Left or right? It’s a question I hear from many people when discussing which arm to take blood pressure from. The biggest surprise about this question is when I hear it from a nurse or medical assistant at the doctor’s office. That’s the last question they should be asking me. If you’re a return patient, they will know already the answer to that question. If it’s the first time at a new doctor, the answer is not right or left.
Which arm to take blood pressure? Which arm to take blood pressure at an initial doctor visit should be both arms. For each subsequent measurement, the arm that recorded the higher blood pressure should be used. Both arms should be measured because a significant difference in BP readings between the right and left arm could signal vascular disease and a greater risk of dying from heart disease.
So when was the last time your blood pressure was checked in both arms? If your blood pressure is taken in one arm that is lower than the other arm, it can give a false indication that your blood pressure is not high. In addition, you can be misdiagnosed with high or low blood pressure. A 69 year old woman was admitted to the hospital for this reason. I’ll tell you her story later. Now you know why I’m shocked when a nurse asks me what arm.
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Which Arm To Take Blood Pressure
Different blood pressure readings in both arms that vary by a few points are typically normal and are not a concern. But if your readings are more than 10 mm Hg different between arms, it could mean trouble for you. That’s why blood pressure shouldn’t be checked in one arm. The following studies and publications indicate blood pressure should be taken in both arms.
The American Heart Association and the American College of Cardiology released new blood pressure guidelines in 2017. In addition to lowering the threshold for diagnosing high blood pressure, they released a checklist for medical professionals to follow when they’re taking blood pressure. The guidelines specifically state at the 1st visit, record blood pressure in both arms. It says if blood pressure is high in one arm, the doctor’s office should take a reading in both arms. In addition, the next time the patient comes in, the BP should be taken from the higher pressure arm. They also have a checklist for home monitoring which follows the same procedure (resource).
A publication in the Texas Heart Institute Journal discussed accurate blood pressure measurements. They mention the American Heart Association and others recommend that BP be taken in both arms during the initial visit (resource). They say the failure to compare the pulses and BP in both arms can have serious consequences. In addition, it states when the difference between both arms is persistent, the arm with the higher pressure should be used for all subsequent measurements.
Harvard Health Publishing indicates, in more than one article, blood pressure should be taken in both arms (resource). The 2nd article (resource) also indicates the arm with the higher blood pressure should be used in the future. In addition, the higher blood pressure reading should be the one to base any treatments.
A study published in The Lancet reviewed 28 eligible studies. They researched an association of a difference in systolic BP between both arms with vascular disease and death. In their findings, the researchers determined measuring BP in both arms might help to identify patients who need further vascular assessment (resource).
Consequences Of Not Taking Blood Pressure In Both Arms
Here’s the story of the 69 year old woman I mentioned earlier. She was admitted to a surgical service of a hospital for management of acute cholecystitis (inflammation of the gallbladder). A nurse took her initial BP and measured it as 130/80 mm Hg. Three days later, a different nurse took her blood pressure and measured it as 70/40 mm Hg. Because of the huge difference and low BP reading, the woman was transferred to the hospital intensive care unit with a presumed diagnosis of sepsis. Sepsis is a life-threatening condition caused by the body’s reaction to an infection.
During the next 2 days, the woman received antibiotics and 2 computed tomographic scans of her stomach and chest. In addition, she was seen by a general surgeon, a critical care physician, a cardiologist and a pulmonologist. Her BP readings in intensive care ranged between 130/80 and 140/90 mm Hg.
Because her low BP had gone away and she appeared to be doing well, she was transferred out of intensive care back to the medical service area. While back there her BP was taken in the left arm and recorded as 70/40 mm Hg and her left arm pulse was very weak. The BP was checked in her right arm and was recorded as 130/80 mm Hg and her pulse there was strong. The hospital then did a magnetic resonance angiogram which generates images of arteries. The results showed she had a narrowing of an artery on her left side.
In this situation, failure to take the woman’s blood pressure in each arm lead to the wrong diagnosis. She received 2 days of treatments, medication and testing she didn’t need (resource).
The Wrong Diagnosis of Low Or High Blood Pressure
There is a checklist in the new blood pressure guidelines for medical professions to follow when taking BP. Failure to do any of them can lead to a wrong diagnosis of low or high blood pressure. One of the things on the checklist is taking blood pressure in both arms during the initial visit or if the pressure is not normal in one arm.
Let’s say you go for a doctor visit one day, and the nurse takes your BP in only one arm and the measurement indicates high blood pressure. Your doctor will be under the impression your blood pressure is high. In addition, the reverse can happen if the BP is low in one arm. The doctor will think your pressure is low or normal when it might actually be high because they never checked the other arm. Or even worse, like the 69 year old woman, they may miss that you have a serious narrowing of an artery on one side of your body.
A Wrong Diagnosis Can Lead To Serious Medical Problems That Can Be Fatal
The following are medical conditions that can result from having different BP in each arm. If BP is never taken in both arms, the opportunity to correct or prevent these conditions is reduced.
Peripheral Artery Disease (PAD): PAD is a narrowing of your arteries that serve your stomach, legs, arms and head. People with PAD are at a higher risk of stroke, heart attack and coronary artery disease. PAD can also lead to an amputation and gangrene. If PAD is diagnosed early, it may be treated with lifestyle changes and medication (resource).
Aortic Dissection: It’s uncommon and is a less common cause of blood pressure different in each arm. Aortic dissection happens when the inner layer of the aorta tears. Blood flows through the tear which causes the inner and middle layers of the aorta to separate. If this blood filled area breaks through the outer wall of the aorta, the result is often fatal.
Problems In Young People: A younger person can have BP different in each arm but usually for different reasons. Blood flow through an artery may be disrupted because of a structural issue. Another reason may be when something inside the body, like a muscle, can press down on an artery and restrict the blood flow.
Tips On Taking Blood Pressure In Both Arms
If you’re taking blood pressure at home or at the doctor, the same procedures should be followed. If you’re interested in a home blood pressure monitor, check out the one I recommend in my blog post right here. This check list is crucial in diagnosing if you have high or low blood pressure. Unfortunately, many of the things on this checklist are not followed by your medical staff. Don’t hesitate about asking a nurse to do the things on this list, especially taking blood pressure in both arms. It’s too bad that most doctor visits are run like an assembly line. The checklist is taken directly from the new blood pressure guidelines released in 2017 (resource).
Can you imagine an airplane pilot skipping things on his checklist when getting ready to fly? The same should happen with a medical professional taking your blood pressure. Maybe it’s easier for the medical professional to skip steps because it’s not their life at risk, it’s yours. The pilot, in addition to doing his job properly, would be putting his own life at risk by skipping his steps. Maybe there should be more accountability when it comes to things like taking blood pressure.
- Relax for at least 5 minutes, sit in a chair, feet on the floor with your back supported.
- Avoid exercise, smoking and caffeine for at least 30 minutes prior to the BP measurement.
- Make sure you have an empty bladder.
- You and the nurse should not talk during your rest period or during the measurement.
- Make sure the cuff is not placed over clothing.
- Your arm should be supported and the cuff positioned on the upper arm at heart level.
- Use the right size cuff. Too small or large can give a false reading.
- At the initial visit or for the first time, take blood pressure in each arm. For all subsequent readings use the arm that gives you the higher reading.
- Wait for 2 to 3 minutes between readings.
- Record all your BP readings including the upper and lower number.
- Use an average of 2 or more readings obtained on 2 or more occasions to estimate your BP level.
- Bring the readings, if taken at home, to your next doctor visit.
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