What is your approach for patients who have marked inter-arm blood pressure differences on home and in office measurements?

I'd first confirm that there is a difference in BP between arms by having the patient alternate BP measurements at home while seated with the back supported in a chair. In the office, I may perform AOBP measurements in both arms, but definitely would compare radial pulses simultaneously. If there is a difference of >15 mm Hg by SBP between arms and no known anatomical abnormality (i.e., prior subclavian bypass or ascending aortic aneurysm repair) or known peripheral arterial disease, and BP is uncontrolled, then I would get a CT angiogram of the chest to assess the aorta for dissection/aneurysm.

If the discrepancy is chronic and or < 15 mm Hg, then I would advise the patient to use the higher of the 2 arms when checking BP.