direct blood pressure measurements in brachial...

Direct Blood Pressure Measurements inBrachial and Femoral Arteries in Children

By MYUNG K. PARK, M.D., AND WARREN G. GUNTHEROTH, M.D.

SUMMARYIntra-arterial pressure in the brachial artery was compared with that in the femoral

artery in children. There were no significant differences in systolic, diastolic, or mean

pressures. The average auscultatory systolic pressure in the arm, obtained with a cuff20% wider than the limb, was identical to the average direct systolic pressure in thebrachial and femoral arteries. The auscultatory systolic pressure in the leg, usingthe same criterion for cuff width, was 11 mm Hg higher than the direct pressures. Thediscrepancy could represent (1) a systematic error in cuff size of inadequate width or

length or (2) additional systolic amplification between the femoral and popliteal ar-

teries. Since the femoral pressure is widely used in cardiac catheterization, this pressureis suggested as the standard for calibrating auscultatory technics. For leg blood pres-

sure measurements a cuff at least 25% wider than the average leg diameter and longenough to encircle the limb is recommended.

Additional Indexing Words:Aging: effect on blood pressurePressure pulses, transmission characteristics

T HE DIAGNOSIS of mild hypertensionin children rests upon an accurate

determination of the blood pressure in the armin relation to normal standards,1 and thediagnosis of coarctation of the aorta requiresaccurate determination of blood pressure inboth arms and legs.

It is generally believed that the systolicblood pressure in the legs is significantlyhigher than that in the arms in adults2 3 aswell as in children.1 4-7 However, Pascarelliet al.8 9 studied consecutive and simultaneousdirect blood pressure measurements in armsand legs in normal adults and in patients withaortic insufficiency and reported that allcomponents of the blood pressures in thebrachial and femoral arteries were essentially

From the Division of Pediatric Cardiology, Depart-ment of Pediatrics, University of Washington Schoolof Medicine, Seattle, Washington.

Investigation was supported by grants from the U.S.Public Health Service, HE 03998 and HE 07158.Dr. Park is supported by a training grant from theNational Heart Institute, TlHE-5281.

Received July 17, 1969; accepted for publicationOctober 18, 1969.

Circulation, Volume XLI, February 1970

Hypertension Standing wavesSystolic amplification

the same. The average age of their patientswas 55 years. O'Rourke and colleagues10found a marked decrease in amplification ofthe systolic pressure in the iliac artery ascompared to that in the aortic arch in subjectsin this age group, whereas children demon-strated four or five times more systolicamplification. Nadas5 stated that systolicamplification in the legs, due to reflectedwaves, accounts for a higher pressure in thelegs than arms. It is, then, uncertain that theresults of Pascarelli would apply in children,and there are no reports on the simultaneousor consecutive measurements of blood pres-sures in the arms and legs by direct arterialpuncture technic in children.The purpose of this study was to establish

whether any disparity in the various compo-nents of blood pressure measurements exists inchildren by direct intra-arterial technic and tocorrelate the arterial pressures with thoseobtained by standard auscultatory technic.

MethodsForty-one sets of blood pressure deterninations

were obtained by direct arterial puncture on 37231

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PARK, GUNTHEROTH

patients who were undergoing diagnostic cardiaccatheterization at the University of WashingtonHospital. The patients ranged from 3 to 15 yearsof age and had various types of congenital heartdisease. Patients with angiographic evidence ofsevere aortic stenosis or coarctation of the aortawere excluded from the study. In four patients,blood pressures changed substantially while theneedles were in place due to excitement, and twosets of measurements from them are included inthe analysis.The patients were sedated in the usual manner

with a meperidine-promethazine-chlorpromazinemixture 45 to 60 min prior to the procedure. Theright brachial artery was isolated under 1%-lidocaine infiltration in the mid-upper arm or inthe antecubital fossa, as part of our routinecutdown procedure for right heart catheterization.The groin of the same side was infiltrated with 1%lidocaine at the same time. After completion ofthe right heart catheterization, arterial punctureswere made in the exposed brachial artery using a21 or 22-gauge short bevel needle and in thefemoral artery using a 20-gauge needle withstylus. (Only a single puncture of the artery waspermitted.) The needles were the same length.The polyethylene connecting tubes for the pair ofneedles were 1 mm in internal diameter and wereof matched length (25 to 35 cm). The pressurewas recorded with a P23Db Statham strain-gaugepressure transducer connected to a Honeywellrecorder, at a paper speed of 25 mm/sec. Thefrequency response of the system was accurate to50 Hz. The pressures were recorded consecutive-ly, switching back and forth on the sametransducer. Zero reference point was taken at thelevel of mid-thorax.

For comparison, auscultatory blood pressureswere obtained from the patients' charts, retro-spectively. These pressures were recorded by theresident physician the day prior to cardiaccatheterization, without sedation, in the supineposition. Cuff sizes were chosen as close as

possible to be 20% wider than the averagediameter of the limb. The stethoscope was placedover the antecubital fossa for the ann, and thepopliteal fossa for the leg. (We could obtain allvalues on only 28 patients, so that the meanspresented below vary slightly from those con-

cerned only with direct pressure measurements.)The values were punched on IBM cards. The

Massey XTAB program, Plot one,1' was employedto determine the means, correlation coefficients,standard deviations, and to generate scatter-grams. Paired-sample t-tests were performed withan Olivetti 101 programmed calculator.

ResultsThe average systolic pressures in the

0

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20 40 60 0 6o0 io12Systolic pressure,femoral artery (mm Hg)

Figure 1

Scattergram of the systolic pressures in the brachialand femoral arteries. The correlation coefficient is0.904. The regression equation is Y = 104.90 + 0.993(X - 104.85).

brachial and femoral arteries were essentiallyidentical with a correlation coefficient of 0.904(fig. 1). The systolic pressure in the brachialartery (BA) averaged 104.90, compared to104.85 in the femoral artery (FA) (table 1).The average diastolic pressure in the BA

was 57.32 and the corresponding value for theFA was 57.17. The correlation coefficient was0.918 (fig. 2). Obviously, the group means arenot significantly different.The group average of the mean pressures in

the BA was 76.14, compared to the average

Table 1

Comparison of Arterial Pressures in the Brachialand Femoral Arteries: 41 Sets of Data*

Arterial pressures (mm Hg)Systolic Diastolic Mean

Mean SD Mean SD Mean SD

Brachial 104.90 16.72 57.32 11.67 76.14 13.28artery

Femoral 104.85 15.22 57.17 11.50 76.55 14.41artery

*There are no significant differences between groupmeans, using paired-sample t-test (P > 0.1).

Circudation, Volume XLI, Nlauy 1970

232

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Scattergram of the diastolic pressures in the brachialand femoral arteries. The correlation coefficient is0.918. The regression equation is Y = 57.32 + 0.932(X- 57.17).

for the FA of 76.55. The correlation coefficientwas 0.965 (fig. 3).

Auscultatory and direct arterial pressures

are compared in table 2. The group means forthe arm (auscultatory), brachial artery, andfemoral artery were all 104 mm Hg, whereasleg auscultatory pressure was 115. Paired-sample t-tests yielded highly significant dif-ferences between the latter group and theother three groups (P < 0.01).

Discussion

Most pediatricians have agreed that, inchildren as in the adults, the systolic pressurein the leg is higher than that in the arm.1' 4-7, 12In contrast, our study indicates that thereis no difference in the various components ofblood pressure (systolic, diastolic, and mean)between the brachial and femoral arteries,although the auscultatory pressures in the legwere higher when standard technics were

used. To be comparable to the arm, thearterial pressure in the leg would have to beobtained at the popliteal fossa. However,during cardiac catheterization, with the pa-tient supine, the femoral artery just below the


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20 40 ro0 80 160 1I20 140Mean pressure, femoral artery (mm Hg)

Figure 3

Scattergram of the mean pressures in the brachial andfemoral arteries. The correlation coefficient is0.965. The regression equation is Y= 76.14 + 0.956(X- 76.55).

inguinal ligament is the only artery in thelower extremity ordinarily studied. At theleast, there is an obvious question raised byour data as to the meaning of a subject's"blood pressure."The systolic pressure in the leg, whether

obtained by needle or auscultation, is higherthan that found in the aorta. This phenome-non of systolic amplification is wellknown.3 13,14 It has been suggested thatsystolic amplification does not occur in thebrachial artery, accounting for the normallylower systolic pressure in the arm.5 However,

Table 2

Comparison of Systolic Pressures by Auscultation andArterial Puncture in Upper and Lower Extremities(Mean and Standard Deviation): 28 Sets of Data*

Pressure (mm Hg)

Arm Leg

By auscultation 103.64 i 8.80 115.19 i 14.93By direct puncture 103.68 i 15.38 103.96 4 14.99

*There are no significant differences between meansexcept for leg pressures obtained by auscultation,which are higher than the other three (P < 0.01).

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PARK, GUNTHEROTH

IMMEDLATELY ABOVE AORTIC VALVE

Figure 4

Intra-arterial pressure recorded at four sites on with-drawal of an N.I.H. angiocardiographic catheter (sideholes) from ascending aorta to the brachial artery inan 8-year-old boy. There is distortion of the waveshape as well as systolic amplification.

our study supports earlier reports that systolicamplification also occurs in the brachialartery.'3' 15 Figure 4 illustrates this amplifica-tion. The record is obtained during thewithdrawal of a side-hole catheter from theascending aorta to the brachial artery. Thepeak systolic pressure rises 10 to 12 mm Hg.The cause of amplification of the systolic

pressure in peripheral arteries remains uncer-tain. It was attributed by Hamilton andDow'6 to standing waves and subsequently, toa more general concept, reflected waves fromthe terminal arterioles.10 14, 17, 18 Figure 5,reproduced from Wiggers,'9 presents theconcept of summation of the forward waveand the rebound wave. There is a curiousproblem with this concept: For summation tooccur, transmission of the rebound wave fromthe recording site to the periphery and backwould require infinite velocity, whereas mostactual measurements of phase velocity range

from 3 to 6 m/sec.10 20, 21 This is not to denyreflected waves, but to question whether theyconstitute the major source of systolic amplifi-cation.

Taylor22 suggested that systolic amplifica-tion represents a fundamental characteristic oftransmission of waves in a non-uniformsystem. The crucial non-uniformity is animpedance mismatch between the low imped-ance elastic aorta and the high impedancemuscular arteries in the periphery. Figure 6shows a dramatic amplification occurringabruptly at the level of the iliac artery in adog. At this level the elastic-collagen ratioreverses from its value of greater than one forthe aorta.22With aging there is generally less systolic

amplification, which O'Rourke and his co-authors'0 attribute to a "decline in peripheralreflection coefficient resulting from decreaseddistensibility of peripheral arteries with age."On the basis of the work of Taylor,22 it is morelikely that the cause is a loss of elasticity in theaorta, causing a "better" impedance matchwith the peripheral arteries.

Finding a higher auscultatory pressure inthe leg than by direct puncture of the femoralartery in our study suggests two alternative

Figure 5

Reproduced from Wiggers.19 Original legend: "Dia-gram illustrating the principles of damping and wavesummation in the arterial system. A, aortic pressurepulse. B, changes in contour and amplitude due todamping. C, nature of rebound wave. D, summationof curves B and C. Ordinate pressure in mm Hg.Abscissae line in 0.1 sec." Reprinted courtesy of thepublisher, Grune & Stratton, Inc.


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PARK, GUNTHEROTH

explanations: (1) The recommended cuffwidth for the leg is inadequate, or (2) there isadditional systolic amplification below thefemoral puncture site, which causes a trueincrease at the popliteal fossa. At presentthere is insufficient data to decide betweenthese alternatives, but considering the wide-spread use of the femoral artery pressure indiagnostic procedures, femoral pressures couldreasonably be taken as the standard and theauscultatory technic altered to conform. Atpresent, the overestimate by auscultationamounts to 11 mm Hg.The most common recommendation for

blood pressure cuff is to cover two thirds ofthe upper arm with the cuff. This recommen-dation ignores variations in fatness of thesubject, and we feel that the current recom-mendation of the American Heart Association2is superior; in other words, that the bag shouldbe 20% wider than the diameter of the limb.This is generally in accord with our experi-ence23 and with that of Moss and Adams12 forthe arm, although the latter used a somewhatmore complicated formula involving circum-ference and age. Obviously, relating the cuffsize to the limb diameter requires a wider cufffor the leg. On the basis of our present study,we suggest use of a leg cuff that is at least 25%wider than the average diameter of the thigh,and one with an air bladder long enough toencircle the limb.

References1. GUNTHEROTH WG, NADAS AS: Blood pressure

measurements in infants and children. PediatClin N Amer 2: 257, 1955

2. KIRKENDALL WM, BURTON AC, EPSTEIN FH, ETAL: Recommendations for human blood pres-sure determination by sphygmomanometers.Circulation 36: 980, 1967

3. RUSHMER RF: Cardiovascular Dynamics, ed 2.Philadelphia, W. B. Saunders Co., 1961

4. KAPLAN S: The heart and circulation in healthand disease. In Textbook of Pediatrics, editedby W. E. Nelson, ed 8. Philadelphia, W. B.Saunders Co., 1964, p 881

5. NADAS AS: Pediatric Cardiology. Philadelphia,W. B. Saunders Co., 1963

6. SCHLESINGER B, MACCARTHY D: Disease of thecardiovascular system. In Garrod, Batten andThursfield's Disease of Children, edited by A

Moncrieff and P Evans, ed 5, vol 1. London,E. Arnold, 1953, p 930

7. BALDWIN JS, DOYLE EF: The heart andcirculation in early life. In Holt, McIntosh andBarnett's Pediatrics, ed 13. New York, Apple-ton-Century-Crofts, 1962, p 520

8. PASCARELLI EF, BERTRAND CA: Comparison ofblood pressures in the arms and legs. New EngJ Med 270: 693, 1964

9. PASCARELLI EF, BERTRAND CA: Comparison ofarm and leg blood pressures in aorticinsufficiency: An appraisal of Hill's sign. BritMed J 2: 73, 1965

10. O'ROURKE MF, BLAZEK JV, MORREELS CL JR, ETAL: Pressure wave transmission along thehuman aorta: Changes with age and in arterialdegenerative disease. Circulation Research 23:567, 1968

11. MASSEY FJ: XTAB computer programs forbiomedical data processing. Modified by R AKronmal and S R Yamell, University ofWashington, January, 1966

12. Moss AJ, ADAMS FH: Problems of Blood Pressurein Childhood. Springfield, Illinois, Charles CThomas, Publisher, 1962

13. KROEKER EJ, WOOD EH: Comparison of simul-taneously recorded central and peripheralarterial pressure pulses during rest, exerciseand tilted position in man. Circulation Re-search 3: 623, 1955

14. HAMILTON WF, WOODBURY RA, HARPER HT JR:Physiologic relationship between intrathoracic,intraspinal and arterial pressures. JAMA 107:853, 1936

15. ROWELL LB, BRENGELMANN GL, BLACKMION JR,ET AL: Disparities between aortic and periph-eral pulse pressures induced by uprightexercise and vasomotor changes in man.Circulation 37: 954, 1968

16. HAMILTON WF, Dow P: An experimental studyof the standing waves in the pulse propagatedthrough the aorta. Amer J Physiol 125: 48,1939

17. LUCHSINGER PC, SNELL RE, PATEL DJ, ET AL:Instantaneous pressure distribution along thehuman aorta. Circulation Research 15: 503,1964

18. MCDONALD DA, TAYLOR MG: The hydrody-namics of the arterial circulation. ProgrBiophys Chem 9: 105, 1959

19. WIGGERS CJ: Circulatory Dynamics. New York,Grune & Stratton, Inc., 1952, p 9

20. ANLIKER M, HISTAND MB, OGDEN E: Dispersionand attenuation of small artificial pressurewaves in the canine aorta. Circulation Research23: 539, 1968

21. TAYLOR MG: Use of random excitation andspectral analysis in the study of frequency-


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dependent parameters of the cardiovascularsystem. Circulation Research 18: 585, 1966

22. TAYLOR MG: Wave travel in arteries and thedesign of the cardiovascular system. InPulsatile Blood Flow, edited by E 0 Attinger.

New York, Blakiston Division, McGraw-HillBook Co., 1964, p 359

23. GUNTHEROTH WG, HowRY C, ANSELL JS; Renalhypertension: A review. Pediatrics 31: 767,1963

Foetal Circulation -Harvey 1628

For the right receiving the blood from the ear, thrusts it forth through thevena arteriosa, and its branch called canalis arteriosus, into the great arterie. Likewise,the left at the same time by the mediation of the motion of the ear, receives thatblood, which is brought into the left ear through that oval hole from the vena cava,and by its tention and constriction thrusts it through the root of the Aorta into the greatarterie likewise. So in Embryons whilst the lungs are idle, and have no action normotion (as if there were none at all) Nature makes use of both the ventricles of theheart, as of one for transmission of blood. And so the condition of Embryons that havelungs and make no use of them, is like to the condition of those creatures whichhave none at all. -The Anatomical Exercises of Dr. William Harvey; De Motu Cordis1628; De Circulatione Sanguinis 1649 (first English text). Edited by GeoffreyKeynes. London, The Nonesuch Press, 1653, p. 46.


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MYUNG K. PARK and WARREN G. GUNTHEROTHChildren

Direct Blood Pressure Measurements in Brachial and Femoral Arteries in

Print ISSN: 0009-7322. Online ISSN: 1524-4539 Copyright © 1970 American Heart Association, Inc. All rights reserved.

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