Incorrect positioning of cuff for blood pressure measurement – clinical relevance
and usefulness of novel cuff design.
Grzegorz Bilo 1, Oscar Sala 1,2, Carlotta Perego 2, Cristina Zorzi 1,3, Juan Eugenio Ochoa Munera 1, Anna
Gluszewska 4, Lan Gao 1, Cinzia Vergani 2, Laura Maria Lonati 1, Gianfranco Parati 1,2
1
Cardiology Unit, Istituto Auxologico Italiano, IRCCS, Milan, Italy; 2 Department of Health Sciences,
Università di Milano-Bicocca, Milan, Italy; 3 Università di Milano, Milan, Italy; 4 Department of Internal
Medicine and Gerontology, Jagiellonian University, Medical College Krakow; Poland
Background
Scientific societies and manufacturers recommend that arm cuff for blood pressure (BP) should be placed with
the bladder centred above brachial artery for correct measurement. Although cuff malpositioning due to its
rotation may be common it is not clear whether the related error is relevant.
Aims
1) To assess the size of error in BP measurement due to incorrect cuff positioning
2) To evaluate the usefulness of a novel arm cuff design to overcome the problem of incorrect cuff positioning
Table 1. Study measurements sequence
Methods
An interim analysis in 41 (out of 50 planned) subjects (selection criteria in Box 1) was performed.
After 10 minutes rest two sequences of BP measurements on both arms were performed in each
participant to address each of the study aims (Table 1):
1) with two mercury sphygmomanometers (one with cuff always correctly placed and the other
with cuff in different positions);
2) with a mercury sphygmomanometer (cuff always in correct position) and an Omron M6Comfort (HEM-7321-E) validated oscillometric device coupled with IntelliWrap cuff placed in
different positions (see Figure 1).
Step
Preliminary
measurement
10 min rest
Entry
measurement 1
Entry
measurement 2
Test of position
relevance
(Aim 1)
BOX 1. Study selection criteria
Inclusion:
Age 18-80 years,
Sinus rhythm
Arm circumference 23 - 42 cm
Stable clinical conditions
Written informed consent
Exclusion:
History of peripheral artery disease
Radial pulse asymmetry or BP difference between arms >5 mmHg
Deformations of any arm which could interfere with accurate measurement
Arm lymphedema
Relevant arrhythmias (frequent ectopic beats, atrial fibrillation/flutter, bradycardia <50 bpm)
Cardiac pacemaker
Patients on oral anticoagulants or with known coagulation alterations
Patient with skin lesions on upper arm(s)
Pregnancy
Preliminary
measurement
Test of
IntelliWrap cuff
(Aim 2)
Figure 1. Omron M6-Comfort
with IntelliWrap cuff
Arm 1 *
Arm 2 *
Device
Cuff position
Device
Cuff position
AU
Correct
AU
Correct
AU
Correct
AU
Correct
AU
Correct
AU
Correct
AU
AU
AU
AU
AU
AU
AU
AU
AU
Correct
90° medially
180°
90° laterally
90° laterally
180°
90° medially
Correct
Correct
AU
AU
AU
AU
AU
AU
AU
AU
OSC
Correct
Correct
Correct
Correct
Correct
Correct
Correct
Correct
Correct
AU
AU
AU
AU
AU
AU
OSC
OSC
OSC
OSC
OSC
OSC
Correct
Correct
Correct
Correct
Correct
Correct
Correct
90° laterally
180°
180°
90° laterally
Correct
OSC
OSC
OSC
OSC
OSC
OSC
AU
AU
AU
AU
AU
AU
Correct
90° laterally
180°
180°
90° laterally
Correct
Correct
Correct
Correct
Correct
Correct
Correct
* - the assignment of sides (left/right) to arms 1 and 2 was done in a random manner
AU – auscultatory mercury device with standard cuff; OSC – oscillometric Omron M6-Comfort
(HEM-7321-E) device coupled with IntelliWrap cuff
Results
Population characteristics: age 50.7±16.0,
26M/15F, BMI 32.8±7.9 kg/m2, arm
circumference 33.3±4.4cm
The effects of different cuff positions on BP
values measured with auscultatory or
oscillometric device are shown in Figure 2.
There was no difference between arms with
auscultatory measurements (mean SBP/DBP
difference was -0.37±2.5 /-0.05±1.8 mmHg)
Oscillometric device produced BP values which
were on average lower than those measured
with mercury device (mean SBP/DBP
difference was -3.8±8.0/-4.6±7.6 mmHg when
both devices were in correct position). This
appears to be due to relative undercuffing with
mercury device equipped with standard size
cuff in subjects with larger arm. For major
clarity the between-arm differences for incorrect
positions shown in Figure 2 are corrected for
the mean between-arm difference with both
devices in correct position.
Figure 2. Effect of incorrect positions of BP measurement cuff of auscultatory (left) and
Omron+IntelliWrap (right) device. The values represent difference between BP measured in the
indicated cuff position and BP measured with auscultatory device in correct position on the opposite
arm and are corrected for the difference observed when both cuffs were in correct positions. Minus sign
indicates underestimation of BP compared with correct position. All BP values in mmHg
Conclusions
Interim results of our study show that incorrect positioning of conventional cuff significantly affects BP measurement results,
with BP overestimation particularly evident when the bladder centre is displaced by 90° laterally or by 180° compared to
correct position. No effect of cuff position was observed when IntelliWrap cuff was used. BP values obtained with oscillometric
device tended to be lower than those obtained by reference method because of relative undercuffing with mercury device
equipped with standard size cuff in subjects with large arm circumference.
Study supported by Omron Healthcare Europe