Blood pressure difference between upper extremities

Specialty: Cardiovascular.

• interbrachial tension gradient
• upper limb blood pressure asymmetry

Why it occurs

• Subclavian artery stenosis (atherosclerotic or compression)
• Acute aortic dissection with ostial occlusion of the supra-aortic trunks
• Subclavian steal syndrome
• Aortic coarctation proximal to the left subclavian outlet
• Takayasu arteritis with stenosis of large arterial vessels
• Thoracic outlet syndrome with extrinsic arterial compression

Initial workup

Simultaneous and repeated recording of blood pressure in both arms with a calibrated oscillometric sphygmomanometer; Duplex Doppler ultrasound of the subclavian arteries and supra-aortic trunks to assess the direction of blood flow in the vertebral arteries (reversed flow in case of subclavian steal); CT angiography of the thoracic and abdominal aorta to definitively rule out aortic dissection or anatomical stenosis of great vessels; Supra-aortic MR angiography if vasculitis is suspected.

Standard management

• Atorvastatin — for the pharmacological management of atheromatous plaque causing stenosis in the subclavian artery; 40 mg once daily orally
• Acetylsalicylic acid — for systemic antiplatelet aggregation in prevention of ischemic events; 100 mg once a day orally
• Metoprolol — beta blocker indicated if aortic dissection is confirmed to control heart rate and blood pressure, reducing ventricular ejection force and dP/dt; infusion of 5 mg repeated intravenous according to hospital protocol
• Ramipril (ACEI indicated for the control of systemic hypertension, using the arm with the highest blood pressure reading for dose titration; 5 to 10 mg once daily).