www.cardiologyjournal.org 163
ORIGINAL ARTICLE
Cardiology Journal
2010, Vol. 17, No. 2, pp. 163–165
Copyright © 2010 Via Medica
ISSN 1897–5593
Address for correspondence: S. Mehran Hosseini, MD, PhD, Department of Physiology, Golestan University of Medical Sciences,
P.O. Box: 49175-553, Gorgan, Iran, tel: +9113736634, fax: +981714440225, e-mail: hosseini@goums.ac.ir
Received: 23.06.2009 Accepted: 17.07.2009
Ageing and ankle pulse pressure
S. Mehran Hosseini, Ali Reza Maleki
Department of Physiology, Golestan University of Medical Sciences, Gorgan, Iran
Abstract
Background: Pulse pressure (PP) is a marker of arterial stiffness. Ageing of the arterial
system is accompanied by atherosclerosis of coronary arteries and atherosclerosis of popliteal
artery. However, severe impairment of the brachial artery is rare. This study investigates
whether there is any significant inter-limb (brachial/ankle) PP difference.
Methods: Blood pressure was measured in a group of young and a group of old non-smoking
men; all were free from medication and disease with a mean age of 22 ± 1.3 and 59 ± 2 years
respectively. The blood pressure was taken while they were in a supine position on three separate
occasions. Lower limb pressure was measured by placing the cuff on the calf muscle. For ausculta-
tion of Korotkoff sounds the stethoscope was placed on the posterior surface of the internal
malleolus. The mean of the second and third readings were rounded off and used for analysis.
Results: Significant differences were found between brachial and ankle PP in both groups
(p < 0.01). The ratio of brachial PP to ankle PP in the young men was greater than 1. In the
old men it was less than 0.15. There was no significant difference between the brachial PP in
the two groups, but on both sides the ankle PP was significantly greater in the old men (p < 0.01).
Conclusions: With the ageing of the arterial system, raised PP is more prominent in the
lower limb (e.g. ankle). Cuff measurement of blood pressure at this site may be a useful index
of peripheral PP changes with ageing. (Cardiol J 2010; 17, 2: 163–165)
Key words: pulse pressure, ageing, ankle
Introduction
Pulse pressure (PP) is a marker of arterial stiff-
ness. High PP (> 60 mm Hg) may be a sign of gen-
eralized atherosclerosis (AS) and is considered
a coronary risk factor [1]. In older people AS of the
coronary and popliteal artery is common and may
be clinically important. However, severe AS of the
brachial artery is rare [2, 3]. These non-homoge-
nous involvements of vessels can also potentate the
effects of pulse wave reflections on PP amplitude [4].
So, with ageing, the peripheral PP in muscular ar-
teries of the upper and lower limbs may be influ-
enced unequally. It seems that ankle PP may be
more informative than brachial PP in the elderly.
Methods
Blood pressure measurements were taken in
the clinical laboratory of the medical faculty be-
tween 9.00am and 11.30am. The participants were
recruited from staff, students and their relatives. All
participants were non-smokers with no drug histo-
ry or atherosclerosis risk factors (such as tobacco
use, family history of coronary artery disease, high
body mass index, hypertension, hyperlipidemia). In
all cases, blood pressure was determined by two
trained medical students over three separate days.
The first values were ignored and the mean of the
second and the third readings was used. After five
minutes of complete rest in the supine position,
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Cardiology Journal 2010, Vol. 17, No. 2
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blood pressure was measured by the auscultatory
method using a mercury-column sphygmomano-
meter (ERKA, Germany) with appropriate cuff size.
To measure the ankle PP, a stethoscope was placed
on the posterior surface of the internal malleolus
and the cuff was fastened on the lower half of the
calf muscles [5]. Any examples of unclear tibialis
artery pulse and/or Korotkoff sound were excluded.
Independent student t-test was used for com-
parison between the two groups. A paired t-test was
used for inter-limb assessment in each group.
Results
The range and the mean age of men in the two
groups were 18–25 and 22 ± 1.3 years (n = 20) for
the young group and 50–70 and 59 ± 2 years (n =
= 20) for the old group respectively. The mean of
systolic and diastolic pressures is shown in Tables 1
and 2. The mean of ankle and brachial PP in right
and left sides is summarized in Table 3.
In each group, there was no significant difference
in systolic, diastolic and PP between left and right sides.
There was a significant difference between brachial and
ankle PP in both groups and also between ankle PP in
both groups in right and left sides (p < 0.05; Fig. 1).
Discussion
In both groups, as expected, systolic pressures
were higher in lower limbs. In the young group,
Table 1. The mean ± SEM of systolic and diastolic pressures of the 18–25 years old group (n = 20).
Brachial Ankle
Right Left Right Left
Systolic pressure 118.10±2.16 117.75±2.34 124.05±2.83 124.60±2.83
Diastolic pressure 73.60±1.49 73.25±1.61 86.15±1.35 87.35±1.86
Table 2. The mean ± SEM of systolic and diastolic pressures of the 50–70 years old group (n = 20).
Brachial Ankle
Right Left Right Left
Systolic pressure 132.95±3.99 128.85±3.98 144.95±3.71 144.5±4.21
Diastolic pressure 85.85±2.46 81.95±3.12 88.90±2.30 88.60±2.49
Table 3. The mean ± SEM of pulse pressures of
the 18–25 and the 50–70 years old groups (n = 20).
18–25 50–70
Right brachial 44.50 ± 2.03 47.10 ± 2.74
pulse pressure
Left brachial 44.50 ± 1.71 46.90 ± 2.65
pulse pressure
Right ankle 37.90 ± 2.24 56.05 ± 3.18
pulse pressure
Left ankle 37.25 ± 2.30 55.90 ± 4.48
pulse pressure
Figure 1. The mean ± SEM of pulse pressures in two
groups; RB — right brachial; LB — left brachial; RA —
right ankle; LA — left ankle.
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S. Mehran Hosseini, Ali Reza Maleki, Ageing and ankle pulse pressure
www.cardiologyjournal.org
ankle PP was lower than brachial PP on the right
and left sides. In the old group, brachial PP was low-
er than ankle PP on both sides. Very few reports
have ever specifically focused on ankle PP. This
may be due to a greater emphasis on indices such
as ankle brachial index or pulse wave velocity in-
dex and so on [6–10]. In the study of Kubo and
Andoh, the brachial PP and the systolic pressure of
ankles were 67 ± 12, 149 and 148 mm Hg respec-
tively, which are close to our findings [11, 12]. This
comparison of course is very rough, because the
cases are not the same regarding age, sex, smok-
ing, medication and general health. Our data shows
the differences between brachial and ankle PP in
each group (p < 0.01), the ratio of brachial PP to
ankle PP in the two groups (> 1 in the young group
and less than 0.15 in the old group) and the much
greater differences between the young group’s an-
kle PP and the old group’s ankle PP than between
their brachial PPs.
In other words, there was no significant differ-
ence between brachial PP in the two groups, but
on both sides the ankle PP was significantly great-
er in the old group (p < 0.01).
Controversies regarding the normal inter-arm
pressure differences, little information about the
abnormal ranges of right and left pressure differ-
ence in lower limbs, a limited sample and the lack
of objective clinical and laboratory examination of
cases must be taken into consideration with this
study. The latter defect is especially important in
the 50–70 years group. Although none of them gave
a history of disease or medication, it is possible that
there was some abnormality in lipid profiles, blood
sugar and/or any other disease which could influ-
ence the results. All these conditions exacerbate
atherosclerosis. So objective verification of them is
not expected to produce any additional important
bias. The higher value of ankle PP in the 50–70 year
old group and almost the same brachial PP in young
and old groups are the main finding of this study,
which suggests that ankle PP is a more informative
index of arterial stiffness with ageing.
Acknowledgements
This work was financially supported by a grant
from Golestan University of Medical Sciences. Sin-
cere thanks are given to all the volunteers and co-
workers.
The authors do not report any conflict of inte-
rest regarding this work.
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