What is the best course of action for an elderly female patient with a history of hypertension who presents with higher blood pressure (hypertension) in her left side than her right side?

Blood Pressure Differential Between Arms in Elderly Hypertensive Patient

Immediate Assessment Required

The priority is to measure blood pressure in both arms simultaneously or sequentially to confirm and quantify the inter-arm blood pressure difference, as a persistent difference ≥10 mmHg systolic warrants evaluation for subclavian artery stenosis or other vascular pathology. 1

Clinical Significance of Inter-Arm BP Differences

• A systolic blood pressure difference ≥10 mmHg between arms is associated with peripheral vascular disease and increased cardiovascular mortality risk 1
• The higher reading should be used for diagnosis and treatment decisions, as it more accurately reflects true systemic blood pressure 1
• In elderly patients with known hypertension, inter-arm differences may indicate atherosclerotic disease affecting the subclavian or axillary arteries 1

Diagnostic Evaluation Algorithm

• Confirm the finding by measuring BP in both arms during the same visit, using proper technique with the patient seated and arms at heart level 1
• If the difference is ≥15 mmHg systolic on repeated measurements, evaluate for subclavian artery stenosis with vascular imaging (duplex ultrasound or CT angiography) 1
• Assess for other manifestations of peripheral arterial disease, including diminished pulses, bruits over the subclavian artery, and symptoms of arm claudication 1

Blood Pressure Measurement Technique in Elderly Patients

• Always measure BP in both sitting and standing positions in elderly patients to detect orthostatic hypotension, defined as a decrease of ≥20 mmHg systolic or ≥10 mmHg diastolic upon standing 1
• Orthostatic hypotension occurs in approximately 7% of men over 70 years and carries a 64% increase in age-adjusted mortality 1
• Use the arm with the higher reading for ongoing BP monitoring and treatment decisions 1

Hypertension Management Considerations

• Target BP <140/90 mmHg for most elderly patients, with <130/80 mmHg considered if well-tolerated and the patient has high cardiovascular risk 2
• For patients ≥80 years or those who are frail, individualize targets with a minimum of <150/90 mmHg 2
• Systolic blood pressure provides superior risk stratification compared to diastolic pressure in elderly patients, correctly classifying 94% of adults over 60 years 1

Treatment Approach for Elderly Hypertensive Patients

• First-line pharmacological options include thiazide-like diuretics, calcium channel blockers (particularly dihydropyridines like amlodipine), or ACE inhibitors/ARBs 2, 3
• Combination therapy with two or more drugs is generally needed to achieve optimal BP control in elderly patients 1
• Start with low doses and titrate slowly in elderly patients to minimize adverse effects, particularly orthostatic hypotension 2

Critical Pitfalls to Avoid

• Do not dismiss inter-arm BP differences as measurement error—persistent differences warrant vascular evaluation 1
• Avoid using heavily calcified or arteriosclerotic brachial arteries for measurement, as they can produce falsely elevated readings 1
• Do not withhold appropriate antihypertensive treatment based on age alone, as clinical trials demonstrate benefit in patients >80 years 2
• Monitor for orthostatic hypotension symptoms (dizziness, unsteadiness, fainting) and adjust medications accordingly, as this is a common barrier to intensive BP control 1

Monitoring Strategy

• Obtain lying and standing BP measurements periodically in all hypertensive patients over 50 years 1
• Reassess BP within 2-4 weeks after any medication adjustment 2
• Achieve target BP within 3 months of initiating or modifying therapy 2