Ankle Brachial Pressure Index: An update for the vascular specialist and general practitioner

Abstract

Objectives Ankle brachial pressure index (ABPI) is an invaluable tool for assessing the severity of peripheral arterial disease. In addition, it can be used as an independent marker of cardiovascular risk, with a predictive ability similar to the Framingham criteria. Identification of an abnormal ABPI should therefore trigger aggressive cardiac risk factor modulation for a patient. Unfortunately, the significance of abnormal ABPIs is poorly understood within the general medical community. This is compounded by the influence of various comorbidities on accurate measurement of ABPI, potentially leading to a wide variability in readings that need to be considered before interpretation in these patient populations. We aim to address these issues by revealing several common misunderstandings and pitfalls in ABPI measurement, describing accurate methodology, and highlighting patient cohorts in whom additional or alternative approaches may be required. Methods We present a narrative review of the role of ABPI in both the community and hospital setting. We have performed a literature review, exploring the validity and reproducibility of methodology for obtaining ABPI, alongside the utility of ABPI in different clinical scenarios. Results The measurement of ABPI is often performed incorrectly. Common pitfalls include inadequate patient preparation, failure to obtain the blood pressure from the correct lower limb artery in patients with tibial disease, failure to account for differences in brachial blood pressure between the arms, inappropriately chosen equipment and patient factors such as highly calcified arteries. Standardisation of methodology greatly improves reliability of the test. Exercise ABPI can identify significant peripheral arterial disease in patients with normal resting ABPI. In addition to its role in peripheral arterial disease, ABPI measurement has a role in assessing venous ulcers, entrapment syndromes and injured extremities; conversely, it has a more limited utility in the diabetic population. Conclusions A thorough understanding of the correct technique and associated limitations of ABPI measurement is essential in accurately generating and interpreting the data it provides. With this knowledge, the ABPI is an invaluable tool to help manage patients with peripheral arterial disease. Perhaps more importantly, ABPI can be used to identify and risk stratify patients with asymptomatic peripheral arterial disease, itself a major indicator of significant underlying cardiovascular disease. With the emergence of best medical therapy, targeted pharmacotherapy and lifestyle changes can reduce the risk of major cardiovascular events in high-risk patients by approximately 30%, particularly in diabetic patients. Therefore, the utility of ABPI transgresses vascular surgery, with an essential role in general practice and public health.

Predictive Value of Limb Artery Indices and Endothelial Functional Tests for the Degree of Coronary Artery Stenosis in a Diabetic Population

“…These effects suggest that baPWV can predict the presence of CHD only in early stages of the disease. In contrast, FMD value and ABI are measurements of diastolic function and blood pressure ratio of blood vessels, 11 and the degree of atherosclerosis has less effect on the accuracy of those indices, resulting in a more accurate assessment of coronary artery stenosis. On the other hand, according to the recommendations of the American Heart Association, ABI is usually judged as abnormal when ≤0.9, 12 although our result was higher due to the poor vascular condition of the diabetic patients.…”

Increased Elastin Degradation in Pseudoxanthoma Elasticum Is Associated with Peripheral Arterial Disease Independent of Calcification

“…In addition, both plasma desmosines and arterial calcification were independently associated with ABI, peripheral arterial disease, and with Fontaine classification, which suggests that these different processes independently contribute to the pathogenesis of PXE. Although low ABI is a measure for the degree of stenosis in the vasculature between the aorta and the peripheral arteries in the legs [ 21 ], a cross-sectional study showed reduced arterial compliance and aortic distensibility in individuals with low ABI [ 22 ]. This suggests that besides stenosis, arterial stiffness also contributes to peripheral arterial disease.…”

Evaluation of arterial stiffness in systolic heart failure

“…The recorded pressure data were processed by the HMS Client Server Hypertension Management software (IEM GmbH, Stolberg, Germany), and aortic PWV was calculated. ABI and carotid IMT were measured according with current guidelines, using commercially available devices (peripheral CW Doppler device; 7 MHz linear ultrasound probe -Aloka Prosound Alpha 10 machine) [ 7,8].…”