Oslel’s Maneuver, Pseudohypertension, and

True Hypetkmsion in the Elderly

FdANZ H. MESSERLI, M.D. The physician cannot prescribe by letter, we must feel the pulse.
New Orleans, Louisiana Seneca

Up to half of the geriatric population has been reported to have arterial

hypertension and, therefore, an augmented risk of heart attack, stroke,
congestive heart failure, and sudden death, Recent studies indicate
that mechanisms serving to elevate arterial pressure in the elderly
diametrically differ from those in younger patients with similar elevation
of arterial pressure. Elderly hypertensive patients have a low cardiac
output, elevated vascular resistance, impaired tissue flow, and In-
creased arterial stiffness. Arterial stiffness, if marked, can give rise to
pseudohypertension-an entity often responsible for inappropriate di-
agnosis and inappropriate therapy in the geriatric population. Pseudo-
hypertenskm can be suspected from a &mple bedside maneuver that
was hinted at by Sir William Osler almost a century ago. Arterial
hypertension seems to accelerate the physiologic process of aging in
the cardiovascular system and threatens, therefore, to set the biologic
clock at a faster pace. Hopefully, antihypettensive agents more clcisely
tailored to underlying mechanisms of pressure elevation will reverse
hypertensive damage to target organs and thereby reset the aging
process of the cardiovascular system at a slower pace.

Arterial pressure increases throughout life in westernized populations,

and more and more elderly people reach arbitrarily set hypertensive
criteria. Accordingly, the prevalence of hypertension becomes progres-
sively higher with aging and may reach almost 50 percent in patients
older than 65 years [ 1,2]. Since life expectancy in westernized countries
has increased from approximately 47 years at the turn of the century to
73 years at present [3] and continues to increase, we can expect to
identify and treat up to 25 million hypertensive elderly patients (or more
than 10 percent of the total population) in the United States in the near
future.
From the Department of Internal Medicine, Sec- Despite such impressive numbers, there is nothing benign about
tion on Hypertensive Diseases, Ochsner Clinic hypertension in the elderly. Data from the Framingham cohort have
and Alton Ochsner Medical Foundation, and Tu- indicated that the risk of a stroke or a heart attack within eight years is two
lane School of Medicine, New Orleans, Louisi- to four times higher in elderly hypertensive patients than in age- and sex-
ana. Requests for reprints should be addressed
to Dr. Frahz H. Messerli, Ochsner Clinic, 1514 matched normotensive subjects [4,5]. Studies from Belgium and Scandi-
Jefferson Highway, New Orleans, Louisiana navia have confirmed that cardiovascular morbidity and mortality in-
70121. Manuscript accepted January 13, 1986. crease in parallel with arterial pressure in the geriatric population [6-91.

906 May 1966 The American Journal bf Medicine Volume 60

 OSLER’S MANEUVER,
INNOCENT BYSTANDER OR DISEASE?
If the foregoing data hold true, why is it still a common
clinical contention that increased arterial pressure in the
elderly is a necessary compensatory process, or at the
worst, an innocent bystander? Several misconceptions
may contribute to this disarray: First, arterial pressure
increases with age in westernized populations, and an
elevated pressure is therefore believed to be a normal
finding in the aged. Second, function and perfusion of vital
organs diminish with age, and elevated pressure is regard-
ed as a physiologic compensatory process serving to
restore adequate blood flow. Third, elderly patients with
essential hypertension often have systolic hypertension,
and it is believed that only diastolic hypertension is a
harbinger of stroke, heart attack, and death. And finally,
until recently, no data have been published to indicate that
pathophysiologic mechanisms of pressure elevation are
different in the geriatric population from those in younger
patients with essential hypertension.
One little-recognized entity that confuses the issue
even more is so-called pseudohypertension that was hint-
ed at by Sir William Osler in 1892:
It may be difficult to estimate how much of the hardness
and firmness (of the artery) is due to the tension of the
blood within the vessel and how much to the thickening
of the wall. If, for example, when the radial is com-
pressed with the index finger, the artery can be felt
beyond the point of compression, its walls are sclerosed
[lOI.
Osler herein not only described the entity that is known
today as pseudohypertension [ 1 l- 131 (inappropriately el-
evated cuff pressure when compared with intra-arterial
pressure because of excessive atheromatosis and/or
medial hypertrophy in the arterial tree), but also suggested
a simple bedside maneuver for its identification. Clearly,
such an overestimation of arterial pressure in the elderly
has important clinical, prognostic, and therapeutic impli-
cations.
PATHOPHYSIOLOGIC CONSlDERATlONS IN THE
ELDERLY
Arterial Hypertension. We recently attempted to untan-
gle the cardiovascular adaptations to high blood pressure
from those of aging by comparing 30 patients older than
65 years who had established essential hypertension and
a similar number of patients younger than 42 years of age
paired with regard to mean arterial pressure, race, sex,
and body measurement [ 141. Holding the pressure equal
and matching the two age groups would allow us to
disregard, at least to a certain extent, the effects of blood
pressure and to define changes that were the result of
aging. Cardiac output was found to be significantly lower
in elderly subjects because of both a lower heart rate and
a smaller stroke volume, although none of them had
May
PSEUDOHYPERTENSION, AND HYPERTENSION IN ELDERLY-MESSERLI
coronary artery disease or congestive heart failure. Simi-
larly, renal blood flow, intravascular volume, and plasma
renin activity were lower in the older than in the younger
hypertensive subjects, indicating volume contraction and
nephrosclerosis [ 141.
Elderly patients also had concentric left ventricular
hypertrophy; posterior wall thickness, septal thickness,
and left ventricular mass were significantly increased.
Could it be that the increased ventricular mass was due to
pseudohypertrophy (replacement of functional myocardi-
urn by inactive tissue because of subclinical amyloidosis,
hemochromatosis, or other infiltrative disorder)? The fact
that end-systolic wall stress was within normal limits [ 151
in the elderly population argued against pseudohyper-
trophy (in which we would expect an inappropriately low
wall stress). However, left ventricular hypertrophy is not
merely a physiologic process compensating for the ele-
vated afterload. Ventricular ectopic activity (coupled and
multifocal beats) has been found to be increased [16] in
patients with left ventricular hypertrophy, thereby increas-
ing the risk of more serious arrhythmias and even sudden
death [ 17,181. Thus, elderly hypertensive patients are
characterized by a hypertrophied heart of the concentric
type that ejects a low cardiac output resulting from a
smaller stroke volume and a lower heart rate. Renal blood
flow is disproportionately reduced because of nephro-
sclerosis, and total peripheral resistance and renal vascu-
lar resistance are elevated, indicating systemic and renal
vascular diease [ 141.
Pseudohypertension and Osler’s Maneuver. In a re-
cent study [ 191, 25 patients older than 65 years of age
who had (by cuff pressure) established essential hyper-
tension were classified as being either Osler-positive or
Osler-negative according to a maneuver that was derived
from the previous description. A patient was said to be
Osler-positive if either the (pulseless) brachial or radial
artery could clearly be palpated despite ipsilateral occlu-
sion of the artery by a cuff pressure that exceeded systolic
values. In contrast, if the artery could no longer be palpat-
ed, the patient was said to be Osler-negative. We found
that Osler-positive patients had cuff pressures that aver-
aged 16 mm Hg (range 10 to 54 mm Hg) above intra-
arterial pressures [ 191. Arterial compliance, as measured
by pulse wave velocity and the diastolic decay of the pulse
tracing, was consistently lower in Osler-positive than in
Osler-negative subjects. Moreover, the difference be-
tween cuff pressure and diastolic intra-arterial pressure, a
measure of the degree of pseudohypertension, correlated
inversely with these indicators of arterial compliance.
Thus, pseudohypertension became progressively more
pronounced as arterial compliance decreased. In our
study, “Osler’s maneuver” was found to be an elegant
bedside technique for differentiating patients with true
hypertension from those whose blood pressure was false-
1988 The American Journal of Medicine Volume 80 907
OLSER’S MANEUVER, PSEUDOHYPERTENSION, AND HYPERTENSION IN ELDERLY-MESSERLI

TABLE I Pathophysiologic Findings in Young and antihypertensive therapy on longevity in the elderly
Elderly Patients with Essential [34-381. Most recently, the European Working Party on
Hypertension
high blood pressure in the elderly reported, in their elegant
Young Elderly placebo-controlled study, a distinct decrease in cardio-
vascular mortality by 27 percent and in deaths from
Cardiac output Increased Decreased
myocardial infarction by 60 percent in the actively treated
Heart rate increased Decreased
Ventricular mass Slightly increased Significantly increased group [39]. There were 14 fewer cardiovascular deaths
Total peripheral Normal Significantly increased per 1,000 patient-years in the treated than in the placebo
resistance population. However, the decrease in total mortality and
Intravascular Normal Decreased cerebrovascular mortality did not achieve statistical signif-
volume
Renal blood flow Slightly increased Significantly increased
icance.
Plasma renin Increased Decreased Why should treatment be less beneficial in the geriatric
activity age group than in young and middle-aged patients? Vari-
ous studies have attempted to answer this question by
using a rigid so-called “stepped-care” approach that
completely disregards underlying mechanisms of pres-
sure elevation in a given patient. Moreover, certain antihy-
ly elevated because of excessive atheromatosis and/or pertensive agents, particularly the thiazide diuretics, have
medial hypertrophy of the large arteries (pseudohyperten- been shown to adversely affect other cardiovascular risk
sion). factors [40-421. Although the relative merit of different
classes of drugs has not been systematically evaluated, it
CLINICAL IMPLICATIONS
seems logical to target the antihypertensive regimen as
The underlying mechanisms of blood pressure elevations closely as possible to the specific cardiovascular abnor-
are diametrically different in elderly patients from those in malities of an individual patient. The concept that “main-
young patients with essential hypertension (Table I). tenance or improvement of tissue flow will become a
Whereas young patients are often characterized by an more relevant goal of antihypertensive therapy than low-
elevated cardiac output (the term “cardiogenic” hyper- ering of pressure per se” [43] is nowhere more important
tension has been used [20]) and an inappropriately normal than in geriatric patients whose tissue flow often is mar-
or only a mildly elevated total peripheral resistance, elder- ginal to begin with. Thus, a drug that may be beneficial in a
ly patients are characterized by a low cardiac output and a young or middle-aged subject with essential hypertension
distinctly elevated total peripheral resistance. Moreover, (i.e., beta-adrenergic receptor blocker or diuretic) may be
target organ involvement in the heart (left ventricular less attractive or even contraindicated in the geriatric
hypertrophy of the concentric type and eventually conges- population [44]. In view of these considerations and also
tive heart failure), kidneys (nephrosclerosis with a corre- of a recent editorial in the Lancet [45], it is regrettable that
sponding decrease in renal blood flow and an elevation in the Systolic Hypertension in the Elderly Program-a
renal vascular resistance [2 1,22]), and brain is common multicenter study just embarked upon in the United
in elderly subjects. Despite low and unresponsive plasma States-again will use the stepped-care approach to
renin activity [23-281, intravascular volume is often con- evaluate the benefit of lowering arterial pressure.’
tracted, and circulating norepinephrine levels are in- Inappropriate Treatment. Elderly hypertensive patients
creased [ 141. are particularly susceptible to adverse effects of antihy-
Similar cardiovascular, fluid volume, and endocrine pertensive drugs [46-481. Part of the susceptibility may
changes have been encountered with age in normoten- be due to the fact that arterial pressure is often overesti-
sive subjects (although to a lesser degree) who were free mated and therefore over-treated in this age group be-
of cardiovascular disease [29-331. It would therefore cause of the concomitant or sole presence of pseudohy-
seem that arterial hypertension serves as a time acceler- per-tension. Such over-treatment would result in an appro-
ator of the “physiologic” aging process of the cardiovas- priate decrease in arterial pressure, which is particularly
cular system. harmful in senescence because of impaired barroreflex
Treatment and Longevity. Can we therefore (mutatis function and also because blood flow to various vital
mutandis) expect that a reduction in arterial pressure organs, such as the brain, heart, and kidneys, may be
would slow down the aging process and add years and marginal to start with. However, pseudohypertension has
quality to the life of our hypertensive senior citizens not only therapeutic but also epidemiologic and clinical
(antihypertensive therapy-an elixir of youth)? Findings implications. The Framingham Study allows us to calcu-
from several studies are contradictory in this regard and late that an increase in blood pressure of 16 mm Hg in a
unfortunately do not show a distinct beneficial effect of geriatric population (such as mimicked in our study in

908 May 1988 The American Journal of Medicine Volume 80

 OSLER’S MANEUVER, PSEUDOHYPERTENSION, AND HYPERTENSION IN ELDERLY-MESSERLI

those subjects with pseudohypertension) would increase CONCLUSIONS AND OUTLOOK

the risk of a stroke fourfold, of congestive heart failure
threefold, and of myocardial infarction twofold [4,5].
Pseudohypertension, therefore, leads to miscalculation of
cardiovascular risk factors and also is often responsible
for adverse effects caused by inappropriately lowered
arterial pressure.
Although patients with pseudohypertension do have
excessive sclerosis in the large arteries, their intra-arterial
pressures lay substantially below the measured values.
Before we label as many as half of our oldsters as
hypertensive and subject them for the remainder of their
days to the risk, inconvenience, and cost of an antihyper-
tensive regimen, the presence of pseudohypertension
should be thoroughly ruled out. Identification of this entity
therefore becomes of utmost importance in the geriatric
population. Although Osler’s maneuver is not infallible
[ 191, it serves as an elegant bedside screening test to
identify patients in whom intra-arterial pressure needs to
be measured.
Almost half of patients above the age of 65 have been
found to be hypertensive and therefore to have an elevat-
ed risk of cardiovascular morbidity and mortality when
compared with their normotensive counterparts. Recent
studies have identified cardiovascular fluid volume and
endocrine findings that serve to elevate arterial pressure
in elderly patients and have indicated that these are differ-
ent from the ones in younger patients with similar degree
of hypertension. Due to increased arterial stiffness, pseu-
dohypertension gives rise to inappropriate diagnosis and
inappropriate treatment in elderly patients. The presence
of essential hypertension serves to accelerate the aging
process in the cardiovascular system. Conversely, specif-
ic antihypertensive drugs that have been shown to reverse
hypertensive damage to target organs (such as hyperten-
sive heart disease and nephrosclerosis) and to increase
organ blood flow can be expected to slow the aging
process and to reset the biologic clock.

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