Current utility of the ankle-brachial index (ABI) in general practice: implications for its use in cardiovascular disease screening

Abstract

BackgroundPeripheral arterial disease (PAD) is a marker of systemic atherosclerosis and associated with a three to six fold increased risk of death from cardiovascular causes. Furthermore, it is typically asymptomatic and under-diagnosed; this has resulted in escalating calls for the instigation of Primary Care PAD screening via Ankle Brachial Index (ABI) measurement. However, there is limited evidence regarding the feasibility of this and if the requisite core skills and knowledge for such a task already exist within primary care. This study aimed to determine the current utility of ABI measurement in general practices across Wales, with consideration of the implications for its use as a cardiovascular risk screening tool.MethodA self-reporting questionnaire was distributed to all 478 General Practices within Wales, sent via their responsible Health Boards.ResultsThe survey response rate was 20%. ABI measurement is primarily performed by nurses (93%) for the purpose of wound management (90%). It is infrequently (73% < 4 times per month) and often incorrectly used (42% out of compliance with current ABI guidance). Only 52% of general practitioners and 16% of nurses reported that patients with an ABI of ≤ 0.9 require aggressive cardiovascular disease risk factor modification (as recommended by current national and international guidelines).ConclusionABI measurement is an under-utilised and often incorrectly performed procedure in the surveyed general practices. Prior to its potential adoption as a formalised screening tool for cardiovascular disease, there is a need for a robust training programme with standardised methodology in order to optimise accuracy and consistency of results. The significance of a diagnosis of PAD, in terms of associated increased cardiovascular risk and the necessary risk factor modification, needs to be highlighted.

Knowledge about ankle-brachial index procedure among residents: being experienced is beneficial but is not enough

“…We believe that this poor knowledge might explain the underutilisation and/or the incorrect use of the ABI in primary care settings such as other common barriers advocated in the literature (e.g., time consuming or expensive equipment) [4,10,16].…”

Survey of ankle–brachial pressure index use and its perceived barriers by general practitioners in the UK

“…Recent surveys on the use of ABPI have suggested that primary care practitioners should receive targeted training to perform and analyse ABPIs 14. Similar recommendations were made over a decade ago, following a large multicentre programme that assessed the practice and perceptions of primary care clinicians, with the PAD Awareness, Risk and Treatment: New Resources for Survival (PARTNERS) in the USA 11.…”

Increase in the Arterial Velocity Pulse Index of Patients with Peripheral Artery Disease

“…The list of indications for ABPI measurement and the number of candidates for the measurement of this parameter are large [11]. However, measurement by the Doppler method requires a high level of skill [12, 13], and measurement by the oscillometric method requires a dedicated equipment [10]. Therefore, ABPI measurement has not been implemented in all potential candidates for measurement of this parameter.…”