What is pseudo hypertension due to hardening of the arteries?

Pseudohypertension Due to Hardening of the Arteries

Pseudohypertension occurs when blood pressure readings are falsely elevated due to extremely rigid or calcified arteries that cannot be properly compressed by a blood pressure cuff, leading to potentially harmful overtreatment with antihypertensive medications.

Definition and Mechanism

Pseudohypertension is a condition where:

• Blood pressure measurements appear abnormally high when using standard non-invasive methods (cuff-based)
• The actual intra-arterial pressure is significantly lower than the measured value
• The discrepancy occurs because severely stiffened, calcified arteries resist compression by the blood pressure cuff 1
• The difference between cuff and intra-arterial measurements can range from 10 to 54 mmHg 2

At-Risk Population

Pseudohypertension is most commonly seen in:

• Elderly patients 1
• Patients with longstanding diabetes mellitus 1, 3
• Individuals with chronic kidney disease 1
• Those with advanced arteriosclerosis 4, 5
• Patients with apparent resistant hypertension (approximately 7% of resistant hypertension cases) 6

Clinical Presentation and Diagnosis

Clinical Clues

• Apparent resistant hypertension despite multiple medications
• Symptoms of orthostatic hypotension despite elevated blood pressure readings
• Elderly patient with unexpectedly high systolic readings
• History of atherosclerotic disease 6

Diagnostic Approaches

1. Osler's Maneuver:

   • Palpate the radial or brachial artery while the blood pressure cuff is inflated above systolic pressure
   • A positive Osler's sign occurs when the artery remains palpable despite being "occluded" by the cuff
   • However, this test has limited reliability - it was present in 7.2% of individuals over 59 years in the SHEP study 1

2. Doppler Assessment:

   • Presence of brachial artery bruit
   • Triphasic blood pressure readings via Doppler 6

3. Gold Standard:

   • Direct intra-arterial blood pressure measurement via radial artery catheterization 1
   • Should be considered when pseudohypertension is strongly suspected

Clinical Implications

Pseudohypertension can lead to:

• Inappropriate diagnosis of resistant hypertension 1
• Overtreatment with antihypertensive medications 1
• Iatrogenic orthostatic hypotension and related complications (falls, fractures) 1
• Increased morbidity due to side effects of unnecessary medications 1

Management Approach

When pseudohypertension is suspected:

1. Confirm the diagnosis:

   • Consider intra-arterial measurement in cases of suspected pseudohypertension, especially when patients experience symptoms of hypotension despite high readings 1

2. Medication adjustment:

   • Reduce or discontinue unnecessary antihypertensive medications
   • Studies show the mean number of antihypertensive medications can be decreased from 3.7 to 2.7 in patients with confirmed pseudohypertension 6

3. Monitor for orthostatic hypotension:

   • Regularly check for postural blood pressure changes
   • Be alert to symptoms like dizziness, unsteadiness, or syncope 1

4. Alternative measurement techniques:

   • Consider using oscillometric devices that automatically determine and analyze blood pressure over 15-20 minutes in a quiet environment 1

Relationship to Arterial Stiffness

The underlying pathophysiology involves:

• Medial hypertrophy and calcification of arterial walls 6, 5
• Decreased arterial compliance correlating with the magnitude of pseudohypertension 2
• Progressive stiffening of large arteries with age and disease 1
• The stiffer the artery, the more pronounced the degree of pseudohypertension 2

Prevention of Adverse Outcomes

To avoid complications from pseudohypertension:

• Consider pseudohypertension in elderly patients with resistant hypertension 1
• Be vigilant for symptoms of orthostatic hypotension despite elevated readings 1
• Adjust treatment goals based on confirmed measurements and clinical presentation
• Recognize that overtreatment based on falsely elevated readings can lead to significant morbidity and decreased quality of life 1