Effect of the shape of the cuff on blood pressure measurement in people with large arms.

Purpose: Previous data suggest that tronco-conical cuffs should be used for accurate blood pressure (BP) measurement in the obese. However, not only arm size but also its shape may affect the accuracy of BP measurement when a cylindrical cuff is used.Methods: In 197 subjects with arm circumference >32 cm, and 157 subjects with arm circumference ≤ 32 cm, the upper-arm was considered as formed from two truncated cones and the frustum slant angles of the proximal (upper angle) and distal (middle angle) truncated cones were measured. Five cylindrical and five tronco-conical cuffs of appropriate size in relation to arm circumference were used.Results: In the group with large arm, the upper slant angle was greater than the middle angle (86.5 ± 1.7° versus 84.7 ± 2.3°), whereas in the group with normal arm the two angles were similar. In the former group, the cylindrical cuff overestimated BP by 2.5 ± 5.4/1.7 ± 4.7 mmHg, whereas in the latter negligible between-cuff BP discrepancies were found. In the whole sample, BP discrepancies between the cylindrical and the tronco-conical cuffs correlated with both arm size and shape, considered as the difference between the upper and middle slant angles (all p < 0.0001). Among the participants with large arm, the between-cuff BP discrepancies increased progressively with increasing upper-middle angle difference (3.75 ± 0.38/2.78 ± 0.32 mmHg for the top tertile, p < 0.001/<0.001).Conclusions: These data indicate that in people with large upper arms, the tronco-conical shape of the arm is more pronounced on the lower than the upper half, a feature that amplifies the BP measurement error when cylindrical cuffs are used.

Intima-media thickness remodelling in hypertensive subjects with long-term well-controlled blood pressure levels.

Aim of this study was to evaluate in a long follow-up the carotid artery remodelling in a cohort of young hypertensive subjects having good blood pressure (BP) control. We studied 20 grade I hypertensives (HT) by assessing the B-mode ultrasound of mean carotid intima-media thickness (mean-IMT) and maximum IMT (M-MAX) in each carotid artery segment (common, bulb, internal), bilaterally. We compared their ultrasound measurements with those recorded 5 and 10 years earlier. While the first 5-year follow-up was observational, in the second 5-year follow-up, lifestyle modifications and/or pharmacological therapy were started to obtain well-controlled BP levels. Office BP was measured at the time of the ultrasound studies and every 6 months during the follow-up. BP levels were: 10 years 144/91 mmHg, 5 years 143/90 mmHg and 129 ± 79 mmHg at the time of the study. In the first 5-year observational follow-up, both mean-IMT and M-MAX increased (Δ 0.116 and Δ 0.165 mm, respectively, p < 0.0005). In the 5-year intervention follow-up, characterized by well-controlled BP, mean-IMT slightly but significantly increased (Δ 0.084 mm, p = 0.004), whereas M-MAX remained stable (Δ 0.026 mm). In our HT, well-controlled BP levels were able to prevent pro-atherogenic remodelling (expressed by M-MAX). Conversely, good BP control slightly decreased but did not stop the progression in mean-IMT, which is likely to reflect some hypertrophy of the arterial media layer.

Effects of smoking on central blood pressure and pressure amplification in hypertension of the young.

The aim of this study was to investigate the effect of cigarette smoking on peripheral and central blood pressure (BP) in a group of young stage I hypertensives. A total of 344 untreated subjects from the HARVEST study were examined (mean age 37±10 years). Patients were divided into three groups based on smoking status: non-smokers, light smokers (⩽5 cigarettes/day) and moderate-to-heavy smokers (>5 cigarettes/day); and into three groups by age: 18-29, 30-39 and ⩾40 years. Central BP measurements and augmentation index (AIx) were calculated from brachial pressure waveform, with applanation tonometry, by means of the Specaway DAT System plus a Millar tonometer. The central waveform was derived from peripheral BP using the same software system of the SphygmoCor System pulse wave analysis. In addition, two indirect measurements of arterial stiffness were calculated: pulse pressure (PP) and systolic BP amplification. Central systolic BP and PP were higher in smokers than in non-smokers (systolic BP: 121.9±13.1 mmHg in non-smokers, 127.2±16.5 mmHg in light smokers, 126.7±15.3 mmHg in those who smoked >5 cigarettes/day, p=0.009; PP: 37.7±9.8 mmHg, 41.5±13.1 mmHg, 41.9±10.5 mmHg, respectively, p=0.005). Lower systolic BP amplification (p<0.001) and PP amplification (p=0.001) were observed in smokers compared to non-smokers. In a two-way ANCOVA analysis, systolic BP amplification markedly declined across the three age groups (p=0.0002) and from non-smokers to smokers (p=0.0001), with a significant interaction between smoking and age group (p=0.05). The AIx was higher in smokers compared to non-smokers (p=0.024). In young hypertensives, smoking has a detrimental effect on central BP, accelerating the age-related decline in BP amplification.

Association of coffee consumption and CYP1A2 polymorphism with risk of impaired fasting glucose in hypertensive patients.

Whether and how coffee use influences glucose metabolism is still a matter for debate. We investigated whether baseline coffee consumption is longitudinally associated with risk of impaired fasting glucose in a cohort of 18-to-45 year old subjects screened for stage 1 hypertension and whether CYP1A2 polymorphism modulates this association. A total of 1,180 nondiabetic patients attending 17 hospital centers were included. Seventy-four percent of our subjects drank coffee. Among the coffee drinkers, 87% drank 1-3 cups/day (moderate drinkers), and 13% drank over 3 cups/day (heavy drinkers). Genotyping of CYP1A2 SNP was performed by real time PCR in 639 subjects. At the end of a median follow-up of 6.1 years, impaired fasting glucose was found in 24.0% of the subjects. In a multivariable Cox regression coffee use was a predictor of impaired fasting glucose at study end, with a hazard ratio (HR) of 1.3 (95% CI 0.97-1.8) in moderate coffee drinkers and of 2.3 (1.5-3.5) in heavy drinkers compared to abstainers. Among the subjects stratified by CYP1A2 genotype, heavy coffee drinkers carriers of the slow *1F allele (59%) had a higher adjusted risk of impaired fasting glucose (HR 2.8, 95% CI 1.3-5.9) compared to abstainers whereas this association was of borderline statistical significance among the homozygous for the A allele (HR 1.7, 95% CI 0.8-3.8). These data show that coffee consumption increases the risk of impaired fasting glucose in hypertension particularly among carriers of the slow CYP1A2 *1F allele.

Regular physical activity is associated with improved small artery distensibility in young to middle-age stage 1 hypertensives.

The aim of the present study was to investigate the association of physical activity with small artery elasticity in the early stage of hypertension. We examined 366 young-to-middle-age stage 1 hypertensives (mean blood pressure 145.6±10.3/92.5±5.8 mmHg), divided into two categories of physical activity, sedentary (n=264) and non-sedentary (n=102) subjects. The augmentation index was measured using the Specaway DAT System. Small artery compliance (C2) was measured by applanation tonometry, at the radial artery, with an HDI CR2000 device. After 6 years of follow-up, arterial distensibility assessment was repeated in 151 subjects. Heart rate was lower in active than in sedentary subjects (71.2±8.9 vs 76.6±9.7 bpm, p<0.001). After adjusting for age, sex, heart rate, smoking, and blood pressure, C2 was higher (8.0±2.6 vs 6.4±3.0 ml/mmHg × 100, p=0.008) in non-sedentary than in sedentary patients. The augmentation index was smaller in the former (8.8±20.1 vs 16.8±26.5%, p=0.044) but the difference lost statistical significance after further adjustment for blood pressure. After 6 years, C2 was still higher in the non-sedentary than sedentary subjects. In addition, an improvement in the augmentation index accompanied by a decline in total peripheral resistance was found in the former. These data show that regular physical activity is associated with improved small artery elasticity in the early phase of hypertension. This association persists over time and is independent of blood pressure and heart rate.

Criteria for a suitable reference cuff for validation studies of blood pressure measuring devices in people with arm circumference between 43 and 50 cm.

OBJECTIVE: Recommendations about the dimensions of the reference cuff for device validations in people with arm size >42 cm are still unavailable. The aim of this study was to identify the criteria for an appropriate reference cuff for validation studies in people with upper arm circumference between 43 and 50 cm. METHODS: In 20 adults with upper arm circumference between 43 and 50 cm (X-large group), 34 subjects with arm circumference between 37 and 42 cm and 78 subjects with arm circumference <37 cm cylindrical and tronco-conical cuffs were compared. In all participants, the pressure transmitted to the arm under the two cuffs was measured using a paper-thin pressure sensor. RESULTS: In the X-large group, all participants had an arm slant angle <86.0°. In this group, the difference between the pressure detected on the arm surface with the sensor using the cylindrical versus the tronco-conical cuff (13.5 mmHg) was larger than in the group with an arm circumference of 37-to 42 cm and the group with a circumference <37 cm (3.7 and 0.6 mmHg, respectively, P < 0.001 versus both). In the whole sample, the between-cuff pressure difference was proportional to the conical shape of the arm ( P < 0.001). CONCLUSIONS: These data suggest that in people with arm size between 43 and 50 cm the reference cuff for validation studies should have a conical shape with an 84-85° slant angle. To comply with current guidelines, an 18.5 × 37.0 cm bladder should be used which would allow proper cuffing in the large majority of subjects.

BP reactivity to public speaking in stage 1 hypertension: influence of different task scenarios.

AIM: To investigate the blood pressure (BP) reaction to public speaking performed according to different emotionally distressing scenarios in stage 1 hypertension. METHODS. We assessed 64 hypertensive and 30 normotensive subjects. They performed three speech tasks with neutral, anger and anxiety scenarios. BP was assessed with the Finometer beat-to-beat non-invasive recording system throughout the test procedure. RESULTS: For all types of speech, the systolic BP response was greater in the hypertensive than the normotensive subjects (all p < 0.001). At repeated-measures analysis of covariate (R-M ANCOVA), a significant group-by-time interaction was found for all scenarios (p ≤ 0.001). For the diastolic BP response, the between-group difference was significant for the task with anxiety scenario (p < 0.05). At R-M ANCOVA, a group-by-time interaction of borderline statistical significance was found for the speech with anxiety content (p = 0.053) but not for the speeches with neutral or anger content. Within the hypertensive group, the diastolic BP increments during the speeches with anxiety and anger scenarios were greater than those during the speech with neutral scenario (both p < 0.001). CONCLUSIONS: These data indicate that reactivity to public speaking is increased in stage 1 hypertension. A speech with anxiety or anger scenario elicits a greater diastolic BP reaction than tasks with neutral content.

Cystatin C as predictor of microalbuminuria in the early stage of hypertension.

BACKGROUND/AIMS: Predictors of microalbuminuria in the early stage of hypertension are not well known. We did a prospective study to investigate whether glomerular hyperfiltration assessed from serum cystatin C predicts development of microalbuminuria in hypertension. METHODS: We assessed 101 treatment-naive subjects screened for stage 1 hypertension and followed-up for a median 3.1 years. Cystatin C was measured at entry and glomerular filtration rate was estimated using the Hoek formula (CystGFR). Urinary albumin and ambulatory blood pressure were measured at entry and during the follow-up. RESULTS: Subjects in the top CystGFR tertile (>115 ml/min/1.73 m(2)) were leaner (p = 0.002) and developed microalbuminuria more frequently (p = 0.02) than the rest of the group. In univariate Cox regression, CystGFR was associated with future microalbuminuria (hazard ratio, 1.06, 95% confidence interval (CI), 1.02-1.10, p = 0.001). After controlling for baseline albumin excretion rate and several confounders, CystGFR remained a significant predictor of microalbuminuria development (hazard ratio, 1.19, 95% CI, 1.03-1.37, p = 0.019). The association between future microalbuminuria and creatinine clearance or glomerular filtration rate estimated with the Cockroft-Gault or the Modification of Diet in Renal Disease formula did not attain the level of statistical significance in this sample. CONCLUSIONS: The present findings indicate that CystGFR is more sensitive than creatinine clearance or estimated glomerular filtration rate for predicting microalbuminuria development in the early stage of hypertension and confirm that hyperfiltration precedes microalbuminuria in this clinical entity.

Only troncoconical cuffs can provide accurate blood pressure measurements in people with severe obesity.

OBJECTIVE: Rectangular (cylindrical) cuffs and bladders are currently used for blood pressure (BP) measurement at the upper arm. However, large arms have a troncoconical shape, which make cylindrical cuffs potentially unsuitable. Aim of this study was to investigate the effect of the shape of the cuff on BP measurement in very obese participants. METHODS: In 33 participants with upper arm mid-circumference at least 42 cm and 33 participants of control, cylindrical and troncoconical cuffs of appropriate size were compared. In addition, in the obese participants, the pressure transmitted to the arm under the cuffs was measured at five cuff pressure levels using a paper-thin pressure sensor. RESULTS: In all obese participants, the upper arm shape was troncoconical (mean ±â€ŠSD slant angle, 84.1 ±â€Š1.4°). In this group, SBP and DBP differences between the troncoconical and the cylindrical cuff were -5.3 ±â€Š4.0 and -3.0 ±â€Š4.3 mmHg, respectively (P < 0.001/=0.01 versus controls). In the obese participants of the top BP quintile, the between-cuff SBP difference was -9.1 ±â€Š5.1 mmHg. Arm slant angle was an independent predictor of the between-cuff SBP discrepancy (P = 0.003). When the cylindrical cuff was used, measurement with the pressure sensor showed a marked disagreement between the pressure in the cuff and the pressure transmitted to the arm (mean difference, -10.2 ±â€Š5.2 mmHg) a difference, which increased with increasing level of the pressure pumped in the cuff. CONCLUSION: In very obese people, cylindrical cuffs overestimate BP chiefly in people with high SBP and thus only troncoconical cuffs should be used.

Validation of the A&D BP UA-651 device with a wide-range cuff for home blood pressure measurement according to the European Society of Hypertension International Protocol revision 2010.

The aim of this study was to determine the accuracy of the A&D BP UA-651 device coupled to a wide-range cuff for home blood pressure (BP) measurement according to the International Protocol of the European Society of Hypertension. The device was evaluated in 33 patients. The mean age of the patients was 56.5±15.1 years. The mean systolic BP was 144.3±23.8 mmHg (range 88 : 196), the mean diastolic BP was 87.5±15.8 mmHg (range 38 : 132), and the mean arm circumference was 29.0±3.4 cm (range 22 : 36). The protocol requirements were followed precisely. The device passed all requirements, fulfilling the standards of the protocol. On average, the device overestimated the systolic BP by 0.7±3.4 mmHg and underestimated the diastolic BP by 0.8±3.6 mmHg. The measurement error was unrelated to the patient's arm circumference. These data show that the A&D BP UA-651 device coupled to a wide-range cuff fulfilled the requirements for validation by the International Protocol over a wide range of arm circumferences and can be recommended for clinical use in the adult population.

Validation of the A&D BP UB-543 wrist device for home blood pressure measurement according to the European Society of Hypertension International Protocol revision 2010.

The aim of this study was to determine the accuracy of the A&D BP UB-543 wrist device for home blood pressure (BP) measurement according to the International Protocol of the European Society of Hypertension. The A&D BP UB-543 monitor is provided with a correct position guidance (CPG) indicator that ensures the correct placement of the wrist at the heart level. Device evaluation was carried out in 33 patients with the CPG indicator on. The mean age of the patients was 53.1±16.4 years, the mean systolic BP was 141.8±25.1 mmHg (range 84 : 196), the mean diastolic BP was 88.2±14.5 mmHg (range 34 : 132), the mean arm circumference was 29.0±3.6 cm (range 21 : 38), and the mean wrist circumference was 17.5±1.4 cm (range 15 : 20). The protocol requirements were followed precisely. The device passed all requirements, fulfilling the standards of the protocol. On average, the device overestimated the systolic BP by 1.1±2.9 mmHg and underestimated diastolic BP by 0.1±3.0 mmHg. These data show that the A&D BP UB-543 wrist device used correctly with the CPG indicator on met the requirements for validation by the International Protocol and can be recommended for clinical use in the adult population.

Validation of the A&D BP UA-651 device for home blood pressure measurement according to the European Society of Hypertension International Protocol revision 2010.

The objective of this study was to determine the accuracy of the A&D BP UA-651 device for home blood pressure (BP) measurement according to the International Protocol of the European Society of Hypertension. Device evaluation was carried out in 33 patients. The mean age of the patients was 48.3±15.5 years, the mean systolic BP was 138.3±24.9 mmHg (range 90-180), the mean diastolic BP was 88.3±13.8 mmHg (range 60-108), and the mean arm circumference was 28.6±3.4 cm (range 23-36). The protocol requirements were followed precisely. The device passed all requirements, fulfilling the standards of the protocol. On average, the device underestimated the systolic BP by 0.4±4.4 mmHg and diastolic BP by 1.3±3.5 mmHg. The device-observer discrepancies were unrelated to patients' clinical characteristics. These data show that the A&D BP UA-651 device fulfilled the requirements for validation by the International Protocol and can be recommended for clinical use in the adult population.

Validation of the Thermor BIOS BD215 device for home blood pressure measurement according to the European Society of Hypertension International Protocol revision 2010.

The objective of this study was to determine the accuracy of the Thermor BIOS BD215 device for home blood pressure (BP) measurement according to the International Protocol of the European Society of Hypertension (ESH). Device evaluation was carried out in 33 patients. The mean age of the patients was 57.0 ± 15.0 years, the mean systolic BP was 142.0 ± 20.3 mmHg (range 100-177 mmHg), the mean diastolic BP was 88.0 ± 14.6 mmHg (range 48-123 mmHg), and the mean arm circumference was 28.0 ± 3.0 cm (range 24-33 cm). The protocol requirements were followed precisely. The device passed all requirements, fulfilling the standards of the protocol. On average, the device overestimated the systolic BP by 0.6 ± 4.2 mmHg and underestimated diastolic BP by -0.5 ± 3.2 mmHg. The device-observer discrepancies were unrelated to patients' clinical characteristics. These data show that the Thermor BIOS BD215 device fulfilled the requirements for validation by the International Protocol and can be recommended for clinical use in the adult population.

Validation of the A&D BP UB-542 wrist device for home blood pressure measurement according to the European Society of Hypertension International Protocol revision 2010.

OBJECTIVE: The objective of this study was to determine the accuracy of the A&D BP UB-542 wrist device for home blood pressure (BP) measurement according to the International Protocol of the European Society of Hypertension (ESH). METHODS: Device evaluation was carried out in 33 patients. The mean age was 50.9±10.1 years, the mean systolic BP was 141.6±22.8 mmHg (range 92 : 189), the mean diastolic BP was 89.2±11.4 mmHg (range 62 : 120), the mean arm circumference was 28.8±3.2 cm (range 23-35), and the mean wrist circumference was 17.1±1.4 cm (range 14-19.5). The protocol requirements were followed precisely. RESULTS: The device passed all requirements, fulfilling the standards of the protocol. On average, the device overestimated the systolic BP by 1.8±7.2 mmHg and diastolic BP by 1.6±5.7 mmHg. CONCLUSION: These data show that the A&D BP UB-542 wrist device met the requirements for validation by the International Protocol and can be recommended for clinical use in the adult population.

Does home blood pressure allow for a better assessment of the white-coat effect than ambulatory blood pressure?

BACKGROUND: The difference between clinic and ambulatory blood pressure (BP) is a poor estimate of the true white-coat effect (WCE) measured with beat-to-beat recording. METHOD: We investigated whether the difference between clinic and home BP (home WCE) was a better estimate of true WCE than ambulatory WCE. In 73 young hypertensives, ambulatory WCE was calculated as the difference between clinic BP and the mean of two 24-h BP recordings, and home WCE as the difference between clinic and home BP (HBP) measured over 6 months. All individuals underwent beat-to-beat BP monitoring with the Finometer. During the recording, a white-coat test (true WCE) and a public speaking test were performed. RESULTS: Ambulatory WCE correlated with home WCE (P  <  0.001 for systolic and diastolic BPs). However, both surrogate WCEs were unrelated to true WCE (P  =  0.93/0.36 and P  =  0.11/0.36, respectively). True WCE correlated with the BP reaction to public speaking (P  <  0.001/P  <  0.001), whereas both surrogate WCEs were unrelated to the BP response to this test (all P  >  0.21). Individuals were divided into two groups according to whether BP response to the doctor's visit was above (WCH+) or below (WCH-) the median. WCH+ patients had similar clinic and ambulatory BPs to WCH- but showed a higher BP response to public speaking. CONCLUSION: As previously observed for ambulatory WCE, home WCE does not reflect the true BP reaction to doctor's visit. BP response to psychosocial stressors is increased in individuals with hyperreactivity to doctor's measurement but not in individuals with white-coat hypertension identified with either ambulatory or HBP measurement.

Rectangular cuffs may overestimate blood pressure in individuals with large conical arms.

OBJECTIVES: Although the upper arm has the shape of a truncated cone, cylindrical cuffs and bladders are currently used for blood pressure (BP) measurement. The aim of this study was to ascertain whether cylindrical and tronco-conical cuffs provide different readings according to arm size and shape. DESIGN: We studied 220 individuals with arm circumference ranging from 22 to 42.5 cm. Four different cylindrical and four different tronco-conical bladders of appropriate size were used. Sequential same-arm measurements were performed in triplicate by two observers using the two cuffs in a random order. In 100 individuals, the actual pressure transmitted to the arm surface by the two cuffs at the central point was also measured. RESULTS: Upper arm shape was tronco-conical in all of the individuals. In a multiple regression, conicity was related to arm circumference (P < 0.001) and length (P = 0.001). Arm conicity and size were independently related to the between-cuff SBP (P = 0.001 and 0.002, respectively) and DBP (P = 0.001 and <0.001, respectively) discrepancies. In the group with arm circumference of 37.5-42.5 cm, the cylindrical cuff overestimated BP measured with the tronco-conical cuff by 2.0 ±â€Š0.4/1.8 ±â€Š0.3 mmHg (P = 0.001 and <0.001). In this group, 15% of individuals found hypertensive with the cylindrical cuff were normotensive when assessed with the conical cuff. Differences as great as 9.7/7.8 mmHg were found in individuals with large arms and slant angle equal to or less than 83°. CONCLUSION: In obese people, the upper arm may have a pronounced tronco-conical shape and cylindrical cuffs may overestimate BP. Tronco-conical cuffs should be used for BP measurement in individuals with large arms.

Factors associated with glomerular hyperfiltration in the early stage of hypertension.

BACKGROUND: Glomerular hyperfiltration predicts development of nephropathy in hypertension but the factors responsible for increased glomerular filtration rate (GFR) are not well known. Aim of this study was to examine which clinical variables influence GFR in the early stage of hypertension. METHODS: Participants were 1,106 young-to-middle-age hypertensive adults with creatinine clearance >60 ml/min/1.73 m(2). Clinic and ambulatory blood pressures (BPs) were measured and the difference between clinic and 24-h systolic BP was defined as the white-coat effect (WCE). In 606 participants, 24-h urinary epinephrine and norepinephrine were also measured. Glomerular hyperfiltration, defined as a GFR ≥150 ml/min/1.73 m(2), was present in 201 subjects. RESULTS: Patients' mean age was 33.1 ± 8.5 years and office BP was 146 ± 10.5/94 ± 5.0 mm Hg. In multivariable linear regression, significant predictors of GFR were younger age (P < 0.0001), male gender (P < 0.0001), 24-h systolic BP (P = 0.0001), body mass (P < 0.0001), WCE (P = 0.02), log-epinephrine (P = 0.01), and coffee use (P < 0.01). In a logistic model, independent predictors of glomerular hyperfiltration were obesity (odds ratio, 95% confidence interval = 6.1, 3.8-9.8), male gender (2.9, 1.8-4.9), age <33 years (2.1, 1.5-3.1), ambulatory hypertension (2.0, 1.4-3.0), WCE >15 mm Hg (1.6, 1.1-2.3), heavy coffee use (2.0, 1.1-3.8), and epinephrine >25 mcg/24 h (1.9, 1.2-3.1). CONCLUSIONS: The novel finding of this study is that hyper-reactivity to stress, as determined by urinary epinephrine level and WCE, and coffee use contribute to determining glomerular hyperfiltration in the early stage of hypertension. Our data may help to identify a subset of patients with glomerular hyperfiltration, who may be at increased risk of chronic kidney disease and may benefit from antihypertensive treatment.

Accuracy of the Microlife large-extra large-sized cuff (32-52 cm) coupled to an automatic oscillometric device.

To determine the accuracy of the large-extra large-sized (L-XL) cuff (32-52 cm) coupled to a Microlife WatchBP Office ABI blood pressure measuring device tested according to the requirements of the International Protocol of the European Society of Hypertension. The L-XL cuff tested in this study is designed to provide accurate blood pressure measurements in patients with large arms (arm circumference≥32 cm) over a wide range of arm circumferences using a single 145±1×320±1 mm bladder. The evaluation was made in 33 patients with a mean±standard deviation age of 53±17 years (range: 30-96 years). Their systolic blood pressure (SBP) was 142±21 mmHg (range: 110-180 mmHg), diastolic blood pressure (DBP) was 87±14 mmHg (range: 62-106 mmHg) and arm circumference was 36±5 cm (range: 32-50 cm). Blood pressure measurements were made in the sitting position. The L-XL cuff coupled to the WatchBP Office ABI passed all three phases of the European Society of Hypertension protocol for SBP and DBP. Mean blood pressure differences between device and observer were -1.3±5.1 mmHg for SBP and -1.8±5.8 mmHg for DBP. Similar device-observer differences were observed in patients divided into two subgroups according to whether their arm circumference was above or below the median in the group. These results indicate that the L-XL cuff coupled to the WatchBP Office ABI monitor provides accurate blood pressure readings in patients with large arms over a wide range of arm circumferences.