Which cuff should I use? Indirect blood pressure measurement for the diagnosis of hypertension in patients with obesity: a diagnostic accuracy review.

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obesity 127 should I use? Indirect blood pressure measurement for the diagnosis of hypertension in patients with obesity : a diagnostic accuracy reviewGreg IrvingJohn HoldenRichard StevensRichard J McManus [1]Department of
obesity 610 (BP) measurement compared with reference standards for the diagnosis of hypertension in patients with obesity with a large arm circumference.DesignSystematic review with meta-analysis with hierarchical summary
obesity 2602 fitting upper arm cuff is sufficiently sensitive and specific to diagnose hypertension in patients with obesity with a large upper arm circumference. If a correctly fitting upper arm cuff cannot be applied, an incorrectly
obesity 3476 with invasive blood pressure.All included studies used body mass index (BMI) >30 as an indicator of obesity . Although BMI generally increases as adiposity increases, due to variation in body composition, it is
obesity 4186 circumference.[3] In the USA, over 30% of the population have a large arm circumference as a consequence of obesity , a figure which can rise to over 60% in some clinics.[4][5]Standard cuffs are ∼22–32 cm with large
obesity 4957 1).Table 1Implications for policyGuidelineGuidanceCommentAmerican Heart Association[8]“In patients with morbid obesity , one will encounter very large arm circumferences…In this circumstance, the clinician may measure
obesity 5805 extremely large arm circumference.”This review would support the use of wrist BP devises in patients with obesity if a correctly fitting upper arm cuff cannot be applied and the device was used at the level of the
obesity 6238 large cuff.”No specific guidance is offered for the use of wrist BP measurement in patients with obesity with a large arm circumference.“The bladder of the cuff should fit around at least 80% of the arm
obesity 6659 arm BP cuff is sufficiently sensitive and specific for the diagnosis of hypertension in patients with obesity . This holds true for patients with BMI>35. It was not possible to undertake a subgroup analysis of those
obesity 7157 Hypertension[10]No specific guidance is offered for the use of wrist BP measurement in patients with obesity with a large arm circumference.Compared with the reference test of invasive BP, a correctly fitting
obesity 7373 arm BP cuff is sufficiently sensitive and specific for the diagnosis of hypertension in patients with obesity . This holds true for patients with BMI>35. It was not possible to undertake a subgroup analysis of those
obesity 7672 pressure.Understanding which alternative method to use is important because hypertension is common in patients with obesity and the consequences of missing the diagnosis is potentially severe at the individual and population
obesity 8088 fitting cuff) and/or ambulatory BP measurement (ABPM) for the diagnosis of hypertension in patients with obesity with a large arm circumference.MethodsSearch methods for identification of studiesMEDLINE, EMBASE, Cochrane
obesity 8824 (correctly fitting cuff) or ABPM for the diagnosis of hypertension in adult (over 18 years) patients with obesity were included. For each index test, all cuff shapes and sizes were considered. Thresholds for hypertension
obesity 12238 evidence of differences between studies sensitivity analyses were undertaken based on: Measurement of obesity : indirect/direct methods, for example, bioelectrical impedance analysis (BIA) or skin fold thickness.Risk
obesity 14337 by reference test below.Table 2Characteristics of included studiesStudySample size (patients with obesity )Mean ageMale (%)Study populationStudy designBennett et al[19]*26––CommunityCross-sectionalBerntsen
obesity 16573 outpatientCross-sectional*Studies with extractable data.All studies used body mass index ≥30 as definition of obesity .Reference test: invasively measured BPSix studies were found with extractable data (eight data sets)
obesity 16734 were found with extractable data (eight data sets) comparing upper arm BP with invasive measurement in obesity yielding a pooled sensitivity of 0.87 (0.79 to 0.93) and a specificity of 0.85 (0.64 to 0.95).[18][27][29][32]
obesity 22974 ambulatory BPOne study with extractable data compared upper arm BP measurement with that of ambulatory BP in obesity .[25] This showed a sensitivity of 0.45 (0.29 to 062) and a specificity of 0.71 (0.60 to 0.81). Given
obesity 23943 comment on how forearm, wrist and finger BP testing perform in relation to invasively measured BP in obesity .Table 4Summary of resultsReferenceIndexNumber of Studies (number of participants)SensitivitySpecificityPositive
obesity 25984 researchers was used to calculate Bland-Altman analyses.All included studies used BMI>30 as an indicator of obesity which has limitations. Although BMI generally increases as adiposity increases, due to variation in
obesity 26290 proportion of muscle mass could have a high BMI. In a similar way arm circumference as a measure of arm obesity may be confounded in the case of an athlete with a low percentage body fat and large, muscular arms.
obesity 26541 BIA, skin fold thickness, underwater weighing. In some populations, the percentage of patients without obesity with a large arm circumference arms can be ∼10% (Latman 2013, personal communication).Some statistical
obesity 27497 the best of our knowledge, to summarise the international literature on indirect BP measurement in obesity . This is perhaps reflected in the variation between international guidelines in their recommendations
obesity 27629 reflected in the variation between international guidelines in their recommendations for BP measurement in obesity .[1][8] The American Heart Association currently advocate the use of forearm BP, the European Society
obesity 28220 arm BP cuff is sufficiently sensitive and specific for the diagnosis of hypertension in patients with obesity . This also hold true for patients with a BMI>35. If a correctly fitting cuff cannot be fitted or is
obesity 29685 measurement techniques (upper arm, forearm wrist, finger) for the diagnosis of hypertension in patients with obesity with a large arm circumference compared with three different reference standards: invasive BP, correctly

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