Screening for Peripheral Artery Disease and Cardiovascular Disease Risk Assessment With the Ankle-Brachial Index: US Preventive Services Task Force Recommendation Statement

Abstract

The USPSTF found few data on the accuracy of the ankle-brachial index (ABI) for identifying asymptomatic persons who benefit from treatment of peripheral arterial disease (PAD) or cardiovascular disease (CVD). Conclusion: The USPSTF concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening for PAD and CVD disease risk using the ABI in asymptomatic adults. Commentary: In the last 5 years, various specialties have weighed in on whether or not performing a screening ABI is worthwhile. Some of you may be surprised to know that both the Society for Vascular Surgery and the American College of Cardiology/American Heart Association released practice guidelines saying it is reasonable to obtain a screening ABI in asymptomatic patients, namely those >65-70 years old and in younger patients with atherosclerotic risk factors. 1,2 However, the American Academy of Family Physicians concluded that there was insufficient evidence to assess the balance of benefits and harms of screening for PAD and CVS using the ABI in asymptomatic adults, 3 as did the current review by the USPSTF. By the way, the U.S. Congress mandates that the Agency for Healthcare Research and Quality (AHRQ) supports the operations of the USPSTF. This is an important article because of its practical implications. If an asymptomatic patient is shown to have an abnormal ABI, don't all of us agree that interventions should not be performed for asymptomatic arterial occlusive disease of the lower extremities? I hope and expect that physicians do not obtain ABIs in asymptomatic patients simply as a means to increase revenue via the noninvasive vascular laboratory. Although the SVS practice guidelines delineate reasonable exceptions, I don't see the value of performing an ABI in most patients without suspected arterial claudication, ischemic rest pain, or ischemic tissue loss. Take-home message: Make sure you have a darn good reason for performing screening ABIs in asymptomatic patients so that you don't get accused of being one of those greedy doctors. References: 1. Guidelines Writing Group, Conte MS, Pomposelli FB, Clair DG, Geraghty PJ, McKinsey JF, et al. Society for Vascular Surgery Lower Extremity Guidelines Writing Group. Society for Vascular Surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities: management of asymptomatic disease and claudication.

Determination of the Ankle-brachial Index in Type 2 Diabetic Patients with an Automatic Oscillometric Device

“…A pathological ABI value is an independent factor of future cardiovascular events [14]. An ABI value of <0.90 increases the relative risk of cardiovascular events and all-cause mortality by two to four times [15].…”

“…A systematic review examined all studies that had given ABI data at baseline and traced acute coronary disease, strokes and all-cause mortality in patients who had not any cardio-or cerebrovascular events [5]. A low ABI value has a predictive value of 92.7% for coronary artery disease [15]. After 5 years, 20% of patients with a PAD have a non-fatal heart attack while 15-30% die (three-quarters of these from cardiovascular deaths) [16].…”

Future directions in cardiovascular disease risk prediction

“…The United States Preventive Services Task Force has recently reviewed the evidence for some tests that are potential candidates for this: ankle-brachial index, coronary artery calcium scoring, high-sensitivity C-reactive protein 16 and exercise electrocardiography (ECG). 17 A summary of their findings is shown in Table 3. Coronary artery calcium scoring has also been assessed in a relatively small randomised controlled trial, randomising individuals to scanning or not prior to assessment of traditional risk factors.…”

The inheritance of cardiovascular disease risk

“…Whilst there have been improvements in early diagnostic measures for CVD, their use is relevant to high resource settings and is not without problems (e.g. see ) and newer therapies for risk reduction as noted above , the reduction of such risk overall on a global scale does not seem to be taking place. This is particularly true of obesity.…”