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+A 71-year-old woman with known diastolic congestive heart failure (CHF) presented to the ER with exacerbation of CHF and a decreased level of consciousness.
+Brachial blood pressure (BP) was measured at 55/40 mmHg.
+The patient had four recent admissions with exacerbation of CHF.
+Her medical history was also significant for autoimmune hepatitis, but preserved liver function; esophageal varices with a bleeding episode; and long-term corticosteroid therapy complicated by adrenal insufficiency, type 2 diabetes mellitus and osteoporosis.
+Recent echocardiography had revealed moderate concentric left ventricular hypertrophy with diastolic dysfunction, and mild to moderate mitral regurgitation.
+Cardiac catheterization in a recent admission demonstrated 50% stenosis in the second diagonal artery, with mild diffuse disease in the other coronary arteries.
+Right ventricular endomyocardial biopsy had ruled out myocarditis and infiltrative cardiomyopathies, but healing ischemic microinfarcts with atheroemboli were observed.
+Previous BP values were also low; systolic BP was between 60 mmHg and 65 mmHg, and diastolic BP was between 40 mmHg and 45 mmHg.
+Following intubation, dopamine was started for hypotension management and was later replaced with noradrenaline.
+The patient developed atrial flutter but successfully converted to sinus rhythm with two direct current electric shocks.
+Cardiology consultation resulted in admission to the coronary care unit (CCU).
+On admission to the CCU, BP was measured at 56/36 mmHg in the left arm but was not detectable in the right arm.
+An arterial line was inserted via the femoral artery, and BP was measured at 191/92 mmHg.
+BP values were consistently much higher through the femoral arterial line than the cuff on the arms, and was higher in the left arm than in the right arm.
+For instance, on the first day post-CCU admission, BP at one point was measured at 170/80 mmHg through the arterial line, while cuff readings on the arms were 83/74 mmHg on the left and 60/39 mmHg on the right arm.
+To investigate the inconsistency between brachial and femoral BP values, a computed tomography (CT) scan of the thorax was obtained using 1.25 mm slices, both before and after intravenous contrast injection with sagittal and coronal planar reformatting of maximum-intensity projection images.
+Analysis of the initial unenhanced CT images showed densely calcified plaque or thrombus at the origins of both subclavian arteries and the right common carotid artery.
+The CT angiogram showed absence of flow in the right subclavian artery, a very tight stenosis at the origin of the left subclavian artery and a tight stenosis at the origin of the right common carotid artery.
+Both vertebral arteries showed normal calibre and flow (Figure 1).
+Further management following the insertion of the femoral arterial line was based on femoral BP readings with diuretics and BP-lowering agents.
+The patient was eventually discharged in stable condition.
+She remained stable during the eight months between discharge and the time the present report was written, without further exacerbation of CHF or related ER visits.