Top

BMC Public Health

Published in:

Open Access 01-12-2024 | Nutrition | Research

Inter-leg systolic blood pressure difference has been associated with all-cause and cardiovascular mortality: analysis of NHANES 1999–2004

Authors: Geng Shen, Zhihao Liu, Leyi Wang, Jianping Li

Published in: BMC Public Health | Issue 1/2024

Abstract

Background

Inter-leg systolic blood pressure difference (ILSBPD) has emerged as a novel cardiovascular risk factor. This study aims to investigate the predictive value of ILSBPD on all-cause and cardiovascular mortality in general population.

Methods

We combined three cycles (1999–2004) of the National Health and Nutrition Examination Survey (NHANES) data. Levels of ILSBPD were calculated and divided into four groups based on three cut-off values of 5, 10 and 15mmHg. Time-to-event curves were estimated with the use of the Kaplan-Meier method, and two multivariable Cox proportional hazards regression models were conducted to assess the hazard ratios (HRs) and 95% confidence intervals (CIs) of all-cause and cardiovascular mortality associated with ILSBPD.

Results

A total of 6 842 subjects were included, with the mean (SD) age of 59.5 (12.8) years. By December 31, 2019, 2 544 and 648 participants were identified all-cause and cardiovascular mortality respectively during a median follow-up of 16.6 years. Time-to-event analyses suggested that higher ILSBPD was associated with increased all-cause and cardiovascular mortality (logrank, p < 0.001). Every 5mmHg increment of ILSBPD brings about 5% and 7% increased risk of all-cause and cardiovascular mortality, and individuals with an ILSBPD ≥ 15mmHg were significantly associated with higher incidence of all-cause mortality (HR 1.43, 95%CI 1.18–1.52, p < 0.001) and cardiovascular mortality (HR 1.73, 95%CI 1.36–2.20, p < 0.001) when multiple confounding factors were adjusted. Subgroup and sensitivity analysis confirmed the relationship.

Conclusions

Our findings suggest that the increment of ILSBPD was significantly associated with higher risk of all-cause and cardiovascular mortality in general population.

Available only for authorised users

GBD 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the global burden of disease study 2019. Lancet Lond Engl. 2020;396(10258):1204–22. https://doi.org/10.1016/S0140-6736(20)30925-9CrossRef

Luengo-Fernandez R, Walli-Attaei M, Gray A, et al. Economic burden of cardiovascular diseases in the European Union: a population-based cost study. Eur Heart J Published Online August. 2023;26:ehad583. https://doi.org/10.1093/eurheartj/ehad583CrossRef

Tsao CW, Aday AW, Almarzooq ZI et al. Heart disease and stroke statistics—2022 update: A report from the American Heart Association. Circulation. Published online February 22, 2022. https://doi.org/10.1161/CIR.0000000000001052

Timmis A, Vardas P, Townsend N, et al. European society of cardiology: cardiovascular disease statistics 2021. Eur Heart J. 2022;43(8):716–99. https://doi.org/10.1093/eurheartj/ehab892CrossRefPubMed

Savji N, Rockman CB, Skolnick AH, et al. Association between advanced age and vascular disease in different arterial territories: a population database of over 3.6 million subjects. J Am Coll Cardiol. 2013;61(16):1736–43. https://doi.org/10.1016/j.jacc.2013.01.054CrossRefPubMed

Kappert K, Böhm M, Schmieder R, et al. Impact of sex on cardiovascular outcome in patients at high cardiovascular risk: analysis of the Telmisartan randomized assessment study in ACE-Intolerant subjects with cardiovascular disease (TRANSCEND) and the ongoing Telmisartan alone and in combination with Ramipril global end point trial (ONTARGET). Circulation. 2012;126(8):934–41. https://doi.org/10.1161/CIRCULATIONAHA.111.086660CrossRefPubMed

Twig G, Yaniv G, Levine H, et al. Body-mass index in 2.3 million adolescents and cardiovascular death in adulthood. N Engl J Med. 2016;374(25):2430–40. https://doi.org/10.1056/NEJMoa1503840CrossRefPubMed

Su HM, Lin TH, Hsu PC, et al. Association of interankle systolic blood pressure difference with peripheral vascular disease and left ventricular mass index. Am J Hypertens. 2014;27(1):32–7. https://doi.org/10.1093/ajh/hpt154CrossRefPubMed

Yu S, Lu Y, Xiong J, et al. The association of four-limb blood pressure differences with cardiovascular risk factors and target organ changes in elderly Chinese: the Northern Shanghai Study. Clin Exp Hypertens N Y N 1993. 2020;42(3):275–80. https://doi.org/10.1080/10641963.2019.1649682CrossRef

10.

Song X, Li G, Qiao A, Chen Z. Association of simultaneously measured four-limb blood pressures with cardiovascular function: a cross-sectional study. Biomed Eng Online. 2016;15(Suppl 2):147. https://doi.org/10.1186/s12938-016-0266-yCrossRefPubMedPubMedCentral

11.

Chen Y, Dong H, Li HW, Zou YB, Jiang XJ. Characteristics of four-limb blood pressure and brachial-ankle pulse wave velocity in Chinese patients with Takayasu arteritis. Blood Press. 2022;31(1):146–54. https://doi.org/10.1080/08037051.2022.2091513CrossRefPubMed

12.

Liu S, Li P, Su H. Four-limb blood pressure measurement with an oscillometric device: a tool for diagnosing peripheral vascular disease. Curr Hypertens Rep. 2019;21(2):15. https://doi.org/10.1007/s11906-019-0917-zCrossRefPubMed

13.

Herráiz-Adillo Á, Soriano-Cano A, Martínez-Hortelano JA, et al. Simultaneous inter-arm and inter-leg systolic blood pressure differences to diagnose peripheral artery disease: a diagnostic accuracy study. Blood Press. 2018;27(2):112–9. https://doi.org/10.1080/08037051.2017.1400903CrossRefPubMed

14.

Yu S, Ji H, Lu Y, et al. Significance of the combination of inter-limb blood pressure differences in the elderly: the Northern Shanghai Study. J Clin Hypertens Greenwich Conn. 2019;21(7):884–92. https://doi.org/10.1111/jch.13588CrossRef

15.

Guo H, Sun F, Dong L et al. The association of four-limb blood pressure with history of stroke in chinese adults: a cross-sectional study. Li Y, ed. PLOS ONE. 2015;10(10):e0139925. https://doi.org/10.1371/journal.pone.0139925

16.

Guo H, Sun F, Zhang H, Dong L, Gu X, Tian Y. Interankle systolic blood pressure difference is a marker of prevalent stroke in Chinese adults: a cross-sectional study. J Clin Hypertens Greenwich Conn. 2017;19(1):58–66. https://doi.org/10.1111/jch.12872CrossRef

17.

Chen SC, Tsai YC, Huang JC, et al. Interankle systolic blood pressure difference and renal outcomes in patients with chronic kidney disease. Nephrol Carlton Vic. 2016;21(5):379–86. https://doi.org/10.1111/nep.12619CrossRef

18.

Sheng CS, Liu M, Zeng WF, Huang QF, Li Y, Wang JG. Four-limb blood pressure as predictors of mortality in elderly Chinese. Hypertension. 2013;61(6):1155–60. https://doi.org/10.1161/HYPERTENSIONAHA.111.00969CrossRefPubMed

19.

Kato S, Lindholm B, Qureshi AR, Mukai H, Yuzawa Y, Maruyama S. Inter-leg systolic blood pressure difference predicts cardiovascular events and mortality in incident hemodialysis patients. Int J Artif Organs. 2020;43(4):217–24. https://doi.org/10.1177/0391398819882703CrossRefPubMed

20.

Hsu PC, Lee WH, Tsai WC, et al. Usefulness of four-limb blood pressure measurement in prediction of overall and cardiovascular mortality in acute myocardial infarction. Int J Med Sci. 2020;17(10):1300–6. https://doi.org/10.7150/ijms.44735CrossRefPubMedPubMedCentral

21.

Chen SC, Chang JM, Tsai YC, et al. Association of interleg bp difference with overall and cardiovascular mortality in hemodialysis. Clin J Am Soc Nephrol. 2012;7(10):1646–53. https://doi.org/10.2215/CJN.04570512CrossRefPubMedPubMedCentral

22.

Hyattsville, Centers for Disease Control and Prevention (CDC). National Center for Health Statistics (NCHS). National Health and Nutrition Examination Survey Questionnaire (or Examination Protocol, or Laboratory Protocol). In:; 2023. https://wwwn.cdc.gov/nchs/nhanes/NhanesCitation.aspx

23.

Johnson CL, Paulose-Ram R, Ogden CL et al. National health and nutrition examination survey: analytic guidelines, 1999–2010. Vital Health Stat 2. 2013;(161):1–24.

24.

Cuschieri S. The STROBE guidelines. Saudi J Anaesth. 2019;13(Suppl 1):S31–4. https://doi.org/10.4103/sja.SJA_543_18CrossRefPubMedPubMedCentral

25.

National Center for Health Statistics. National Health and Nutrition Examination Survey: Lower Extremity Disease - Peripheral Neuropathy (LEXPN). https://wwwn.cdc.gov/Nchs/Nhanes/1999-2000/LEXPN.htm

26.

K K, N SSASMS. Simultaneously measured inter-arm and inter-leg systolic blood pressure differences and cardiovascular risk stratification: a systemic review and meta-analysis. J Am Soc Hypertens JASH. 2015;9(8). https://doi.org/10.1016/j.jash.2015.05.013

27.

Sheng CS, Liu M, Zeng WF, Huang QF, Li Y, Wang JG. Four-limb blood pressure as predictors of mortality in elderly Chinese. Hypertens Dallas Tex 1979. 2013;61(6):1155–60. https://doi.org/10.1161/HYPERTENSIONAHA.111.00969CrossRef

28.

Moon I, Kim HL, Lim WH, et al. Association between inter-leg blood pressure difference and cardiovascular outcome in patients undergoing percutaneous coronary intervention. PLoS ONE. 2021;16(10):e0257443. https://doi.org/10.1371/journal.pone.0257443CrossRefPubMedPubMedCentral

29.

Guo H, Sun F, Dong L, et al. The association of four-limb blood pressure with history of stroke in Chinese adults: a cross-sectional study. PLoS ONE. 2015;10(10):e0139925. https://doi.org/10.1371/journal.pone.0139925CrossRefPubMedPubMedCentral

30.

Zhang Z, Ma J, Tao X, Zhou Y, Liu X, Su H. The prevalence and influence factors of inter-ankle systolic blood pressure difference in community population. PLoS ONE. 2013;8(8):e70777. https://doi.org/10.1371/journal.pone.0070777CrossRefPubMedPubMedCentral

31.

Chen SC, Chang JM, Tsai YC, et al. Association of interleg BP difference with overall and cardiovascular mortality in hemodialysis. Clin J Am Soc Nephrol CJASN. 2012;7(10):1646–53. https://doi.org/10.2215/CJN.04570512CrossRefPubMed

32.

Cao K, Xu J, Shangguan Q, et al. Association of an inter-arm systolic blood pressure difference with all-cause and cardiovascular mortality: an updated meta-analysis of cohort studies. Int J Cardiol. 2015;189:211–9. https://doi.org/10.1016/j.ijcard.2015.04.079CrossRefPubMed

33.

Clark CE, Taylor RS, Shore AC, Ukoumunne OC, Campbell JL. Association of a difference in systolic blood pressure between arms with vascular disease and mortality: a systematic review and meta-analysis. Lancet Lond Engl. 2012;379(9819):905–14. https://doi.org/10.1016/S0140-6736(11)61710-8CrossRef

34.

Sharafi M, Amiri Z, Haghjoo E, et al. Association between inter-arm blood pressure difference and cardiovascular disease: result from baseline Fasa adults cohort study. Sci Rep. 2023;13(1):9648. https://doi.org/10.1038/s41598-023-36205-1CrossRefPubMedPubMedCentral

35.

Tomiyama H, Ohkuma T, Ninomiya T, et al. Simultaneously measured interarm blood pressure difference and stroke. Hypertension. 2018;71(6):1030–8. https://doi.org/10.1161/HYPERTENSIONAHA.118.10923CrossRefPubMed

36.

English JA, Carell ES, Guidera SA, Tripp HF. Angiographic prevalence and clinical predictors of left subclavian stenosis in patients undergoing diagnostic cardiac catheterization. Catheter Cardiovasc Interv off J Soc Card Angiogr Interv. 2001;54(1):8–11. https://doi.org/10.1002/ccd.1230CrossRef

37.

Weinberg I, Gona P, O’Donnell CJ, Jaff MR, Murabito JM. The systolic blood pressure difference between arms and cardiovascular disease in the Framingham heart study. Am J Med. 2014;127(3):209–15. https://doi.org/10.1016/j.amjmed.2013.10.027CrossRefPubMed

Title: Inter-leg systolic blood pressure difference has been associated with all-cause and cardiovascular mortality: analysis of NHANES 1999–2004
Authors: Geng Shen
Zhihao Liu
Leyi Wang
Jianping Li
Publication date: 01-12-2024
Publisher: BioMed Central
Keyword: Nutrition
Published in: BMC Public Health / Issue 1/2024
Electronic ISSN: 1471-2458
DOI: https://doi.org/10.1186/s12889-024-18508-8

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Inter-leg systolic blood pressure difference has been associated with all-cause and cardiovascular mortality: analysis of NHANES 1999–2004

Abstract

Background

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 1/2024

Does sensation-seeking behavior influence the patterns of flavored e-cigarette use? A cross-sectional study among Indonesian adolescents and young adults

Neighborhood-level factors associated with COVID-19 vaccination rates: a case study in Chicago

Kazakh adults in Xinjiang have a prevalent obesity problem but a low prevalence of diabetes

Changes in, and factors associated with family functioning: results of four cross-sectional household surveys from 2011 to 2017 in Hong Kong

The association of sexual minority status and bullying victimization is modified by sex and grade: findings from a nationally representative sample

School-aged children’s movement behaviours and subjective health complaints in Japan: a cross-sectional study during COVID-19 pandemic-related school closures and after school reopenings