nature publishing group
See reviewer commentary page 1189
Blood Pressure Measurement Method and Inter-Arm
Differences: A Meta-Analysis
Willem J. Verberk1, Alfons G.H. Kessels2 and Theo Thien3
Background
Screening for inter-arm difference (IAD) of blood pressure (BP) at
each first visit is recommended by numerous guidelines whereas
it is unclear whether the method by which IAD is measured has
significant influence on the IAD value.
Methods
A systematic review is made of the studies reporting on double-
arm measurements and the association of IAD with procedure
characteristics (Medline/PubMed, Embase, and Cochrane Library).
Results
The mean absolute IAD was 5.4 ± 1.7 and 3.6 ± 1.2 mm Hg for systolic
and diastolic BP, respectively. Of all subjects 14% had a systolic IAD
≥10 mm Hg, 4% a systolic IAD ≥20 mm Hg, and 7% a diastolic IAD
≥10 mm Hg. The relative risk (RR) of obtaining a systolic IAD ≥10 and
20 mm Hg and a diastolic IAD ≥10 mm Hg is higher when measuring
sequentially instead of simultaneously (2.2 (95% CI: 1.4–3.6), P < 0.01;
4.8 (95% CI: 1.1–21.9), P < 0.05 and 2.5 (95% CI: 1.0–6.3) P < 0.05,
Measuring inter-arm differences (IADs) in blood pressure
(BP) is recommended by numerous guidelines to be per-
formed at each first visit.1–6 This is because significant IAD
in BP may indicate the presence of congenital heart disease,
peripheral vascular disease, unilateral neurological, muscu-
loskeletal abnormalities, or aortic dissection.7 However, even
when the IAD has seemingly no pathological background,
relevant IADs (i.e., ≥10 mm Hg) are still important to know, as
office measurements consequently performed at the arm with
the lowest BP can lead to a wrong diagnosis and undertreat-
ment of hypertension.8 In addition, to verify the effectiveness
of antihypertensive therapy it is of clinical importance that BP
is measured in the same arm on all sequential occasions.9
Despite the large-scale recommendation of performing double-
arm measurements the procedure is not clearly described in the
guidelines. The lack of a clear description about the preferred
method has led to a wide variation in IAD assessment and
1Microlife Corporation, Taipei, Taiwan; 2Department of Clinical Epidemiology
and Technology Assessment, University Hospital Maastricht, Maastricht,
The Netherlands; 3Radboud University Nijmegen, Medical Center,
Department of General Internal Medicine, Nijmegen, The Netherlands.
Correspondence: Willem J. Verberk (Willem.verberk@microlife.ch)
Received 21 October 2010; first decision 13 November 2010; accepted 11 June 2011.
© 2011 American Journal of Hypertension, Ltd.
AMERICAN JOURNAL OF HYPERTENSION | VOLUME 24 NUMBER 11 | 1201-1208 | November 2011 1201
original contributions
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respectively), when using a manual instead of an automated device
(2.1 (95% CI: 1.1–3.9), P < 0.05; 4.4 (95% CI: 1.8–10.8), P < 0.01 and
3.7 (95% CI: 1.6–8.6), P < 0.01, respectively) and when performing
only one BP measurement instead of multiple (2.0 (95% CI: 1.1–3.8),
P < 0.05; 4.3 (95% CI: 1.6–11.4), P < 0.01 and 4.4 (95% CI: 1.7–11.4),
P < 0.01, respectively).
Conclusion
Screening for IAD of BP is important but the measurement
methodology has a major influence on IAD results. To prevent
overestimation and observer bias IAD should be assessed
simultaneously at both arms, with one or two automatic devices and
multiple readings should be taken.
Keywords: automatic oscillometric device; blood pressure;
blood pressure measurement; double-arm measurements;
hypertension; inter-arm difference; simultaneous measurements
American Journal of Hypertension, advance online publication 21 July 2011;
doi:10.1038/ajh.2011.125
interpretation with undesirable consequences. For instance,
overestimation of the IAD could lead to unnecessary referral
to a specialist and cause an unnecessary burden for healthcare.
The present review therefore aimed at investigating the influ-
ence of methodology of BP measurement on the IAD value.
Methods
Identification of papers. For performing the present meta-
­analysis the Prisma guidelines were used as a reference.10 We
performed systematic searches for IADs in PUBMED, Medline,
EMBASE, and the Cochrane databases using the following
keywords: inter-arm measurements, double-arm measure-
ments, IAD, peripheral vascular disease, subclavian stenosis,
subclavian steal syndrome. Additional studies were found from
reference lists of identified articles and reviews. Two investiga-
tors (W.J.V. and T.T.) independently screened the full text of all
potentially relevant articles. In case of disagreement the article
was discussed to reach consensus.
Study selection. We included only those papers that fulfilled
the following criteria:
1. Papers that were published in either the English or Dutch
language.
original contributions
2. The procedure of assessing IAD was described in suffi-
cient detail.
3. Data of the average left and right BP values or the IAD
value or number of relevant IADs were provided.
Statistical analysis. Analyses were performed with meta-anal-
ysis random-effects meta-regression using aggregate-level data
(“metareg”) in Stata version 9.2 Texas. Results were pooled
weighted with inverse variances (direct pooling).11 Because
age, gender, and BP value of the right arm might influence the
difference in BP, these variables were also entered in the regres-
sion model to reduce heterogeneity. When standard deviations
were missing in the study, we imputed the highest standard
deviations from all studies. In case of “zero-counts” 0.5 was
added to the specific cell.12
There were two studies13,14 that performed both the simul-
taneous and the sequential method. When relevant for overall
comparison between the simultaneous and sequential method,
we used data from both methods. The Kolmogorov–Smirnov
test was performed to test whether distribution deviated from
normal and when this was the case log-transformation was
performed for analysis and the exponentiated coefficients were
interpreted as the relative risk (RR).
If studies performed inter-arm measurements in multiple
visits we used only the first visit. Heterogeneity was tested
using I2 statistics and I2 >0.5 was arbitrarily chosen as indicat-
ing notable heterogeneity.15
Results
Data selection
As shown in Figure 1 literature research identified 688
abstracts from which 46 papers were selected by two authors
(W.J.V. and T.T.). Of these 24 papers were excluded after care-
ful consideration. These papers, with reason for exclusion, are
provided in Supplementary Appendix S1 online.
Description of studies
The 22 cross-sectional studies that were selected for analysis
(Table 1) entailed 14,540 patients who had a median age of 56
(range 31–79) years, a median male % of 36 (range 0–48) and
covered a wide diverse population (hypertensive, normoten-
sive, elderly, diabetics, HIV patients, and pregnant women).
The heterogeneity test showed that the proportion variation
due to heterogeneity (I2) ranged from 0.81 to 0.96. BP meas-
urement was predominantly performed in a sitting posi-
tion but four studies reported supine position.16–19 BP was
measured with a standard mercury device,14,20–25 an aneroid
device,16 an automated oscillometric device8,9,13,14,17–19,26–32
and an automated auscultatory device.33 Of the automated
devices used in the included studies in all but 4 (refs. 17–
19,27) a validated device was used as listed on the websites of
www.dableducational.org and/or www.bhsoc.org indicating to
have passed one of the recognized protocols for validation of
BP devices.34–36 Most studies reported to have measured arm-
circumference for selecting the appropriate sized cuff and to
have waited for 5 min before starting BP measurement. To
1202 november 2011 | VOLUME 24 NUMBER 11 | AMERICAN JOURNAL OF HYPERTENSION
Inter-arm blood pressure differences
688 Citations identified in PubMed,
Medline, Cochrane and Embase
653 Excluded because abstract title and
abstract did not fulfil inclusion criteria
35 Full-text articles considered for
inclusion
11 Articles identified from references
46 Full-text articles considered for
inclusion
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24 Studies excluded because not
fulfilling inclusion criteria (appendix I)
22 Studies included in analysis
Figure 1 | Flow chart of article selection.
determine IAD measurements left and right arm BP measure-
ments were performed sequentially or simultaneously. When
performed simultaneously all studies but one24 used auto-
mated devices. On average BP was similar in the right and left
arm for systolic (136 ± 5 and 135 ± 5 mm Hg; P = 0.68) and
diastolic BP (78 ± 3 and 77 ± 3 mm Hg; P = 0.61), respectively.
IADs
Prevalences of subjects with a systolic IAD ≥10 and 20 mm Hg
were provided in 19 (refs. 8,9,13,16–20,23–33) (n = 14,047)
and 13 studies9,16,17,19–22,25,27,29,30,32,33 (n = 6,508), respectively.
Seventeen studies8,9,16,17,19–22,24,25,27–33 (n = 12,956) showed
the number of subjects with a diastolic IAD ≥10 mm Hg and
six studies9,17,20,27,32,33 (n = 4,447) a diastolic IAD ≥20 mm Hg.
Systolic IAD values (right–left BP values) were provided or
could be calculated in 11 studies9,14,17,21,25,28–33 (n = 8,109).
Diastolic IAD values in eight studies14,17,18,21,28,29,32,33
(n = 2,696). Absolute systolic and diastolic IADs were given in
seven studies9,18,19,22,26,27,29 (n = 5,528). Kolmogorov–Smirnov
analysis showed that the IAD prevalences were not normally
distributed
Methods of BP measurements
Tables 2 and 3 provide differences between groups separated
for measurement methods (simultaneous vs. sequential meas-
urements), device (manual vs. automatic) and the number
of readings (1 vs. 2 or more readings) used to determine
IAD prevalences (Table 2), average and absolute IAD val-
ues (Table 3). There were 12 studies8,9,13,14,17,18,24,26,28,29,31,32
(n = 8,853) in which simultaneous measurements and 12
studies13,14,16,19–23,25,27,30,33 (n = 6,001) in which sequential
measurements were performed, which means that in two stud-
ies13,14 both methods were assessed. In 14 studies an auto-
mated oscillometric device8,9,13,14,17–19,26–32 (n = 12,644) was
used for IAD determination, in seven studies9,17,20,27,32,33
(n = 2,063) a manual sphygmomanometer (aneroid or mer-
cury) and in one study an automated auscultatory device.33
There were seven studies in which only one measurement
Inter-arm blood pressure differences original contributions

Table 1 | Studies to inter-arm differences of blood pressure

Age Men Readings n (%) ≥10 mm Hg n (%) ≥20 mm Hg IAD (R–L) (mm Hg)
Reference Population n (years) (%) (n) Device Method Systolic Diastolic Systolic Diastolic Systolic Diastolic
16 NT (29%) 447 48 ± 15 59 1a Aneroid Seqa 119 (26.6)a 67 (15.0)a 32 (7.2)a −2.3 ± 12a −0.8 ± 7a
HT (71%) 3b Sim, (5.3)b,c (4.0)b,c (0.1)b,c 0.5 ± 5b −1.3 ± 5b
2 observersb
20 NT (32%) 174 (24–70) 56 3 MS Seq 84 (48) 48 (28) 23 (13) 11 (6)
HT (68%)
20 NT (100%) 23 (18–89) 30 1 MS Seq 14 (61) 10 (43) 6 (26) 2 (9)
33 Elderly 174 76 ± 9 16 6 AAD Seq 2 (1.4) 0 2 (1) 0 0.93 ± 4.0 0.72 ± 2.8

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26 HP 40 74 35 8 AOD Sim 4 (10) 4.2 (3.1–3.5) (A) 3.6 (2.8–4.4) (A)
26 HP 40 31 20 8 AOD Sim 1 (3) 3.3 (2.6–4.1) (A) 2.7 (2.0–3.3) (A)
17 HP (–CVD) 364 49 57 4 AOD Sim 19 (5.2) 23 (6.3) 0 (0) 1 (0.3) 1.1 ± 4.9 0 ± 5.1
(0.6–1.6) (–0.5 to 0.5)
21 GP 237 >16 years — 1 MS Seq 95 (40) 55 (23) 4.8 (3–6.5) 3.7 (2.4–5)
(routine)
22 HP 280 60 — 1 MS Seq 65 (23.2) 38 (13.6) — —
9 HP + staff 400 56 ± 20 50 2 AOD Sim 80 (20) 45 (11) 14 (3.5) 15 (3.8) 1.81 ± 8.6 –0.23 ± 8.3
6.32 ± 6.12 (A) 5.06 ± 6.57 (A)
23 HT 100 55 ± 10 33 1 MS Seq (blinded, 18 (18)
2 observers)
18 Gen pop 1,090 62 ± 11 36 1 AOD Sim 99 (9.1) –0.6 ± 6.6 1.1 ± 4.7
1 device 4.9 ± 4.4 (A) 3.7 ± 3.0 (A)
24 Elderly 528 79 ±10 32 2 MS Sim 70 (14) 28 (5) — —
2 observers
27 Volunteers 854 56 49 3 AOD Seq 79 (9.2) 14 (1.6) 9 (1.1) 1 (0.1) 4.61 ± 4.10 (A) 2.96 ± 2.51(A)
27 HT Siblings 2,395 56 39 3 AOD Seq (14.2) (2.8) (1.8) (0.1) 5.35 ± 4.98 (A) 3.09 ± 2.73 (A)
28 HP + staff 384 54 ± 18 49 4 AOD Sim 13 (3.4) 4 (1.4) 1.2 ± 5.0 0.4 ±4.2
29 HT 94 70 ± 10 40 4 AOD Sim 18 (19) 7 (7) 3.1± 7.0 1.6 ± 5.6
5.9 ± 4.9 (A) 4.6 ± 3.6 (A)
25 HT 247 69 45 2 MS Seq 57 (23) 15 (6) 8 (3) 1.6 (0.4–2.9) –1.4 (0.8–2.0)
14 HT ® 145 58 ± 16 48 3b aAOD aSim (1&3) 1.5 ± 3.3 (1&3) 0.9 ± 2.5 (1&3)
(2 devices)
bMS bSeq (2) 3.1 ± 6.4 (2) 1.4 ± 3.8 (2)
13 DM ® 169 67 ± 10 50 1A AOD SeqA 55 (33) — —
1B 2 devices SimB 27 (16)
2C Sim C 16 (9)
30 HP ± CKD® 421 63 ± 13 95 3 AOD Seq 158 (38) 60 (15) 40 (10) 5.1
Seq 83 (20) 29 (7) 12 (4) 2.9
(+ 1 week)
19 HIV ♀ (+) 335 — 0 2 AOD Seq 87 (26) 50 (15) 20 (6) 6 ± 5 (A) 4 ± 3 (A)
controls (–) 238+
97–
31 Pregnant 5,435 32 0 2–6a AOD Sim 450 (8.3) 124 (2.3) 0.8 –0.6
(HT + NT) (–10.3 to 11.9) (–8.3 to 7.0)
32 HP 63 61 ± 13 54 3 AOD Sim 0 0 0 0 0.04 ± 5.1 0.4 ± 3.2
1 device
8 DM 101 66 ± 13 59 4 AOD Sim 10 (10) 3 (3) — —
Data provide average ± s.d. of all readings.
!, average of both populations together; (A), absolute difference; (R–L), blood pressure values of the right arm—blood pressure values of the left arm; ®, reproducibility study; AAD,
automatic ausculatory device; AOD, automatic oscillometric device; CAD, coronary artery disease; CKD, chronic kidney disease; CVD, cardiovascular disease; D, diastolic blood pressure;
dia, diastolic; DM, diabetes mellitus; Gen pop, general population; GP, general practitioner; HP indicates hospital referred patients; HT, hypertensives; IAD, inter-arm difference; MS, manual
sphygmomanometer; n(%) Δ, number and percentage of patients with an inter-arm difference greater than or similar to 10 or 20 mm Hg; n, number; NT, normotensives; PVD, peripheral
vascular disease; Ran, randomized; S, systolic blood pressure; seq, sequential measurements; Sim, simultaneous measurements, Sup, supine position; sys, systolic; X-linked, crosslinked.
aPatients were measured until variations between consecutive readings fell within 10mm Hg in systolic pressure and 6 mm Hg in diastolic pressure. bOnly the first method is used for the

present analysis, this study compared different methods and investigated reproducibility; c, measurements not patients.

AMERICAN JOURNAL OF HYPERTENSION | VOLUME 24 NUMBER 11 | november 2011 1203

original contributions Inter-arm blood pressure differences

Table 2 | Differences in prevalences inter-arm difference (IAD) between groups divided by measurements, device and number of
readings
Overall mean Measurements Device Readings
Prevalences (%) (95% CI) RR: Seq/Sim P RR: Man/Auto P RR: 1/≥2 P
Systolic
IAD ≥10 mm Hg (%) 13.6 (10.1–18.4) 2.2 (1.4–3.6) <0.01 2.1 (1.1–3.9) <0.05 2.0 (1.1–3.8) <0.05
IAD ≥20 mm Hg (%) 4.2 (2.4–7.5) 4.8 (1.1–21.9) <0.05 4.4 (1.8–10.8) <0.01 4.3 (1.6–11.4) <0.01
Diastolic (mm Hg)
IAD ≥10 mm Hg (%) 6.5 (3.8–11.2) 2.5 (1.0–6.3) <0.05 3.7 (1.6–8.6) <0.01 4.4 (1.7–11.4) <0.01
IAD ≥20 mm Hg (%) 0.7 (0.2–2.4) 0.4 (0–18.4) 0.64 17.4 (0.2–1,445.1) 0.21 — —

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All values are provided as RR and 95% confidence intervals (CIs).
1/≥2 readings, 1 reading divided by 2 or more readings; Man/Auto, manual divided by automatic; Seq/Sim, relative risk (RR) values were calculated by dividing the IAD prevalences
obtained from sequential by those from simultaneous measurements.

Table 3 | Differences in average and absolute inter-arm difference (IAD) values between groups divided by measurements, device and
number of readings
Overall Measurements Device Readings
average Seq–Sim P Man–Auto P 1–≥2 P
Systolic
IAD absolute 5.4 ± 1.7 0.8 ± 3.4 0.81 4.0 ± 6.4 0.55 1.2 ± 4.1 0.78
(mm Hg)
IAD (mm Hg) 0.57 ± 1.9 0.5 ± 3.2 0.87 0.4 ± 6.0 0.94 0.6 ± 4.9 0.91
Diastolic (mm Hg)
IAD absolute 3.6 ± 1.2 –0.6 ± 2.5 0.81 1.2 ± 6.7 0.86 0.4 ± 3.0 0.91
(mm Hg)
IAD (mm Hg) 0.5 ± 1.3 0.6 ± 2.3 0.79 −0.7 ± 3.8 0.86 0.1 ± 3.3 0.98
All values are provided as mean ± s.e.m.
1–≥2 readings, differences between studies that performed 1 and 2 or more readings to determine IAD. Man–Auto, differences between a manual and automatic device; Seq–Sim
indicates differences between average and absolute IAD values obtained with sequential and simultaneous measurements.

was performed13,16,18,20–23 (n = 2,515) to determine IAD and
16 studies8,9,14,17,19,20,24–33 (n = 12,339) provided two or more
measurements. One study was divided in subpopulations
which were measured one and three times.20
As shown in Table 2 the method of IAD performance had a
significant influence on systolic (IAD ≥10 and 20 mm Hg) and
diastolic (IAD ≥10) prevalence: sequential measurements led
to a significant higher prevalence than simultaneous meas-
urements (RR ranges from 2.2 to 4.8), the use of a manual BP
device led to a significant higher prevalence than when using
an automated device (RR ranges from 2.1 to 4.4).
However, there was a strong relationship between devices
and measurement methods: all, except one, ­simultaneous
measurements were performed with automated devices
(Figure 2). For this reason, we performed a post hoc multi-
variate analysis using both method (simultaneous or sub-
sequent) and devices (automated or manual) as covariates.
Results for systolic IAD prevalence showed that the method
(RR 1.9 (95% CI: 1.2–3.2), P < 0.05) but not the device (RR 1.5
(95% CI: 0.9–2.7), P = 0.13) had a significant influence on the
prevalence.
With regard to the number of readings it was shown that
one reading resulted in a significant higher prevalence than
when two or more readings were performed (RR ranges from
2.0 to 4.4). For average and absolute IAD values there were no
s­ ignificant differences (Table 3).
There was a significant (P < 0.01) and negative correlation
of the systolic IAD ≥10 mm Hg and the number of readings
(Figure 3).
Overall, the method (simultaneous or sequential), the
device, and the number of measurements had no significant
effect on mean and mean absolute IADs.
Patient characteristics
There was no correlation with systolic mean absolute and
mean IAD and BP values, age, and gender or for diastolic IADs
and IAD prevalences (data not shown).
Discussion
The findings in the present paper showed that the average
mean absolute IAD is 5.4 and 3.6 mm Hg for systolic and
diastolic BP, respectively and 14% of all subjects had a systo-
lic IAD of 10 mm Hg or more. The number of subjects with
a systolic and diastolic IAD ≥10 mm Hg and systolic IAD
≥20 mm Hg was significantly lower when BP was measured
with an automatic instead of a manual device, when meas-
urements were performed simultaneously instead of sequen-
tially and with two or more measurements than with only one

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Inter-arm blood pressure differences original contributions

Reference Device Method ES (95% Cl)

Stergiou, 2008 32 Auto Simultaneous 0.01 (−0.01, 0.03)

Orme, 1999 17 Auto Simultaneous 0.05 (0.03, 0.08)

Kimura, 2004 18 Auto Simultaneous 0.09 (0.07, 0.11)

Fotherby, 1993 26 Auto Simultaneous 0.10 (0.01, 0.19)

9
Lane, 2002 Auto Simultaneous 0.20 (0.16, 0.24)

Clark, 2009 8 Auto Simultaneous 0.10 (0.04, 0.16)

Kleefstra, 2007 13 Auto Simultaneous 0.16 (0.10, 0.22)

Clark, 2007 29

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Auto Simultaneous 0.19 (0.11, 0.27)

Fotherby, 1993 26 Auto Simultaneous 0.03 (−0.02, 0.07)

Poon, 2008 31 Auto Simultaneous 0.08 (0.08, 0.09)

Karagiannis, 2005 28 Auto Simultaneous 0.03 (0.02, 0.05)

Mendelson, 2004 24 Manual Simultaneous 0.13 (0.10, 0.16)

Hashimoto, 1984 33 Auto Subsequent 0.01 (−0.00, 0.03)

Lazar, 2008 19 Auto Subsequent 0.26 (0.21, 0.31)

13
Kleefstra, 2007 Auto Subsequent 0.33 (0.25, 0.40)

Arnett, 2005 27 Auto Subsequent 0.09 (0.07, 0.11)

Arnett, 2005 27 Auto Subsequent 0.14 (0.13, 0.16)

Agarwal, 2008 30 Auto Subsequent 0.38 (0.33, 0.42)

Kristensen, 1982 20 Manual Subsequent 0.50 (0.43, 0.57)

Pesola, 2002 23 Manual Subsequent 0.18 (0.10, 0.26)

Harrison, 1960 16 Manual Subsequent 0.27 (0.23, 0.31)

29
Clark, 2007 Manual Subsequent 0.23 (0.18, 0.28)

0
Prevalence systolic IAD > 10 mm Hg

Figure 2 | Forest plot of the prevalences of subjects with a systolic inter-arm difference (IAD) of ≥10 mm Hg. The studies are grouped by device (automated or
manual) and measurement method (simultaneous or subsequent).

70
Systolic IAD ≥10 mm Hg significant differences shown when groups were separated
according to different methods. There were no significant dif-
60
ferences between BP values on the right and left arm.
50
Prevalence (%)

40
Strength and weakness of the paper
30 r 2 = 0.11; P < 0.01 This study should be interpreted within the context of its limi-
20 tations. Studies showed a substantial heterogeneity, there was a
10 wide disparity among several methods and subjects and it was
0 not always clear how the patient population had to be inter-
0 2 4 6 8
preted and what the main reason was (method, population
Readings (n)
device) for finding differences in value and prevalence of IAD.
Figure 3 | The prevalence of subjects with a systolic inter-arm difference (IAD) For this reason it might be questioned whether these studies
of ≥10 mm Hg related to the number of readings, r2 values are calculated with should be pooled for analysis at all. However, the authors are
log transformation. of the opinion that despite the large heterogeneity the pooled
analysis is a useful method as this heterogeneity is mainly
r­ eading. In ­addition, there was a significant trend toward a related to the different measurement procedures used (device,
lower prevalence of systolic IAD ≥10 with each extra measure- method, readings) and thus reflects clinical practice. Seen
ment. Because in all except one study simultaneous measure- within the limitations, the analysis therefore provides use-
ments were performed with automated devices, it appeared ful clinical information. In some papers standard deviations
that the method but not the device had a significant influ- or variances were not provided so that the highest standard
ence on outcome. For mean and absolute IADs there were no deviations from all studies was imputed. Studies that reported

AMERICAN JOURNAL OF HYPERTENSION | VOLUME 24 NUMBER 11 | november 2011 1205

original contributions
more pairs of readings are more likely to have used automated
rather than manual methods. The same studies are likely to
have contributed to each relevant section of the results. These
items cause a limit to the conclusions that can be drawn inde-
pendently about each facet of the measurement technique. On
the other hand the use of automated devices seems strongly
related to simultaneous measurements as automated devices
facilitate the simultaneous measurements, whereas simulta-
neous measurements with manual devices are very difficult
to accomplish in clinical practice. In addition, two observers
are less likely to perform measurements simultaneously than
when one automated device with two cuffs or two automated
devices are used.
Papers published before the year 1960 were excluded from
the present review. Although this line is arbitrary it may be
justified by the following arguments. First, although the mer-
cury sphygmomanometer could be of sufficient quality in the
early years stethoscopes were of lesser quality and a poor qual-
ity stethoscope has a major influence on accuracy.37 Second,
most of the studies from before 1960 lack a detailed method
description which makes it complicated or impossible to
know how to interpret the values. Third, at that time the 4th
Korotkoff sound was commonly used to determine the diasto-
lic BP value. Fourth, as can be seen from the review of Clark et
al. many studies from before 1960 show very high prevalences
of patients with relevant IADs; these values seem not compa-
rable with the values from younger papers and imply that this
is the result of methods or patient selection.38 Several large-
scale studies have been published that were excluded for the
present paper because of the methods that were used.39–41
Although these papers contain interesting information, for
the present review we chose only to compare those studies in
which double-arm measurements were performed with regu-
lar BP monitors. Although, Doppler devices are commonly
used to measure systolic upper-arm pressure when assessing
ankle brachial index it is not recognized as routine tool to per-
form upper-arm BP measurements.
There were significant differences for prevalences (IAD ≥10
or 20 mm Hg) but not for mean and absolute mean IAD val-
ues. This, is most likely, related to the cutoff values; in other
words: although the value is not significantly higher there is a
greater chance that it is above the threshold value. Finally, in
the present study we could not find a relationship with aver-
age IAD values and IAD prevalences (IAD ≥10 or 20 mm Hg)
and patient characteristics such as age, gender, and BP values.
However, this does not mean that there is not such a relation-
ship but the possibilities for analyzing were limited by the lack
of access to full data.
Sequential and simultaneous measurements
In the present analysis, simultaneous measurements resulted
in much fewer patients with a systolic IAD ≥10 mm Hg as
compared to sequential measurements. This finding was in
agreement with the finding of others who compared both
methods.13,14 A reason for the higher IAD with sequential
measurements could be related to a cuff-response or white-
1206 november 2011 | VOLUME 24 NUMBER 11 | AMERICAN JOURNAL OF HYPERTENSION
Inter-arm blood pressure differences
coat effect which causes the first measurement to be higher
than the next.27,42,43 In addition, BP is a variable hemody-
namic phenomenon that constantly fluctuates over time, mak-
ing sequential measurements difficult to compare.
In order to exclude the possibility of erroneous IAD
determination due to sequential performance some inves-
tigators have performed simultaneous double-arm meas-
urements with two observers44,45 or with two automatic
monitors.8,9,13,14,17,26,28,29,31,46 Although the latter seems a
good idea a minor bias can still be introduced due to a delay
between readings and inter-device differences even when
devices are from the same brand.9 Changing the devices
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halfway through the performance might reduce the influ-
ence of the inter-device difference8,9,17,26,28,29 but compli-
cates the measurement procedure. For this reason, automatic
devices with two identical cuffs may give the opportunity
of performing the most accurate simultaneous double-arm
measurements. Momentarily, automatic oscillometric double-
cuff devices have been developed (e.g., Microlife WatchBP
Office32) for diagnosis in regular healthcare and thus elimi-
nate the practical concern that a device with the possibility to
perform simultaneous measurements could not be widely dis-
tributed among clinics or general practitioner practices.47
Device
Data from the present paper showed a significant lower preva-
lence of relevant IADs (≥10 mm Hg) between studies that used
an automatic instead of a manual device. This might be due
to observer bias related to the latter and digit preference that
could increase the BP difference between the arms.1 In addi-
tion, most studies that used a manual device also measured
both arms sequentially instead of simultaneously, which lead to
a higher number of relevant IADs. However, it is unlikely that
this is the only cause of the significant higher IAD ≥10 mm Hg
prevalence obtained with a manual device because sequential
measurements could also lead to a smaller difference in IAD as
the second measurement is taken with knowledge of the first.
Multiple measurements
The present paper showed a significant trend toward fewer sub-
jects with a relevant IAD when more readings were performed.
This finding is underscored by the study of Arnett et al. who
showed that increasing the number of BP measurements
from one to three resulted in a decrease in the mean absolute
systolic IAD (from 6.3 to 4.6 mm Hg) and a 30% reduction in
variance in the difference between the right arm and the left
arm.27 From other studies it is known that the reproducibility
increases with more BP readings.48 From studies that investi-
gated the reproducibility of IAD13,14,30 only one study showed
that IADs are reproducible and carry prognostic formation.30
In that study three measurements were assessed to determine
the IAD value which might be the reason for the high repro-
ducibility. Eguchi et al. also used three measurements but their
opposite conclusion might be influenced by the low IAD of
≥5 mm Hg that was chosen as endpoint, which overall is not
considered a relevant IAD value.14
Inter-arm blood pressure differences
Clinical significance of inter-arm measurements
The present data show that 14% of the subjects had an IAD
of 10 mm Hg or more for systolic BP. This seems to justify the
recommendation in the guidelines and from many investiga-
tors9,17,18,21,24,26,28,30 to perform BP measurements on both
arms at each first visit. The importance of determining the
IAD is confirmed by the finding that the mean absolute IAD
was 5 and 4 mm Hg for systolic and diastolic BP, respectively.
Although an IAD of 5 mm Hg may not be clinically relevant
for an individual patient on a population basis this difference
has been associated with e.g., a 34% difference in stroke.49 In
addition, results from a health survey led to the estimation
that underestimation of systolic BP by >10 mm Hg could fail to
prevent >4,000 fatal and nonfatal coronary events and >6,000
fatal and nonfatal strokes each year in England.50
Studies that provided the relationship between IAD and car-
diovascular risk in the long-term22,25,30 showed that a systolic
and diastolic IAD ≥10 mm Hg and a systolic IAD ≥20 mm Hg
led to significant shorter event free survival time as com-
pared to those with lower systolic IAD values.22,25 In addition,
Agarwal et al. showed among patients with renal disease that
every 10 mm Hg difference in systolic BP between the arms
conferred a mortality hazard of 1.24 (95% CI: 1.01–1.52).30
Due to reasons as provided above it is alarming that IAD is
determined by only 23% of the physicians51 and that very few
general practitioners and hospital physicians follow “even the
most critical aspects of BP measurement guidelines.”52
Patient characteristics
The present paper did not see any relationship with IAD
value and/or prevalence and patient characteristics such as
age, gender, and BP. An overview from other studies that
investigated the relationship of IAD with certain patient
characteristics is provided in Supplementary Appendix S2
online. Overall, there is a wide heterogeneity among studies
with regard to most patient characteristics except for obesity
and ankle brachial index (seems related to IAD value) and
age, gender, handedness, and diabetes (seems not related to
IAD value).
Results of the present analysis showed that the mean abso-
lute IAD value is 5 and 4 mm Hg for systolic and diastolic BP
value and 14% of all subjects had a systolic IAD ≥10 mm Hg.
This together with the findings that the IAD value is related to
cardiovascular risk underscores the importance of performing
double-arm measurements at each first visit.
The method of how IAD screening is performed seems to
have a major influence (commonly overestimation) on the
value of IAD and should therefore be clearly described in the
guidelines. Results of the present study indicate that inter-arm
BP measurements should be determined by simultaneous BP
measurements with one automatic device with two cuffs or
two automated devices and a diagnosis of an IAD of 10 mm Hg
or more should be based on multiple readings.
Supplementary material is linked to the online version of the paper at http://
www.nature.com/ajh
AMERICAN JOURNAL OF HYPERTENSION | VOLUME 24 NUMBER 11 | november 2011 1207
original contributions
Disclosure: W.J.V. is an official employee of Microlife Corporation (Taipei,
Taiwan). A.G.H.K. and T.T. declared no conflict of interest.
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