Should blood pressure (BP) be checked in both arms when evaluating chest pain?

Blood Pressure Measurement in Both Arms is Essential When Evaluating Chest Pain

Blood pressure should always be measured in both arms during the initial evaluation of chest pain, as a difference of >10 mmHg in systolic BP between arms may indicate arterial stenosis or aortic dissection and is associated with increased cardiovascular risk. 1, 2

Rationale for Bilateral BP Measurement in Chest Pain

Clinical Significance

• A significant inter-arm BP difference (>10 mmHg systolic) may indicate:
  • Arterial stenosis
  • Possible aortic dissection (especially important in chest pain evaluation)
  • Coarctation of the aorta
  • Increased cardiovascular disease risk 1

Technique for Proper Measurement

1. Measure BP in both arms at the initial visit
2. Use validated devices with appropriate cuff size based on arm circumference
3. Position patient seated comfortably after 5 minutes of rest
4. Place cuffs at heart level with back and arm supported
5. If a difference >10 mmHg is detected, confirm with additional measurements 1

Management of Inter-Arm BP Differences

When a Difference is Detected

• For differences >10 mmHg systolic:

  • Use the arm with higher BP for all subsequent measurements 1, 2
  • Document the difference in the patient's medical record
  • Consider further cardiovascular risk assessment 1

• For differences ≥20 mmHg systolic:

  • Urgent further investigation is warranted, especially in the context of chest pain
  • Consider vascular imaging studies
  • Evaluate for possible aortic dissection if accompanied by chest/back pain 2

Special Considerations in Chest Pain Evaluation

• In patients with suspected aortic dissection:

  • Accurate BP measurement is critical for diagnosis and management
  • Dissection-related occlusion of aortic branch arteries can result in erroneously low BP readings in the affected limb
  • BP may need to be measured in both arms and, sometimes, both legs to determine the highest central blood pressure 1

• In acute chest pain management:

  • When aortic dissection is suspected, control systolic BP to values between 100-120 mmHg
  • Beta-blockers are first-line agents to reduce the force of left ventricular ejection 1

Common Pitfalls to Avoid

• Relying on a single measurement in one arm only
• Failing to position both arms at heart level during measurement
• Ignoring consistent inter-arm differences
• Using an inappropriately sized cuff
• Overlooking the significance of BP differences in the context of chest pain 2

Clinical Impact

Detecting significant inter-arm BP differences during chest pain evaluation can:

• Identify patients at higher risk for cardiovascular events
• Help diagnose potentially life-threatening conditions like aortic dissection
• Guide appropriate treatment decisions and monitoring strategies 1

While absolute differences in BP between arms are common at an individual level (with studies showing systolic differences of 5.4±4.8 mmHg), clinically significant differences (>10 mmHg) require attention and may alter management decisions in chest pain evaluation 3.