Pseudohypertension in Peripheral Artery Disease: Why a Normal Arm Cuff Reading Can Be Misleading

If you’re over 50 and have been diagnosed with peripheral artery disease (PAD), especially if you’ve noticed stiff or hardened arteries in your arms, that “normal” blood pressure reading from your upper-arm cuff may not tell the full story. This is especially true in cases of pseudohypertension peripheral artery disease, a well-documented but often overlooked phenomenon where calcified brachial arteries falsely elevate cuff-based readings—making it appear as though your blood pressure is high when your true central arterial pressure is actually normal or even low. It’s a classic example of diagnosis by assumption rather than accurate physiology. One common misconception is that “if the cuff says it’s fine, it is fine”—but for people with advanced PAD and medial arterial calcification, that assumption can delay appropriate care or lead to unnecessary antihypertensive treatment.

Another frequent misunderstanding is that pseudohypertension only affects older adults with diabetes—it’s more closely tied to arterial wall stiffness and calcium deposition, which can occur independently of glycemic status. Up to 20% of adults over 70 with symptomatic PAD show signs of non-compressible brachial arteries during routine cuff measurement—a red flag for possible pseudohypertension.

Why Pseudohypertension Peripheral Artery Disease Matters

Pseudohypertension arises when calcium deposits harden the walls of the brachial artery—the vessel most commonly used for standard sphygmomanometer readings. Because the artery won’t compress fully under cuff pressure, the device registers artificially high systolic and diastolic values. Studies estimate that up to 15–25% of patients with severe PAD and radiographic evidence of medial calcification may experience this artifact. Left unrecognized, pseudohypertension peripheral artery disease can lead to overtreatment: inappropriate BP-lowering medications may cause dizziness, falls, or reduced perfusion to already compromised limbs. Conversely, missing true hypertension—or misreading low central pressure as “normal”—can increase stroke or heart failure risk.

The condition is strongly associated with chronic kidney disease, diabetes, and long-standing hypertension itself—creating a complex clinical overlap that demands careful interpretation.

How to Measure Blood Pressure Accurately in PAD

Standard upper-arm oscillometric or auscultatory cuffs are unreliable when brachial arteries are non-compressible. Instead, clinicians may use alternative methods:

• Radial artery tonometry: A non-invasive technique that estimates central aortic pressure using pulse wave analysis at the wrist. It bypasses the calcified brachial segment entirely and correlates well with intra-arterial measurements.
• Thigh-cuff oscillometry: Placing the cuff around the thigh and using the popliteal artery for measurement avoids upper-arm calcification. Systolic values here tend to be ~10–20 mm Hg higher than arm readings—but more physiologically accurate when brachial vessels are incompressible.
• Doppler-assisted auscultation: Using ultrasound guidance to detect flow sounds below the cuff improves sensitivity in borderline cases.

Importantly, the American College of Cardiology/American Heart Association (ACC/AHA) guidelines note that “non-compressible arteries should prompt consideration of alternative measurement sites or modalities,” especially in patients with known PAD or diabetes.

Who Should Pay Special Attention?

Adults aged 50 and older with:

• Confirmed PAD (e.g., ankle-brachial index <0.9),
• Known medial arterial calcification on X-ray or CT,
• Diabetes mellitus (particularly with long duration or renal involvement),
• Chronic kidney disease (eGFR <60 mL/min/1.73m²),
• Symptoms like leg claudication, non-healing ulcers, or recurrent syncope despite “controlled” BP.

These individuals benefit from periodic reassessment—not just of BP numbers, but of how those numbers were obtained.

Practical Steps You Can Take

Start by discussing your PAD history and any prior imaging (like X-rays showing vascular calcification) with your primary care provider or cardiologist. Ask whether your current BP readings reflect true arterial pressure—or whether alternative methods might be more appropriate.

At home:

• Avoid relying solely on upper-arm automatic cuffs if you have known PAD or symptoms suggesting poor upper-limb perfusion (e.g., weak radial pulse, delayed capillary refill).
• If using a home monitor, choose one validated for use in arrhythmia or PAD populations—and confirm its accuracy with your clinician.
• When visiting the clinic, ask whether your brachial artery was assessed for compressibility (a simple “roll test” or palpation can help identify rigidity).

Tracking your blood pressure trends can help you and your doctor make better decisions. Consider keeping a daily log or using a monitoring tool to stay informed.

Seek medical evaluation promptly if you notice:

• Recurrent dizziness or lightheadedness upon standing,
• Unexplained fatigue or confusion,
• Worsening leg pain or coolness despite stable “normal” BP readings,
• Frequent falls without obvious cause.

A Reassuring Note

Understanding pseudohypertension peripheral artery disease doesn’t mean your health is harder to manage—it means you now have deeper insight into how your body works. With the right tools and awareness, accurate blood pressure assessment is absolutely achievable. If you're unsure, talking to your doctor is always a good idea.

FAQ

#### What is pseudohypertension peripheral artery disease?

Pseudohypertension peripheral artery disease refers to falsely elevated blood pressure readings caused by calcified, non-compressible brachial arteries in people with advanced PAD. The cuff cannot properly occlude the stiffened vessel, leading to inaccurate high values—even when true central pressure is normal.

#### Can pseudohypertension peripheral artery disease cause harm?

Yes—if undetected, it may lead to unnecessary antihypertensive therapy, increasing risks of hypotension, falls, or reduced limb perfusion. Conversely, it can mask true hypotension or normotension in someone who actually needs different cardiovascular management.

#### How is pseudohypertension diagnosed in PAD patients?

Diagnosis involves clinical suspicion (e.g., non-palpable or “pipe-stem” brachial arteries), confirmation of arterial calcification via imaging, and corroborating BP measurements using alternative methods—such as radial tonometry or thigh-cuff oscillometry.

#### Is pseudohypertension only found in elderly patients?

While more common after age 65, pseudohypertension peripheral artery disease can occur in younger adults with aggressive calcification—especially those with end-stage kidney disease, diabetes, or genetic disorders affecting vascular mineral metabolism.

#### Does arm-cuff blood pressure always work for people with PAD?

No. In moderate-to-severe PAD with medial calcification, standard arm-cuff measurements frequently overestimate true arterial pressure. Clinicians should consider alternative techniques whenever brachial artery compressibility is uncertain.