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Effect of the shape of the cuff on blood pressure measurement in people with large arms
Open accessAbstract
Purpose: Previous data suggest that tronco-conical cuffs should be used for accurate blood pressure (BP) measurement in the obese. However, not only arm size but also its shape may affect the accuracy of BP measurement when a cylindrical cuff is used.Methods: In 197 subjects with arm circumference >32 cm, and 157 subjects with arm circumference ≤ 32 cm, the upper-arm was considered as formed from two truncated cones and the frustum slant angles of the proximal (upper angle) and distal (middle angle) truncated cones were measured. Five cylindrical and five tronco-conical cuffs of appropriate size in relation to arm circumference were used.Results: In the group with large arm, the upper slant angle was greater than the middle angle (86.5 ± 1.7° versus 84.7 ± 2.3°), whereas in the group with normal arm the two angles were similar. In the former group, the cylindrical cuff overestimated BP by 2.5 ± 5.4/1.7 ± 4.7 mmHg, whereas in the latter negligible between-cuff BP discrepancies were found. In the whole sample, BP discrepancies between the cylindrical and the tronco-conical cuffs correlated with both arm size and shape, considered as the difference between the upper and middle slant angles (all p < 0.0001). Among the participants with large arm, the between-cuff BP discrepancies increased progressively with increasing upper-middle angle difference (3.75 ± 0.38/2.78 ± 0.32 mmHg for the top tertile, p < 0.001/<0.001).Conclusions: These data indicate that in people with large upper arms, the tronco-conical shape of the arm is more pronounced on the lower than the upper half, a feature that amplifies the BP measurement error when cylindrical cuffs are used.
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There is some inconsistency in the recommendations by scientific societies on the issue of miscuffing.
“However, there is some inconsistency in the recommendations by scientific societies on the issue of miscuffing [1,4,90,98–100].”
Current recommendations for manual auscultatory devices require a cuff with the length of the inflatable bladder covering 75-100% of the mid-arm circumference and the width covering 37-50% of the length of the mid-arm.
“Current recommendations for manual auscultatory devices require a cuff with the length of the inflatable bladder covering 75–100% of the mid-arm circumference of the individual and the width covering 37–50% of the length of the mid-arm [90,98].”
For automated oscillometric upper arm-cuff devices, the cuff is also the signal sensor and each cuff size should be validated in an adequate number of individuals according to the validation standard used.
“For automated oscillometric upper arm-cuff devices, the cuff is also the signal sensor and each cuff size should be validated in an adequate number of individuals according to the validation standard used [90,98].”
The rules for the dimensions of the inflatable bladder do not necessarily apply for oscillometric devices, and the accuracy of each oscillometric device should be assessed in association with the recommended cuff size in validation studies.
“The above-mentioned rules for the dimensions of the inflatable bladder do not necessarily apply for oscillometric devices, and the accuracy of each oscillometric device should be assessed in association with the recommended cuff size in validation studies [90,98].”
The use of wide-range cuffs with oscillometric devices is particularly useful, yet such devices require documentation of their blood pressure measurement accuracy throughout the entire range of arm size of recommended use according to the validation protocol requirements.
“The use of wide-range cuffs with oscillometric devices is particularly useful, yet such devices require documentation of their BP measurement accuracy throughout the entire range of arm size of recommended use according to the validation protocol requirements [98].”
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“>42 cm), as there are issueswith the cuff size and shape of the reference (auscultatory) BP measurement as well [102].”
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“When managing these individuals, it would be advisable, if possible, to choose a tronco-conical cuff of appropriate size for better matching the cuff to the patient’s arm, compared with using a cylindrical cuff [ 11, 12].”
Self-citationThe Effect of Intraoperative Hypotension on Postoperative Renal Function
Kim, B., Sangha, G., Singh, A., & Bohringer, C. (2023) · Current Anesthesiology Reports · doi:10.1007/s40140-023-00564-2 · Cited by 7
“A cuff that is too large will underestimate BP, and a cuff that is too small will overestimate BP. Measurement errors are especially common in obese patients with large arms when standard cylindrical cuffs are used [38].”
Accuracy of blood pressure measurement across BMI categories using the OptiBP™ mobile application
Caillat, M., Degott, J., Wuerzner, A., Proençain, M., Bonnier, G., Knebel, J., Stoll, C., Christen, U., Durgnat, V., Hofmann, G., et al. (2022) · Blood Pressure · doi:10.1080/08037051.2022.2132214 · Cited by 6
“However, we observed a positive correlation between the errors in DBP and large arm size, confirming the difficulties in precisely measuring BP in obese patients [13].”
BackgroundChallenges in blood pressure measurement in children with obesity: focus on the cuff
Evripidou, K., Chainoglou, A., Kotsis, V., & Stabouli, S. (2025) · Pediatric nephrology (Berlin, West) · doi:10.1007/s00467-025-06678-5 · Cited by 4
“The calculation of the angle size in degrees is based on the following equation: in which ‘C 1 ’ is the proximal AC, ‘C 2 ’ is the distal AC, and ‘L’ is the arm length [27, 34, 35].”
InfluentialBlood Pressure Assessment Across the Lifespan: Improving Clinical Research and Clinical Practice
Abdalla, M., Juraschek, S. P., Biaggioni, I., Bowling, C. B., Balijepalli, R. C., Brady, T. M., Bress, A. P., Brook, R. D., Cohen, J. B., Commodore-Mensah, Y. Y., et al. (2026) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2026.02.5124 · Cited by 2
Saladini, F., Albini, F., Guardo, A. D., Fra, G. P., Mos, L., Omboni, S., Predotti, P., Rabbia, F., Tocci, G., Parati, G., et al. (2025) · High Blood Pressure & Cardiovascular Prevention · doi:10.1007/s40292-025-00778-x · Cited by 1
“…hand, the limited use of devices providing information on central haemodynamics (central BP, pulse wave velocity) and on peripheral arteries their BP was detected by a tronco-conical cuff [9], in particular among people with large upper arms and a pronounced tronco-conical shape of the arm [ 11].”
Self-citationSlade, L., Syeda, N., Mistry, H., Bone, J., Wilson, M., Blackman, M., Poston, L., Godfrey, K., von Dadelszen, P., Magee, L., et al. (2025) · International Journal of Obesity · doi:10.1038/s41366-025-01803-8 · Cited by 1
“Future work should aim to evaluate, as much as possible, the complex interplay between risk factors for adverse pregnancy outcomes and the associations and contributors to overweight and obesity.”
Office BP measurement using conical cuffs in children and adolescents with obesity
Evripidou, K., Álvarez-Pitti, J., Blas-Zapata, A. D., Chainoglou, A., Goulas, I., Herberigs, K., Hamdani, G., & Stabouli, S. (2024) · Blood Pressure · doi:10.1080/08037051.2024.2411294 · Cited by 1
“The sample size was calculated by setting a 95% CI, a power of 80%, and an expected difference between the means of 3 mmHg for absolute BP values and 0.2 for z-score values, based on the available adults’ studies [5,9,11].”
InfluentialPitfalls of Cuff Size and Blood Pressure Measurement.
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Lakhal, K., Dauvergne, J. E., & Boulain, T. (2026) · Anesthésie & Réanimation · doi:10.1016/j.anrea.2026.08.002
Intraoperative Hypotension and Risk of Cuff Blood Pressure InaccuracyPreprint
Kwon, S., Kim, S., Cole, D. J., Bovik, A., Giovannucci, E., & Cannesson, M. (2026) · medRxiv · doi:10.64898/2026.07.20.26358528
“Arterial stiffness from calcification or aging, an improperly sized cuff relative to the patient’s arm circumference, arm shape, and irregular pulses can all contribute to inaccuracy in Cuff BP measurement 19,30,37–39 .”
Antza, C., Anyfanti, P., Kotoulas, S., & Kotsis, V. (2025) · Journal of Hypertension · doi:10.1097/hjh.0000000000004142
Metadata
- Authors
- Palatini, P., Benetti, E., Fania, C., Ermolao, A., Spinella, P., Battista, F., Gasperetti, A., & Saladini, F.
- Affiliations
- University of Padua (IT)
- U.O. Medicina Generale, Casa di Cura Villa Maria SRL, Padova, Italy;
- Corresponding author
- Palatini, Paolo
- ORCID
- Venue
- Blood Pressure
- Publisher
- Informa UK Limited
- Published
- 2020-03-14
- Volume
- 29
- Issue
- 4
- Pages
- 241-246
- ISSN
- 0803-7051 (ISSN-L)
- 1651-1999
- OpenAlex
- W3011987291
- Cited by
- 16
- References
- 0
- Citations by year
- 2026: 3 · 2025: 4 · 2024: 4 · 2023: 2 · 2022: 2 · 2021: 1
- FWCI
- 0.77
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Blood Pressure (publishedVersion)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
- Padua Research Archive (University of Padova) (submittedVersion, other-oa)
- Funders
- Università degli Studi di Padova
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Blood Pressure and Hypertension Studies
- Physical Sciences › Engineering › Biomedical Engineering › Non-Invasive Vital Sign Monitoring
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Health and Disease Prevention
- Keywords
- blood pressure measurement, arm circumference, obesity, measurement error, cuff size
- MeSH terms
- Adult, Aged, Blood Pressure, Blood Pressure Determination, Equipment Design, Female, Humans, Male, Middle Aged, Obesity, Predictive Value of Tests, Reproducibility of Results, Upper Extremity, Adiposity
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