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Written by Amanda Matthews
Spoon Feed
Blood pressure readings taken with a patient’s arm resting in their lap or on their side showed between a 4-7 mmHg increase in systolic blood pressure compared to taking a measurement with the patient’s arm supported on a desk at heart level.
ARMS up or down
We recently covered how a cuff too small for the patient could falsely elevate SBP by almost 20 points. This was a crossover randomized clinical trial that compared three different arm positions for the measurement of blood pressure: 1) arm supported on a desk with midcuff at the level of the heart (reference standard), 2) arm resting on patient’s lap, and 3) arm unsupported on patient’s side. Study participants were volunteers between the ages of 18-80, with 133 participants. In order to standardize conditions and try to replicate a clinical scenario, patients were asked to empty their bladder and walk for two minutes prior to sitting; similar to walking in for a clinic visit. They then sat with their backs supported for five minutes before blood pressure measurements. Primary outcomes were the differences in mean SBP and DBP between the “desk” blood pressure and the two arm positions (lap and side). Average blood pressure was 126/74 mm Hg for the desk position, 130/78 mm Hg for the lap position, and 133/78 mm Hg for the side position. Subgroup analysis found SBP was overestimated by approximately 9 mm Hg among individuals with hypertensive blood pressures when their arm was positioned at the side.
How will this change my practice?
I do not think this study will ultimately be practice-changing in the ED; however, it is important knowledge for clinicians to have. In this current time of ED crowding, it’s unrealistic to have a patient sit still and upright for five minutes with their back supported or to find a desk to rest their arm on for a blood pressure reading. Additionally, many of our patients are too sick to physically perform that task. We can certainly improve our use of the automated BP cuff in the ED. Every clinician has seen a cuff going off while a patient is getting an IV or waving their arm around to make a point. Knowing the discrepancies that exist with different arm positioning is helpful, and certainly if a reading is not making sense with the overall clinical picture I will take the time to try and reposition a patient for an accurate reading or obtain a manual BP.
Source
Arm Position and Blood Pressure Readings: The ARMS Crossover Randomized Clinical Trial. JAMA Intern Med. 2024 Oct 7:e245213. doi: 10.1001/jamainternmed.2024.5213. Epub ahead of print. PMID: 39373998
