Inter-arm blood pressure difference in post-stroke patients with hemiparesis

Inter-arm blood pressure difference in post-stroke patients with hemiparesis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Inter-arm blood pressure difference in post-stroke patients with hemiparesis Hai-ping PENG, Liang TAO, Min TANG, Hai Su This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2441705/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 27 Dec, 2023 Read the published version in Journal of Human Hypertension → Version 1 posted 10 You are reading this latest preprint version Abstract The aim of this study was to Tinvestigate that inter-arm blood pressure (BP) difference (IAD) in post-stroke patients with hemiparesis. This study enrolled 420 post-stroke patients with hemiparesis. Simultaneous bilateral arm BP was measured with two automatic BP devices, and the systolic BP difference ≥ 10 mm Hg was recorded as sIAD. The arm with higher systolic BP (SBP) was assigned as the reference arm. Our results showed that the prevalence of sIAD was 18.1% in the total group. The paretic arms had similar mean SBP levels (133.6 ± 18.4 vs 133.8 ± 18.4 mm Hg, NS) and DBP (77.8 ± 11.5 vs 77.2 ± 10.9 mm Hg, NS) as compared with the unaffected arms. The detection rate of hypertension on the SBP values of the reference arm was higher than that on the unaffected arm (41.8% vs 36.3). In is convoluted that the prevalence of sIAD ≥ 10 mmH was 18.1% and that for dIAD ≥ 10 mmH was 9% in the post-stroke patients with hemiparesis, thus, bilateral arm BP measurement is encouraged for evaluating IAD and decreasing the miss diagnosis of hypertension. Health sciences/Diseases/Cardiovascular diseases/Hypertension Health sciences/Health care/Disease prevention IAD post-stroke paralysis blood pressure Introduction According to the current hypertension guidelines, the accurate blood pressure (BP) measurement is to measure bilateral arm BP at first to identify the reference arm, the arm has higher BP reading, and then, the reference arm is used for BP measurement [ 1 – 3 ] . It is well known that bilateral arm BP measurement may evaluate inter-arm BP difference (IAD). At present, systolic IAD (sIAD) ≥ 10 mm Hg is considered as a predictor subclavian artery stenosis [ 4 – 6 ] . Meanwhile, increased IAD was positively correlated with CAD severity [ 7 ] . Unfortunately, the prevalence of IAD in the post-stroke patients was not deeply investigated. However, a study found that indirect BP measurement in paretic arm is often inaccurate as the changes in muscle tone [ 8 ] . In addition, some studies suggested that paretic arm may have multiple patho-physiological changes: artery construction, vascular endothelial dysfunction [ 9 , 10 ] , thromboembolic formation [ 11 ] , and skeletal muscle atrophy [ 12 ] . Even there is conflicting evidence, most doctors and nurses use the unaffected (or healthy) arm for BP measurement in the post-stroke patients with hemiparesis [ 13 – 15 ] . As a result, the IAD could be not evaluated in these patients. The main aim of this study was to evaluate the prevalence of IAD in the post-stroke patients underwent rehabilitation; the second aim was to evaluate the possible variation for hypertension diagnosis based on the traditional method (to use unaffected arm) from that on reference arm in a cohort of post-stroke patients with hemiparesis. This information is useful for physicians for better diagnosing and managing hypertension in these patients. Subjects And Methods This study was approved by the Ethics Committee of Ningbo Rehabilitation Hospital, and oral informed consent was received as the bilateral arm BP measurement is a non-invasive clinical examination. 1.1 Subjects This hospital-based observational study from May 2018 to July of 2020 included 420 post-stroke patients with hemiparesis, who underwent rehabilitation treatment in Ningbo Rehabilitation Hospital. The mean age was 64.7 ± 14.6 years old (19–98 year old) in this studied population. Table 1 The characteristic of the 420 post-stroke patients with hemiparesis Age (year) 64.7 ± 14.6 Male N (%) 289(68.8) Hypertension N (%) 291(69.3) Diabetes N (%) 105 (25) CHD N (%) 27(6.4) CKDN (%) 13(3.1) COPD N (%) 3(0.7) Smoking N (%) 111(26.4) Drinker N (%) 123(29.3) ACEI/ARB N (%) 140(33.3) CCB N (%) 189(45) Diuretic N (%) 85 (20.2) CHD: coronary heart disease; CKD: chronic kidney disease; COPD: chronic obstructive pulmonary disease; ACEI: angiotensin converting enzyme inhibitors; ARB: angiotensin receptor blocker; CCB: calcium channel blocker. The diagnosis of stroke was confirmed with computer tomography (CT) or magnetic resonance imaging (MRI). All patients suffered from the first stroke and were treated in a general hospital for at least 12 days. The exclusion criteria were arrhythmia (including atrial fibrillation and premature beat), acute myocardial infarction, aortic coarctation, congenital heart disease, heart failure and the history of trans-radial coronary intervention. In this study, the pulse of the radial artery was populated at first in order to exclude pulseless disease. Most of them were in the stage of 2–4 on the Brunnstrom phases. 1.2 Methods The bilateral arm BP measurement was performed after administration using two validated automatic BP measurement devices (Omron, HEM-7403) for 3 times with a 1-min interval, and the average of 3 readings was recorded as the final BP. The BP difference between the paretic and unaffected arms was recorded as BPp-u, and its absolute value was recorded also. The percentage of the patients with systolic (sIAD) or diastolic IAD (dIAD) ≥ 10mmHg was calculated, respectively. According to the current hypertension guidelines, the arm with higher systolic BP (SBP, at least ≥ 1 mm Hg ) detected by the bilateral-arm measurement was assigned as the reference arm for the subsequent BP measurement [ 1 – 3 ] . The diagnosis rates of hypertension were calculated on the BP levels from the unaffected arm or the reference arm, respectively. The criteria for hypertension was SBP/DBP ≥ 140 and/or 90mmHg 1.3 Statistical analysis Data were created in Excel 2003 and analyzed with SPSS23.0. Continuous variables were expressed as mean ± SD. The t-test, variance (ANOVA) test and the omnibus test were used for statistical analysis. Linear regression analysis was used to determine the relationship between the ankle-arm BP differences among three stages. P < 0.05 was considered statistically significant. Results In the 420 post-stroke patients with hemiparesis, 219 had paretic right arm (52.1%) and 201 had paretic left arm (47.9%). The mean absolute BPp-u values were 5.8 ± 5.8 mm Hg for the total patients. Meanwhile, the absolute BPp-u values were similar between the patients with paretic right arm or the paretic left arm (4.9 ± 4.6 mm Hg vs 5.8 ± 5.7 mm Hg). The prevalence of sIAD was 18.1% and that for dIAD was 9% in the total group. Meanwhile, the prevalence of sIAD in the patients with paretic right arm or paretic left arm were similar (16.9% vs 19.4%); similar results were found on dIAD (8.2% vs 10.0%) (Table 2 ). Table 2 The percentage of IAD in the 420 patients Total (N = 420) Paretic right arm (N = 219) Paretic left arm (N = 201) sIAD ≥ 10mmHg n(%) 76(18.1) 37 (16.9) 39 (19.4) dIAD > 10mmHg n (%) 38(9.0) 18 (8.2) 20 (10.0) The paretic arms had similar mean SBP levels (133.6 ± 18.4 vs 133.8 ± 18.4 mm Hg, NS) and DBP (77.8 ± 11.5 vs 77.2 ± 10.9 mm Hg, NS) as compared with the unaffected arms in the total patients. On SBP levels, a reference arm was assigned on the right arm in 45.2% patients, and on the left arm in 46.4% patients; In other 35 patients (8.3%) the bilateral SBP was equal (no reference arm was assigned) (Table 3 ). Table 3 The assigning of reference arm in the 420 patients Right paralysis (N = 219) Left paralysis (N = 201) Total (N = 420) paretic unaffected paretic unaffected paretic unaffected SBP(mmHg) 133.9 ± 18.9 133.7 ± 18.9 133.3 ± 18.0 133.9 ± 17.9 133.6 ± 18.4 133.8 ± 18.4 DBP(mmHg) 77.9 ± 11.9 77.7 ± 11.1 77.7 ± 11.0* 76.7 ± 10.6 77.8 ± 11.5 77.2 ± 10.9* *: compared with the paralysis side, p < 0.05; The SBP and DBP levels on the reference arm were significantly higher than those on the unaffected arm regardless of the paralysis side. Meanwhile, the detection rate of systolic hypertension (40% vs 35.2% ) and diastolic hypertension (16.9% vs 13.1%) was higher based on the BP values of reference arm than those on the unaffected arm, although the difference had not statistical meaning (Table 4 ). Table 4 The hypertension detection rate on the BP values of unaffected or reference arm Unaffected arm Reference arm SBP (mmHg) 133.8 ± 18.4 136.6 ± 18.2* HT-SBP n (%) 148(35.2) 168(40.0) DBP (mmHg) 77.3 ± 10.9 79.7 ± 11.1* HT-DBP n (%) 55(13.1) 71(16.9) HT: hypertension; * compared with the relative parameter of unaffected arm, p < 0.05; Discussion This study found that the prevalence of sIAD was high as 18.6% i n these post-stroke patients with hemiparesis. Based on 16 studies, Clark et al. pointed out that the pooled estimates of prevalence for sIAD ≥10 mmHg were 11.2% in hypertension, 7.4% in diabetes, and 3.6% for a general adult population [16] . Another study showed that the prevalence rates of sIAD≥10 mmHg were 12.8% in Chinese community hypertensive population [17] . The prevaluence of IAD in this population was higher as compared with the previous reports. As sIAD ≥10mm Hg is associated with poor outcome and high burden of cerebral small-vessel diseases in the post-stroke patients [14,18-20] , bilateral BP measurement in the post-stroke patients is necessary to screen the sIAD. Thus, we encourage to measure bilateral arm BP at first to screen IAD. According to the current hypertension guidelines, bilateral arm BP should be measured at first to identify a reference arm for subsequent BP measurement. However, almost physicians and nurses use the unaffected arm for BP measurement in the post-stroke patients with hemiparesis, at least in China [15] . Our study found in these patients, the possibility of reference arm assigned on the unaffected arm or on the paretic arm was almost the same (194 cases vs 191cases). These results mean that the paretic arm may have not obvious patho-physiological abnormality, at least in rehabilitation period. Furthermore, the present study also demonstrated that the mean SBP and DBP levels measured on the reference arm were significantly higher by 2.9/2.4 mm Hg than those on the unaffected arm. When using the SBP values from unaffected arm, the detection rate of systolic hypertension was 35.2%, while this rate increased to 40.0% when using the values from reference arm, and there was a difference of 5 percentages. In other words, of the 168 patients with true hypertension, 22 patients were misdiagnosed as normotensives when using the BP values of unaffected arm. These results clearly indicted that using the unaffected arm to measure BP may miss the diagnosis of hypertension in post-stroke patients with hemiparesis. Therefore, we suggest that bilateral arm BP measurement at first to identify the reference arm, and the BP values measured on the reference arm are used for hypertension diagnosis [1,2] . A previous study enrolled 236 post-stroke patients with hemiplegic paralysis and found that the paralyzed arm had similar mean SBP and DBP levels as compared with the unaffected arm [21] . Clinical implications It is important to screen IAD in the post-stroke patients even in the rehabilitation period with bilateral arm BP measurement, the traditional approach to using unaffected arm for BP measurement is not reasonable, as this method could not detect IAD at first, meanwhile, using the unaffected arm for BP measurement may underestimate BP levels and hypertension detection rate. A study showed that using BP from higher instead of lower reading arms reclassified 12% of people over thresholds used to diagnose hypertension. For accurate diagnosis and management of hypertension bilateral arm BP measurement should be measured [22] . Limitation This study was performed in the post-stroke patients with hemiparesis in rehabilitation period, thus, the values may be not exactly similar for the acute stroke patients, because the muscle tone of the paretic arm may vary with the acute or chronic phases, which may impact the BP measurement. Previously, Dewar et al. found that a flaccid arm was associated with a lower reading as the hypotonic muscle and easier occlusion of the brachial artery [8] . Secondly, no imaging of the arm and leg artery was collected to confirm their artery disease in this study. But these limitations did not influence our conclusion. Conclusion The prevalence of sIAD ≥ 10 mmH was 18.1% and that for dIAD ≥ 10 mmH was 9% in the post-stroke patients with hemiparesis, thus, bilateral arm BP measurement is encouraged for evaluating IAD and decreasing the miss diagnosis of hypertension. Summary Table What is known about topic According to the current hypertension guidelines, the bilateral arm blood pressure (BP) should be measured at first. Unfortunately, the prevalence of IAD in the post-stroke patients with hemiparesis is not deeply investigated as the unaffected arm is used for BP measurement in these patients now. What this study adds' . The prevalence of sIAD ≥10 mmH was 18.1% and that for dIAD≥10 mmH was 9% in the post-stroke patients with hemiparesis in rehabilitation period. Bilateral arm BP measurement is encouraged for evaluating IAD and correct diagnosis of hypertension. Declarations There are no conflicts of interest. References Pickering TG, Hall JE, Appel LJ, 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 Public Education of the American Heart Association Council on High Blood Pressure Research. Circulation. 2005 ,111(5):697-716 Williams B, Mancia G, Spiering W, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH)[J]. European heart journal, 2018, 39(33): 3021-3104. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA /ABC/ACPM/AGS/APhA /ASH/ASPC /NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults[J].Hypertension .2018,71:13-5. Clark CE, Taylor RS, Shore AC,et al. Association of a difference in systolic blood pressure between arms with vascular disease and mortality: a systematic review and meta-analysis.Lancet. 2012,379:905-914. Singh S, Sethi A, Singh M, et al. Simultaneously measured inter-arm and inter-leg systolic blood pressure differences and cardiovascular risk stratification: a systemic review and meta-analysis. J Am Soc Hypertens. 2015,9(8):640–50. Singh S, Sethi A, Singh M, et al. Prevalence of simultaneously measured interarm systolic blood pressure difference and its clinical and demographic predictors: a systemic review and meta-analysis[J]. Blood pressure monitoring, 2015, 20(4): 178-185. Das S, Iktidar MA, Das J, Chowdhury F, Roy S. Inter-arm blood pressure difference as a tool for predicting coronary artery disease severity. Open Heart. 2022 Aug;9(2):e002063. doi: 10.1136/openhrt-2022-002063. PMID: 35961695; PMCID: PMC9379529. Dewar R, Sykes D, Mulkerrin E, et al. The effect of hemiplegia on blood pressure measurement in the elderly[J]. Postgraduate medical journal, 1992, 68(805): 888-891. Shenberger JS, Leaman GJ, Neumyer MM, et al. Physiologic and structural indices of vascular function in paraplegics. Med Sci Sports Exerc. 1990,22(1):96-101. Wang JS, Yang CF, Liaw MY, et al. Suppressed cutaneous endothelial vascular control and hemodynamic changes in paretic extremities with edema in the extremities of patients with hemiplegia. Arch Phys Med Rehabil. 2002 ,83(7):1017-23. Harvey RL. Hemiplegia and contralateral upper limb claudication--a case of dual disability from pseudoaneurysm of the brachiocephalic artery: a brief report. Am J Phys Med Rehabil. 1999 ,78(1):56-9. Yin MZ, Kim HJ, Suh EY, et al. Endurance exercise training restores atrophy-induced decreases of myogenic response and ionic currents in rat skeletal muscle artery[J]. Journal of Applied Physiology. 2019, 126(6): 1713-1724. Garland M. Practical Management of Stroke [J]. Postgraduate medical journal.1985, 61(721): 1026. Yagi S, Ichikawa S, Sakamaki T , et al. Blood pressure in the paretic arms of patients with stroke. The New England journal of medicine. 1986,315(13), 836. Yin Lei. Foundation of Nursing Science [M]. Beijing: People ’s Medical Publishing House, 2004: 98 Christopher E Clark,Rod S Taylor,Angela C Shore, John L Campbell. Prevalence of systolic inter-arm differences in blood pressure for different primary care populations: systematic review and meta-analysisBr J Gen Pract . 2016 Nov;66(652):e838-e847. Yu Y, Liu L, Lo K, Tang S, Feng Y. Prevalence and associated factors of inter-arm blood pressure difference in Chinese community hypertensive population. Postgrad Med. 2021 Mar;133(2):188-194. Harvey RL. Hemiplegia and contralateral upper limb claudication--a case of dual disability from pseudoaneurysm of the brachiocephalic artery: a brief report. Am J Phys Med Rehabil. 1999 ,78(1):56-9. Yin MZ, Kim HJ, Suh EY, et al. Endurance exercise training restores atrophy-induced decreases of myogenic response and ionic currents in rat skeletal muscle artery[J]. Journal of Applied Physiology. 2019, 126(6): 1713-1724. Garland M. Practical Management of Stroke [J]. Postgraduate medical journal.1985, 61(721): 1026. Tao L, Tang M, Peng HP, Gu MB, Zhang HZ, Zhou G, Su H. Is the blood pressure different between the paralyzed and unaffected arms or legs? Blood Press Monit. 2020 Oct;25(5):242-245. Clark CE, Warren FC, Boddy K, McDonagh STJ, Moore SF, Teresa Alzamora M, Ramos Blanes R, Chuang SY, Criqui MH, Dahl M, Engström G, Erbel R, Espeland M, Ferrucci L, Guerchet M, Hattersley A, Lahoz C, McClelland RL, McDermott MM, Price J, Stoffers HE, Wang JG, Westerink J, White J, Cloutier L, Taylor RS, Shore AC, McManus RJ, Aboyans V, Campbell JL. Higher Arm Versus Lower Arm Systolic Blood Pressure and Cardiovascular Outcomes: a Meta-Analysis of Individual Participant Data From the INTERPRESS-IPD Collaboration. Hypertension. 2022 Oct;79(10):2328-2335. Additional Declarations There is NO conflict of interest to disclose. Cite Share Download PDF Status: Published Journal Publication published 27 Dec, 2023 Read the published version in Journal of Human Hypertension → Version 1 posted Editorial decision: revise 22 Feb, 2023 Review # 2 received at journal 21 Feb, 2023 Reviewer # 2 agreed at journal 06 Feb, 2023 Review # 1 received at journal 29 Jan, 2023 Reviewer # 1 agreed at journal 16 Jan, 2023 Reviewers invited by journal 13 Jan, 2023 Editor assigned by journal 11 Jan, 2023 Submission checks completed at journal 09 Jan, 2023 First submitted to journal 06 Jan, 2023 Unknown event 06 Jan, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2441705","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":167598262,"identity":"e9912aad-a3a7-456e-8e86-217c31117c00","order_by":0,"name":"Hai-ping PENG","email":"","orcid":"","institution":"","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hai-ping","middleName":"","lastName":"PENG","suffix":""},{"id":167598263,"identity":"f2f0478e-1da4-4fd4-bc5b-6fbc37fc747d","order_by":1,"name":"Liang TAO","email":"","orcid":"","institution":"","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Liang","middleName":"","lastName":"TAO","suffix":""},{"id":167598264,"identity":"691b3887-7343-49ff-be7e-f125a455735b","order_by":2,"name":"Min TANG","email":"","orcid":"","institution":"","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Min","middleName":"","lastName":"TANG","suffix":""},{"id":167598265,"identity":"41b3f48e-1523-4d88-86f3-1416893ee73e","order_by":3,"name":"Hai Su","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzklEQVRIiWNgGAWjYJCCw2CSvYGBmUQtPAdI0AJRKZFApBb5GTmGhwtq7uQZ3Hz+8HFhG4M8v9gB/FoMbuQYHJ5x7Fmxwe0cY+OZbQyGM2cnENAiAdTCw3Y4ccPtHDZp3jaGBIPbBLQAHQbU8g+o5ebxZ8RpYQA5jLcNqOUGgxlxWgzOPCs4zNv3rFjyDNAvPOckCPtFvj1582eeb3fy+I4ff/iYp8xGnl+akMMYOAyAxIEEhQNgngQh5SDA/gCsRb6BGMWjYBSMglEwIgEA1RJI0wWm4sEAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0003-3309-9636","institution":"the Second Affiliated Hospital of Nanchang University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Hai","middleName":"","lastName":"Su","suffix":""}],"badges":[],"createdAt":"2023-01-04 07:46:51","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2441705/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2441705/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41371-023-00886-y","type":"published","date":"2023-12-27T05:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":48893607,"identity":"a352db99-e399-44cc-86c8-4a98d3deecf1","added_by":"auto","created_at":"2023-12-28 08:06:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":226154,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2441705/v1/acf64677-3d1f-461a-b37f-2877ebec6a9a.pdf"}],"financialInterests":"There is \u003cb\u003eNO\u003c/b\u003e conflict of interest to disclose.","formattedTitle":"Inter-arm blood pressure difference in post-stroke patients with hemiparesis","fulltext":[{"header":"Introduction","content":"\u003cp\u003e According to the current hypertension guidelines, the accurate blood pressure (BP) measurement is\u003c/p\u003e \u003cp\u003eto measure bilateral arm BP at first to identify the reference arm, the arm has higher BP reading, and then, the reference arm is used for BP measurement \u003csup\u003e[\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e–\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. It is well known that bilateral arm BP measurement may evaluate inter-arm BP difference (IAD). At present, systolic IAD (sIAD) ≥ 10 mm Hg is considered as a predictor subclavian artery stenosis \u003csup\u003e[\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e–\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. Meanwhile, increased IAD was positively correlated with CAD severity \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. Unfortunately, the prevalence of IAD in the post-stroke patients was not deeply investigated.\u003c/p\u003e \u003cp\u003eHowever, a study found that indirect BP measurement in paretic arm is often inaccurate as the changes in muscle tone \u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. In addition, some studies suggested that paretic arm may have multiple patho-physiological changes: artery construction, vascular endothelial dysfunction \u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e, thromboembolic formation \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e, and skeletal muscle atrophy \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. Even there is conflicting evidence, most doctors and nurses use the unaffected (or healthy) arm for BP measurement in the post-stroke patients with hemiparesis \u003csup\u003e[\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e–\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. As a result, the IAD could be not evaluated in these patients.\u003c/p\u003e \u003cp\u003eThe main aim of this study was to evaluate the prevalence of IAD in the post-stroke patients underwent rehabilitation; the second aim was to evaluate the possible variation for hypertension diagnosis based on the traditional method (to use unaffected arm) from that on reference arm in a cohort of post-stroke patients with hemiparesis. This information is useful for physicians for better diagnosing and managing hypertension in these patients.\u003c/p\u003e "},{"header":"Subjects And Methods","content":"\u003cp\u003eThis study was approved by the Ethics Committee of Ningbo Rehabilitation Hospital, and oral informed consent was received as the bilateral arm BP measurement is a non-invasive clinical examination.\u003c/p\u003e\n\u003ch2\u003e1.1 Subjects\u003c/h2\u003e\n\u003cp\u003eThis hospital-based observational study from May 2018 to July of 2020 included 420 post-stroke patients with hemiparesis, who underwent rehabilitation treatment in Ningbo Rehabilitation Hospital. The mean age was 64.7\u0026thinsp;\u0026plusmn;\u0026thinsp;14.6 years old (19\u0026ndash;98 year old) in this studied population.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eThe characteristic of the 420 post-stroke patients with hemiparesis\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\u003ccolgroup\u003e\u003c/colgroup\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAge (year)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e64.7\u0026thinsp;\u0026plusmn;\u0026thinsp;14.6\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMale N (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e289(68.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHypertension N (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e291(69.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDiabetes N (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e105 (25)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCHD N (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e27(6.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCKDN (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13(3.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCOPD N (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3(0.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSmoking N (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e111(26.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDrinker N (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e123(29.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eACEI/ARB N (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e140(33.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCCB N (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e189(45)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDiuretic N (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e85 (20.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\"\u003eCHD: coronary heart disease; CKD: chronic kidney disease; COPD: chronic obstructive pulmonary disease; ACEI: angiotensin converting enzyme inhibitors; ARB: angiotensin receptor blocker; CCB: calcium channel blocker.\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe diagnosis of stroke was confirmed with computer tomography (CT) or magnetic resonance imaging (MRI). All patients suffered from the first stroke and were treated in a general hospital for at least 12 days. The exclusion criteria were arrhythmia (including atrial fibrillation and premature beat), acute myocardial infarction, aortic coarctation, congenital heart disease, heart failure and the history of trans-radial coronary intervention. In this study, the pulse of the radial artery was populated at first in order to exclude pulseless disease. Most of them were in the stage of 2\u0026ndash;4 on the Brunnstrom phases.\u003c/p\u003e\n\u003ch2\u003e1.2 Methods\u003c/h2\u003e\n\u003cp\u003eThe bilateral arm BP measurement was performed after administration using two validated automatic BP measurement devices (Omron, HEM-7403) for 3 times with a 1-min interval, and the average of 3 readings was recorded as the final BP.\u003c/p\u003e\n\u003cp\u003eThe BP difference between the paretic and unaffected arms was recorded as BPp-u, and its absolute value was recorded also. The percentage of the patients with systolic (sIAD) or diastolic IAD (dIAD)\u0026thinsp;\u0026ge;\u0026thinsp;10mmHg was calculated, respectively.\u003c/p\u003e\n\u003cp\u003eAccording to the current hypertension guidelines, the arm with higher systolic BP (SBP, at least\u0026thinsp;\u0026ge;\u0026thinsp;1 mm Hg ) detected by the bilateral-arm measurement was assigned as the reference arm for the subsequent BP measurement \u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe diagnosis rates of hypertension were calculated on the BP levels from the unaffected arm or the reference arm, respectively. The criteria for hypertension was SBP/DBP\u0026thinsp;\u0026ge;\u0026thinsp;140 and/or 90mmHg\u003c/p\u003e\n\u003ch2\u003e1.3 Statistical analysis\u003c/h2\u003e\n\u003cp\u003eData were created in Excel 2003 and analyzed with SPSS23.0. Continuous variables were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD. The t-test, variance (ANOVA) test and the omnibus test were used for statistical analysis. Linear regression analysis was used to determine the relationship between the ankle-arm BP differences among three stages. P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIn the 420 post-stroke patients with hemiparesis, 219 had paretic right arm (52.1%) and 201 had paretic left arm (47.9%). The mean absolute BPp-u values were 5.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.8 mm Hg for the total patients. Meanwhile, the absolute BPp-u values were similar between the patients with paretic right arm or the paretic left arm (4.9\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6 mm Hg vs 5.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.7 mm Hg).\u003c/p\u003e\n\u003cp\u003eThe prevalence of sIAD was 18.1% and that for dIAD was 9% in the total group. Meanwhile, the prevalence of sIAD in the patients with paretic right arm or paretic left arm were similar (16.9% vs 19.4%); similar results were found on dIAD (8.2% vs 10.0%) (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eThe percentage of IAD in the 420 patients\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eTotal (N\u0026thinsp;=\u0026thinsp;420)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eParetic right arm (N\u0026thinsp;=\u0026thinsp;219)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eParetic left arm (N\u0026thinsp;=\u0026thinsp;201)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003esIAD\u0026thinsp;\u0026ge;\u0026thinsp;10mmHg n(%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e76(18.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e37 (16.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e39 (19.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003edIAD\u0026thinsp;\u0026gt;\u0026thinsp;10mmHg n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e38(9.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e18 (8.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e20 (10.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe paretic arms had similar mean SBP levels (133.6\u0026thinsp;\u0026plusmn;\u0026thinsp;18.4 vs 133.8\u0026thinsp;\u0026plusmn;\u0026thinsp;18.4 mm Hg, NS) and DBP (77.8\u0026thinsp;\u0026plusmn;\u0026thinsp;11.5 vs 77.2\u0026thinsp;\u0026plusmn;\u0026thinsp;10.9 mm Hg, NS) as compared with the unaffected arms in the total patients.\u003c/p\u003e\n\u003cp\u003eOn SBP levels, a reference arm was assigned on the right arm in 45.2% patients, and on the left arm in 46.4% patients; In other 35 patients (8.3%) the bilateral SBP was equal (no reference arm was assigned) (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eThe assigning of reference arm in the 420 patients\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eRight paralysis (N\u0026thinsp;=\u0026thinsp;219)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eLeft paralysis (N\u0026thinsp;=\u0026thinsp;201)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eTotal (N\u0026thinsp;=\u0026thinsp;420)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eparetic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eunaffected\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eparetic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eunaffected\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eparetic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eunaffected\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eSBP(mmHg)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e133.9\u0026thinsp;\u0026plusmn;\u0026thinsp;18.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e133.7\u0026thinsp;\u0026plusmn;\u0026thinsp;18.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e133.3\u0026thinsp;\u0026plusmn;\u0026thinsp;18.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e133.9\u0026thinsp;\u0026plusmn;\u0026thinsp;17.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e133.6\u0026thinsp;\u0026plusmn;\u0026thinsp;18.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e133.8\u0026thinsp;\u0026plusmn;\u0026thinsp;18.4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eDBP(mmHg)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e77.9\u0026thinsp;\u0026plusmn;\u0026thinsp;11.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e77.7\u0026thinsp;\u0026plusmn;\u0026thinsp;11.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e77.7\u0026thinsp;\u0026plusmn;\u0026thinsp;11.0*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e76.7\u0026thinsp;\u0026plusmn;\u0026thinsp;10.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e77.8\u0026thinsp;\u0026plusmn;\u0026thinsp;11.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e77.2\u0026thinsp;\u0026plusmn;\u0026thinsp;10.9*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"8\"\u003e*: compared with the paralysis side, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05;\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe SBP and DBP levels on the reference arm were significantly higher than those on the unaffected arm regardless of the paralysis side. Meanwhile, the detection rate of systolic hypertension (40% vs 35.2% ) and diastolic hypertension (16.9% vs 13.1%) was higher based on the BP values of reference arm than those on the unaffected arm, although the difference had not statistical meaning (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab4\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eThe hypertension detection rate on the BP values of unaffected or reference arm\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eUnaffected arm\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eReference arm\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSBP (mmHg)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e133.8\u0026thinsp;\u0026plusmn;\u0026thinsp;18.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e136.6\u0026thinsp;\u0026plusmn;\u0026thinsp;18.2*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHT-SBP n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e148(35.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e168(40.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDBP (mmHg)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e77.3\u0026thinsp;\u0026plusmn;\u0026thinsp;10.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e79.7\u0026thinsp;\u0026plusmn;\u0026thinsp;11.1*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHT-DBP n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e55(13.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e71(16.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\"\u003eHT: hypertension; * compared with the relative parameter of unaffected arm, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05;\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study found that\u0026nbsp;the\u0026nbsp;prevalence of \u003cu\u003esIAD was high as 18.6% i\u003c/u\u003en these post-stroke\u0026nbsp;patients with hemiparesis.\u0026nbsp;Based on\u0026nbsp;16 studies, Clark et al. pointed out that the\u0026nbsp;pooled estimates of prevalence for sIAD \u0026ge;10 mmHg were 11.2% in hypertension, 7.4% in diabetes, and 3.6% for a general adult population\u003csup\u003e[16]\u003c/sup\u003e.\u0026nbsp;Another study showed that the\u0026nbsp;prevalence rates of sIAD\u0026ge;10 mmHg\u0026nbsp;were 12.8%\u0026nbsp;in\u0026nbsp;Chinese community hypertensive population\u003csup\u003e[17]\u003c/sup\u003e.\u0026nbsp;The\u0026nbsp;prevaluence of IAD in this population was higher as compared with the previous reports.\u0026nbsp;As\u0026nbsp;sIAD \u0026ge;10mm Hg is associated with poor outcome and high burden of cerebral small-vessel diseases in the post-stroke patients\u003csup\u003e\u0026nbsp;[14,18-20]\u003c/sup\u003e,\u0026nbsp;bilateral BP measurement in the post-stroke patients is necessary to screen the\u0026nbsp;sIAD. Thus, we encourage to measure bilateral arm BP at first to screen IAD.\u003c/p\u003e\n\u003cp\u003eAccording to the current hypertension guidelines, bilateral arm BP should be measured at first to identify a reference arm for subsequent BP measurement. However,\u0026nbsp;almost physicians and nurses use the unaffected arm for BP measurement in the post-stroke\u0026nbsp;patients with hemiparesis, at least in China\u003csup\u003e\u0026nbsp;[15]\u003c/sup\u003e.\u0026nbsp;Our study found in these\u0026nbsp;patients,\u0026nbsp;the possibility of reference arm assigned on the unaffected arm or on the paretic arm was almost the same (194 cases vs 191cases). These results mean that the paretic arm may have not obvious patho-physiological abnormality, at least in rehabilitation period.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFurthermore, the present study also demonstrated that the\u0026nbsp;mean SBP and DBP levels measured on the reference arm were significantly higher by 2.9/2.4 mm Hg than those on the unaffected arm.\u0026nbsp;When using the SBP values from unaffected arm, the detection rate of systolic hypertension was 35.2%, while this rate increased to 40.0% when using the values from reference arm, and there was a difference of 5 percentages. In other words, of the 168 patients with true hypertension, 22 patients were misdiagnosed as normotensives when using the BP values of unaffected arm. These results clearly indicted that using the unaffected arm to measure BP may miss the diagnosis of hypertension in post-stroke\u0026nbsp;patients with hemiparesis. Therefore, we suggest that bilateral arm BP measurement at first to identify the reference arm, and the BP values measured on the reference arm are used for hypertension diagnosis\u0026nbsp;\u003csup\u003e[1,2]\u003c/sup\u003e.\u0026nbsp;A previous\u0026nbsp;study enrolled 236 post-stroke patients with hemiplegic paralysis\u0026nbsp;and found that the paralyzed arm had similar mean SBP and DBP\u0026nbsp;levels as compared with the unaffected arm\u003csup\u003e[21]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical implications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;It is important to screen IAD in the post-stroke patients even in the rehabilitation period with bilateral arm BP measurement, the traditional approach to using unaffected arm for BP measurement is not reasonable,\u0026nbsp;as this method could not detect IAD at first, meanwhile, using the unaffected arm for BP measurement may underestimate BP levels and hypertension detection rate. A study showed that using BP from higher instead of lower reading arms reclassified 12% of people over thresholds used to diagnose hypertension.\u0026nbsp;For accurate diagnosis and management of hypertension\u0026nbsp;bilateral arm BP measurement\u0026nbsp;should be measured\u0026nbsp;\u003csup\u003e[22]\u003c/sup\u003e\u003csup\u003e.\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was performed in the post-stroke\u0026nbsp;patients with hemiparesis\u0026nbsp;in rehabilitation period, thus, the values may be not exactly similar for the acute stroke patients, because the\u0026nbsp;muscle tone of the paretic arm may vary with the\u0026nbsp;acute or chronic phases, which may\u0026nbsp;impact the BP measurement. Previously, Dewar et al. found that a flaccid arm was associated with a lower reading as the hypotonic muscle and easier occlusion of the brachial artery\u0026nbsp;\u003csup\u003e[8]\u003c/sup\u003e. Secondly, no imaging of the arm and leg artery was collected to confirm their artery disease in this study. But these limitations did not influence our conclusion.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe prevalence of sIAD\u0026thinsp;\u0026ge;\u0026thinsp;10 mmH was 18.1% and that for dIAD\u0026thinsp;\u0026ge;\u0026thinsp;10 mmH was 9% in the post-stroke patients with hemiparesis, thus, bilateral arm BP measurement is encouraged for evaluating IAD and decreasing the miss diagnosis of hypertension.\u003c/p\u003e "},{"header":"Summary Table","content":"\u003cp\u003e\u003cstrong\u003eWhat is known about topic\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003eAccording to the current hypertension guidelines, the bilateral arm blood pressure (BP) should be\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003emeasured at first.\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003eUnfortunately, the prevalence of IAD in the post-stroke patients with hemiparesis is not deeply investigated as the unaffected arm is used for BP measurement in these patients now.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eWhat this study adds'\u003c/strong\u003e.\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003eThe prevalence of sIAD \u0026ge;10 mmH was 18.1% and that for dIAD\u0026ge;10 mmH was 9% in the post-stroke patients with hemiparesis in rehabilitation period.\u003c/li\u003e\n\u003cli\u003eBilateral arm BP measurement is encouraged for evaluating IAD and correct diagnosis of hypertension.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Declarations","content":"\u003cp\u003eThere are no conflicts of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePickering TG, Hall JE, Appel LJ, et al. 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PMID: 35961695; PMCID: PMC9379529.\u003c/li\u003e\n\u003cli\u003eDewar R, Sykes D, Mulkerrin E, et al. The effect of hemiplegia on blood pressure measurement in the elderly[J]. Postgraduate medical journal, 1992, 68(805): 888-891.\u003c/li\u003e\n\u003cli\u003eShenberger JS, Leaman GJ, Neumyer MM, et al. Physiologic and structural indices of vascular function in paraplegics. Med Sci Sports Exerc. 1990,22(1):96-101.\u003c/li\u003e\n\u003cli\u003eWang JS, Yang CF, Liaw MY, et al. Suppressed cutaneous endothelial vascular control and hemodynamic changes in paretic extremities with edema in the extremities of patients with hemiplegia. Arch Phys Med Rehabil. 2002 ,83(7):1017-23.\u003c/li\u003e\n\u003cli\u003eHarvey RL. Hemiplegia and contralateral upper limb claudication--a case of dual disability from pseudoaneurysm of the brachiocephalic artery: a brief report. Am J Phys Med Rehabil. 1999 ,78(1):56-9.\u003c/li\u003e\n\u003cli\u003eYin MZ, Kim HJ, Suh EY, et al. Endurance exercise training restores atrophy-induced decreases of myogenic response and ionic currents in rat skeletal muscle artery[J]. Journal of Applied Physiology. 2019, 126(6): 1713-1724.\u003c/li\u003e\n\u003cli\u003eGarland M. Practical Management of Stroke [J]. Postgraduate medical journal.1985, 61(721): 1026.\u003c/li\u003e\n\u003cli\u003eYagi S, Ichikawa S, Sakamaki T , et al. Blood pressure in the paretic arms of patients with stroke.\u0026nbsp;The New England journal of medicine.\u0026nbsp;1986,315(13), 836.\u003c/li\u003e\n\u003cli\u003eYin Lei. Foundation of Nursing Science [M]. Beijing: People \u0026rsquo;s Medical Publishing House, 2004: 98\u003c/li\u003e\n\u003cli\u003eChristopher E Clark,Rod S Taylor,Angela C Shore,\u0026nbsp;John L Campbell. Prevalence of systolic inter-arm differences in blood pressure for different primary care populations: systematic review and meta-analysisBr J Gen Pract . 2016 Nov;66(652):e838-e847.\u003c/li\u003e\n\u003cli\u003eYu Y, Liu L, Lo K, Tang S, Feng Y. Prevalence and associated factors of inter-arm blood pressure difference in Chinese community hypertensive population. Postgrad Med. 2021 Mar;133(2):188-194. \u0026nbsp;\u003c/li\u003e\n\u003cli\u003e\u0026nbsp;Harvey RL. Hemiplegia and contralateral upper limb claudication--a case of dual disability from pseudoaneurysm of the brachiocephalic artery: a brief report. Am J Phys Med Rehabil. 1999 ,78(1):56-9.\u0026nbsp;\u003c/li\u003e\n\u003cli\u003eYin MZ, Kim HJ, Suh EY, et al. Endurance exercise training restores atrophy-induced decreases of myogenic response and ionic currents in rat skeletal muscle artery[J]. Journal of Applied Physiology. 2019, 126(6): 1713-1724.\u003c/li\u003e\n\u003cli\u003eGarland M. Practical Management of Stroke [J]. Postgraduate medical journal.1985, 61(721): 1026.\u003c/li\u003e\n\u003cli\u003eTao L, Tang M, Peng HP, Gu MB, Zhang HZ, Zhou G, Su H. Is the blood pressure different between the paralyzed and unaffected arms or legs? Blood Press Monit. 2020 Oct;25(5):242-245.\u003c/li\u003e\n\u003cli\u003eClark CE, Warren FC, Boddy K, McDonagh STJ, Moore SF, Teresa Alzamora M, Ramos Blanes R, Chuang SY, Criqui MH, Dahl M, Engstr\u0026ouml;m G, Erbel R, Espeland M, Ferrucci L, Guerchet M, Hattersley A, Lahoz C, McClelland RL, McDermott MM, Price J, Stoffers HE, Wang JG, Westerink J, White J, Cloutier L, Taylor RS, Shore AC, McManus RJ, Aboyans V, Campbell JL. Higher Arm Versus Lower Arm Systolic Blood Pressure and Cardiovascular Outcomes: a Meta-Analysis of Individual Participant Data From the INTERPRESS-IPD Collaboration. Hypertension. 2022 Oct;79(10):2328-2335.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-human-hypertension","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"jhh","sideBox":"Learn more about [Journal of Human Hypertension](http://www.nature.com/jhh/)","snPcode":"41371","submissionUrl":"https://mts-jhh.nature.com/cgi-bin/main.plex","title":"Journal of Human Hypertension","twitterHandle":"@jhhypertension","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"IAD, post-stroke, paralysis, blood pressure, ","lastPublishedDoi":"10.21203/rs.3.rs-2441705/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2441705/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe aim of this study was to Tinvestigate that inter-arm blood pressure (BP) difference (IAD) in post-stroke patients with hemiparesis. This study enrolled 420 post-stroke patients with hemiparesis. Simultaneous bilateral arm BP was measured with two automatic BP devices, and the systolic BP difference\u0026thinsp;\u0026ge;\u0026thinsp;10 mm Hg was recorded as sIAD. The arm with higher systolic BP (SBP) was assigned as the reference arm. Our results showed that the prevalence of sIAD was 18.1% in the total group. The paretic arms had similar mean SBP levels (133.6\u0026thinsp;\u0026plusmn;\u0026thinsp;18.4 vs 133.8\u0026thinsp;\u0026plusmn;\u0026thinsp;18.4 mm Hg, NS) and DBP (77.8\u0026thinsp;\u0026plusmn;\u0026thinsp;11.5 vs 77.2\u0026thinsp;\u0026plusmn;\u0026thinsp;10.9 mm Hg, NS) as compared with the unaffected arms. The detection rate of hypertension on the SBP values of the reference arm was higher than that on the unaffected arm (41.8% vs 36.3). In is convoluted that the prevalence of sIAD\u0026thinsp;\u0026ge;\u0026thinsp;10 mmH was 18.1% and that for dIAD\u0026thinsp;\u0026ge;\u0026thinsp;10 mmH was 9% in the post-stroke patients with hemiparesis, thus, bilateral arm BP measurement is encouraged for evaluating IAD and decreasing the miss diagnosis of hypertension.\u003c/p\u003e","manuscriptTitle":"Inter-arm blood pressure difference in post-stroke patients with hemiparesis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-01-17 07:51:43","doi":"10.21203/rs.3.rs-2441705/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"revise","date":"2023-02-22T12:24:40+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"This content is not available.","date":"2023-02-21T18:33:59+00:00","index":2,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2023-02-06T14:58:26+00:00","index":2,"fulltext":"This content is not available."},{"type":"editorInvitedReview","content":"This content is not available.","date":"2023-01-29T19:44:18+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2023-01-16T08:33:08+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewersInvited","content":"","date":"2023-01-13T18:49:38+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-01-12T00:27:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-01-09T12:19:47+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Human Hypertension","date":"2023-01-07T02:14:32+00:00","index":"","fulltext":""},{"type":"checksFailed","content":"","date":"2023-01-06T11:43:50+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-human-hypertension","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"jhh","sideBox":"Learn more about [Journal of Human Hypertension](http://www.nature.com/jhh/)","snPcode":"41371","submissionUrl":"https://mts-jhh.nature.com/cgi-bin/main.plex","title":"Journal of Human Hypertension","twitterHandle":"@jhhypertension","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"95e64f65-76bc-47a0-957f-83c1ca5888e8","owner":[],"postedDate":"January 17th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":18399253,"name":"Health sciences/Diseases/Cardiovascular diseases/Hypertension"},{"id":18399254,"name":"Health sciences/Health care/Disease prevention"}],"tags":[],"updatedAt":"2023-12-28T08:06:42+00:00","versionOfRecord":{"articleIdentity":"rs-2441705","link":"https://doi.org/10.1038/s41371-023-00886-y","journal":{"identity":"journal-of-human-hypertension","isVorOnly":false,"title":"Journal of Human Hypertension"},"publishedOn":"2023-12-27 05:00:00","publishedOnDateReadable":"December 27th, 2023"},"versionCreatedAt":"2023-01-17 07:51:43","video":"","vorDoi":"10.1038/s41371-023-00886-y","vorDoiUrl":"https://doi.org/10.1038/s41371-023-00886-y","workflowStages":[]},"version":"v1","identity":"rs-2441705","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2441705","identity":"rs-2441705","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}