|Year : 2022 | Volume
| Issue : 2 | Page : 139-144
Role of ankle brachial pressure index (ABI) in screening patients with risk factors for developing peripheral vascular disease
Mithilesh Yadav1, Mohd Azam Haseen2, Syed Amzad Ali Rizvi1, Mayank Yadav2
1 Department of General Surgery, JNMCH, A.M.U, Aligarh, Uttar Pradesh, India
2 Department of Cardiothoracic and Vascular Surgery, JNMCH, A.M.U, Aligarh, Uttar Pradesh, India
|Date of Submission||05-Oct-2021|
|Date of Acceptance||01-Nov-2021|
|Date of Web Publication||13-Jun-2022|
Department of General Surgery, JNMCH, A.M.U, Aligarh, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: Peripheral vascular diseases (PVDs) are trigged by various risk factors. The presence of PVD is associated with higher cardiovascular morbidity and mortality. Ankle brachial index (ABI) is the sensitive and also cost-effective diagnosing tool for peripheral artery disease. ABI is important for screening of peripheral arterial disease in patients at risk and for diagnosing the disease in patients having lower-extremity symptoms. Materials and Methods: This prospective observational study was performed at J. N. Medical College, A. M. U., Aligarh, UP on 135 adult patients who are asymptomatic for PVD but have one or more risk factors. Demographic and clinical data were recorded. Systolic Blood pressure of both arms and lower limb were measured using sphygmomanometer and hand held Doppler. Ankle brachial pressure index (ABPI) is detected by dividing higher of the two ankle pressures by the higher of the two brachial artery pressure. Results: Majority of the patients were aged between 46 and 65 years, males more than females. It was observed that diabetes, hypertension, smoking, and dyslipidemia patients have significantly lower ABPI score (<0.9) compared to other patients. USG Doppler has showed 10.4% were having abnormal findings and the ABI (0.68 ± 0.17) was significantly lower than the normal ones (0.89 ± 0.09). Receiver operating curve shows that ABPI below 0.77 can be used as cut-off to predict the occurrence and risk of developing PVD for screening asymptomatic with sensitivity 88.4 and specificity 85.7 and accuracy 90.1%. Conclusion: Comorbid conditions such as smoking, diabetes, hypertension, and dyslipidemia increase the risk of PVD. ABPI is a valid method to screen PVD with high levels of sensitivity and specificity.
Keywords: Ankle brachial index, peripheral vascular disease, risk factors, systolic blood pressure
|How to cite this article:|
Yadav M, Haseen MA, Rizvi SA, Yadav M. Role of ankle brachial pressure index (ABI) in screening patients with risk factors for developing peripheral vascular disease. Indian J Vasc Endovasc Surg 2022;9:139-44
|How to cite this URL:|
Yadav M, Haseen MA, Rizvi SA, Yadav M. Role of ankle brachial pressure index (ABI) in screening patients with risk factors for developing peripheral vascular disease. Indian J Vasc Endovasc Surg [serial online] 2022 [cited 2022 Jul 1];9:139-44. Available from: https://www.indjvascsurg.org/text.asp?2022/9/2/139/347264
| Introduction|| |
Peripheral arterial disease (PAD) is a dysfunction characterized by the decreased blood flow in the limbs because of narrowing or obstruction of vessels tributaries. The concept of PAD also includes the impairment of the carotid arteries, renal, vertebral, and mesenteric, but not aortic diseases.
PAD causes significant disability and loss of function. As the atherosclerosis process continues it will lead to complications like myocardial infarction and cerebrovascular attacks. Peripheral vascular disease (PVD) is asymptomatic in about 40.0%.
Approximately 12.0% of the adults have PAD and the occurrence slightly more in men than women. A strong association exists between advancing age and the prevalence of PAD. Almost 20.0% of older adults above 70 years have PAD. In an elderly hypertensive population from the Systolic Hypertension in Elderly Program, the prevalence of PAD was 38.0% in black men, 25.0% in white men, 41.0% in black women, and 23.0% in white women.
The diagnosis of PAD must not be ignored for two important reasons. First, the patients with PAD might experience several problems, such as ischemic rest pain, claudication, ischemic ulcerations, revascularizations, repeated hospitalizations, and limb loss. These lead to poor quality of life and high rate of depression. Even patients who have no symptoms in legs have poorer functional performance, smaller calf muscle area, poorer quality of life, and greater calf muscle fat than an age-matched group of patients without PAD. Second, PAD patients have greater likelihood of having myocardial infarction, stroke, and cardiovascular death and have higher rate of all-cause mortality than patients without PAD.
Above two-third of patients with PAD are asymptomatic and are not diagnosed with systemic cardiovascular disease, resulting in insufficient treatment of their risk factors. The cardio-vascular disease burden related with PAD is same, whether it is the asymptomatic or symptomatic form. This therefore justifies the need to identify asymptomatic patients in order to intervene early and reduce the risk of cardiovascular-related mortality.
Ankle brachial index (ABI) is an efficient method of diagnosing presence and severity of PAD. A low Ankle brachial pressure index (ABPI) value (<0.9) has the sensitivity of 79.0%–95.0% and specificity of approximately 95.0% for peripheral artery disease. Hence ABI very useful bedsides test before the invasive investigations to fairly estimate patient's clinical prognosis. People with a history of hypertension, smoking, abnormal lipid profile, and diabetes are prone to develop PAD s because of reduced ABI.
Despite the significance of early detection, diagnosis of PAD is generally overlooked in the routine history and examination. A few patients who complain about claudication are misclassified of having leg pain because of arthritis, old age, or muscular pain. Thus, a lack of knowledge about morbidity and mortality related with PAD are major barrier to PAD diagnosis and prevention. Therefore, a need to increase physician knowledge and awareness about PAD and complete guidelines for detection of PAD is required. The treatment of PAD and management of the risk factors are valuable, which provides validation for performing the ABI measurements to aid early diagnosis of PAD.
| Materials and Methods|| |
This prospective observational study was performed for duration of 2 year (November 2019 to October 2021) on 135 adult patients who are asymptomatic for PVDs but have one or more risk factors and fit to the inclusion criteria were recruited for this study. The research procedure followed was in accordance with the approved ethical standards.
As shown in [Figure 1], patient giving consent and all the patients who are asymptomatic for PVDs but have one or more risk factors to be included in study while patient not giving consent for study, with known history of surgical intervention for PVD, <30 years and already having PVDs symptoms such as Leg pain, Leg ulcers, intermittent claudication, or gangrene were excluded from the study.
|Figure 1: Protocol for study: Flow chart of patients for enrollment and treatment procedures. CTVS: Cardiothoracic and vascular surgery, OPD: Out patient Ward, ABI: Ankle brachial pressure index, CTVS: Cardiothoracic and vascular surgery, OPD: Out patient ward, ABI: Ankle Brachial Pressure Index|
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Risk factors included
- Smoking-present or past smoker
- Dyslipidemia-Total Cholesterol concentration, ≥200 mg/dL; low density lipoprotein-cholesterol, ≥130 mg/dL; Triglyceride, >150 mg/dL; and high density lipoprotein-cholesterol, <35 mg/dL (13)
- Hypertension-resting blood pressure is persistently at or above 130/80 (American Heart Association November 2017 guidelines)
- Diabetes mellitus-Symptoms of diabetes mellitus * plus casual plasma glucose concentration ≥200 mg per dL or
FPG ≥126 mg per dL or2 hrPPG ≥200 mg/dL after a 75 g glucose load
- Known case of stroke and coronary artery diseases.
The patients were placed supine, without the head or any extremities dangling over the edge of the table. A Doppler probe (was using HADECO MINIDOP ES 100VX) and an aneroid sphygmomanometer (blood pressure cuff) were used.
The higher systolic reading of the left and right arm brachial artery is usually used in the evaluation. The pressures in each foot's posterior tibial artery and dorsalis pedis artery are measured with higher of the two values used as ABI for that leg.
Ankle brachial pressure index = PL/PA
Where PL is the systolic blood pressure of dorsalispedis or posterior tibial arteries and PA is the highest of the left and right arm brachial systolic blood pressure.
Ankle brachial pressure index <0.9 was taken as abnormal
Then the patient was subjected to USG color Doppler studies and compares our ABPI and Doppler results to calculate the efficacy of ABPI.
Microsoft Excel was used in making the database and generating graphs, while the data were analyzed using the IBM SPSS Statistics for Windows, Version 23.0. (Armonk, NY: IBM Corp., USA) for Windows. Mean and standard deviation were used to describe quantitative data meeting normal distribution. Continuous two independent groups were compared by parametric independent Student's t-test. P values less than 0.05 (P < 0.05) was considered statistically significant.
| Observation/Results|| |
The mean age of the studied patients was 57.67 ± 10.28 years, and male (68.9%) were in majority. Patients were affected by Stroke or CAD (90.4%) followed by dyslipidemia (51.1%), hypertension (43.7%), and diabetes mellitus (41.5%) also 36.3% were smokers. The majority of the patients were having ABI ≥0.9 (58.0%) followed by <0.9 (42.0%) with mean ABI as 0.87 ± 0.12 [Table 1].
|Table 1: Distribution of cases on the basis of the demographic, risk factors and other parameters|
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Males were significantly having lower ABI (79.3%) than females (P = 0.023), and the patients with hypertension, DM, and dyslipidemia significantly having the ABI below 0.9 (P < 0.05). SBP of lower limbs was significantly lower in ABI below 0.9 and significantly higher in Upper Limbs in ABI below 0.9 (<0.001) [Table 2].
|Table 2: Association of ankle brachial index with various studied parameters|
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USG Doppler has showed 14 (10.4%) were having abnormal findings and the ABI of those abnormal cases (0.68 ± 0.17) was significantly lower than the normal ones (0.89 ± 0.09) (P < 0.001) [Table 3].
Receiver operating curve (ROC) [Figure 2] which shows that ABPI below 0.77 can be used as cutoff to predict the occurrence and risk of developing PAD for screening asymptomatic with sensitivity 88.4 and specificity 85.7 and accuracy 90.1% [Table 4].
|Figure 2: Above is the receiver operating curve which shows that ankle brachial pressure index below 0.77 can be used as cut off to predict the occurrence and risk of developing peripheral arterial disease for screening asymptomatic with sensitivity 88.4 and specificity 85.7 and accuracy 90.1%|
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|Table 4: Cutoff, sensitivity, specificity and accuracy of the ABPI to predict developing peripheral arterial disease|
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| Discussion|| |
Persons with PAD (ABI <0.9) who never experience an exertional leg symptoms have inferior functional performance, poor quality of life, and adverse calf muscle features compared with the persons with intermittent claudication and also compared with asymptomatic, sedentary, age-matched group of non PAD persons. Patients with PAD have higher 10 year cardiovascular mortality than similar age-matched controls without PAD (18.7% vs. 4.4%), even after adjusting for conventional cardiovascular risk factors. The risk of cardiovascular morbidity was similar between asymptomatic and symptomatic PAD and is comparable to or higher than cardiovascular risk of secondary prevention populations.
In the present study, the majority of the patients were in the age range 46–65 years (65.9%) with mean age 57.67 ± 10.28 years. There was a male predominance (68.9%) followed by females (31.1%). Most of the patients were affected by Stroke or CAD (90.4%), followed by dyslipidaemia (51.1%), hypertension (43.7%), and diabetes mellitus (41.5%) also 36.3% were smokers. It was found that the majority of the patients were having ABI ≥0.9 (58.0%) followed by <0.9 (42.0%) with mean ABI as 0.87 ± 0.12.
Our findings were in accordance with Verma et al. who reported the mean age of all patients in our study was 47 years. There was one peak in the age group between 36 and 50 years (44%) and another peak was in patients of age group 51 and 65 years (28%). Male to female ratio was 6.2:1, showing male predominance. The most common risk factor associated with chronic leg ulcer patients in our study was smoking (86.0%). Others were diabetes (30.0%), k/c/o ischaemia (58.0%), DM and hypertension both (10%), and hypertension alone in (4.0%) cases. The mean value of ABI of the studied patients was 0.95. Anwar FM et al. in their study found that the mean age of the studied patients was 57.67 ± 10.28. 57.03% patients were males and 42.97% was females. 37.4% were smokers, 50.4% having diabetes, 39.3% have hypertension and 34.0% have dyslipidemia. 0.74 was minimum, 1.08 was maximum with 0.93 mean are the ABI of the study population. It was observed that 37.70% patients have ABI <0.9 with more or equal to 0.9 number 62.30%
In our study, males were significantly having lower ABI (79.3%) than females (P = 0.023) and the patients with hypertension, DM, and dyslipidemia significantly having the ABI below 0.9 (P < 0.05). SBP of lower limbs was significantly lower in ABI below 0.9 and significantly higher in Upper Limbs in ABI below 0.9 (<0.001). Similar to our findings Anwar FM et al. reported a significant association between gender and level of ABPI (P < 0.05) as maximum number of males showed ABI index <0.9 compared to females. Hypertension, smoking, diabetes and dyslipidemia were associated significantly with ABPI because their ABPI value was lower significantly than those without any risk factor. Verma M et al. reported the mean ABI value of diseased limb was 0.94, and it was associated significantly with smoking (former or current smokers)(P < 0.05). Studies by de Vinuesa et al., and Guerrero et al. showed an increased prevalence of PVD in males and also revealed that the previous clinical record of DM increased the risk of getting PVD which co-relates to our study. The cardio-vascular health study reached comparable conclusions among its 5084 subjects aged 65 years or above with PVD defined as an ABPI less than 0.9. The Limburg PAD Study as well as the PANDORA study showed that smoking, diabetes, and hypertension are the most important risk factors for PAD. Our results are in agreement with these studies, which showed evidence of an association between smoking, age, hypertension, and diabetes with PAD. The PAD patients had a significantly higher prevalence of diabetes (P = 0.001) and smoking (P = 0.024) compared with patients with a normal ABI was reported by Kravos et al.
As reported by Gadhvi et al. systolic BP of nonsmokers and total smokers, there was a significant difference found in systolic BP between nonsmokers and mild, moderate, and heavy smokers. Systolic BP in smokers was higher than nonsmokers (P < 0.05). Shahi et al. observed that the mean systolic blood pressure was found 152.2 ± 23.39 mmHg varied from 110 to 200 mmHg in cases (PVD) and 134.4 ± 26.2 mmHg varied from 100 to 190 mmHg in controls. The mean systolic blood pressure was significantly (P < 0.001) higher in PVD patients.
In the present study, USG Doppler has showed 14 (10.4%) were having abnormal findings, and the ABI of those abnormal cases (0.68 ± 0.17) was significantly lower than the normal ones (0.89 ± 0.09) (P < 0.001). We draw a ROC which shows that ABPI below 0.77 can be used as cut off to predict the occurrence and risk of developing PAD for screening asymptomatic with sensitivity 88.4% and specificity 85.7% and accuracy 90.1%
The sensitivity, specificity, and accuracy of the ABI as a PAD diagnostic tool is well documented Lijmer et al. who demonstrated a sensitivity of 79.0% and specificity of 96.0%. Premalatha et al. conducted a study aiming to evaluate specificity and sensitivity of ABPI measured by the peripheral Doppler with color-duplex ultrasound for detection of PVD and concluded that ABI is good initial screening tool with very high specificity and sensitivity.
In several studies, the sensitivity of an ABI measured at rest is about 68%–84%, and the specificity is about 84.0%–99.0%., Measuring the ABI after exercising (e.g., walking on a treadmill) increases the sensitivity of the test for identifying PAD by about another 25.0%. The pooled sensitivity and specificity of ABI <0.90 for PAD diagnosis were 75.0% and 86.0%. Evidence summary by an American College of Cardiology and an American Heart Association also recommended that ABI 95.0%. Weragoda J et al. in their study reported that ABPI 0.89 was established as the best cutoff value to recognize individuals with PVD. At this level of ABPI, high sensitivity (87.0%), specificity (99.10%), positive predictive value (98.90%), and negative predictive value (88.40%) were observed.
This study showed that the probability of progression of PAD increased with the number of risk factors. There was a significant risk of worsening of disease in patients presenting with 2 or more cardiovascular risk factors. Low ABPI is associated with an increase in cardiovascular mortality relative risk as compared to those with normal ABPI. The accuracy of this simple, noninvasive tool, as illustrated by the high sensitivity and specificity it can differentiate between lower limb pain secondary to osteoarthritis of the knee, neurological pain due to spinal canal stenosis, and genuine atherosclerotic PAD and the wider issues that come with that diagnosis.
| Conclusion|| |
The study results concluded that ABPI is a valid method to screen PVD with high levels of sensitivity and specificity in low-resource primary and secondary health care settings. ABPI is a safe, reliable, and cost-effective method of monitoring PAD.
Recommendations of the study
- There is a need to increase public awareness of PAD and its risk factors
- Train primary care physicians on use of Doppler devices for measuring ABI and increase their awareness of the importance of ABI measurement for the detection of asymptomatic PAD and the need for early vascular referrals.
Financial support and sponsorship
Department of CTVS, JNMCH, A.M.U by providing instruments used in study.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Rac-Albu M, Iliuta L, Guberna SM, Sine C. The role of ankle-brachial index for predicting peripheral arterial disease. J Clin Med 2014;9:295-302.
Weitzji, Byrne J, Clagettgp, Farkouh ME, Porter JM, Sackett DL, et al
. Diagnosis and treatment of chronic arterial insufficiency of the lower extremities: A critical review. Circulation 1996;94:3026-49.
Hiatt WR. Medical treatment of peripheral arterial disease and claudication. N Engl J Med 2001;344:1608-21.
Regensteiner JG, Hiatt WR. Current medical therapies for patients with peripheral arterial disease: A critical review. Am J Med 2002;112:49-57.
Olin JW, Sealove BA. Peripheral artery disease: Current insight into the disease and its diagnosis and management. Mayo Clin Proc 2010;85:678-92.
Regensteiner JG, Hiatt WR, Coll JR, Criqui MH, Treat-Jacobson D, McDermott MM, et al
. The impact of peripheral arterial disease on health-related quality of life in the peripheral arterial disease awareness, risk, and treatment: New resources for survival (PARTNERS) program. Vasc Med 2008;13:15-24.
McDermott MM, Guralnik JM, Ferrucci L. Asymptomatic peripheral arterial disease is associated with more adverse lower extremity characteristics than intermittent claudication. Circulation 2008;117:2484-91.
Hooi JD, Kester AD, Stoffers HE. Asymptomatic peripheral arterial occlusive disease predicted cardiovascular morbidity and mortality in a 7-year follow-up study. J Clin Epidemiol 2004;57:294-300.
Graham I, Atar D, Borch-Johnsen K, Boysen G, Burell G, Cifkova R, et al
. European guidelines on cardiovascular disease prevention in clinical practice. Eur J Cardiovasc Prev Rehabil 2007;14:S1-113.
Kim ES, Wattanakit K, Gornik HL. Using the ankle-brachial index to diagnose peripheral artery disease and assess cardiovascular risk. Clev Clin J Med 2012;79:651-61.
Anwar FM, Gopinath A. Assessment of risk factors causing peripheral arterial disease with the use of ankle brachial pressure index in asymptomatic patients. Int J Surg Sci 2020;4:219-22.
McDermott M, Guralnik J, Ferrucci L, Tian L, Liu K, Liao Y, et al
. Asymptomatic peripheral arterial disease is associated with more adverse lower extremity characteristics than intermittent claudication. Circulation 2008;117:2484-91.
Alahdab F, Wang AT, Elraiyah TA, Malgor RD, Rizvi AZ, Lane MA. A systematic review for the screening for peripheral arterial disease in asymptomatic patients. J Vasc Surg 2015;61:42-53.
Verma M, Singh AK, Kumar V, Mishra B. Role of ankle brachial index (ABI) in management of non-healing ulcers of lower limb. J Univer Surg 2018;6:6.
de Vinuesa SG, Ortega M, Martinez P, Goicoechea M, Campdera FG, Luño J. Subclinical peripheral arterial disease in patients with chronic kidney disease: Prevalence and related risk factors. Kidney Int Suppl 2005;67:S44-7.
Guerrero A, Montes R, Muñoz-Terol J, Gil-Peralta A, Toro J, Naranjo M, González-Pérez P, et al
. Peripheral arterial disease in patients with stages IV and V chronic renal failure. Nephrol Dialysis Transplant 2006;21:3525-31.
Kannel WB, McGee D, Gordon T. A general cardiovascular risk profile: The Framingham study. Am J Cardiol 1976;38:46-51.
Hooi JD, Stoffers HE, Kester AD. Risk factors and cardiovascular diseases associated with asymptomatic peripheral arterial occlusive disease: The Limburg PAOD study. Scand J Prim Health Care 1998;16:177-82.
Carvounis CP, Nikas N. Prevalence of peripheral arterial disease in subjects at moderate cardiovascular risk: Greek results of the PANDORA study. Hellenic J Cardiol 2014;55:294-304.
Kravos A, Bubnic-Sotosek K. Ankle-brachial index screening for peripheral artery disease in asymptomatic patients between 50 and 70 years of age. J Int Med Res 2009;37:1611-9.
Gadhvi MA, Shah SJ, Patel L. Comparative study of ankle-brachial pressure index in male smokers of Western India. Natl J Physiol Pharm Pharmacol 2019;9:590-4.
Shahi MS, Rahman A, Wadud MS, Saha UK, Ahmed AT, Ali Z, et al
. Association of ankle brachial pressure index (ABPI) in patients with ischemic stroke: A case control study. Chattagram Maa O Shishu Hosp Med Coll J 2013;12:27-33.
Lijmer JG, Hunink MG, van den Dungen JJ, Loonstra J, Smit AJ. ROC analysis of noninvasive tests for peripheral arterial disease. Ultrasound Med Biol 1996;22:391-8.
Premalatha G, Shanthirani S, Deepa R, Markovitz J, Mohan V. Prevalence and risk factors of peripheral vascular disease in a selected South Indian population: The Chennai urban population study. Diabetes Care 2000;23:1295-300.
Aday AW, Kinlay S, Gerhard-Herman MD. Comparison of different exercise ankle pressure indices in the diagnosis of peripheral artery disease. Vasc Med 2018;23:541-8.
Kinlay S, Gerhard-Herman MD. Current status of the ABI in diagnosis, risk assessment and screening. J Am Coll Cardiol 2019;73:1719-22.
Xu D, Zou L, Xing Y, Hou L, Wei Y, Zhang J, et al
. Diagnostic value of ankle-brachial index in peripheral arterial disease: A meta-analysis. Can J Cardiol 2013;29:492-8.
Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, et al
. ACC/AHA 2005 practice guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): A collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation 2006;113:e463-654.
Weragoda J, Seneviratne R, Weerasinghe MC, Wijeyaratne SM. Risk factors of peripheral arterial disease: A case control study in Sri Lanka. BMC Res Notes 2016;9:508.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]