186
Commentary
Measuring blood pressure: thoughts about arms Marie-Ève Leblanca,b, Lyne Cloutierc and Paul Poiriera,b
Tel: + 1 418 656 4767; fax: + 1 418 656 4581; e-mail: [email protected]
Blood Pressure Monitoring 2015, 20:186–188 a
b
Institut Universitaire de Cardiologie et de Pneumologie, Faculty of Pharmacy, Laval University, Laval and cDepartment of Nursing, University of Quebec at Trois-Rivières, Trois-Rivières, Québec, Canada
Received 19 November 2014 Accepted 9 January 2015 Accepted 22 January 2015
Correspondence to Paul Poirier, MD, PhD, FRCPC, FACC, FAHA, Institut Universitaire de Cardiologie et de Pneumologie de Québec (IUCPQ), 2725 Chemin Sainte-Foy, QC, Canada G1V 4G5
Blood pressure measurement and mastectomy: what is the real issue in using the arm on the same side as previous mastectomy? Following mastectomy, there is a risk for lymphedema, defined as the accumulation of protein-rich fluid in tissues following inadequate lymphatic drainage. This is a troublesome issue that can cause cosmetic deformity, physical discomfort, and upper-extremity disability associated with arm and hand swelling [1]. Around 21% of women with a history of breast cancer have high blood pressure or hypertension [2], whereas 15% to 20% of women with breast cancer will develop lymphedema [1]. Knowing that one fifth of women with a history of breast cancer have abnormal blood pressure and that the same proportion will have lymphedema, this is clinically relevant. The issue encountered by healthcare professionals (physician, nurse, etc.) is related to the ‘general recommendation’ to avoid blood pressure measurement on the same side as previous mastectomy, particularly if the patient has undergone lymph node removal or radiation therapy. In fact, there is no established recommendation for blood pressure measurements for women who have had a previous mastectomy. No studies have determined the risk of having blood pressure taken on the arm on the same side as previous mastectomy. To our knowledge, there is no scientifically proven harmful impact published in the literature on the measurement of blood pressure on the same arm as previous mastectomy. Prevention of lymphedema is based on intuitive reasoning. Authors have echoed this hypothesis by reporting that tight, constrictive clothing can constrict collateral circulation and is a risk factor for lymphedema without, in fact, any strong scientific background [3]. Counseling women to avoid blood pressure measurement on the same side as previous mastectomy, arguing that it is potentially harmful, may definitely be a barrier for proper hypertension management. 1359-5237 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
To undo the misconception on the unfounded fear of measuring blood pressure on the same arm as previous mastectomy, it is important to note that pressure may be used to treat lymphedema [4]. Indeed, the use of blood pressure cuffs in women with established lymphedema should not be contraindicated as the management strategy relies primarily on vascular compression. Custom compression garments exert a pressure of 40 mmHg, graduated compression garments exert a pressure of up to 80 mmHg, and higher pressures from pneumatic pumps exert a force of 150 mmHg. Authors claimed that sporadic blood pressure readings should not be harmful for lymphedematous limbs or cause any injury [4]. Breast cancer survivors are fragile emotionally and postmastectomy women are reluctant to have their blood pressure taken on the same arm not because of pain, but because of the fear that “something bad will happen”. Hospitalized patients have signs above their bed: ‘No blood pressure or venipuncture on the arm ‘X’. Having one doctor or nurse dispute this teaching might adversely affect the patient psychologically. Therefore, it will take time for this dogma to change. Also, even if occasional measurement of blood pressure on a postmastectomy arm is not harmful, it is important to emphasize that assessment/follow-up of cardiovascular risk factors (such as blood pressure) in postmastectomy women is not the main clinician’s principal preoccupation. In fact, surveillance after a breast cancer diagnosis focuses on tests and examination to prevent/avoid recurrence of disease [5]. In addition, it is not known that ambulatory blood pressure monitoring (ABPM) (which tightens the cuff more than 50 times in 24 h) is harmful in postmastectomy women. One may argue that the accuracy of blood pressure measurement is not known in postmastectomy women as lymphedema may interfere with Korotkoff sound transmission or the oscillometric signal. If lymphedema is problematic in terms of cuff size, a forearm blood pressure measurement approach may be a valid, more comfortable alternative method instead of using the usual upper-arm method [6]. Following the principle that proper blood pressure follow-up should include evaluation of blood pressure on DOI: 10.1097/MBP.0000000000000113
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
Blood pressure: thoughts about arms Leblanc et al. 187
both arms, to assess in which arm the blood pressure value is higher, the fear related to avoidance of blood pressure measurement on the postmastectomy side needs to be evaluated further. This would provide the opportunity for healthcare professionals to both be reassured and also reassure concerned women on lymphedema/blood pressure assessment and, consequently, ensure better hypertension follow-up.
Ambulatory blood pressure measurement: on which arm should we place the device? ABPM is a blood pressure measurement methodology that is integrated into the Canadian Hypertension Educative Program (CHEP) [7]. ABPM has been proven to be better than clinically measured blood pressure in predicting cardiovascular risk [8] and remains an important complementary method to confirm a diagnosis of systemic hypertension. ABPM was not discussed in the Eighth Joint National Committee (JNC 8) [9], but is covered in the American Heart Association (AHA) [10] and in the European Society of Hypertension (ESH) guidelines [11]. Despite the importance of ABPM in hypertension management, the methodological principles related to the choice of arm for cuff installation are not standardized in all hypertension guidelines. In the latest most recently updated CHEP recommendation, the following issues are mentioned: (i) reasons for using ABPM, (ii) importance of using a validated device, (iii) blood pressure threshold values, and (iv) magnitude of change expected in nocturnal blood pressure. There is no mention about which arm should be used for ABPM [7]. By contrast, the AHA recommendation [10] suggests the nondominant arm for ABPM device installation. In the ESH guidelines, details on the importance of the choice of arm are clearly discussed that specify the importance of selecting the arm in which blood pressure value is the highest for ABPM cuff installation [11]. The lack of agreement in hypertension guidelines on which arm should be used for blood pressure determination is of concern as this issue was highlighted in two meta-analyses and in the Framingham Heart Study [12–14]. Both meta-analyses have reached similar conclusions on the importance of assessing blood pressure values in both arms for better evaluation of cardiovascular risk [12,13]. The authors evaluated (i) the association between an interarm difference of 10 mmHg or more and cardiovascular disease and mortality [12] and (ii) whether interarm difference had an influence on interarm results [13]. They concluded that a difference of 10 mmHg or more should be indicative of further investigation [12,13]. In the Framingham Heart Study, which included 3390 participants, results suggested that a modest interarm systolic blood pressure difference (1 − SD unit increment) was associated with a higher risk of a future
cardiovascular risk event [14]. Interarm blood pressure measures should be determined simultaneously in both arms with one or two automatic devices and multiple readings should be obtained [13]. This issue should be discussed in future North American Hypertension guidelines to emphasize the fact that blood pressure should always be measured in the arm in which the value is higher. Interarm blood pressure differences should always be assessed preferably in both arms simultaneously before ABPM device installation. Second, the arm with the highest value should be considered for ABPM (if the interarm difference exceeds 10 mmHg), even if this arm is the dominant one. In conclusion, myths on ABPM installation and the preferential arm and fear of taking blood pressure on the postmastectomy side require additional attention in research as well as in hypertension guidelines. Blood pressure measurement should be obtained in both arms before ABPM installation, and the arm with higher blood pressure value should probably be chosen for ABPM measurement (irrespective of dominance or postmastectomy). Second, there is no scientifically reported rationale to avoid the arm on the postmastectomy side; safe and informative measurements can be obtained in both arms.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1
Petrek JA, Pressman PI, Smith RA. Lymphedema: current issues in research and management. CA Cancer J Clin 2000; 50:292–307. 2 Patterson RE, Flatt SW, Saquib N, Rock CL, Caan BJ, Parker BA, et al. Medical comorbidities predict mortality in women with a history of early stage breast cancer. Breast Cancer Res Treat 2010; 122:859–865. 3 Dell DD, Doll C. Caring for a patient with lymphedema. Nursing (Brux) 2006; 36:49–51. 4 Greene AK, Borud L, Slavin SA. Blood pressure monitoring and venipuncture in the lymphedematous extremity. Plast Reconstr Surg 2005; 116:2058–2059. 5 Margenthaler JA, Johnson FE, Cyr AE. Intensity of follow-up after breast cancer surgery: low versus high? Ann Surg Oncol 2014; 21:733–737. 6 Leblanc MÉ, Croteau S, Ferland A, Bussières J, Cloutier L, Hould FS, et al. Blood pressure assessment in severe obesity: validation of a forearm approach. Obesity (Silver Spring) 2013; 21:E533–E541. 7 Dasgupta K, Quinn RR, Zarnke KB, Rabi DM, Ravani P, Daskalopoulou SS, et al. Canadian Hypertension Education Program. The 2014 Canadian Hypertension Education Program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension. Can J Cardiol 2014; 30:485–501. 8 Hansen TW, Jeppesen J, Rasmussen S, Ibsen H, Torp-Pedersen C. Ambulatory blood pressure monitoring and risk of cardiovascular disease: a population based study. Am J Hypertens 2006; 19:243–250. 9 James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2014; 311:507–520. 10 Pickering TG, Hall JE, Appel LJ, Falkner BE, Graves J, Hill MN, et al. Recommendations for blood pressure measurement in humans and experimental animals: part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
188 Blood Pressure Monitoring 2015, Vol 20 No 4
11
12
Public Education of the American Heart Association Council on High Blood Pressure Research. Circulation 2005; 111:697–716. O’Brien E, Parati G, Stergiou G, Asmar R, Beilin L, Bilo G, et al. European Society of Hypertension Working Group on Blood Pressure Monitoring. European Society of Hypertension position paper on ambulatory blood pressure monitoring. J Hypertens 2013; 31:1731–1768. Clark CE, Taylor RS, Shore AC, Ukoumunne OC, Campbell JL. Association of a difference in systolic blood pressure between arms with vascular disease
13
14
and mortality: a systematic review and meta-analysis. Lancet 2012; 379:905–914. Verberk WJ, Kessels AG, Thien T. Blood pressure measurement method and inter-arm differences: a meta-analysis. Am J Hypertens 2011; 24:1201–1208. Weinberg I, Gona P, O’Donnell CJ, Jaff MR, Murabito JM. The systolic blood pressure difference between arms and cardiovascular disease in the Framingham Heart Study. Am J Med 2014; 127:209–215.
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
Commentary
Measuring blood pressure: thoughts about arms Marie-Ève Leblanca,b, Lyne Cloutierc and Paul Poiriera,b
Tel: + 1 418 656 4767; fax: + 1 418 656 4581; e-mail: [email protected]
Blood Pressure Monitoring 2015, 20:186–188 a
b
Institut Universitaire de Cardiologie et de Pneumologie, Faculty of Pharmacy, Laval University, Laval and cDepartment of Nursing, University of Quebec at Trois-Rivières, Trois-Rivières, Québec, Canada
Received 19 November 2014 Accepted 9 January 2015 Accepted 22 January 2015
Correspondence to Paul Poirier, MD, PhD, FRCPC, FACC, FAHA, Institut Universitaire de Cardiologie et de Pneumologie de Québec (IUCPQ), 2725 Chemin Sainte-Foy, QC, Canada G1V 4G5
Blood pressure measurement and mastectomy: what is the real issue in using the arm on the same side as previous mastectomy? Following mastectomy, there is a risk for lymphedema, defined as the accumulation of protein-rich fluid in tissues following inadequate lymphatic drainage. This is a troublesome issue that can cause cosmetic deformity, physical discomfort, and upper-extremity disability associated with arm and hand swelling [1]. Around 21% of women with a history of breast cancer have high blood pressure or hypertension [2], whereas 15% to 20% of women with breast cancer will develop lymphedema [1]. Knowing that one fifth of women with a history of breast cancer have abnormal blood pressure and that the same proportion will have lymphedema, this is clinically relevant. The issue encountered by healthcare professionals (physician, nurse, etc.) is related to the ‘general recommendation’ to avoid blood pressure measurement on the same side as previous mastectomy, particularly if the patient has undergone lymph node removal or radiation therapy. In fact, there is no established recommendation for blood pressure measurements for women who have had a previous mastectomy. No studies have determined the risk of having blood pressure taken on the arm on the same side as previous mastectomy. To our knowledge, there is no scientifically proven harmful impact published in the literature on the measurement of blood pressure on the same arm as previous mastectomy. Prevention of lymphedema is based on intuitive reasoning. Authors have echoed this hypothesis by reporting that tight, constrictive clothing can constrict collateral circulation and is a risk factor for lymphedema without, in fact, any strong scientific background [3]. Counseling women to avoid blood pressure measurement on the same side as previous mastectomy, arguing that it is potentially harmful, may definitely be a barrier for proper hypertension management. 1359-5237 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
To undo the misconception on the unfounded fear of measuring blood pressure on the same arm as previous mastectomy, it is important to note that pressure may be used to treat lymphedema [4]. Indeed, the use of blood pressure cuffs in women with established lymphedema should not be contraindicated as the management strategy relies primarily on vascular compression. Custom compression garments exert a pressure of 40 mmHg, graduated compression garments exert a pressure of up to 80 mmHg, and higher pressures from pneumatic pumps exert a force of 150 mmHg. Authors claimed that sporadic blood pressure readings should not be harmful for lymphedematous limbs or cause any injury [4]. Breast cancer survivors are fragile emotionally and postmastectomy women are reluctant to have their blood pressure taken on the same arm not because of pain, but because of the fear that “something bad will happen”. Hospitalized patients have signs above their bed: ‘No blood pressure or venipuncture on the arm ‘X’. Having one doctor or nurse dispute this teaching might adversely affect the patient psychologically. Therefore, it will take time for this dogma to change. Also, even if occasional measurement of blood pressure on a postmastectomy arm is not harmful, it is important to emphasize that assessment/follow-up of cardiovascular risk factors (such as blood pressure) in postmastectomy women is not the main clinician’s principal preoccupation. In fact, surveillance after a breast cancer diagnosis focuses on tests and examination to prevent/avoid recurrence of disease [5]. In addition, it is not known that ambulatory blood pressure monitoring (ABPM) (which tightens the cuff more than 50 times in 24 h) is harmful in postmastectomy women. One may argue that the accuracy of blood pressure measurement is not known in postmastectomy women as lymphedema may interfere with Korotkoff sound transmission or the oscillometric signal. If lymphedema is problematic in terms of cuff size, a forearm blood pressure measurement approach may be a valid, more comfortable alternative method instead of using the usual upper-arm method [6]. Following the principle that proper blood pressure follow-up should include evaluation of blood pressure on DOI: 10.1097/MBP.0000000000000113
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
Blood pressure: thoughts about arms Leblanc et al. 187
both arms, to assess in which arm the blood pressure value is higher, the fear related to avoidance of blood pressure measurement on the postmastectomy side needs to be evaluated further. This would provide the opportunity for healthcare professionals to both be reassured and also reassure concerned women on lymphedema/blood pressure assessment and, consequently, ensure better hypertension follow-up.
Ambulatory blood pressure measurement: on which arm should we place the device? ABPM is a blood pressure measurement methodology that is integrated into the Canadian Hypertension Educative Program (CHEP) [7]. ABPM has been proven to be better than clinically measured blood pressure in predicting cardiovascular risk [8] and remains an important complementary method to confirm a diagnosis of systemic hypertension. ABPM was not discussed in the Eighth Joint National Committee (JNC 8) [9], but is covered in the American Heart Association (AHA) [10] and in the European Society of Hypertension (ESH) guidelines [11]. Despite the importance of ABPM in hypertension management, the methodological principles related to the choice of arm for cuff installation are not standardized in all hypertension guidelines. In the latest most recently updated CHEP recommendation, the following issues are mentioned: (i) reasons for using ABPM, (ii) importance of using a validated device, (iii) blood pressure threshold values, and (iv) magnitude of change expected in nocturnal blood pressure. There is no mention about which arm should be used for ABPM [7]. By contrast, the AHA recommendation [10] suggests the nondominant arm for ABPM device installation. In the ESH guidelines, details on the importance of the choice of arm are clearly discussed that specify the importance of selecting the arm in which blood pressure value is the highest for ABPM cuff installation [11]. The lack of agreement in hypertension guidelines on which arm should be used for blood pressure determination is of concern as this issue was highlighted in two meta-analyses and in the Framingham Heart Study [12–14]. Both meta-analyses have reached similar conclusions on the importance of assessing blood pressure values in both arms for better evaluation of cardiovascular risk [12,13]. The authors evaluated (i) the association between an interarm difference of 10 mmHg or more and cardiovascular disease and mortality [12] and (ii) whether interarm difference had an influence on interarm results [13]. They concluded that a difference of 10 mmHg or more should be indicative of further investigation [12,13]. In the Framingham Heart Study, which included 3390 participants, results suggested that a modest interarm systolic blood pressure difference (1 − SD unit increment) was associated with a higher risk of a future
cardiovascular risk event [14]. Interarm blood pressure measures should be determined simultaneously in both arms with one or two automatic devices and multiple readings should be obtained [13]. This issue should be discussed in future North American Hypertension guidelines to emphasize the fact that blood pressure should always be measured in the arm in which the value is higher. Interarm blood pressure differences should always be assessed preferably in both arms simultaneously before ABPM device installation. Second, the arm with the highest value should be considered for ABPM (if the interarm difference exceeds 10 mmHg), even if this arm is the dominant one. In conclusion, myths on ABPM installation and the preferential arm and fear of taking blood pressure on the postmastectomy side require additional attention in research as well as in hypertension guidelines. Blood pressure measurement should be obtained in both arms before ABPM installation, and the arm with higher blood pressure value should probably be chosen for ABPM measurement (irrespective of dominance or postmastectomy). Second, there is no scientifically reported rationale to avoid the arm on the postmastectomy side; safe and informative measurements can be obtained in both arms.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1
Petrek JA, Pressman PI, Smith RA. Lymphedema: current issues in research and management. CA Cancer J Clin 2000; 50:292–307. 2 Patterson RE, Flatt SW, Saquib N, Rock CL, Caan BJ, Parker BA, et al. Medical comorbidities predict mortality in women with a history of early stage breast cancer. Breast Cancer Res Treat 2010; 122:859–865. 3 Dell DD, Doll C. Caring for a patient with lymphedema. Nursing (Brux) 2006; 36:49–51. 4 Greene AK, Borud L, Slavin SA. Blood pressure monitoring and venipuncture in the lymphedematous extremity. Plast Reconstr Surg 2005; 116:2058–2059. 5 Margenthaler JA, Johnson FE, Cyr AE. Intensity of follow-up after breast cancer surgery: low versus high? Ann Surg Oncol 2014; 21:733–737. 6 Leblanc MÉ, Croteau S, Ferland A, Bussières J, Cloutier L, Hould FS, et al. Blood pressure assessment in severe obesity: validation of a forearm approach. Obesity (Silver Spring) 2013; 21:E533–E541. 7 Dasgupta K, Quinn RR, Zarnke KB, Rabi DM, Ravani P, Daskalopoulou SS, et al. Canadian Hypertension Education Program. The 2014 Canadian Hypertension Education Program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension. Can J Cardiol 2014; 30:485–501. 8 Hansen TW, Jeppesen J, Rasmussen S, Ibsen H, Torp-Pedersen C. Ambulatory blood pressure monitoring and risk of cardiovascular disease: a population based study. Am J Hypertens 2006; 19:243–250. 9 James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2014; 311:507–520. 10 Pickering TG, Hall JE, Appel LJ, Falkner BE, Graves J, Hill MN, et al. Recommendations for blood pressure measurement in humans and experimental animals: part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
188 Blood Pressure Monitoring 2015, Vol 20 No 4
11
12
Public Education of the American Heart Association Council on High Blood Pressure Research. Circulation 2005; 111:697–716. O’Brien E, Parati G, Stergiou G, Asmar R, Beilin L, Bilo G, et al. European Society of Hypertension Working Group on Blood Pressure Monitoring. European Society of Hypertension position paper on ambulatory blood pressure monitoring. J Hypertens 2013; 31:1731–1768. Clark CE, Taylor RS, Shore AC, Ukoumunne OC, Campbell JL. Association of a difference in systolic blood pressure between arms with vascular disease
13
14
and mortality: a systematic review and meta-analysis. Lancet 2012; 379:905–914. Verberk WJ, Kessels AG, Thien T. Blood pressure measurement method and inter-arm differences: a meta-analysis. Am J Hypertens 2011; 24:1201–1208. Weinberg I, Gona P, O’Donnell CJ, Jaff MR, Murabito JM. The systolic blood pressure difference between arms and cardiovascular disease in the Framingham Heart Study. Am J Med 2014; 127:209–215.
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
