Response to the Letter by Ozturk and Colleagues Entitled: “Inter‐Arm Blood Pressure Differences May Be Important in Predicting Mortality”

To the Editor: We thank Ozturk and colleagues for their comments on the manuscript entitled: “Inter-Arm Blood Pressure Difference in Hospitalized Elderly Patients Is Not Associated With Excess Mortality.” There is little doubt thatmeasuring blood pressure (BP) in both arms, particularly at the initial encounter, is essential in order to both define the arm in which BP is higher and to identify those unusual cases in which subclavian artery stenosis or other anomaly results in significant BP differences between the two arms. In addition, it has been reported that BP differences between arms exist even in young, apparently healthy individuals without risk factors for atherosclerosis. Ozturk and colleagues claim that in our study the characteristics of the vascular disease of the patients were not well defined. Although imaging of the subclavian vessels was not performed in our cohort to identify those with significant subclavian artery atherosclerosis, it was also not performed in any of the other studies in which the association between inter-arm BP difference and mortality was evaluated. If inter-arm BP difference is to be used for prognostic purposes in large-scale populations and even in the individual patient, it is not feasible to perform imaging of the subclavian vessels in all patients. If significant inter-arm BP differences are recognized (ie, ≥20 mm Hg), we agree that such imaging should be performed as this might have a true therapeutic implication for the rare individual in which this is encountered. The elderly population is unique as these patients may have a larger burden of atherosclerosis and comorbidities and therefore the clinical implications of inter-arm BP differences may be more significant; however, we have previously reported that inter-arm BP difference in this population is not reproducible. This is whywe think this study is important, as it failed to prove the association between inter-arm BP difference and mortality in hospitalized elderly patients, in contrast to other studies in which such an association was reported. The constantly increasing population of individuals 65 years and older is certainly unique and characterization of cardiovascular risk factors in these patients ismandatory.