, Dudley, West Midlands, UK
Hypertension and its cause may be missed by failure to
measure blood pressure in both arms. We report a case
of Takayasu’s arteritis where diagnostic confusion
Keywords: Takayasu’s arteritis
Introduction
The British Hypertension Society has recently pub-
lished their latest guidelines on the management of
hypertension.1 In these, it is not clear whether blood
pressure should be measured in either or both arms
although the 1999 World Heath Organisation—Inter-
national Hypertension Society Guidelines do clearly
recommend the measurement of blood pressure in
both arms at the first visit.2 We describe the clinical
course of a patient to demonstrate that failure to
measure blood pressure in both arms may lead to
failure in diagnosing and managing hypertension
and its underlying cause.
Case report
A 56-year-old Caucasian lady, a long term smoker
of 20 cigarettes daily, presented to general medical
outpatients in 1998 with a 2-month history of acute
general debility, fatigue, mild weight loss, severe
headache, upper girdle myalgia, left arm pain and
acute left-sided hearing loss. Clinical examination
was unremarkable apart from high blood pressure
at 200/110 mm Hg. Erythrocyte sedimentation rate
(ESR) was raised at 75 mm/h and, in the absence of
other serological abnormalities, a diagnosis of Giant
Cell arteritis was made. Despite oral prednisolone
40 mg daily there was only partial resolution of her
constitutional symptoms and headaches, and con-
tinuing left-sided arm pain and hearing loss. ESR
remained between 30– 40 mm/h. Attempts to reduce
Correspondence: Dr MJ Banks MB MRCP, Department of Rheuma-
tology, The Guest Hospital, Dudley, DY1 4SE, West Midlands,
UK. E-mail: banksmj얀drsnet.co.uk
www.nature.com/jhh
arose because there was a failure to detect a difference
in blood pressure between the arms.
Journal of Human Hypertension (2001) 15, 573–575
her steroids resulted in clinical relapse, but further
investigation revealed, normal CT scan of the head,
normal temporal artery biopsy and persisting senso-
rineural hearing loss.
Her blood pressure was repeatedly elevated at
190–210/90–110 mm Hg and she was commenced
on atenolol 50 mg daily. This was stopped by her
general practitioner, who found her blood pressure
to be normal at 110/70 mm Hg, only to be restarted
in outpatients where her blood pressure was
recorded at 210/110 mm Hg.
She was referred to the Rheumatology Department
where her presenting history was confirmed but the
left arm pain was felt to have claudication character-
istics. Examination revealed diminished volume of
left upper limb pulses compared to the right, blood
pressure of 130/100 mm Hg in the left arm and
190/115 mm Hg in the right, loud left carotid and
subclavian bruits, a IVth heart sound and grade II
hypertensive retinopathy.
Review of the patient’s history revealed unex-
plained arthralgias, myalgias and a normochromic
normocytic anaemia with raised ESR since 1984
(aged 42). She had been complaining of ‘pain and
heaviness’ of the left arm since 1987. She had had
previous episodes of sensorineural hearing loss in
1988 and 1991 and in 1997 she had complained of
chest pain, which was felt to be typical angina.
Takayasu’s arteritis and hypertension were diag-
nosed. An arch aortogram (Figure 1) showed a nor-
mal aortic arch but tight stenosis of the proximal left
subclavian artery with involvement of the left com-
mon carotid. The aorta was patent and coronary
angiography was normal. Despite normal ECG and
chest X-ray, echocardiography showed concentric
left ventricular (LV) hypertrophy with preserved LV
 Hypertension is not a disease of the left arm
MJ Banks et al
574
Figure 1 Arch aortogram showing stenosis of left subclavian
artery (arrow).
systolic function. Hypertension was confirmed by
24 h blood ambulatory pressure monitoring on the
right arm.
The patient was treated with five courses of inter-
mittent IV pulsed methylprednisolone (10 mg/kg)
and cyclophosphamide (15 mg/kg), followed by
maintenance therapy with methotrexate 7.5 mg/
week and oral prednisolone (currently 10 mg daily).
This led to resolution of all constitutional symp-
toms, control of her ESR, improvement in hearing
but continuing, residual left arm claudication, for
which angioplasty was performed with good results.
Her hypertension is controlled on ramipril 5 mg
daily.
Discussion
Takayasu’s arteritis is a rare chronic inflammatory
disease, which normally affects the aorta and its
main branches, and less often, the pulmonary
arteries. In the early systemic phase, it can present
with slow-onset, non-specific constitutional symp-
toms, arthralgias, myalgias and anaemia, often lead-
ing to a great delay in diagnosis.3,4 In the late occlus-
ive phase, it usually presents with symptoms of
claudication (particularly upper limb), headaches,
paraesthesiae, visual disturbances, and more rarely,
angina, arthritis, inflammatory eye disease5,6 or sen-
sorineural hearing loss.7,8 Although these two
phases were thought to be distinct9 more recent ser-
ies suggest an overlap, with patients frequently
describing features of both4,10 as in this case. Presen-
tation of Takayasu’s arteritis is rare after the age of
40 years, but the need for an age criterion has been
debated by several authors.11,12 In the present case,
Journal of Human Hypertension
although a definite diagnosis was made at the age of
58, the patient had symptoms and signs suggestive
of Takayasu’s at least since the age of 42 and met
five of the six (three needed) American College of
Rheumatology Criteria for classification of Takaya-
su’s arteritis13 but only two of the five (three needed)
for Giant Cell arteritis.14
Hypertension is common in Takayasu’s arteritis15
and may be related to changes of vascular com-
pliance, renal vascular ischaemia with hypereninae-
mia or increased sensitivity of the carotid body.16,17
The diagnosis and treatment of hypertension in this
disease is imperative, as the commonest causes of
death are congestive heart failure, myocardial infarc-
tion and strokes,5,11 while retinopathy and severe
systemic hypertension are predictive of increased
mortality.18,19
We present this case to highlight the necessity to
measure blood pressure in both arms before a diag-
nosis of hypertension can be confidently excluded.
In retrospect, blood pressure measurements in the
right arm were correct whereas those in the left were
misleading resulting in inappropriate cessation of
therapy, which may have significant prognostic
sequelae. Although Takayasu’s arteritis is a rare
example, such a situation may be encountered more
commonly following trauma, damage to the brachial
artery following catheterisation or extensive athero-
sclerosis.
In the context of identifying other cardiovascular
risk factors it has been emphasised that ‘hyperten-
sion is not a disease of the left arm’. This has been
taken on board by the new BHS guidelines which
provide clear recommendations for primary and sec-
ondary prevention of cardiovascular disease.1 It may
be that the same dictum should be applied one step
earlier, by stating explicitly in the BHS recommen-
dations, as it is in the WHO guidelines, that blood
pressure should be measured in both arms.
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