- Email: [email protected]
Arm circumference influences blood pressure even when applying the correct cuff size: Is a further correction needed?
Arm circumference influences blood pressure even when applying the correct cuff size: Is a further correction needed? Jeremy P. Loenneke, Paul D. Loprinzi, Takashi Abe, Robert S. Thiebaud, Kirsten M. Allen, J. Grant Mouser, Michael G. Bemben PII: DOI: Reference:
S0167-5273(15)30573-8 doi: 10.1016/j.ijcard.2015.10.009 IJCA 21299
To appear in:
International Journal of Cardiology
Received date: Revised date: Accepted date:
24 August 2015 23 September 2015 3 October 2015
Please cite this article as: Loenneke Jeremy P., Loprinzi Paul D., Abe Takashi, Thiebaud Robert S., Allen Kirsten M., Grant Mouser J, Bemben Michael G., Arm circumference influences blood pressure even when applying the correct cuff size: Is a further correction needed?, International Journal of Cardiology (2015), doi: 10.1016/j.ijcard.2015.10.009
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1
Arm Circumference Influences Blood Pressure Even when Applying the Correct Cuff Size: Is a further correction needed?
PT
Jeremy P. Loenneke1, Paul D. Loprinzi2, Takashi Abe3, Robert S. Thiebaud4, Kirsten M. Allen5,
RI
J. Grant Mouser5, Michael G. Bemben5
1
SC
Department of Health, Exercise Science, and Recreation Management, Kevser Ermin Applied Physiology Laboratory, The University of Mississippi, University, MS. 2
NU
Department of Health, Exercise Science, and Recreation Management, Center for Health Behavior Research, The University of Mississippi, University, MS. National Institute of Fitness and Sports in Kanoya, Kanoya, Kagoshima, Japan
4
Department of Kinesiology, Texas Wesleyan University, Fort Worth, TX.
MA
3
5
AC CE P
TE
D
Department of Health and Exercise Science, Neuromuscular Research Laboratory, The University of Oklahoma, Norman, OK.
Word Count: 975
Corresponding Author: Jeremy Paul Loenneke, PhD P.O. Box 1848. University, MS 38677 Phone: (662) 915-5567 Fax: (662) 915-5525
Email: [email protected]
ACCEPTED MANUSCRIPT 2
It is well established that blood pressure cuff size plays an important role in accurate ascertainment of blood pressure [1], which is of paramount importance because blood pressure is
PT
a critical determinant of cardiovascular function and disease risk [2]. We provide evidence
RI
demonstrating that arm circumference, even when applying the correct cuff size, may still
NU
be considered based on the following observations.
SC
influence blood pressure. Our opinion is that further correction factors for arm size may need to
It should be noted that our main interest lies not in the measure of blood pressure per se, but with
MA
the methodology of applying partial blood flow restriction (BFR) during low intensity exercise. Briefly, the application of BFR with low load (20-30% one repetition maximum 1RM))
TE
D
resistance training has been repeatedly demonstrated to produce increases in muscle size and strength similar to that of traditional resistance training (70% 1RM) [3]. Our work has centered
AC CE P
on the idea of making this BFR stimulus relative to the individual and one way we do that is by applying the pressure relative to the size of the limb [4]. Our findings have repeatedly demonstrated that a bigger limb requires a greater pressure and this limb circumference measure has repeatedly shown to explain as much of the variance in arterial occlusion as the body composition of the limb to which the stimulus is being applied [5, 6]. In doing these methodological studies for BFR, we routinely took brachial systolic blood pressure (bSBP) in the supine position to see if this variable would help us better apply appropriate BFR pressures within our research. For these studies, the measurements were taken in the supine position, following 10 minutes of quiet rest and participants did not exercise prior to, consume caffeine within 8 hours of, or eat within 2 hours of any of the measurements. We have noted that arm size is the largest predictor of arterial occlusion in the upper and lower body, suggesting a larger
ACCEPTED MANUSCRIPT 3
limb requires a greater pressure [5]. As previously noted in the lower body, accounting for tissue composition of the limb did not explain more variance than limb circumference, though it was
PT
noted that muscle thickness appeared to explain more unique variance in arterial occlusion than
RI
fat thickness did [5].
SC
One observation that we repeatedly made, though did not report was that bSBP appeared to be
NU
higher in those with bigger arms, despite using the appropriate cuff size recommended by the manufacturer. In fact, although not shown in that study, we observed a direct correlation
MA
between bSBP and arm circumference (r=0.609). When considering that larger limbs required greater pressures, we wondered if this could also be observed within the same person. When
TE
D
looking at our previous study (Table 5 in Loenneke et al. [5]), it becomes quite clear that there are large differences between arterial occlusion in the arm (134 mmHg) and leg (245 mmHg)
AC CE P
when applying the pressure with the same sized cuff. This finding is important as it suggests that all other conditions being similar, a larger limb requires a greater pressure.
When first considering these observations, it seemed that these results would be quickly explained by differences in body composition. In other words, bigger individuals may be carrying more adipose tissue and perhaps that explains some of our relationship between bSBP and arm circumference. However, as previously noted, these relationships do not appear to be largely explained by limb composition. In fact, when the participants of the previous study were placed into quartiles based on arm circumference (Table 1), it became clear that arms with the greatest circumference were more muscular than those with the smallest circumference but did not appear to have more fat on their arm compared to those with smaller arms. Additionally,
ACCEPTED MANUSCRIPT 4
those with larger, more muscular arms, were more likely to be classified as pre-hypertensive or hypertensive compared to smaller arms, despite, again, using the appropriate cuff size for each
PT
participant. This is a finding that turned out to be in alignment with our analyses from nationally
RI
represented data (N=33,261) from the National Health and Nutrition Examination Survey (Table 2), which demonstrated that those with greater arm circumference had higher blood pressure,
SC
despite applying the appropriate cuff size; results were unchanged when controlling for various
NU
parameters, such as age and body mass index.
MA
Our observations, stemming from both experimental data (Table 1) and population-based data (Table 2), suggest that arm circumference may play an important role in blood pressure values,
TE
D
even when the appropriate cuff size is applied. Although we have focused on the potential for misclassification of those with larger more muscular arms, it stands to reason that this may work
AC CE P
in the opposite direction as well. In other words, those with smaller arms may be misclassified as normal despite having elevated blood pressure. It is acknowledged that a sphygmomanometer is an indirect estimate of blood pressure (i.e. not the direct method of an intra-arterial catheter), however, this is the standard method of blood pressure assessment in clinical practice. We do not intend to marginalize the risk of high blood pressure nor do we intend to convey an oversimplified view that limb circumference is the only driver of blood pressure. However, it is our opinion, at minimum, clinicians should consider their patient’s arm circumference size when interpreting their blood pressure values, despite using the appropriate cuff size as recommended by the manufacturer. Further, to most accurately measure blood pressure and the implications that it has on health, it is our belief that a further correction factor for arm size may be needed. We encourage future research to develop an appropriate correction factor and examine the extent
ACCEPTED MANUSCRIPT 5
to which this may or may not improve our interpretation of blood pressure measurement. Further, it is possible that the arm circumference ranges associated with each cuff may be too
AC CE P
TE
D
MA
NU
SC
RI
PT
large to accurately adjust for arm size and thus may need to be reconsidered.
ACCEPTED MANUSCRIPT 6
Acknowledgements: The authors are not aware of any affiliations, memberships, funding, or financial holdings that
PT
might be perceived as affecting the objectivity of this manuscript. This study was not supported
RI
by any funding.
SC
Author Contributions
NU
JPL conceived the study, acquired and interpreted the data, drafted manuscript, and performed statistical analysis. PDL interpreted the data, drafted manuscript, and performed statistical
MA
analysis. TA conceived the study, interpreted the data, drafted manuscript, and helped with statistical analysis. RST acquired and interpreted the data, critically reviewed the manuscript,
TE
D
and provided technical support. KMA acquired the data, critically reviewed the manuscript, and provided technical support. JGM acquired the data, critically reviewed the manuscript, and
AC CE P
provided technical support. MGB interpreted the data, critically reviewed the manuscript, provided supervision and internal funding.
ACCEPTED MANUSCRIPT 7
References
PT
[1] Recklinghausen V. Ueber Blutdruckmessung beim Menschen. Archiv fur experimentelle Pathologie und Pharmakologie. 1901;46:78-132.
RI
[2] Banach M, Bromfield S, Howard G, Howard VJ, Zanchetti A, Aronow WS, et al. Association of systolic blood pressure levels with cardiovascular events and all-cause mortality among older adults taking antihypertensive medication. Int J Cardiol. 2014;176:219-26.
SC
[3] Loenneke JP, Wilson JM, Marin PJ, Zourdos MC, Bemben MG. Low intensity blood flow restriction training: a meta-analysis. Eur J Appl Physiol. 2012;112:1849-59.
NU
[4] Loenneke JP, Fahs CA, Rossow LM, Thiebaud RS, Mattocks KT, Abe T, et al. Blood flow restriction pressure recommendations: a tale of two cuffs. Front Physiol. 2013;4:249.
MA
[5] Loenneke JP, Allen KM, Mouser JG, Thiebaud RS, Kim D, Abe T, et al. Blood flow restriction in the upper and lower limbs is predicted by limb circumference and systolic blood pressure. Eur J Appl Physiol. 2015;115:397-405.
AC CE P
TE
D
[6] Loenneke JP, Fahs CA, Rossow LM, Sherk VD, Thiebaud RS, Abe T, et al. Effects of cuff width on arterial occlusion: implications for blood flow restricted exercise. Eur J Appl Physiol. 2012;112:2903-12.
ACCEPTED MANUSCRIPT 8
Tables
28-31.9 59 5.9 (6.6)b 1.6 (0.6)a 21 (7)a 11 a
32-36.9 45 7.6 (1.3)c 1.2 (0.9)b 14 (11)b 28 b
SC
RI
24-27.9 48 4.9 (6.3)a 1.4 (0.4)ab 23 (6)a 6a
37-46 19 8.5 (1.9)d 1.8 (1.5)a 18 (14)ab 47 b
MA
NU
Arm Circumference (cm) Sample Size (n) Muscle Thickness (cm) Fat Thickness (cm) Relative Fat Thickness (%) % pre-hypertensive/hypertensive *defined as values ≥120/80.
PT
Table 1. Comparisons between arm circumference classifications. Data are presented as mean (standard deviation). Different letters for each variable across each arm circumference classification indicates statistical difference (p<0.05).
AC CE P
TE
D
Table 2. Association between arm circumference and blood pressure among adult Americans (N=33,261; weighted=195.8 million), 1999-2012 National Health and Nutrition Examination Survey. Arm Circumference Quintiles (cm) Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5 P-Trend † 16.8-28.7 28.8-31.3 31.4-33.7 33.8-36.7 36.8-62.4 Sample Size (n) 6816 6574 6611 6668 6592 Mean arm circumference 26.5 (0.02) 30.1 (0.01) 32.5 (0.01) 35.1 (0.01) 40.1 (0.04) Systolic Blood Pressure (mmHg) 119.3 (0.3) 120.9 (0.3) 122.4 (0.3) 123.9 (0.2) 124.8 (0.2) <0.001 Diastolic Blood Pressure (mmHg) 68.4 (0.2) 69.1 (0.2) 71.0 (0.2) 72.8 (0.2) 73.3 (0.2) <0.001 Mean Arterial Blood Pressure (mmHg) 85.4 (0.2) 86.3 (0.2) 88.1 (0.2) 89.8 (0.2) 90.5 (0.2) <0.001 % Hypertensive (≥140/90 mmHg) 16.0 (0.1) 15.3 (0.1) 15.7 (0.1) 17.6 (0.1) 19.7 (0.1) <0.001 † The medians for blood pressure (systolic, diastolic, and mean arterial pressure) of the quintiles were fit as continuous variables to estimate the trend across quintiles in a linear regression model. For the categorical variable, % hypertensive, a design-based likelihood ratio test was used to determine whether a statistically significant difference occurred between % hypertensive and quintiles of arm circumference. Mean arterial blood pressure was calculated using the following formula: ([diastolic blood pressure x 2) + systolic blood pressure]/3).
S0167-5273(15)30573-8 doi: 10.1016/j.ijcard.2015.10.009 IJCA 21299
To appear in:
International Journal of Cardiology
Received date: Revised date: Accepted date:
24 August 2015 23 September 2015 3 October 2015
Please cite this article as: Loenneke Jeremy P., Loprinzi Paul D., Abe Takashi, Thiebaud Robert S., Allen Kirsten M., Grant Mouser J, Bemben Michael G., Arm circumference influences blood pressure even when applying the correct cuff size: Is a further correction needed?, International Journal of Cardiology (2015), doi: 10.1016/j.ijcard.2015.10.009
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1
Arm Circumference Influences Blood Pressure Even when Applying the Correct Cuff Size: Is a further correction needed?
PT
Jeremy P. Loenneke1, Paul D. Loprinzi2, Takashi Abe3, Robert S. Thiebaud4, Kirsten M. Allen5,
RI
J. Grant Mouser5, Michael G. Bemben5
1
SC
Department of Health, Exercise Science, and Recreation Management, Kevser Ermin Applied Physiology Laboratory, The University of Mississippi, University, MS. 2
NU
Department of Health, Exercise Science, and Recreation Management, Center for Health Behavior Research, The University of Mississippi, University, MS. National Institute of Fitness and Sports in Kanoya, Kanoya, Kagoshima, Japan
4
Department of Kinesiology, Texas Wesleyan University, Fort Worth, TX.
MA
3
5
AC CE P
TE
D
Department of Health and Exercise Science, Neuromuscular Research Laboratory, The University of Oklahoma, Norman, OK.
Word Count: 975
Corresponding Author: Jeremy Paul Loenneke, PhD P.O. Box 1848. University, MS 38677 Phone: (662) 915-5567 Fax: (662) 915-5525
Email: [email protected]
ACCEPTED MANUSCRIPT 2
It is well established that blood pressure cuff size plays an important role in accurate ascertainment of blood pressure [1], which is of paramount importance because blood pressure is
PT
a critical determinant of cardiovascular function and disease risk [2]. We provide evidence
RI
demonstrating that arm circumference, even when applying the correct cuff size, may still
NU
be considered based on the following observations.
SC
influence blood pressure. Our opinion is that further correction factors for arm size may need to
It should be noted that our main interest lies not in the measure of blood pressure per se, but with
MA
the methodology of applying partial blood flow restriction (BFR) during low intensity exercise. Briefly, the application of BFR with low load (20-30% one repetition maximum 1RM))
TE
D
resistance training has been repeatedly demonstrated to produce increases in muscle size and strength similar to that of traditional resistance training (70% 1RM) [3]. Our work has centered
AC CE P
on the idea of making this BFR stimulus relative to the individual and one way we do that is by applying the pressure relative to the size of the limb [4]. Our findings have repeatedly demonstrated that a bigger limb requires a greater pressure and this limb circumference measure has repeatedly shown to explain as much of the variance in arterial occlusion as the body composition of the limb to which the stimulus is being applied [5, 6]. In doing these methodological studies for BFR, we routinely took brachial systolic blood pressure (bSBP) in the supine position to see if this variable would help us better apply appropriate BFR pressures within our research. For these studies, the measurements were taken in the supine position, following 10 minutes of quiet rest and participants did not exercise prior to, consume caffeine within 8 hours of, or eat within 2 hours of any of the measurements. We have noted that arm size is the largest predictor of arterial occlusion in the upper and lower body, suggesting a larger
ACCEPTED MANUSCRIPT 3
limb requires a greater pressure [5]. As previously noted in the lower body, accounting for tissue composition of the limb did not explain more variance than limb circumference, though it was
PT
noted that muscle thickness appeared to explain more unique variance in arterial occlusion than
RI
fat thickness did [5].
SC
One observation that we repeatedly made, though did not report was that bSBP appeared to be
NU
higher in those with bigger arms, despite using the appropriate cuff size recommended by the manufacturer. In fact, although not shown in that study, we observed a direct correlation
MA
between bSBP and arm circumference (r=0.609). When considering that larger limbs required greater pressures, we wondered if this could also be observed within the same person. When
TE
D
looking at our previous study (Table 5 in Loenneke et al. [5]), it becomes quite clear that there are large differences between arterial occlusion in the arm (134 mmHg) and leg (245 mmHg)
AC CE P
when applying the pressure with the same sized cuff. This finding is important as it suggests that all other conditions being similar, a larger limb requires a greater pressure.
When first considering these observations, it seemed that these results would be quickly explained by differences in body composition. In other words, bigger individuals may be carrying more adipose tissue and perhaps that explains some of our relationship between bSBP and arm circumference. However, as previously noted, these relationships do not appear to be largely explained by limb composition. In fact, when the participants of the previous study were placed into quartiles based on arm circumference (Table 1), it became clear that arms with the greatest circumference were more muscular than those with the smallest circumference but did not appear to have more fat on their arm compared to those with smaller arms. Additionally,
ACCEPTED MANUSCRIPT 4
those with larger, more muscular arms, were more likely to be classified as pre-hypertensive or hypertensive compared to smaller arms, despite, again, using the appropriate cuff size for each
PT
participant. This is a finding that turned out to be in alignment with our analyses from nationally
RI
represented data (N=33,261) from the National Health and Nutrition Examination Survey (Table 2), which demonstrated that those with greater arm circumference had higher blood pressure,
SC
despite applying the appropriate cuff size; results were unchanged when controlling for various
NU
parameters, such as age and body mass index.
MA
Our observations, stemming from both experimental data (Table 1) and population-based data (Table 2), suggest that arm circumference may play an important role in blood pressure values,
TE
D
even when the appropriate cuff size is applied. Although we have focused on the potential for misclassification of those with larger more muscular arms, it stands to reason that this may work
AC CE P
in the opposite direction as well. In other words, those with smaller arms may be misclassified as normal despite having elevated blood pressure. It is acknowledged that a sphygmomanometer is an indirect estimate of blood pressure (i.e. not the direct method of an intra-arterial catheter), however, this is the standard method of blood pressure assessment in clinical practice. We do not intend to marginalize the risk of high blood pressure nor do we intend to convey an oversimplified view that limb circumference is the only driver of blood pressure. However, it is our opinion, at minimum, clinicians should consider their patient’s arm circumference size when interpreting their blood pressure values, despite using the appropriate cuff size as recommended by the manufacturer. Further, to most accurately measure blood pressure and the implications that it has on health, it is our belief that a further correction factor for arm size may be needed. We encourage future research to develop an appropriate correction factor and examine the extent
ACCEPTED MANUSCRIPT 5
to which this may or may not improve our interpretation of blood pressure measurement. Further, it is possible that the arm circumference ranges associated with each cuff may be too
AC CE P
TE
D
MA
NU
SC
RI
PT
large to accurately adjust for arm size and thus may need to be reconsidered.
ACCEPTED MANUSCRIPT 6
Acknowledgements: The authors are not aware of any affiliations, memberships, funding, or financial holdings that
PT
might be perceived as affecting the objectivity of this manuscript. This study was not supported
RI
by any funding.
SC
Author Contributions
NU
JPL conceived the study, acquired and interpreted the data, drafted manuscript, and performed statistical analysis. PDL interpreted the data, drafted manuscript, and performed statistical
MA
analysis. TA conceived the study, interpreted the data, drafted manuscript, and helped with statistical analysis. RST acquired and interpreted the data, critically reviewed the manuscript,
TE
D
and provided technical support. KMA acquired the data, critically reviewed the manuscript, and provided technical support. JGM acquired the data, critically reviewed the manuscript, and
AC CE P
provided technical support. MGB interpreted the data, critically reviewed the manuscript, provided supervision and internal funding.
ACCEPTED MANUSCRIPT 7
References
PT
[1] Recklinghausen V. Ueber Blutdruckmessung beim Menschen. Archiv fur experimentelle Pathologie und Pharmakologie. 1901;46:78-132.
RI
[2] Banach M, Bromfield S, Howard G, Howard VJ, Zanchetti A, Aronow WS, et al. Association of systolic blood pressure levels with cardiovascular events and all-cause mortality among older adults taking antihypertensive medication. Int J Cardiol. 2014;176:219-26.
SC
[3] Loenneke JP, Wilson JM, Marin PJ, Zourdos MC, Bemben MG. Low intensity blood flow restriction training: a meta-analysis. Eur J Appl Physiol. 2012;112:1849-59.
NU
[4] Loenneke JP, Fahs CA, Rossow LM, Thiebaud RS, Mattocks KT, Abe T, et al. Blood flow restriction pressure recommendations: a tale of two cuffs. Front Physiol. 2013;4:249.
MA
[5] Loenneke JP, Allen KM, Mouser JG, Thiebaud RS, Kim D, Abe T, et al. Blood flow restriction in the upper and lower limbs is predicted by limb circumference and systolic blood pressure. Eur J Appl Physiol. 2015;115:397-405.
AC CE P
TE
D
[6] Loenneke JP, Fahs CA, Rossow LM, Sherk VD, Thiebaud RS, Abe T, et al. Effects of cuff width on arterial occlusion: implications for blood flow restricted exercise. Eur J Appl Physiol. 2012;112:2903-12.
ACCEPTED MANUSCRIPT 8
Tables
28-31.9 59 5.9 (6.6)b 1.6 (0.6)a 21 (7)a 11 a
32-36.9 45 7.6 (1.3)c 1.2 (0.9)b 14 (11)b 28 b
SC
RI
24-27.9 48 4.9 (6.3)a 1.4 (0.4)ab 23 (6)a 6a
37-46 19 8.5 (1.9)d 1.8 (1.5)a 18 (14)ab 47 b
MA
NU
Arm Circumference (cm) Sample Size (n) Muscle Thickness (cm) Fat Thickness (cm) Relative Fat Thickness (%) % pre-hypertensive/hypertensive *defined as values ≥120/80.
PT
Table 1. Comparisons between arm circumference classifications. Data are presented as mean (standard deviation). Different letters for each variable across each arm circumference classification indicates statistical difference (p<0.05).
AC CE P
TE
D
Table 2. Association between arm circumference and blood pressure among adult Americans (N=33,261; weighted=195.8 million), 1999-2012 National Health and Nutrition Examination Survey. Arm Circumference Quintiles (cm) Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5 P-Trend † 16.8-28.7 28.8-31.3 31.4-33.7 33.8-36.7 36.8-62.4 Sample Size (n) 6816 6574 6611 6668 6592 Mean arm circumference 26.5 (0.02) 30.1 (0.01) 32.5 (0.01) 35.1 (0.01) 40.1 (0.04) Systolic Blood Pressure (mmHg) 119.3 (0.3) 120.9 (0.3) 122.4 (0.3) 123.9 (0.2) 124.8 (0.2) <0.001 Diastolic Blood Pressure (mmHg) 68.4 (0.2) 69.1 (0.2) 71.0 (0.2) 72.8 (0.2) 73.3 (0.2) <0.001 Mean Arterial Blood Pressure (mmHg) 85.4 (0.2) 86.3 (0.2) 88.1 (0.2) 89.8 (0.2) 90.5 (0.2) <0.001 % Hypertensive (≥140/90 mmHg) 16.0 (0.1) 15.3 (0.1) 15.7 (0.1) 17.6 (0.1) 19.7 (0.1) <0.001 † The medians for blood pressure (systolic, diastolic, and mean arterial pressure) of the quintiles were fit as continuous variables to estimate the trend across quintiles in a linear regression model. For the categorical variable, % hypertensive, a design-based likelihood ratio test was used to determine whether a statistically significant difference occurred between % hypertensive and quintiles of arm circumference. Mean arterial blood pressure was calculated using the following formula: ([diastolic blood pressure x 2) + systolic blood pressure]/3).