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Measurement of blood pressure in the brachial and posterior tibial arteries using the Doppler method
498
Brie[ clinical and laboratory observations
5. Moorhead, P. S., Nowell, P. C., Mellman, W. J., Battips, D. M., and Hungerford, D. A.: Chromosome preparations of leukocytes cultured from human peripheral blood, Exp. Cell Res. 20: 613, 1960. 6. Morishima, A., Grumbach, M. M., and Taylor, J. H.: Asynchronous duplication of human chromosomes and the origin of sex chromatin, Proc. Natl. Acad. Sci. 48:1: 756, 1962. 7. O'Riordan, M. L., Robinson, J. A., Buckton, K. E., and Evans, H. J.: Distinguishing between the chromosomes involved in Down's syndrome (trisomy 21) and chronic myeloid leukemia (Ph') by fluorescence, Nature 230: 167, 1971. 8. Uchida, I. A., and Lin, C. C.: Fluorescent staining of human chromosomes: Identification of some common aberrations, Can. Med. Assoc. J. 105: 479, 1971. 9. Federman, D. D., Davidoff, F. M., and OueIlette, E.: Presumptive Y/D translocation
Measurement of blood pressure in the brachial and posterior tibial arteries using the Doppler method Alexis F. Hartmann, Jr., M.D.,* R. Klint, M.D., A. Hernandez, M.D., and D. Goldring, M.D., with the technical assistance of Charles Crawford, B.S., and Barbara Graham, St. Louis, Mo.
From the Edward Mallinckrodt Department o[ Pediatrics, Division o[ Cardiology, Washington University School o[ Medicine, and St. Louis Children's Hospital. Supported in part by the Arthur Fund, Scott Centsch Memorial Fund, William T. Beauchamp Memorial Fund, and the John Clay Seier Fund. "~Reprint address: St. Louis Children's Hospital, 500 S. Kingshlghway, St. Louis, Mo. 63110.
The Journal o[ Pediatrics March 1973
10. 11.
12.
13. 14. 15.
in mixed gonadal dysgenesis, J. Med. Genet. 4: 36, 1967. Noel, B., Emerit, I., Luciani, J. M., and Quack, B. A.: A familial Y/autosome translocation in man, Clin. Genet. 2: 1, 1971. Nakagome, Y., Smith, H. D., and Soukup, S. W.: A presumptive Y-autosome translocation in a boy with congenital malformations, Am. J. Dis. Child. 116: 205, 1968. Buhler, E. M., Muller, H., and Stalder, G.: A strongly fluorescing abnormal chromosome in a malformed child, Humangenetik 12: 64, 1971. Jacobs, P.: Structural abnormalities of the sex chromosomes, Br. Med. Bull. 25: 94, 1969. Borgaonkar, D. S., and Hollander, D. H.: Quinacrine flourescence of the human Y chromosome, Nature 230: 52, 1971. Robinson, J. W., and Bfickton, K. E.: Flourescence of variant and abnormal Y chromosomes, Chromosoma 35: 342, 1971.
THE MEASURE.~ENT of blood pressure by the auscultatory m e t h o d in the lower extremity often proves to be a frustrating experience in the older child, especially if he is obese or muscular. T h e cuff is often h a r d to keep in place a r o u n d the thigh d u r i n g inflation, even with the sizes r e c o m m e n d e d by the A m e r i c a n H e a r t A s s o c i a t i o n / and the Korotkoff sounds are frequently difficult to hear in the popliteal area. Some patients complain of discomfort during inflation of the cuff. Finally, the e x a m i n e r has to use different size cuffs when c o m p a r i n g pressures in the arms a n d legs. Measurements of lower extremity blood pressure in adults can be even more frustrating; this p r o m p t e d Hocken 2 to suggest that the same cuff used for the a r m be placed just above the ankle and that the K o r o t k o f f sounds be listened for over the dorsalis pedis or posterior tibial arteries. H e found close correlation between the pressures in the arms and leg-s by this auscultatory method, but the Korotkoff sounds could not be h e a r d in about 10 per cent of the patients. Close correlation of intra-arterial pressure in the brachial a n d femoral arteries has also been reported by Park and G u n t h e r o t h ? T h e purpose of this report is to show that the above difficulties
Volume 82 Number 3
Brief clinical and laboratory observations 4 9 9
IRfl,
I
"1-
l.l.J
,
i
f
RIGHT ARM BLOOD PRESSURE Fig. 1. Simultaneous recordings of the Doppler-shifted signals, the sphygmomanometer cuff pressure, and the electrocardiogram. The arrow on the left points to the first signal which appears as the cuff pressure reaches systolic level. As the cuff pressure reaches the diastolic level there is a sudden reduction in the amplitude of the signal (arrow to the right). Table I. Average blood pressure (ram. Hg) (six determinations in each patient)
No.o/patients 44
Arms J Legs Systolic J Diastolic Systolic 1Diastolic 109 -+ 10.34
67 + 10.49
112 -'2 12.43
can be circumvented by the use of the ultrasonic Doppler technique? MATERIALS
AND METHODS
Forty-four patients who had no evidence of cardiovascular disease were selected for study. Their ages ranged from 6.5 to 25 years with a mean of 12.6 years. Their weights ranged from 17 to 90.9 Kg. with an average of 44 Kg. There were 30 males and 14 females. All subjects were studied in the supine position. The circumference of the right upper arm at its midlength and that of the lower leg just above the ankle were measured at the position of cuff placement. The width of the cuff was 20 to 25 per cent greater than the diameter of the arm or leg. The same cuff was used for both upper and lower extremities since the difference in the average values of the circumference of the upper and lower extremities in the above anatomic locations was only 0.5 inch. The inflatable cuff length was sufficient to encircle the extremities completely. (The cuff characteristics were those recommended by the American Heart Association?) Blood pressure was measured in the upper and lower extremities utilizing the Doppler technique, as previously described, s An infant-size (1 • 2 cm.) flat transducer was placed over the brachial or posterior tibial artery distal to the pressure cuff. Three blood
68 -+ 10.79
I
Differencearms.legs Systolic J Diastolic 2.65 + 5.09
6.1 + 3.97
pressure determinations were made in each of the four extremities and recorded with the aid of an Electronics for Medicine multichannel recorder using light-sensitive paper which had been previously calibrated. A representative tracing is shown in Fig. 1. Since there was no significant difference between the pressures in the upper extremities, only the right arm pressures were used for comparison with the pressures in the lower extremity. The average of three systolic and diastolic pressure determinations from each leg was compared with the average of three values obtained from the right arm. RESULTS
The systolic pressures obtained in the arms ranged from 90 to 145 ram. Hg, and the corresponding systolic pressures obtained in the legs ranged from 89 to 159 ram. Hg (Table I). The correlation coefficient for systolic pressures was 0.914. The paired data of the observed systolic pressures in the arms and legs showed that the systolic pressures in the legs were slightly but significantly higher than those obtained in the arms. The mean difference between the two sets of values was + 2.66 ram. Hg (S. D. +_5.6), p < 0.001. The diastolic pressures obtained for the arms ranged from 48 to 87 ram. Hg and compared well with those obtained in the legs, which ranged from 50 to 90 ram. Hg.
50 0
Brief clinical and laboratory observations
The correlation coefficient for these measurements was 0.949. T h e paired diastolic pressure measurements in the arms and legs did not differ significantly (p > 0.3). DISCUSSION T h e method described in the present study offers an easy and accurate means of measuring the blood pressure in the lower extremities. T h e accuracy and reliability of the Doppler method has been tested in this laboratory, 4 as well as by a number of other investigators. ~-~ No difficulty was encountered in measuring the pressure in the lower extremities in any of the subjects in this study. T h e systolic pressures in the posterior tibial arteries were statistically slightly higher than those in the brachial arteries. Since the pressure obtained by the Doppler technique is a true reflection of the intra-arterial pressure, 4 the slightly higher pressure in the foot vessel is real and not due to improper cuff size or technique. T h e systolic pressure amplification of peripheral arteries has been noted by others, 3 but a satisfactory explanation is not yet available. T h e pressures found in the posterior tibial artery were only slightly higher (2.66 mm. H g mean difference) and from a clinical standpoint should not be of major significance. T h e method described in this report may be useful in the evaluation of residual or recurrent coarctation of the aorta in older children and adults who have had surgical re-
The Journal of Pediatrics March 1973
pair. This method is also simple to apply in critically ill patients who have parenteral fluids being administered in the upper extremities or who are in an oxygen tent; the ankle and foot are obviously m u c h more accessible than the arms in such patients. We feel that the measurement of pressure in the lower extremities using the technique described in this report deserves consideration as the method of choice. REFERENCE
1. Kirkendall, W. M., Burton, A. C., Epstein, F. H., and Freis, E. D.: Recommendations for human blood pressure determination by sphygmomanometers, Circulation 36: 980, 1967. 2. Hocken, A. G.: Measurement of blood pressure in the leg, Lancet 1: 466, 1967. 3. Park, M. K., and Guntheroth, W. G.: Direct blood pressure measurements in brachial and femoral arteries in children, Circulation 41: 231, 1970. 4. Hernandez, A., Goldring, D., and Hartmann, A. F., Jr.: Measurement of blood pressure in infants and children by the Doppler ultrasonic technique, Pediatrics 48: 788, 1971. 5. Stegall, H. F., Kardon, M. D., and Kemmerer, W. T.: Indirect measurement of arterial blood pressure by Doppler ultrasonic sphygmomanometry, J. Appl. Physiol. 25: 793, 1968. 6. Sheppard, L. C., Jolinson, T. S., and. Kirklin, J. W.: Controlled study of brachial artery blood pressure measured by a new indirect method, J. Assoc. Adv. Med. Instrument 5: 297, 1971. 7. McLaughlin, G. W., Kirby, R. R., Kemmerer, W. T., and deLemos, R. A.: Indirect measurement of blood pressure in infants utilizing Doppler ultrasound J. PI~DIATR. 79: 300, 1971.
Brie[ clinical and laboratory observations
5. Moorhead, P. S., Nowell, P. C., Mellman, W. J., Battips, D. M., and Hungerford, D. A.: Chromosome preparations of leukocytes cultured from human peripheral blood, Exp. Cell Res. 20: 613, 1960. 6. Morishima, A., Grumbach, M. M., and Taylor, J. H.: Asynchronous duplication of human chromosomes and the origin of sex chromatin, Proc. Natl. Acad. Sci. 48:1: 756, 1962. 7. O'Riordan, M. L., Robinson, J. A., Buckton, K. E., and Evans, H. J.: Distinguishing between the chromosomes involved in Down's syndrome (trisomy 21) and chronic myeloid leukemia (Ph') by fluorescence, Nature 230: 167, 1971. 8. Uchida, I. A., and Lin, C. C.: Fluorescent staining of human chromosomes: Identification of some common aberrations, Can. Med. Assoc. J. 105: 479, 1971. 9. Federman, D. D., Davidoff, F. M., and OueIlette, E.: Presumptive Y/D translocation
Measurement of blood pressure in the brachial and posterior tibial arteries using the Doppler method Alexis F. Hartmann, Jr., M.D.,* R. Klint, M.D., A. Hernandez, M.D., and D. Goldring, M.D., with the technical assistance of Charles Crawford, B.S., and Barbara Graham, St. Louis, Mo.
From the Edward Mallinckrodt Department o[ Pediatrics, Division o[ Cardiology, Washington University School o[ Medicine, and St. Louis Children's Hospital. Supported in part by the Arthur Fund, Scott Centsch Memorial Fund, William T. Beauchamp Memorial Fund, and the John Clay Seier Fund. "~Reprint address: St. Louis Children's Hospital, 500 S. Kingshlghway, St. Louis, Mo. 63110.
The Journal o[ Pediatrics March 1973
10. 11.
12.
13. 14. 15.
in mixed gonadal dysgenesis, J. Med. Genet. 4: 36, 1967. Noel, B., Emerit, I., Luciani, J. M., and Quack, B. A.: A familial Y/autosome translocation in man, Clin. Genet. 2: 1, 1971. Nakagome, Y., Smith, H. D., and Soukup, S. W.: A presumptive Y-autosome translocation in a boy with congenital malformations, Am. J. Dis. Child. 116: 205, 1968. Buhler, E. M., Muller, H., and Stalder, G.: A strongly fluorescing abnormal chromosome in a malformed child, Humangenetik 12: 64, 1971. Jacobs, P.: Structural abnormalities of the sex chromosomes, Br. Med. Bull. 25: 94, 1969. Borgaonkar, D. S., and Hollander, D. H.: Quinacrine flourescence of the human Y chromosome, Nature 230: 52, 1971. Robinson, J. W., and Bfickton, K. E.: Flourescence of variant and abnormal Y chromosomes, Chromosoma 35: 342, 1971.
THE MEASURE.~ENT of blood pressure by the auscultatory m e t h o d in the lower extremity often proves to be a frustrating experience in the older child, especially if he is obese or muscular. T h e cuff is often h a r d to keep in place a r o u n d the thigh d u r i n g inflation, even with the sizes r e c o m m e n d e d by the A m e r i c a n H e a r t A s s o c i a t i o n / and the Korotkoff sounds are frequently difficult to hear in the popliteal area. Some patients complain of discomfort during inflation of the cuff. Finally, the e x a m i n e r has to use different size cuffs when c o m p a r i n g pressures in the arms a n d legs. Measurements of lower extremity blood pressure in adults can be even more frustrating; this p r o m p t e d Hocken 2 to suggest that the same cuff used for the a r m be placed just above the ankle and that the K o r o t k o f f sounds be listened for over the dorsalis pedis or posterior tibial arteries. H e found close correlation between the pressures in the arms and leg-s by this auscultatory method, but the Korotkoff sounds could not be h e a r d in about 10 per cent of the patients. Close correlation of intra-arterial pressure in the brachial a n d femoral arteries has also been reported by Park and G u n t h e r o t h ? T h e purpose of this report is to show that the above difficulties
Volume 82 Number 3
Brief clinical and laboratory observations 4 9 9
IRfl,
I
"1-
l.l.J
,
i
f
RIGHT ARM BLOOD PRESSURE Fig. 1. Simultaneous recordings of the Doppler-shifted signals, the sphygmomanometer cuff pressure, and the electrocardiogram. The arrow on the left points to the first signal which appears as the cuff pressure reaches systolic level. As the cuff pressure reaches the diastolic level there is a sudden reduction in the amplitude of the signal (arrow to the right). Table I. Average blood pressure (ram. Hg) (six determinations in each patient)
No.o/patients 44
Arms J Legs Systolic J Diastolic Systolic 1Diastolic 109 -+ 10.34
67 + 10.49
112 -'2 12.43
can be circumvented by the use of the ultrasonic Doppler technique? MATERIALS
AND METHODS
Forty-four patients who had no evidence of cardiovascular disease were selected for study. Their ages ranged from 6.5 to 25 years with a mean of 12.6 years. Their weights ranged from 17 to 90.9 Kg. with an average of 44 Kg. There were 30 males and 14 females. All subjects were studied in the supine position. The circumference of the right upper arm at its midlength and that of the lower leg just above the ankle were measured at the position of cuff placement. The width of the cuff was 20 to 25 per cent greater than the diameter of the arm or leg. The same cuff was used for both upper and lower extremities since the difference in the average values of the circumference of the upper and lower extremities in the above anatomic locations was only 0.5 inch. The inflatable cuff length was sufficient to encircle the extremities completely. (The cuff characteristics were those recommended by the American Heart Association?) Blood pressure was measured in the upper and lower extremities utilizing the Doppler technique, as previously described, s An infant-size (1 • 2 cm.) flat transducer was placed over the brachial or posterior tibial artery distal to the pressure cuff. Three blood
68 -+ 10.79
I
Differencearms.legs Systolic J Diastolic 2.65 + 5.09
6.1 + 3.97
pressure determinations were made in each of the four extremities and recorded with the aid of an Electronics for Medicine multichannel recorder using light-sensitive paper which had been previously calibrated. A representative tracing is shown in Fig. 1. Since there was no significant difference between the pressures in the upper extremities, only the right arm pressures were used for comparison with the pressures in the lower extremity. The average of three systolic and diastolic pressure determinations from each leg was compared with the average of three values obtained from the right arm. RESULTS
The systolic pressures obtained in the arms ranged from 90 to 145 ram. Hg, and the corresponding systolic pressures obtained in the legs ranged from 89 to 159 ram. Hg (Table I). The correlation coefficient for systolic pressures was 0.914. The paired data of the observed systolic pressures in the arms and legs showed that the systolic pressures in the legs were slightly but significantly higher than those obtained in the arms. The mean difference between the two sets of values was + 2.66 ram. Hg (S. D. +_5.6), p < 0.001. The diastolic pressures obtained for the arms ranged from 48 to 87 ram. Hg and compared well with those obtained in the legs, which ranged from 50 to 90 ram. Hg.
50 0
Brief clinical and laboratory observations
The correlation coefficient for these measurements was 0.949. T h e paired diastolic pressure measurements in the arms and legs did not differ significantly (p > 0.3). DISCUSSION T h e method described in the present study offers an easy and accurate means of measuring the blood pressure in the lower extremities. T h e accuracy and reliability of the Doppler method has been tested in this laboratory, 4 as well as by a number of other investigators. ~-~ No difficulty was encountered in measuring the pressure in the lower extremities in any of the subjects in this study. T h e systolic pressures in the posterior tibial arteries were statistically slightly higher than those in the brachial arteries. Since the pressure obtained by the Doppler technique is a true reflection of the intra-arterial pressure, 4 the slightly higher pressure in the foot vessel is real and not due to improper cuff size or technique. T h e systolic pressure amplification of peripheral arteries has been noted by others, 3 but a satisfactory explanation is not yet available. T h e pressures found in the posterior tibial artery were only slightly higher (2.66 mm. H g mean difference) and from a clinical standpoint should not be of major significance. T h e method described in this report may be useful in the evaluation of residual or recurrent coarctation of the aorta in older children and adults who have had surgical re-
The Journal of Pediatrics March 1973
pair. This method is also simple to apply in critically ill patients who have parenteral fluids being administered in the upper extremities or who are in an oxygen tent; the ankle and foot are obviously m u c h more accessible than the arms in such patients. We feel that the measurement of pressure in the lower extremities using the technique described in this report deserves consideration as the method of choice. REFERENCE
1. Kirkendall, W. M., Burton, A. C., Epstein, F. H., and Freis, E. D.: Recommendations for human blood pressure determination by sphygmomanometers, Circulation 36: 980, 1967. 2. Hocken, A. G.: Measurement of blood pressure in the leg, Lancet 1: 466, 1967. 3. Park, M. K., and Guntheroth, W. G.: Direct blood pressure measurements in brachial and femoral arteries in children, Circulation 41: 231, 1970. 4. Hernandez, A., Goldring, D., and Hartmann, A. F., Jr.: Measurement of blood pressure in infants and children by the Doppler ultrasonic technique, Pediatrics 48: 788, 1971. 5. Stegall, H. F., Kardon, M. D., and Kemmerer, W. T.: Indirect measurement of arterial blood pressure by Doppler ultrasonic sphygmomanometry, J. Appl. Physiol. 25: 793, 1968. 6. Sheppard, L. C., Jolinson, T. S., and. Kirklin, J. W.: Controlled study of brachial artery blood pressure measured by a new indirect method, J. Assoc. Adv. Med. Instrument 5: 297, 1971. 7. McLaughlin, G. W., Kirby, R. R., Kemmerer, W. T., and deLemos, R. A.: Indirect measurement of blood pressure in infants utilizing Doppler ultrasound J. PI~DIATR. 79: 300, 1971.