BLOOD PRESSURE MEASUREMEN T: ARM CI RCUMFERENCE AND CUFF SI ZE AVAI LABI LI TY
Eu gen ia Vellu do Veiga1 Edn a Apar ecida Mou r a Ar cu r i2 Ly ne Clout ier3 Jair Lício Fer r eir a Sant os4
Veiga EV, Ar cur i EAM, Clout ier L, Sant os JLF. Blood pr essur e m easur em ent : ar m cir cum fer ence and cuff size availabilit y. Rev Lat ino- am En fer m agem 2 0 0 9 j u lh o- agost o; 1 7 ( 4 ) : 4 5 5 - 6 1 .
To av oid in accu r at e blood pr essu r e ( BP) r eadin gs, t h e Am er ican Hear t Associat ion ( AHA) r ecom m en ds cu f f w idt h ( CW) encir cling 40% of t he ar m cir cum fer ence ( AC) and cuff lengt h at least 80- 100% . This st udy aim ed t o id en t if y in p at ien t s´ AC, t h e cor r esp on d in g cu f f size an d t h e cu f f size av ailab ilit y . I n t ot al, 8 1 AC w er e m easur ed in t he r ight ar m . The cuff sizes t o fit t hem w er e calculat ed accor ding t o AHA AC/ CW w idt h 0.40 r at io. The AC var ied fr om 17.5 t o 40.5 cm and t he cor r esponding cuff w idt h fr om 6 t o 16cm . The st andar d cuff 12 by 23 cm , t he only size available in t he clinics, w as appr opr iat e for only 17.3% of t he subj ect s, w hose AC var ied bet w een 32.5 and 34.3 cm . The lack of availabilit y of differ ent cuff sizes cont inues being a challenging pr oblem t o be faced. The st andar d cuff available, 12cm lar ge, did not fit 82.7% of t he ident ified AC, r esult ing in over or u n der est im at ed BP r egist er s.
DESCRI PTORS: blood pr essu r e det er m in at ion ; blood pr essu r e; h y per t en sion ; n u r sin g car e
LA MEDI CI ÓN DE LA PRESI ÓN ARTERI AL: CI RCUNFERENCI A DEL BRAZO Y
DI SPONI BI LI DAD DE MANGUI TOS
Par a ev it ar m edidas im pr ecisas de la pr esión ar t er ial ( PA) , la Am er ican Hear t Asociat ion ( AHA) r ecom ien da que el ancho del m anguit o ( AM) cir cunde 40% de la cir cunfer encia del br azo ( CB) y el lar go sea de 80- 100% . El obj et ivo de est e est udio fue ident ificar las CBs de pacient es int er nados, los m anguit os cor r espondient es y los t am años disponibles en las clínicas. Com o m ét odo, 8 1 CBs fuer on m edidas en el br azo der echo. Los anchos fuer on ident ificados según la r azón CB/ AM 040, pr opuest a por la AHA. Se obt uv o com o r esult ado que las CBs v ar iar on de 1 7 , 5 a 4 0 , 5 y los m anguit os cor r espondient es de 6 a 1 6 cm . El m anguit o est ándar de 1 2 x 2 3 cm , ú n ico dispon ible en las clín icas, fu e apr opiado par a apen as 1 7 , 3 % de los su j et os, cu y as CBs v ar iar on en t r e 32,5 y 34,3cm . Se v er ifica que la falt a de disponibilidad de difer ent es t am años de m anguit os cont inúa siendo un desafío a ser enfr ent ado. Se concluye que el m anguit o est ándar disponible no at iende a las CBs ident ificadas, r esult ando en r egist r os sobr e o subest im ados de la PA.
DESCRI PTORES: det er m inación de la pr esión sanguínea; pr esión sanguínea; hiper t ensión; at ención de enfer m er ía
MEDI DA DA PRESSÃO ARTERI AL: CI RCUNFERÊNCI A BRAQUI AL E
DI SPONI BI LI DADE DE MANGUI TOS
Par a ev it ar m edidas im pr ecisas da pr essão ar t er ial ( PA) , a Am er ican Hear t Associat ion ( AHA) r ecom enda que a lar gur a do m anguit o ( LM) cir cunde 40% da cir cunfer ência do br aço ( CB) e o com pr im ent o de 80- 100% . O obj et ivo dest e est udo foi ident ificar as CBs de pacient es int er nados, os m anguit os cor r espondent es e os t am anhos disponíveis nas clínicas. Com o m ét odo, 81 CBs for am m edidas no br aço dir eit o. As lar gur as for am ident ificadas segundo a r azão CB/ LM 040, pr opost a pela AHA. Obt ev e- se com o r esult ados que as CBs v ar iar am de 17, 5 a 40,5 e os m anguit os cor r espondent es de 6 a 16cm . O m anguit o padr ão 12x23cm , único disponível nas clínicas, foi apr opr iado par a apen as 1 7 , 3 % dos su j eit os, cu j as CBs v ar iar am en t r e 3 2 , 5 e 3 4 , 3 cm . Ver ifica- se qu e a falt a de disponibilidade de difer ent es t am anhos de m anguit os cont inua sendo desafio a ser encar ado. Conclui-se q u e o m an g u it o p ad r ão d isp on ív el n ão at en d e às CBs id en t if icad as, r esu lt an d o em r eg ist r os su p er ou su best im ados da PA.
DESCRI TORES: det er m in ação da pr essão ar t er ial; pr essão ar t er ial; h iper t en são; cu idados de en fer m agem
1RN, Ph.D., Associat e Pr ofessor, Escola de Enfer m agem de Ribeir ão Pr et o, Univer sidade de São Paulo, WHO Collabor at ing Cent r e for Nur sing Resear ch Developm ent , Br azil, e- m ail: evveiga@eer p.usp.br ; 2RN, Ph.D., Full Pr ofessor, Univer sidade de Guar ulhos, Br azil , em ail: ear cur i@globo.com ; 3RN, Ph.D., Univer sit é du Québec à Tr ois- Rivièr es, Canada, e- m ail: lyne.clout ier @uqt r.ca; 4Ph.D., Full Pr ofessor, Faculdade de Medicina de Ribeir ão Pr et o, Univer sidade de São Paulo, Brazil, e- m ail: j alifesa@usp.br.
I NTRODUCTI ON
I
t is em phasized in t he lit erat ure t hat different f a c t o r s m a y i n f l u e n c e b l o o d p r e s s u r e ( B P)m easur em ent accuracy. Ther e ar e sev er al er r or s t hat
can be m ade by t he obser ver ( per son w ho m easur es
b l o o d p r e ssu r e )( 1 ) d u e t o p o o r BP m e a su r e m e n t
k now ledge or lack of at t ent ion( 2- 4). The m ain sour ces
of inaccurat e BP readings are relat ed t o t he incorrect
use of t he equipm ent( 5- 6), t he env ir onm ent( 7) and t he
incr ease of pat ient ’s alar m in fr ont of his doct or ( t he
“ w hit e coat effect ” phenom enon)( 8) . How ever, t he use
of a w r ong cuff size t o ar m cir cum fer ence ( AC) is t he
m ost discu ssed cau se of im pr ecise m easu r em en t .
To av oid ov er or u n d er BP est im at ion , t h e
r at io ar m cir cum fer ence/ cuff w idt h ( AC/ CW) m ust be
ar ound 0.40and t he cuff lengt h m ust encircle AC from
80 t o 100%( 9- 10) , as r ecom m ended by t he Am er ican
H e a r t A s s o c i a t i o n( 1 1 ). Th e Eu r o p e a n S o c i e t y o f
H y p e r t e n s i o n A n n u a l M e e t i n g 2 0 0 7 e s t a b l i s h e d
guidelines( 12) w hich r ecom m ended a st andar d bladder
12 - 13 cm long, size appr opr iat e t o near ly 10- 30 %
of ad u lt s’ ar m cir cu m f er en ce. I n ad d it ion , a b ig g er
bladder f or f at ar m s ( 3 5 cm ) an d a sm aller on e f or
t hin ar m s w er e also r ecom m ended( 12).
Nar r ow cuffs can ov er est im at e BP v alues, as
dem onst r at ed in 1901( 13). The high r eadings r esult in
e x ce ssi v e i n t a k e o f a n t i - h y p e r t e n si v e d r u g s w i t h
sev er e consequences, such as dizziness and faint ing.
Co n v e r s e l y, l a r g e r c u f f s m a y u n d e r e s t i m a t e B P
r eadin gs in lean su bj ect s, r esu lt in g in m isdiagn osis
and m ist r eat m ent of hyper t ension( 14). I n spit e of t hese
f act s, h eal t h p r o f essi o n al s cu r r en t l y u se o n l y o n e
st andar d cuff t o m easure BP, w it h no dist inct ion am ong
dif f er en t ar m cir cu m f er en ces.
The possibilit y of poor BP evaluat ion is not a
qu est ion of con cer n f or m an y n u r ses or ph y sician s.
Alt h ou gh sev er al gu idelin es h av e r ecom m en ded t h e
u se o f t h e co r r e ct cu f f w i d t h si n ce 1 9 5 1( 1 5 ), n o
consensus has been r eached r egar ding t he cuff sizes
t o be corr ect ly used in childr en and adult s. Moreover,
w e do not k now w het her healt h pr ofessionals w ould
be able t o select t h e pr oper cu f f size an d u se it , if
av ailable in t he m ar k et and m edical unit s.
Ma n y q u est i o n s r em a i n u n a n sw er ed m o r e
t h a n f i v e d e c a d e s s i n c e t h e A m e r i c a n H e a r t
Associat ion at t est ed t hat t he pr oper cuff m ust be 20%
l a r g e r t h a n a r m d i a m e t e r t o e n s u r e p r e c i s e B P
r ead in g s. Th er e ar e t w o asp ect s t o b e con sid er ed :
t he num ber of different cuff sizes t o fit t he ent ire arm
ci r cu m f e r e n ce r a n g e o f t h e w o r l d p o p u l a t i o n a n d
w h et h er t h er e w ou ld b e d if f er en ces am on g p eop le
f r o m d i f f e r e n t co u n t r i e s, r e g i o n s o r i n p a t i e n t s i n
differ en t clin ics.
Se v e r a l st u d i e s a i m e d t o i n v e st i g a t e t h e
a c c u r a c y o f s p h y g m o m a n o m e t e r s a n d n u r s e s ’
k n ow led g e ab ou t t h e b lood p r essu r e m easu r em en t
pr ocedur e, but t o our know ledge few have been done
t o i d e n t i f y t h e a r m ci r cu m f e r e n ce r a n g e o f a d u l t
in pat ien t s associat ed w it h t h e pr oper cu f f size. Th e
sam ple of a st udy r ecent ly developed in Br azil included
on ly n on h osp it alized ch ild r en an d ad olescen t s( 1 6 ).
Man y su bj ect s in clu ded in h y per t en sion st u dies ar e
oft en affect ed by m et abolic sy ndr om e, diabet es, and
obesit y. These pat ient s’ ar m cir cum fer ence is usually
bigger t han 33 cm , dem anding a cuff lar ger t han t he
t r adit ional st andar d one ( 12x 23 cm ) . How ever, m any
subj ect s, such as young adult s, w om en, slim or nor m al
w eig h t p er son s w it h an ar m cir cu m f er en ce sm aller
t han 29 cm , need a nar r ow er cuff t han t he st andar d
one. The w r ong choice of cuff for t hose pat ient s can
r e su l t n o t o n l y i n h y p e r t e n si o n m i sd i a g n o si s a n d
incorrect t reat m ent , but also in an inaccurat e analysis
o f a n y v a r i a b l e a s s o c i a t e d w i t h B P, s u c h a s
ant ihy per t ensiv e t r eat m ent cont r ol, obesit y, phy sical
exercise, sm oking, physiological or em ot ional aspect s,
am on g ot h er s.
Th e d i scr ep an ci es b et w een t h e t h eo r et i cal
fr am ew or k and cuff size r ecom m endat ions for pr act ice
in t he hy per t ension societ ies´ st at em ent s lead us t o
ch e ck w h a t i s h a p p e n i n g i n t h e w a r d s w h e r e w e
pr act ice n u r sin g car e edu cat ion .
OBJECTI VES
To ident ify inpat ient s’ ar m cir cum fer ence and
t he corresponding cuff size according t o t he t radit ional
AHA AC/ Cuff Widt h 0.40 rat io. To check in t he war ds
t h e cu f f sizes’ av ailab ilit y t o m easu r e BP in t h ese
pat ien t s.
METHOD
A cr o ss- sect i o n a l st u d y w a s co n d u ct ed i n
p a t i e n t s a d m i t t e d t o m e d i ca l w a r d s o f d i f f e r e n t
sp eci a l t i es o f a g en er a l u n i v er si t y h o sp i t a l i n t h e
in t er ior of Sao Pau lo. Th e size of t h e sam p le w as
er r or in est im at e and r at io t est s, w it h 0.90 pr obabilit y:
( n = 2 . 6 9 x 0 . 2 5 / 0 . 0 1 y ield ed n = 6 7 . 2( 1 7 ). Th e 0 . 1 0
ad j u st m en t r esu l t ed i n a cal cu l at ed sam p l e o f 8 1
subj ect s. All invit ed pat ient s com plied w it h our st udy,
so t h e m ax im u m er r or d ecr eased t o 0 . 9 0 . Th e 8 1
volunt eer s aged fr om 17 t o 60 year s, 63% w er e m ale.
Th e y w e r e a d m i t t e d t o cl i n i ca l w a r d s o f se v e r a l
sp ecialized u n it s: Car d iolog y ( 3 5 . 8 % ) , Nep h r olog y
( 1 2 . 3 % ) , En d o c r i n o l o g y ( 1 2 . 3 % ) , H e m a t o l o g y
( 12.3% ) , Gast r oent er ology ( 12.3% ) , Ger iat r ic ( 8.7% )
and t o t he Gener al Clinic ( 6.2% ) . The sam ple included
o n l y p a t i e n t s w i t h g o o d m e n t a l h e a l t h , a b l e t o
u n d er st an d t h e r esear ch p r oced u r e an d t o an sw er
t he r esear cher s’ quest ions. The st udy w as car r ied out
af t er t h e Et h ics an d Resear ch Com m it t ee ap p r ov al
and t he disclaim er pat ient signat ur e.
Up p er ar m cir cu m f er en ces w er e m easu r ed
by t hree cardiology specialized nur ses, dur ing r out ine
blood pr essur e m easur em ent , t r ained t o avoid er r or s.
A s r e c o m m e n d e d i n t h e 1 9 9 3 A m e r i c a n H e a r t
Asso ci at i o n Gu i d el i n es XX, t h e ci r cu m f er en ce w as
m easur ed at t he m idpoint bet w een t he acr om ium and
olecr anon of t he r ight ar m , suppor t ed at hear t lev el
( f o u r t h i n t er co st al sp ace) , w i t h t h e p at i en t ei t h er
sit t ing or ly ing dow n. I n cases of discom for t due t o
br achial ar t er y cat het er izat ion and special condit ions,
t he left ar m w as used.
I n or d er t o est im at e t h e cor r ect cu f f w id t h
f o r each p at i en t , w e ad o p t ed t h e Am er i can Hear t
Associat ion ar m cir cum fer ence/ cuff w idt h 0 . 4 0 r at io.
Alt hough t he 0.38 r at io r epr esent s exact ly a cuff w idt h
20% lar ger t han upper ar m diam et er, w e adopt ed 0.40
because it is univ er sally accept ed and used. The cuff
lengt h should encir cle at least 80% t he ar m .
Cu f f av ailab ilit y w as ch eck ed w h en BP w as
m e a su r e d . We a l so i n t e r v i e w e d n u r se s a n d st a f f
m e m b e r s r e s p o n s i b l e f o r t h e p u r c h a s e o f
sp h y g m o m an o m et er s.
RESULTS
Th e r esu lt s ar e p r esen t ed in t h e f ollow in g
o r d e r : p a t i e n t d i s t r i b u t i o n a c c o r d i n g t o c l i n i c a l
sp eci al t y, an d g en d er ( Tab l e 1 ) ; b od y m ass i n d ex
d ist r ib u t ion t o g en d er ( Tab le 2 ) ; b od y m ass in d ex
d ist r ib u t ion t o ag e ( Tab le 3 ) , an d Tab le 4 p r esen t s
pat ien t s‘ ar m cir cu m f er en ce an d cor r espon din g cu f f
w i d t h . Re g a r d i n g t h e a n a l y s i s o f t h e s a m p l e ’ s
d em o g r a p h i c ch a r a ct er i st i cs, f r o m t h e 8 1 st u d i ed
y t l a i c e p S l a c i n i l C r e d n e G e l a
M Female Total
n % n % N %
y g o l o i d r a
C 22 27.1 7 8.7 29 35.8 y g o l o r h p e
N 6 7.4 4 4.9 10 12.3
y g o l o n i r c o d n
E 3 3.7 7 8.6 10 12.3
y g o l o m u e n
P 9 11.1 1 1,2 10 12.3 y g o l o r e t n e o r t s a
G 6 7.4 4 4.9 10 12.3
c i n il C l a c i d e
M - - 5 6.2 5 6.2
c i r t a i r e
G 5 6.1 2 2.5 7 8.7
l a t o
T 51 63.0 30 37.0 81 100
subj ect s, 51 ( 63% ) w er e m ale, being t he age aver age
55.4 year s. The sam ple w as com posed of adolescent s
( 4.9% ) , adult s ( 54.3% ) , and elder ly subj ect s ( 40.7% ) .
Alt hough diagnosis ident ificat ion w as not an obj ect ive
of t his st udy, Table 1 allow s us t o k now t he k ind of
clinic t he pat ient s w er e adm it t ed t o.
Tab le 1 – Gen d er d ist r ib u t ion accor d in g t o clin ical
specialt y. Ribeir ão Pr et o, 2 0 0 2
Th e d a t a f r o m p a t i en t s i n ca r d i o l o g y a n d
n ep h r olog y r each alm ost 5 0 % of t h e sam p le. Not e
t h at 1 2 . 3 % o f t h e p at i en t s w er e ad m i t t ed d u e t o
endocr inology pr oblem s. Many of t hem show ed sever e
obesit y. At dat a collect ion , 2 5 % of t h e sam ple h ad
sy st olic ar t er ial p r essu r e ≥ 1 4 0 m m Hg , an d 2 3 . 4 %
d i ast o l i c ≥ 9 0 m m Hg . Th e m aj o r i t y o f t h e p at i en t s
r e c e i v e d t h r e e o r m o r e d i a g n o s i s , r e a c h i n g 1 1
diagnoses in t w o of t hem t hat suggest com plex it y in
t heir ev aluat ion and t r eat m ent .
Table 2 - Body m ass index dist r ibut ion as a funct ion
of gender. Ribeir ão Pr et o, 2002
* I LI B Rat ing ( 1994)
Dat a in Table 2 show t he high rat e of obese
p a t i e n t s , r e a c h i n g 3 8 . 2 % o f t h e s a m p l e . Th e
asso ci at i o n b et w een b o d y m ass i n d ex an d g en d er
indicat es a fav or able m ale r at e for under or nor m al m / g K * I M B 2 r e d n e G l a t o T e l a
M Female
n % N % n %
5 2 l a m r o n r o r e d n U t h g i e w 4
2 29.6 12 14.8 36 44.4
5 , 7 2 -5 2 t h g i e w r e v
O 9 11.1 1 1.2 10 12.3 9 , 9 2 -5 , 7 2 y t i s e b o I e d a r
G 3 3.7 5 6.1 8 9.9
9 , 9 3 -0 3 y t i s e b o II e d a r
G 6 7.4 7 8.6 13 16.0
d e r o n g
I 9 11.1 5 6.1 14 17.3 l
a t o
e g A s r y 5 2 -7 1 s t n e c s e l o d A s r y 0 6 -6 2 s t l u d A s r y 0 6 > y l r e d l
E Total
n % n % N % n %
5 2 r o r e d n U l a m r o n t h g i e w
1 1.2 19 23.4 16 19.7 36 44.4
5 , 7 2 -5 2 t h g i e w r e v
O 1 1.2 5 6.1 4 4.9 10 12.3 9 , 9 2 -5 , 7 2 I e e r g e D y t i s e b o
- - 7 8.6 1 1.2 8 9.9
9 , 9 3 -0 3 II e e r g e D y t i s e b o
1 1.2 10 12.3 2 2.5 13 16.0
d e r o n g
I 1 1.2 3 3.7 10 12.3 14 17.3
l a t o
T 4 4.9 44 54.3 33 40.8 81 100
f f u c t c e r r o C ) . m c ( h t d i w m r A ) . m c ( e c n e r e f m u c r i
c n %
7 17.5-19.4 5 6.2 8 20.0-22.3 10 12.3 9 22.5-24.2 6 7.4
0
1 25.0-27.2 16 19.7 1
1 27.5-29.9 12 14.8 2
1 30.0-32.0 14 17.3 3
1 32.5-34.3 6 7.4 4
1 35.0-37.0 8 10.0 5
1 38.0-38.6 3 3.7 6
1 40.5 1 1.2
l a t o
T 81 100
w eigh t pat ien t s, t w ice as m u ch as t h at obser v ed in
fem ales. How ever, because m any of t he pat ient s could
not be w eight ed, it w as not possible t o obt ain a pr ecise
evaluat ion of t he st udied sam ple w it h r espect t o body
m ass in dex classif icat ion .
Table 3 - Body m ass index dist r ibut ion accor ding t o
age. Ribeir ão Pr et o, 2002
Sour ce: * I LI B Rat ing ( 1994)
Dat a r egar ding t he associat ion bet w een body
m a s s i n d e x a n d a g e r e v e a l t h a t , a m o n g t h r e e
adolescent s, t w o ar e under or nor m al w eight ed. Adult
subj ect s also pr esent ed high values in t his cat egor y.
As f a r a s t h e el d er l y su b j ect s, f a v o r a b l e r a t es o f
ob esit y d eg r ees I or I I ar e in d icat ed , alt h ou g h t h e
n u m b er o f i g n o r ed w ei g h t i s g r eat er t h an t h at o f
adult s. This fact could have influenced t he dat a, w hich
r evealed a low er fr equency of under w eight and nor m al
pat ient s in t he elder ly gr oup.
Table 4 - Ar m cir cum fer ence and cor r espondent cuff
w id t h d ist r ib u t ion ob t ain ed f r om p at ien t s. Rib eir ão
Pr et o, 2002
As obser ved in Table 4, t he applicat ion of t he
a r m ci r cu m f e r e n ce / co r r e ct cu f f w i d t h 0 . 4 0 r a t i o
r evealed m or e t han 50% of t he subj ect s w it h an ar m
cir cum fer ence sm aller t han 30 cm ; t hus, t hey needed
a cu f f w i d t h n a r r o w er t h a n 1 2 cm . As f a r a s t h e
possibilit y of ov er est im at ion, ar m cir cum fer ence w as
b i g g er t h an 3 2 cm i n 2 2 . 3 % of t h e sam p l e. Th ese
pat ient s need cuffs lar ger t han 12 cm . Only 17.3% of
t he par t icipant s in t he st udy have ar m cir cum fer ence
in t he r ange fr om 30 t o 32 cm , for w hom t he st andar d
cuff of 12 cm is adequat e.
Th e u se of t h e r at io 0 . 4 0 t o calcu lat e t h e
pr oper cuff size t o fit t he st udied ar m cir cum ferences
r esult ed in a cuff w idt h r ange fr om 6 t o 16 cm .
Ou r obser v at ion t h at on ly t h e st an dar d cu ff
size w as av ailab le in t h e w ar d s w as r ein f or ced b y
n u r ses an d en g in eer in g t ech n ician s in ch ar g e, w h o
confirm ed t hat only t his cuff w as used in all pat ient s.
Th e per son n el r espon sible f or t h e pu r ch ase of su ch
equipm ent had not been advised about t he possibilit y
of acqu ir in g dif f er en t cu f f sizes, despit e t h e n ar r ow
range of cuff sizes available in t he m arket . The findings
sh ow n in t ab le 4 in d icat in g r eq u ir em en t of sev er al
cuff sizes r ev eal discr epancy bet w een t he t heor et ical
f r am ew or k an d t h e cu f f size applied t o ch eck blood
pr essur e in hospit alized pat ient s.
DI SCUSSI ON
Th e d em og r ap h ic ch ar act er ist ics r elat ed t o
g en d er an d ag e con f ir m t h e p r esen t r ealit y in t h e
h ealt h car e sy st em of m an y cou n t r ies. Pat ien t s ar e
adm it t ed accor ding t o t heir diagnoses t o over cr ow ded
w ar ds of a gener al hospit al, w her e adolescent s, adult s,
an d elder ly people r em ain all t oget h er in t h e sam e
w ar d. Th e n u m ber of h y per t en siv e su bj ect s r each es
m or e t han 25% of t he sam ple. How ever, m any of t hese
pat ient s could be w r ongly diagnosed due t o t he cuff
av ailabilit y pr oblem .
A c c o r d i n g t o t h e b o d y m a s s i n d e x , a
sig n if ican t seg m en t of t h e st u d ied sam p le ( 4 4 . 4 % )
w as classified as being under or norm al w eight . These
f i n d i n g s a r e d i f f er en t f r o m t h o se g a t h er ed i n t h e
cam p u s of t h e Un iv er sit y of São Pau lo in t h e 8 0 s,
w her e near ly 20% of t he subj ect s w er e t hin and 50%
h ad n or m al w eig h t( 1 8 ). Th u s, t h e n u m b er of ob ese
( 3 0 % ) w as low er t h an w h at h as been f ou n d in t h e
pr esent st udy, in w hich 38.2% of t he pat ient s had a
O b e s i t y r a t e s a r e d i f f e r e n t f r o m t h o s e
e s t i m a t e d i n B r a z i l s o m e y e a r s a g o : 4 0 % a r e
ov er w eig h t an d ob ese, r each in g 1 5 t o 2 0 % am on g
childr en and adolescent s. I n t hese t w o gr oups, obesit y
rat es hav e doubled and t r ipled, r espect ively. Obesit y
prevalence is increasing w orldw ide and excess w eight
i s a sso ci a t ed w i t h ch r o n i c- d eg en er a t i v e d i sea ses,
w h i ch r e su l t s i n p o o r q u a l i t y o f l i f e a n d se r i o u s
s o c i o e c o n o m i c i m p a c t , a r e l e v a n t p u b l i c h e a l t h
con cer n . Solv in g t h is p r ob lem h as b een on e of t h e
gr eat est challenges in t he healt h car e ar ea( 19) at t he
beginning of t his cent ur y.
Despit e t he possibilit y of bias w hen com par ing
t he healt h st at us of t w o differ ent populat ions, people
in t h eir w or k p lace v er su s in p at ien t s su b j ect s, ou r
f i n d i n g s co n f i r m t h e f a ct t h a t o b e si t y r a t e s a r e
in cr easin g in Br azil. Th e associat ion of obesit y w it h
hyper t ension, diabet es, car diovascular and nephr ology
d iseases, r esu lt s in t h e elev at ed r at es ob ser v ed in
t he pr esent sam ple. These r at es dr aw special at t ent ion
t o b l o o d p r e ssu r e e v a l u a t i o n o f o b e se su b j e ct s,
p a r t i cu l a r l y t h o se u n d e r t r e a t m e n t i n h o sp i t a l s,
because t heir ar m cir cum fer ences higher t han 33 cm
n e e d c u f f s l a r g e r t h a n t h e s t a n d a r d o n e . Ma n y
invest igat ors, nurses, physicians, phar m acologist s and
ot her s, do not know t hat t he st andar d cuff size is ideal
for ar m cir cum fer ences fr om 30 t o 33 cm . Mor eov er,
t h ey do n ot k n ow h ow t o cor r elat e age, body m ass
index and ar m cir cum fer ence t o cuff dim ensions.
Dat a associat in g ag e an d b od y m ass in d ex
sh ow t h at w e can f in d an y in dex v alu e in ch ildr en ,
adult s or t he elder ly. This m eans t hat w e need cuffs
nar r ow er t han 12 cm t o ser ve elder ly people w ho ar e
t hin as w ell m any subj ect s w it h nor m al size, w eight
and ar m cir cum fer ence, par t icular ly w om en in Japan,
Kor ean, Afr ica, Asia and Fr ance, as w ell as in ot her
count r ies. Many hav e ar m cir cum fer ence low er t han
30 cm , young lean w om en low er t han 26 cm , differ ent
f r o m o b e s e s u b j e c t s n e e d i n g l a r g e r c u f f s . A s
em ph asized, on ly lar ger cu ffs h av e been a qu est ion
of concern in blood pressure m easurem ent evaluat ion,
a s ca n b e ch e ck e d i n t h e 2 0 0 5 Am e r i ca n H e a r t
A s s o c i a t i o n Gu i d e l i n e s f o r b l o o d p r e s s u r e
m easur em ent , w her e a cuff of 12 cm is r ecom m ended
for an ar m cir cum fer ence of 22 t o 26 cm( 19).
Follow ing a cohor t of 530 subj ect s fr om t he
Univ er sit y of Sao Paulo( 18) dur ing t he last 2 6 y ear s,
w e hav e dem onst r at ed t hat t he use of t he st andar d
cu f f ( 1 2 cm ) i n a r m s o f 2 2 - 2 6 cm ca n r e su l t i n
h y per t en sion m isdiagn osis an d m ist r eat m en t du e t o
b l o o d p r e s s u r e u n d e r e s t i m a t e d r e a d i n g s .
Car diov ascular and gest at ional com plicat ions, as w ell
as hear t failur e, st roke, pr eeclam psia, eclam psia, and
ear ly placent al displacem ent w er e com m on pr oblem s
obser ved in t he cohor t of t his longit udinal st udy( 18).
Fo r t u n a t e l y, t h e 2 0 0 6 B r a z i l i a n
r ecom m endat ions for blood pr essur e m easur em ent( 20)
m aint ained t he decision m ade in t he 1993 Am er ican
Hear t Associat ion guidelines( 10), w hich include a cuff
1 0 c m l a r g e . Th e 2 0 0 7 Eu r o p e a n S o c i e t y o f
Hy per t en sion gu idelin es r ecom m en d a st an dar d cu ff
1 3 x 3 4 cm . As m en t ion ed , t h ey also r ecom m en d a
bigger on e f or f at ar m s an d a sm aller on e f or t h in
ar m s( 21).
The adult s show ed higher blood m ass index
lev els t han t he elder ly subj ect s, leading t o t he belief
t h at t h e u se of an “ ad u lt cu f f ” m ay j eop ar d ize t h e
r esult s, since br achial cir cum fer ences do not alw ay s
cor r espond t o such denom inat ion. The aut hor s of t he
1 9 6 7 A m e r i c a n H e a r t A s s o c i a t i o n g u i d e l i n e s( 9 )
r ecom m en ded n ot labelin g t h e st an dar d cu f f 1 2 cm
l a r g e a s “ a d u l t cu f f ”, b eca u se i t d o es n o t a l w a y s
cor r esp on d t o t h e ap p r op r iat e w id t h . Fu r t h er m or e,
high obesit y indices cannot be indist inct ly cor r elat ed
t o l a r g e r a r m s o r l a r g e r cu f f s, a s sh o w e d i n o u r
f in din gs. Th e applicat ion of t h e ar m cir cu m f er en ce/
cor r ect cuff w idt h 0.40 r at io r evealed t hat m or e t han
5 0 % of t h e su b j ect s n eed ed a cu f f w id t h n ar r ow er
t h an 1 2 cm , an d 2 2 . 2 % n eed ed lar g er on es ( ar m /
cir cum fer ence bigger t han 32 cm ) . The cuff w idt h r ange
t o com ply w it h t he st udied ar m cir cum fer ence applying
su ch r at io v ar ies fr om 7 t o 1 6 cm . How ever, in t h e
unit s w her e t he sur vey w as car r ied out , only one cuff
w idt h w as pr ovided ( 12 cm ) , suit able for only 17.3%
of t he par t icipat ing pat ient s. The possibilit y of blood
pr essur e r eadings being under or ov er est im at ed is a
r ealit y. As not ed in Table 3, m any pat ient s should be
r eceiv in g an t i- h y p er t en siv e t r eat m en t , b u t p r ecise
ev alu at ion an d t r eat m en t ar e n ot easily obt ain ed in
such sit uat ion, as probably occurs in hospit als around
t he w or ld.
Th e A m e r i c a n H e a r t A s s o c i a t i o n
r ecom m en d ed an ar m cir cu m f er en ce/ cor r ect w id t h
r at io of 0.40 fr om 1951 t o 2005( 11,15). I n 2005, a r at io
of 0.46 was also m ent ioned( 11). As show n in Table 5,
applying a r at io of 0.40 in our sam ple r esult ed in t he
con clu sion t h at a lar ge cu f f size r an ge w as n eeded
not t o have over or under est im at ion of blood pr essur e
v alu es. Becau se a sin g le cu f f size w as av ailab le in
t hat m any hyper t ensive pat ient s ar e under poor blood
pr essur e ev aluat ion and w r ong t r eat m ent .
Lack of av ailabilit y of sev er al cuff sizes is a
ser i o u s m a r k et p r o b l em , f a ced n o t o n l y b y so m e
cl i n i ci a n s o r n u r se s, b u t a l so b y b l o o d p r e ssu r e
m easu r em en t r esear ch er s. Af t er t h e cu f f size er r or
was observed in children, pregnant wom en and crit ical
pat ient s, t he first aut hor of t his invest igat ion raised an
et hical concern about t he regist rat ion of a wrong blood
pressure value in a pat ient ’s record( 5). Brazilian nurses
have been researching on blood pressure m easurem ent
and trying to attract specialists’ attention to the serious
public healt h problem of hypert ension m isdiagnosis and
incorrect treatm ent(18). I t is bewildering why hypertensive
societies find it so hard to solve the problem s caused by
inappropriat e cuff size.
This st udy cont r ibut es t o nur ses’ k now ledge
r egar din g t h e discr epan cies bet w een t h e t h eor et ical
f r am ew or k of b lood p r essu r e m easu r em en t d ev ices
an d t h e cu f f size u sed in p r act ice. Blood p r essu r e
m easurem ent is t he nursing procedure m ost perform ed
in t he world. The aut hors believe t hat effort s m ust be
d o n e t o p r o v i d e i n f o r m a t i o n t o b r o a d e n n u r si n g
k now ledge, focusing on t he cuff size effect on blood
pressure m easurem ent . The m at t er could be discussed
in cont inuous educat ional pr ogr am s, r aising nur ses´
aw ar en ess on t h e n eed f or a gr eat er av ailabilit y of
appr opr iat e m easu r em en t t ools. Th is cou ld im pr ov e
qualit y of life and decrease cost s in healt h area.
CONCLUSI ON
The st udy show ed t hat differ ent cuff sizes ar e
needed t o cov er t he ent ir e ar m cir cum fer ence r ange
d e m a n d e d b y a d o l e s c e n t s , a d u l t s a n d t h e a g e d
inpat ient s of a gener al hospit al.
The r esult s show ed a lar ge ar m cir cum fer ence
r an g e, r eq u i r i n g sev er al cu f f si zes t o av o i d b l o o d
pr essur e m easur em ent s er r or s. Our findings indicat e
discr epancies bet w een t he t r adit ional Am er ican Hear t
Associat ion t heor et ical fr am ew or k for blood pr essur e
m easur em ent and clinical pr act ice. Only t he st andar d
cuff size w as available t o be used in t he ent ire st udy
sam ple. The lack of differ ent cuff sizes is not a local
pr oblem as r epor t ed in m any ot her st udies( 3- 5,7,18). As
sh o w n i n t h i s r esea r ch , o n l y t h e st a n d a r d cu f f i s
com m only available in healt h car e unit s. Unfor t unat ely,
m any subj ect s cont inue t o r eceive poor blood pr essur e
e v a l u a t i o n a n d t h i s o f t e n r e su l t s i n h y p e r t e n si o n
m i s d i a g n o s i s , c a r d i o v a s c u l a r a n d g e s t a t i o n a l
com plicat ion s an d deat h s.
ACKNOW LEDGMENTS
The aut hor s w ould like t o t hank Mr s. Car olina
Godoy Veiga da Cu n h a ( M. A. in TESL, Un iver sit y of
I llin ois at Ur ban a- Ch am paign , USA) f or h er r ev ision
of t he English language.
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