Blood Pressure Cuff Size Research: A Summary For Health Care Personnel

Appendix D - American Heart Association Blood Pressure Cuff Size Guidelines

*From Circulation (1993;88:2460-2467), by Dorothee Perloff,MD; Carlene Grim, MSN, SpDN; John Flack, MD; Edward D. Frohlich, MD; Martha Hill, PhD, RN; Mary McDonald, MSPH, RN; and Bruce Z. Morgenstern, MD, Writing Group.  (This table is adapted from one found at http://www.americanheart.org/presenter.jhtml?identifier=3000861 )

**There is some overlapping of the recommended range for arm circumferences; the American Heart Association generally recommends that the larger cuff be used for borderline measurements. 

Medical Care for Obese Patients: Advice for Health Care Professionals (Article from the website of the American Academy of Family Physicians, found at www.aafp.org/afp/20020101/81.html)

"Accurate measurement of blood pressure requires special consideration.  A standard-sized blood pressure cuff should not be used on persons with an upper-arm circumference of more than 34 cm [~13 inches].  Large arm cuffs or thigh cuffs can aid in an accurate determination of blood pressure."

Medical References Summary

Maxwell, MH et al.  Error in Blood-Pressure Measurement Due to Incorrect Cuff Size in Obese Patients.  Lancet.  July 3, 1982.  2(8288):33-6.  

Classic study that found that 37% of obese "hypertensives" were actually normotensive, and had been misdiagnosed because the wrong-sized cuff was used.  They recommended the following cutoffs for arm size/cuff size:  <33 cm (13 inches) = regular cuff;  33-41 cm (13-16 inches) = large cuff; and >41 cm (>16 inches) = thigh cuff.  

O'Brien, E. Review: A Century of Confusion; Which Bladder for Accurate Blood Pressure Measurement? J Human Hypertens. September 1996.  10(9):565-72. 

"The use of cuffs containing inappropriate bladders is a serious source of error which must inevitably lead to 
incorrect diagnosis in practice, and erroneous conclusions in hypertension research. There is unequivocal evidence that either too narrow or too short a bladder (undercuffing) will cause overestimation of BP...A detailed review of the literature...clearly indicates that substantial error is caused by the use of inappropriate cuffs." 

Graves, JW. Prevalence of Blood Pressure Cuff Sizes in a Referral Practice of 430 Consecutive Adult Hypertensives. Blood Press Monit. Feb 2001. 6(1):17-20. 

"Overestimation of blood pressure by using an inappropriately small cuff has been well documented....Health care settings such as the emergency department or outpatient clinics where hypertensive patients are encountered should have easy access to both large and standard adult cuffs." Recommends 33 cm (13") as cutoff for needing a large cuff, and notes, "Beginning at an arm circumference >29 cm [11.4 inches], and with increasing inaccuracy as arm circumference increases, the standard cuff increasingly overestimates blood pressure."

Linfors, EW et al. Spurious Hypertension in the Obese Patient. Effect of Sphygmomanometer Cuff Size on Prevalence of Hypertension. Arch Intern Med. July 1984. 144(7):1482-5. 

Lists common BP cuff myths held by many medical personnel, such as arm circumference not being important in assessing BP, that errors would occur only in the very obese, that BP changes only minimally as long as the BP cuff encircles the arm, etc. "The prevalences of high blood pressure and borderline high blood pressure were twofold greater with the standard cuff than with the large adult or thigh cuffs in obese patients."

Manning, DM et al.  Miscuffing: Inappropriate Blood Pressure Cuff Application.  Circulation.  October 1983.  68(4):763-6.

Studied nurses and doctors taking blood pressure readings to see how well personnel followed the cuff size recommendations of the American Heart Association.  Found that miscuffing occurred 32% of the time in the overall population.  Of the subgroup of patients that required a non-standard cuff size (both extra-small or extra-large), 72% were miscuffed.

Aylett, M et al.  Evaluation of Normal and Large Sphygmomanometer Cuffs Using the Omron 705CP.  J Hum Hypertens.  Feb. 2001.  15(2):131-4.  

"We recommend that large cuffs should be used for all patients with an arm circumference of 28 cm or above."  [Kmom note:  28 cm equals about 11 inches.]

Guagnano, MT et al. Many Factors Can Affect the Prevalence of Hypertension in Obese Patients: Role of Cuff Size and Type of Obesity. Panminerva Med. March 1998. 40(1):22-7. 

Found that when the correct large-sized cuff was used, the prevalence of hypertension was "strikingly lower" in 
overweight and obese women, compared to when the regular-sized cuff was used. 

Iyriboz, Y et al.  Agreement Between Large and Small Cuffs in Sphygmomanometry:  A Quantitative Assessment.  J Clin Monit.  March 1994.  10(2):127-33.  

"Arm circumference plays an important role in determining proper cuff size for BP measurement.  The small cuff overestimates BP in patients with large arm circumferences (>29 cm), which represents more than 75% of the U.S. adult population...In conclusion, using an inappropriate cuff---the most common error in indirect BP measurement---can significantly distort BP readings."

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