Elderly patients with diabetes or renal failure and diffuse vascular disease can occasionally develop a condition called 'pseudomalignant hypertension' ( Messerii.,. 1985). As a result of advanced atherosclerosis, their blood vessels become relatively non-compressible. This makes it very difficult, and sometimes impossible, to measure an accurate cuff blood pressure and can result in artefactually elevated blood pressure measurements. There are numerous case reports of such patients receiving unnecessarily aggressive antihypertensive agents in efforts to control their artefactual hypertension, which even result in shock or cardiac arrest of the patient. In such cases, intra-arterial catheter monitoring shows the true pressure to be much lower than that measured by sphygmomanometry. These patients can sometimes be detected by use of a procedure called Osler's maneuver (Messerii 1985) whereby a blood pressure cuff on the arm is inflated above the auscultated systolic pressure. The radial and brachial arteries are then directly palpated; if either remains palpable, the patient is said to have a 'positive test'. Such patients have actual intra-arterial pressures 20 to 60 mmHg lower than those determined by cuff. If a patient has a positive Osler maneuver, only direct intra-arterial monitored measurements are absolutely reliable. Obviously, automated non-invasive blood pressure devices cannot be considered reliable in such cases. This condition should be suspected if a patient continues to have severely elevated cuff blood pressures despite appropriate therapeutic measures, or if the patient's overall condition appears inconsistent with his or her measured blood pressure.
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