We describe a simple bedside procedure (which we call 'Osler's maneuver') that differentiates patients with true hypertension from those whose blood pressure is spuriously elevated because of excessive sclerosis of the large arteries ('pseudohypertension'). The maneuver is performed by assessing the palpability of the pulseless radial or brachial artery distal to a point of occlusion of the artery manually or by cuff pressure. We classified 24 elderly hypertensive patients as either Osler-positive (n = 13) or Osler-negative (n = 11), and measured their intraarterial pressure, arterial compliance, and systemic hemodynamics. Patients with pseudohypertension (Osler-positive) and falsely elevated blood-pressure readings, with a difference of 10 to 54 mm Hg between cuff and intraarterial pressure. Arterial compliance was lower in Osler-positive subjects and correlated with the difference between cuff and intraarterial pressures, indicating that the stiffer the artery, the more pronounced the degree of pseudohypertension. Pseudohypertension is common in the elderly and becomes more severe as arterial compliance decreases and sclerosis of large arteries progresses.

/pdf/osler-s-maneuver-and-pseudohypertension-4ye0q4122h.pdf

Osler's Maneuver and Pseudohypertension

Peripheral arterial disease (PAD) has been demonstrated to be prevalent in the primary care setting. However, it has also been shown to be unrecognized and under-treated. Owing to the association with cardiovascular disease it has been recommended to screen high-risk patients for PAD in the primary care setting using the ankle-brachial index (ABI). ABI has been demonstrated to be highly sensitive and specific in diagnosing PAD in patients with significant stenosis. However, the utility in patients with less severe stenosis and calcified vessels is in question. The aims of this study were to determine the diagnostic utility of measuring the ABI at rest in patients referred to the vascular laboratory for evaluation of suspected PAD, and to assess the added value of pulse volume recordings and post-exercise studies in patients with a normal ABI. A computerized vascular diagnostic laboratory database was queried for symptomatic outpatients referred for measurement of segmental blood pressure, the ABI or pulse volume recordings by physicians not specialized in the evaluation and management of patients with peripheral vascular disease. Of 707 patients undergoing outpatient physiologic arterial evaluations between February 1, 2003 and July 31, 2004, 396 met these inclusion criteria. Data recorded included rest- ing ABI, ABI following treadmill exercise test and the presence of abnormal pulse volume recordings. The study population (n 396) consisted of equal numbers of men and women (mean age 69 years, range 19-100 years). Among 396 studies, rest- ing ABI values were normal in 183 (46.2%) and abnormal in 159 (40.2%). Of the 138 patients who underwent exercise testing, 84 had normal ABI readings at rest. In the 84 patients who had a normal ABI at rest and underwent exercise testing, the ABI fell below 0.9 after exercise in 26 (31%). Arterial non-compressibility was detected in 54 (13.6%) patients, whose average age was 67 years. Thirteen (24%) of those with non-compressible vessels had abnormal pulse volume recording (PVR) results, compared to five with normal resting ABI who had abnormal PVR findings (2.7%). In conclusion, this study demonstrated that nearly half of patients referred to the outpatient vascular laboratory because of suspected arterial disease had a nor- mal resting ABI. While it is recommended that the ABI be measured at rest in patients at risk of PAD in primary care practice, these findings suggest that patients with symptoms of PAD should be more completely evaluated in a vascular labora- tory. Furthermore, when the ABI is normal at rest in patients with symptoms of inter- mittent claudication, exercise testing is recommended to enhance the sensitivity for detection of PAD.

/pdf/limitation-of-the-resting-ankle-brachial-index-in-29229touxo.pdf

Limitation of the resting ankle-brachial index in symptomatic patients with peripheral arterial disease

https://www.annemergmed.com/article/S0196-0644(89)80933-3/pdf

Drug- and toxin-induced rhabdomyolysis

CLINICAL SCENARIO Is This Patient's Blood Pressure Really Elevated? A 46-year-old man who has recently moved to your neighborhood presents with a painful ankle sprain. Before he leaves, you decide to check his blood pressure (BP) and obtain an initial reading of 164/102mm Hg. He denies having high BP previously. WHY IS ACCURATE BP MEASUREMENT IMPORTANT? Elevated arterial BP, or hypertension, is important because it is common, it is clinically silent, it leads to cardiovascular disease (CVD), and it decreases life expectancy. Because surveys find that approximately 20% 1-3 of North American adults have an elevated BP (systolic BP ≥140 mm Hg and/or diastolic BP ≥90 mm Hg) or are taking antihypertensive medication, physicians are advised to check all patients periodically for BP elevation. 3-7 On the other hand, overestimation of BP can erroneously label people as hypertensive and potentially result in unnecessary dietary restrictions, exposure to potential side effects

Does This Patient Have Hypertension?: How to Measure Blood Pressure

Systolic occlusion leg and brachial pressures were determined using a Doppler ultrasonic method in 24 diabetic subjects with either past or evolving gangrene due to arterial occlusive disease of the lower extremities. The leg-brachial ratios were correlated with x-ray determined leg vascular calcification. Ratios above 1.10 were invariably associated with heavy continuous calcification of the tibial vessels; lesser degrees of arterial calcification had normal or depressed leg-brachial ratios. Medial calcification might be causally related to the abnormally elevated leg systolic pressures not infrequently noted in diabetic patients. Based on the observed occurrence of reamputation in association with normal or elevated leg-brachial ratios, it appears that a Doppler pressure index above 0.90 is not a reliable indicator of adequate blood flow in severe diabetic occlusive arterial disease.

Elevated Leg Systolic Pressures and Arterial Calcification in Diabetic Occlusive Vascular Disease

FALSE blood pressure recordings result from many causes, including the auscultatory gap, arrhythmias, partial obstruction of the brachial artery, pulsus paradoxus, shock, obesity, and errors in technique.1 Another cause of false blood pressure readings is Monckeberg arteriosclerosis of the brachial arteries severe enough to prevent compression by the blood pressure cuff. However, we had never observed this previously. Our search of the literature yielded no references for this entity. Therefore, we report the following case. Report of a Case An 82-year-old, alert white man was admitted to the Veterans Administration Hospital, Dayton, Ohio, on May 3, 1973, complaining chiefly of abdominal pain and diarrhea of seven days' duration, and of shortness of breath for 15 to 20 years. The patient had previously been told that he had high blood pressure. He denied having chest pain, paroxysmal nocturnal dyspnea, or peripheral edema. A hospital summary from an admission in 1968

"Pipe-stem" brachial arteries. A cause of pseudohypertension.

Transient acute renal failure, hemolysis, and myopathy occurred during an episode of isopropyl alcohol intoxication. Whether these three phenomena represent a direct toxic effect of isopropyl alcohol ingestion remains a matter of conjecture. Only further observations of other cases of isopropyl alcohol poisoning will establish the significance of the features described. Despite the similarities of intoxication with isopropyl alcohol to that with ethyl alcohol, there are certain clinical features which may be of value in differentiating the two.

James T. Taguchi

Papers

"Pipe-stem" brachial arteries. A cause of pseudohypertension.

Isopropyl Alcohol Intoxication: Report of a Case Associated With Myopathy Renal Failure, and Hemolytic Anemia