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A smaller ABI change 0. Among patients with intermittent claudication followed up for a mean period of 2. In the absence of revascularization, an ABI decrease is correlated with clinical deterioration. Clinical improvement in terms of an increased walking distance, however, is not correlated with an ABI increase. The level of ABI and the corresponding ankle pressure is useful to predict limb outcomes. From a clinical perspective, PAD may not progress in a parallel manner in both limbs, so it is necessary to assess the ABI in both limbs during follow-up.

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The ABI change correlates poorly with improvement in symptoms or functional performance. After angioplasty, an ABI increase of 0. The ABI is not site specific and may reflect changes elsewhere in the arterial tree.


Considering its low sensitivity for predicting graft failure, the measurement of the ABI alone is not a reliable method of surveillance after revascularization. Compared with individuals without PAD, those with PAD have poorer walking endurance, slower walking velocity, and lower physical activity levels. However, some PAD patients restrict their physical activity to avoid exertional leg symptoms 88 ; therefore, patient report of symptoms cannot be construed as a reliable measure of the degree of functional limitation.

The association of lower ABI values with greater functional impairment in cohorts restricted to men and women with PAD is less consistent. Several studies that included only PAD participants reported that lower ABI values are not associated with greater functional limitations. However, it is important to point out that characteristics contributing to functional impairment and decline in people with PAD are multifactorial and include muscle size and composition, inflammation, lower-extremity strength, mitochondrial function, and behavioral factors.

The ABI serves as a measure of systemic atherosclerosis and thus is associated with both atherosclerotic risk factors and prevalent CVD in other vascular beds. A low ABI is associated with many cardiovascular risk factors, including hypertension, diabetes mellitus, dyslipidemia, smoking history, and several novel cardiovascular risk factors eg, C-reactive protein, interleukin-6, homocysteine, and chronic kidney disease.

Therefore, it is not known whether the strength of the associations between low ABI and cardiovascular risk factors differs with alternative measurement methods and thresholds of ABI. A strong and consistent relationship between low ABI and prevalent coronary artery disease and cerebrovascular disease has been demonstrated in several population-based cohort studies that included individuals with existing CVD.

In most studies, odds ratios range from 1. Low ABI is also associated with prevalent cerebrovascular disease, with odds ratios in the range of 1.

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Whether the association of low ABI with prevalent CVD would differ with alternative measurement methods or definitions is unknown. In the ARIC study, 29 the association of low ABI and coronary artery disease was strong in both men and women, but there was no association of low ABI with stroke in women despite a strong association reported in men.

In a Spanish study, low ABI was associated with coronary artery disease in both men odds ratio, 2. Few studies have evaluated the association of an abnormally high ABI, indicative of vascular calcification, with cardiovascular risk factors or with prevalent CVD. High ABI is associated directly with male sex, diabetes mellitus, and hypertension but is inversely associated with smoking and hyperlipidemia. The ABI is a measure of the severity of atherosclerosis in the legs but is also an independent indicator of the risk of subsequent atherothrombotic events elsewhere in the vascular system.

In the general population, cardiovascular risk equations incorporating traditional risk factors such as age, sex, cigarette smoking, hypercholesterolemia, hypertension, and diabetes mellitus have been used to predict future risk of events. More precise identification of high-risk individuals may permit appropriate targeting of aggressive risk reduction therapies, although this strategy has not been properly evaluated. The ABI has been investigated as a risk predictor in several population-based cohort studies, mostly in Europe — and North America. Furthermore, the increased risks are independent of established CVD and risk factors at baseline, suggesting that the ABI, as an indicator of atherosclerosis, might enhance the accuracy of risk prediction with established scoring systems.

The ABI Collaboration performed an individual-based meta-analysis of 16 population cohorts to investigate in a large data set whether the ABI provided information on the risk of cardiovascular events and mortality independent of the Framingham Risk Score FRS and might improve risk prediction when combined with the FRS. Use of the ABI resulted in reclassification of the risk category in both men and women.

Since this meta-analysis, a recent report from MESA presented consistent data in different ethnic groups in the United States. Additional analyses are encouraged to use several recent metrics assessing the improvement of CVD risk prediction with the ABI. Specifically, criteria such as discrimination, calibration, and net reclassification improvement are awaited.

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Although an ABI cut point of 0. Thus, the graph of mortality or other cardiovascular outcome by ABI level is a reverse J-shaped curve in which the lowest level of risk normal is from 1. Figure 1. Hazard ratios for total mortality in men and women by ankle-brachial index at baseline for all studies combined in the ABI Collaboration.

Reproduced from Fowkes et al 6 with permission from the publisher.

The postexercise ABI is also predictive of risk. In the case of a normal ABI at rest, the presence of an abnormal ABI after exercise is associated with increased mortality. As one of the least expensive and most available markers of atherosclerosis, the ABI is a highly appropriate measurement for CVD risk assessment in primary care. The standardized ABI measurement proposed in this document has very good test characteristics for the diagnosis of PAD and should be considered for appropriate reimbursement. Body position and knee or hip flexion influence the ABI.

These positions affect ankle pressure because the ankle is lower than the heart in the seated but not in the supine position, and consequently, the pressure is higher. The ABI averages 0. Therefore, patients should be lying flat for an accurate ABI measurement, with the head and heels fully supported, ie, not hanging over the end of the examination table. Gornik et al recommended a formula to correct the seated ABI under standardized conditions in patients who cannot lie down.

However, no external validation of this formula is available. The effect of the duration of the rest period on the reliability of ABI measurement is unknown. The length of the rest period before performing the ABI measurement has varied among studies, 10 with most studies using a 5- to minute period. Longer delays are impractical in the clinical setting. Even after a resting period, the first limb measurement tends to provide higher systolic pressures during a sequential limb by limb measurement. Smoking cigarettes also may affect the ABI.

Studies of brachial blood pressure measurement highlight the importance of an appropriate cuff size to avoid inaccurate measurements. The cuff wrapping method spiral or parallel affects the ankle SBP, with lower values occurring with the spiral cuff wrapping method. Given these data and the fact that the straight method is used to assess arm blood pressure, parallel wrapping is also preferred for the ankles. Although the measurement of the ABI by a pressure cuff is noninvasive, safe, and well tolerated in most circumstances, cuff inflation should be interrupted if it is painful.

Caution is advised in 2 clinical situations.

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Direct apposition of the ankle cuff over open wounds and ulcers should be avoided or prevented by an impermeable dressing. In addition, cuff inflation should be avoided over a recently placed bypass graft because of the potential risk of causing graft thrombosis. Several noninvasive techniques are used to detect limb flow or pulse volume for measuring the ABI, primarily Doppler ultrasound and oscillometric methods. The former uses a continuous-wave Doppler probe for detection of arterial flow Figure 2.

The SBP is determined with a pneumatic cuff, which is first inflated until flow ceases and then deflated slowly until there is reappearance of the flow signal. The corresponding cuff pressure is the SBP. The oscillometric technique is based on the assumptions that the maximum oscillations appearing during cuff deflation correspond to the mean arterial pressure and that SBP and diastolic blood pressure can be calculated from this pressure with mathematical algorithms.

These algorithms, based on empirical data from healthy subjects, were originally developed to measure arm blood pressure. The validation studies for oscillometric methods 48 , , — are summarized in Table III in the online-only Data Supplement. Some studies, but not others, have questioned the validity of the oscillometric method for the detection of PAD. Figure 2. Ankle pressure measurement with a Doppler probe: posterior tibial A and dorsalis pedis B arteries.

Figure 3. Difference between ankle pressures measured with an oscillometric device CASMED and Doppler y axis according to the ankle pressure bands obtained with Doppler x axis. Reprinted from Korno et al with permission from the publisher. Other methods used to measure ABI include plethysmography, photoplethysmography, , , auscultation, and pulse palpation. The photoplethysmography method, in which a sensor is placed on the great toe to detect flow after cuff deflation, correlated well with Doppler in several series of patients with PAD.

A cool environment causes digital vasoconstriction. A laser Doppler probe placed on the dorsum of the foot to detect flow was used for ABI measurements in 1 study. Measurement of ABI using auscultation with a stethoscope was assessed in a Japanese study.


The intraobserver coefficient of variation CoV of the ABI with the Doppler method varies widely in the literature, from 4. Overall, these results are superior to those obtained with an automated oscillometric method, which has a CoV ranging from 5. The interobserver variability has been studied extensively for the Doppler method, but there are few data for other methods.

The ABI measured by Doppler in all limbs showed significantly better reproducibility than the 2 alternative methods of using a stethoscope or an oscillometry for the arms. Several studies reported higher ABI reproducibility when measured by skilled examiners.