Arm Circumference, Shape, and Length: How Interplaying Variables Affect Blood Pressure Measurement in Obese Persons
Abstract
Obesity has reached epidemic proportions worldwide.1 The World Health Organization projects that by 2015 2.3 billion persons will be overweight (body mass index [BMI, calculated as weight in kilograms divided by height in meters squared], 25–29), and another 700 million will be obese (with BMI ≥ 30).2 In the United States alone, more than 78 million adults (35.7%) and 12.5 million children and adolescents (16.9%) are obese.3 As obesity has increased, so has arm circumference, especially to greater than 33 cm. This increasing prevalence creates unique demands for clinicians caring for obese persons across the lifespan in all practice settings. Even basic assessment techniques such as measurement of blood pressure are challenging.4–6Accuracy of blood pressure measurement is contingent on many factors, including correct cuff size and location of measurement.7 According to the American Heart Association (AHA8; Table 1), ideal cuffs have bladder widths at least 40% and lengths 80% of midarm circumference (length to width ratio of 2:1). Therefore, cuff bladders must get longer and wider as arm circumference increases; otherwise mismatching may occur. The most common mismatch is using small or short cuffs (bladder too small).9 Such “undercuffing” leads to overestimates of systolic blood pressure (SBP) and diastolic blood pressure (DBP; range of error, 2.4–30 mm Hg), resulting in erroneous classification of patients as hypertensive, leading to unnecessary therapy.8–10In addition to arm circumference, researchers in a recent study determined that upper arms are troncoconical in shape (obese or not).11 Differences between proximal and distal upper arm circumference ranged from 1 to 20 cm, with a mean of 8.7 cm. Although sex and degree of obesity influenced shape, arm circumference was the factor that most significantly influenced conicity index. Increased conicity associated with obesity (or muscularity) can result in poor cuff fit.12 To complicate matters more, obese patients of small stature may have short upper arms.10 Thus, if cuffs that are too wide are used (bladders too large), arm length poses a problem. Although thigh cuffs may be the best fit for the arm circumference, the distal cuff end will be too long, extending past the elbow/antecubital fossa. This situation results in “overcuffing,” which yields a false underestimate of blood pressure (range of error, 10–30 mm Hg).9,10 These anatomic challenges and the many cuff choices are compounded by the potential lack of consistent use of a particular cuff size between clinicians, further reducing the reliability of blood pressure values that guide critical treatment decisions. As a result, the following PICO (population, intervention, control, and outcomes) question was chosen for this clinical review: What is the most accurate method of assessing blood pressure in obese persons?A search of the MEDLINE and CINAHL databases, limited to the past 10 years, was conducted with the following search terms: obese, overweight, blood pressure monitoring, cuff size, and conical shaped.Eleven observational studies were retrieved (Table 2). In 2 studies,11,13 cuff types were compared (standard vs large, rigid cylindrical vs conical); in 3 studies,4,17,21 blood pressure measurements obtained via direct intra-arterial vs ausculatory/oscillometric techniques were compared; and in 6 studies,14–16,18–20 blood pressure measurements obtained from the upper arm versus the forearm were compared.Existing evidence on blood pressure assessment in obese persons is at level C (Table 3). Not surprisingly, current evidence suggests that when vital decisions are required in the treatment of critically ill obese patients, direct intra-arterial measurement of blood pressure should be used instead of ausculatory/oscillometric techniques, which are associated with significant error.4,17A second recommendation relates to matching cuffs with the size and shape of the upper arm. Preferably on admission, clinicians should measure the arm circumference midway between the shoulder and elbow and evaluate the shape of the upper arm. Based on size and shape dimensions, an appropriately sized cuff as closely aligned to the AHA’s guidelines as possible should be selected. This assessment is essential as evidence shows that standard cuffs yield overestimates of blood pressure in obese persons13 compared with larger appropriately sized cuffs.Although the AHA recommends long cuffs with large arm circumferences and short upper arms,8 McFarlane10 points out that these cuffs do not meet the bladder size standard because only the outside cuff material is extra long. Indeed, Watson et al20 reported that extra-long cuffs used on the upper arm in patients with large arm circumferences were associated with significantly higher SBP (compared with standard cuffs). In an unpublished study, McFarlane compared blood pressure measurements obtained in the forearm and upper arm using extra-long versus appropriately-sized cu
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An automated oscillometric device successfully validated in adults may not be accurate in pregnancy or preeclampsia.
“An automated oscillometric device, which has been successfully validated in adults may not be accurate in pregnancy or preeclampsia [90,191]”
Using a standard size cuff on large arms can overestimate BP.
“One of the main issues in the management of patients with large arm circumference is the limited availability of properly sized cuffs, which can end up in an overestimation of BP whilst using a standard size cuff [194,195].”
Limited availability of properly sized cuffs is a main issue in managing patients with large arm circumference.
“One of the main issues in the management of patients with large arm circumference is the limited availability of properly sized cuffs, which can end up in an overestimation of BP whilst using a standard size cuff [194,195].”
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“Several factors influence the accuracy of blood pressure measurements, including cuff parameters (e.g., cuff width and length) [2], biomechanical properties (e.g., elastic properties of the brachial artery wall) [3], and hemodynamic status of the cardiovascular system. e.g. mean blood pressure,…”
Background
- Authors
- Halm, M. A.
- Affiliations
- Salem Hospital (US)
- Corresponding author
- Halm, Margo A.
- ORCID
- Halm, Margo A.
- Venue
- American Journal of Critical Care
- Publisher
- AACN Publishing
- Published
- 2014-03-01
- Volume
- 23
- Issue
- 2
- Pages
- 166-170
- ISSN
- 1062-3264 (ISSN-L)
- 1937-710X
- OpenAlex
- W2151782327
- Cited by
- 15
- References
- 25
- Citations by year
- 2024: 2 · 2023: 1 · 2022: 1 · 2021: 1 · 2020: 2 · 2018: 5 · 2017: 1 · 2016: 1 · 2015: 1
- FWCI
- 0.69
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- American Journal of Critical Care (publishedVersion)
- PubMed (publishedVersion)
- 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
- obesity, blood pressure measurement, cuff size, arm circumference, arm length
- MeSH terms
- Arm, Blood Pressure Determination, Diagnostic Errors, Humans, Obesity, Databases, Bibliographic
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