#562 - BP Cuff Size, Menopausal Vasomotor Rx, Falling Forward

From the Literature

1)  When It Comes to Blood Pressure (BP) Cuffs, Size Matters

Clinical practice guidelines recommend selecting an appropriately sized blood pressure cuff based on mid-arm circumference prior to measuring BP.  Appropriate cuff size is determined by arm circumference, which is measured by identifying the midpoint of the upper arm (typically in the middle of the bicep) and measuring with the arm relaxed.  According to the American Heart Association, properly sized cuffs correspond to the following arm circumferences: 

The negative impact of the use of inappropriately sized cuffs (“miscuffing”) has been shown for both manual and automated BP devices.  The degree of variation from the appropriate size will determine the amount of error.  An undersized cuff will overestimate systolic blood pressure by approximately 5-10 mmHg and diastolic blood pressure by 2-6 mmHg even more if the mismatch is more than one cuff size.  An oversized cuff will underestimate systolic blood pressure (SBP) by approximately 5-10 mmHg and diastolic blood pressure (DBP) by 1-5 mmHg.  According to recent data from the National Health and Nutrition Examination Survey (NHANES), about half of US adults require a large or extra-large cuff size.  Therefore, the majority of errors are in using a cuff size that is too small, thus overestimating the actual blood pressure.  Additional studies have highlighted how improper cuff size could contribute to misdiagnosis, inappropriate treatment, and adverse health outcomes. 

Given the increased emphasis on home blood pressure readings, a recent study examined the availability of appropriate cuff sizes for the most popular home BP devices from Amazon.  Of the 10 devices reviewed, 9 offered cuff sizes covering arm circumferences from 22 to 42 cm (1 device with 2 cuff sizes) and 1 from 22 to 40 cm. Based on data from the NHANES survey 2015 to 2020, 6.7% of US adults (corresponding to 17.3 million adults based on the 2023 US census) could not use these devices as is since their arm circumferences were <22 cm (0.3% [0.8 million], including 32.3% with hypertension) or >42 cm (6.4% [16.5 million], including 67.3% with hypertension). The proportion of adults not covered by these devices was higher in Black adults (11.8%) than in other racial/ethnic groups (White adults [6.6%], Hispanic adults [5.2%], and Asian adults [1.8%]; P <0.001).  The authors concluded that ideally,  consumers should be able to select their appropriate cuff size without any additional cost. Furthermore, clinicians should instruct patients about how to measure arm circumference and the importance of selecting an appropriate cuff size when purchasing a home BP device.  They also expressed concern regarding the hidden racial disparity when it comes to access to home BP cuffs.

Mark’s Comments:

I continue to be amazed at all the potential confounding variables that must be considered to be able to measure blood pressure “correctly” (29 in one review – see 3^rd reference below).  Given the potential negative impact of inaccurate readings for patients and that BP measurement is on most ACO scorecards, finding ways to measure accurately becomes even more imperative.   

At the least, we should be educating patients (and each other) of the importance of proper cuff size, and perhaps should be listing this on the patients “Problem List” under the “overview” section of the Hypertension diagnosis. 

References:

• Ishigami J et al.  Effects of cuff size on the accuracy of blood pressure readings: the Cuff(SZ) randomized crossover trial. JAMA Intern Med. 2023;183:1061–1068. Link
• Kaur E et al.  Arm Size Coverage of Popular Over-the-Counter Blood Pressure Devices and Implications in US Adults. Hypertension. October 2024;.81:e125–e127.. Link
• Kallioinen K, et al.  Sources of inaccuracy in the measurement of adult patients’ resting blood pressure in clinical settings: a systematic review.  J Hypertens. 2017 Mar; 35(3): 421–441. Link

From the Literature

2)  A New Option for Menopausal Vasomotor Symptoms

Vasomotor symptoms (VMS - flushing, hot flashes, sweating) are very common for women in perimenopause, and are very disruptive – to relationships, sleep, and overall quality of life. Our options have been limited to hormones, selective serotonin reuptake inhibitors, blood pressure medications like clonidine – all of which have significant adverse effects or don’t work very well. Yes, gabapentin has also been tried, naturally, with similar results.

In May 2023, the FDA approved a new medication, a neurokinase 3 receptor antagonist called fezolinetant (trade name Veozah, which is no more memorable or easy-to-say). A systematic review of the available literature on fezolinetant has been recently published. The authors searched seven literature databases for randomized controlled trials of the medication vs. placebo. They appraised the studies using the Cochrane Risk of Bias tool, assessed the studies for heterogeneity and pooled the results via meta-analysis. The primary outcome was change in frequency of VMS. Secondary outcomes included quality of life scores, other measures of VMS frequency, and safety data – namely transaminase elevations, sleep disturbances, and other adverse events.

The researchers found 330 possibly relevant studies and ultimately selected five studies with six reports (containing data for 2080 patients). The included subjects had an average of 7-8 VMS episodes per day, and the trials studied a range of fezolinetant doses - 45, 60, or 90 mg per day. The included studies were of low risk of bias, four lasted 12 weeks and one lasted a year. Fezolinetant was associated with a mean difference of 2.62 fewer episodes per day than placebo at 12 weeks (95% confidence interval (CI), 1.84–3.41). Quality of life was not significantly different between the groups. More women achieved an over 75% reduction in symptoms with fezolinetant than with placebo (Odds ratio (OR) 3.07 (95% CI, 2.20–4.30), NNT~5) and sleep improved in the treatment group (OR 2.39 (95% CI, 1.60–3.58), NNT~ 11). The only significant adverse event found was an increase in alanine aminotransferase (ALT) levels over three times the upper limit of normal (OR 2.38 (95%CI, 1.04–5.41), NNT~83). Heterogeneity in the analyses was overall low to moderate.

John’s Comments:

Well, this drug seems to help…somewhat. The authors found it curious, and I agree, that the quality-of-life measure used did not show any significant differences with the intervention despite a reduction in symptom frequency, improved sleep, and no major side effects.   Some other neurokinase inhibitors have been studied but were abandoned due to hepatotoxicity, so the ALT elevation is something that bears close watching. Even though the drug was tested at multiple doses, the FDA-approved dose is only 45 mg. This drug may be worth trying, but price may be prohibitive (Goodrx.com lists it in the mid-$500 range), and I can’t even find it on several commercial formularies.

Referencs:

• Bonga KN, Mishra A, Maiti R, Padhy BM, Meher BR, Srinivasan A. Efficacy and Safety of Fezolinetant for the Treatment of Menopause-Associated Vasomotor Symptoms: A Meta-analysis. Obstet Gynecol. 2024;143(3):393-402. Link

From PeerRxMed ( www.PeerRxMed.org )

3)  How Will You “Fall Forward” in the Coming Months?

"Life starts all over again when it gets crisp in the fall." — F. Scott Fitzgerald

As the fall colors begin to settle in and the last traces of summer slip away, we’re offered a beautiful opportunity for transition and reflection. There's something undeniably special about the shift from the long, warm days of summer to the shorter, crisper days of autumn. It feels like nature is inviting us to slow down, refocus, and prepare ourselves for the months ahead.

Autumn provides a different kind of energy—one that encourages us to ground ourselves, take stock of the year so far, and make any necessary adjustments as we enter the final stretch of the calendar. It’s a season rich with symbolism, from the shedding of leaves to the harvest of crops, and it can serve as a powerful reminder for us to do some shedding and harvesting of our own.

Remember that the PeerRxMed process involves those valuable PRx90 quarterly check-ins— “up to 90 minutes every 90 days” to touch base with yourself and your PeerRx partner. These conversations help to pause and recalibrate both personal and professional growth. It’s time to schedule that meeting again. To spark your discussion, here are some questions to ground and focus your reflections:

• What have you learned about yourself in the past 90 days?
• What goals or priorities will you focus on in the next quarter? Which will leave you disappointed if unaccomplished by the time we check in next?
• Do you have a break or vacation planned? What can you do this season that will bring you joy or peace?

In the spirit of fall, here are some additional questions to guide your personal reflection and dialogue, inspired by the themes of harvesting and shedding:

Fall Harvest: Fall is the season of reaping what we’ve sown. Take a moment to reflect on the seeds you planted earlier in the year. What projects or goals are coming to fruition? Which areas of your life are yielding the most growth and satisfaction? As you gather your personal and professional harvest, celebrate your wins, big and small. Then, think about what still needs attention. Is there something you’ve been nurturing that is now ripe for the picking?

Fall Shedding: Just as trees shed their leaves in preparation for winter, fall can be a time to let go of things that are no longer serving you. What have you been holding onto that you need to release? This could be a mindset, a habit, or even a project that’s run its course. Consider lightening your load to make room for fresh energy and new opportunities. As you let go, you create space for clarity and focus.

Don’t miss this perfect chance to “fall forward” by embracing the natural shift of the season. Take time for introspection, realignment, and meaningful conversations with your PeerRx partner. Three months from now, as winter begins, you’ll be glad you made the most of this autumnal pause, ensuring you’re well-positioned for whatever comes next.

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Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org