Dear Dr Roach: I would like to comment on your column regarding blood-pressure differences between the arms.
A difference of greater than 10 mmHg between the two arms in systolic pressure is considered abnormal. We see patients not uncommonly in consultation for this reason alone, perhaps as many as one a month. Almost always, the reason for the difference is blockage of the subclavian artery. The wrist pulse on the side with lower blood pressure may be normal, diminished or absent in those patients. From 30 years of observation, I have noticed that patients with BP differences between the arms are nearly always female smokers (or former smokers), and the left subclavian is much more likely to be affected (have a lower blood pressure) than the right. Why this sex difference should be and why the left side should predominate is not understood and, to my knowledge, has not been described in print. Additionally, the presentation is usually in a non-obese woman in her 40s or 50s who is still smoking.
The significance of the finding is that it is a red flag waving for tobacco cessation and is a marker that that person's arteries have already been significantly altered by the habit. Fortunately, the incidence of arm symptoms associated with the lower BP on that side is quite low 鈥� perhaps one in 10 have any symptoms. It is important, of course, for such patients to be aware of the difference between the arms only to remember which arm (the higher arm systolic number) has the correct measurement (most often, but not always, the right). Jerry Svoboda, MD, FACS
I thank Dr. Svoboda for his expertise and will add difference in arm blood pressures to my (already very long list) of reasons to quit smoking immediately.
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Dear Dr Roach: I am a 78-year-old female who has had three orthopedic surgeries (hip repair, hip replacement and knee replacement) with spinal anesthesia in two years. Each time, the anesthesia has left me with severe orthostatic hypotension requiring medication for months. If I should ever need surgery again, is there any other anesthetic that would be just as effective and not make me ill? A.P.
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This actually is a very common problem, with at least half of people undergoing orthopedic surgery having some orthostatic hypotension (a lowering of blood pressure upon sitting or standing) immediately after surgery. You have had a very prolonged reaction. I spoke with an anesthesiologist at the Cleveland Clinic, who told me that the issue could have been any of the anesthetic and adjuvant agents that were used. He recommended more salt and water before any operation and longer time in progressively upright positions before trying to get up post-operatively.
Finally, your next anesthesiologist could look at your preoperative and anesthesia records and try to figure out what agent you had that was most likely to have been causing this, so to avoid its use next time.
I hope you don鈥檛 have another recurrence.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to [email protected]
