General practice

Use of ankle brachial pressure index to predict cardiovascular events and death: a cohort study

^a Wolfson Unit for Prevention of Peripheral Vascular Diseases, Department of Public Health Sciences, University of Edinburgh, Edinburgh EH8 9AG, ^b Royal Infirmary of Edinburgh NHS Trust, Edinburgh EH3 9YW

Correspondence to: Professor Fowkes.

Abstract

Objective: To determine whether a low ankle brachial pressure index is associated with an increased risk of cardiovascular events and death, and whether the prediction of such events could be improved by including this index.
Design: Cohort study.
Setting: 11 practices in Edinburgh, Scotland.
Subjects: 1592 men and women aged 55-74 years selected at random from the age-sex registers of 11 general practices and followed up for 5 years.
Main outcome measures: Incidence of fatal and non-fatal cardiovascular events and all cause mortality.
Results: At baseline 90 (5.7%) of subjects had an ankle brachial pressure index </=0.7, 288 (18.2%) had an index </=0.9, and 566 (35.6%) </=1.0. After five years subjects with an index </=0.9 at baseline had an increased risk of non-fatal myocardial infarction (relative risk 1.38, 95% confidence interval 0.88 to 2.16), stroke (1.98, 1.05 to 3.77), cardiovascular death (1.85, 1.15 to 2.97), and all cause mortality (1.58, 1.14 to 2.18) after adjustment for age, sex, coronary disease, and diabetes at baseline. The ability to predict subsequent events was greatly increased by combining the index with other risk factors--for example, hypertensive smokers with normal cholesterol concentrations had a positive predictive value of 25.0%, increasing to 43.8% in subjects with a low index and decreasing to 15.6% in those with a normal index.
Conclusion: The ankle brachial pressure index is a good predictor of subsequent cardiovascular events, and improves on predictions by conventional risk factors alone. It is simple and accurate and could be included in routine screening of cardiovascular status.

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    StumbleUpon    Technorati    What's this?

Relevant Article

Ankle brachial pressure index?

Patrick Chong, David Gerrard, and Peter Leopold
BMJ 2009 338: b1599. [Extract] [Full Text]

This article has been cited by other articles:

• Diehm, C., Allenberg, J. R., Pittrow, D., Mahn, M., Tepohl, G., Haberl, R. L., Darius, H., Burghaus, I., Trampisch, H. J., for the German Epidemiological Trial on Ankle Brac, (2009). Mortality and Vascular Morbidity in Older Adults With Asymptomatic Versus Symptomatic Peripheral Artery Disease. Circulation 120: 2053-2061 [Abstract] [Full text]  
• Helfand, M., Buckley, D. I., Freeman, M., Fu, R., Rogers, K., Fleming, C., Humphrey, L. L. (2009). Emerging Risk Factors for Coronary Heart Disease: A Summary of Systematic Reviews Conducted for the U.S. Preventive Services Task Force. ANN INTERN MED 151: 496-507 [Abstract] [Full text]  
• Aquarius, A. E., Smolderen, K. G., Hamming, J. F., De Vries, J., Vriens, P. W., Denollet, J. (2009). Type D Personality and Mortality in Peripheral Arterial Disease: A Pilot Study. Arch Surg 144: 728-733 [Abstract] [Full text]  
• Hong Zhang, , Li, X.-Y., Yajun Si, , Xilie Lu, , Liping Chen, , Zhaoyang Liu, (2009). Manifestation of lower extremity atherosclerosis in patients with high ankle-brachial index. British Journal of Diabetes & Vascular Disease 9: 160-164 [Abstract]  
• El-Menyar, A., Amin, H., Rashdan, I., Souliman, K., Deleu, D., Saadat, K., Al Mahmeed, W., Bakir, S., Wasif, A., Ben Brek, A., Bazargani, N., Aziz, A. A., Singh, R., Hatou, I., Mahmoud, H., Al Suwaidi, J. (2009). Ankle-Brachial Index and Extent of Atherosclerosis in Patients From the Middle East (the AGATHA-ME Study): A Cross-Sectional Multicenter Study. ANGIOLOGY 60: 329-334 [Abstract]  
• Chong, P., Gerrard, D., Leopold, P. (2009). Ankle brachial pressure index?. BMJ 338: b1599-b1599 [Full text]  
• Tavintharan, S., Ning Cheung, , Su Chi Lim, , Tay, W., Shankar, A., Shyong Tai, E., Wong, T. Y. (2009). Prevalence and risk factors for peripheral artery disease in an Asian population with diabetes mellitus. Diabetes and Vascular Disease Research 6: 80-86 [Abstract]  
• Criqui, M. H., Alberts, M. J., Fowkes, F. G. R., Hirsch, A. T., O'Gara, P. T., Olin, J. W., for Writing Group 2, (2008). Atherosclerotic Peripheral Vascular Disease Symposium II: Screening for Atherosclerotic Vascular Diseases:: Should Nationwide Programs Be Instituted?. Circulation 118: 2830-2836 [Full text]  
• Criqui, M. H., Ninomiya, J. K., Wingard, D. L., Ji, M., Fronek, A. (2008). Progression of Peripheral Arterial Disease Predicts Cardiovascular Disease Morbidity and Mortality. J Am Coll Cardiol 52: 1736-1742 [Abstract] [Full text]  
• Ankle Brachial Index Collaboration, (2008). Ankle Brachial Index Combined With Framingham Risk Score to Predict Cardiovascular Events and Mortality: A Meta-analysis. JAMA 300: 197-208 [Abstract] [Full text]  
• Sutton-Tyrrell, K., Venkitachalam, L., Kanaya, A. M., Boudreau, R., Harris, T., Thompson, T., Mackey, R. H., Visser, M., Vaidean, G. D., Newman, A. B., for The Health, Aging, and Body Composition Study, (2008). Relationship of Ankle Blood Pressures to Cardiovascular Events in Older Adults. Stroke 39: 863-869 [Abstract] [Full text]  
• Gornik, H. L. (2008). Peripheral arterial disease enters the biomarker era. Does risk stratification tell us something that we don't already know?. Eur Heart J 29: 150-152 [Full text]  
• Feringa, H. H. H., Bax, J. J., Hoeks, S., van Waning, V. H., Elhendy, A., Karagiannis, S., Vidakovic, R., Schouten, O., Boersma, E., Poldermans, D. (2007). A Prognostic Risk Index for Long-term Mortality in Patients With Peripheral Arterial Disease. Arch Intern Med 167: 2482-2489 [Abstract] [Full text]  
• Haugen, S., Casserly, I. P., Regensteiner, J. G., Hiatt, W. R. (2007). Risk assessment in the patient with established peripheral arterial disease. Vasc Med 12: 343-350 [Abstract]  
• Clark, C. E, Campbell, J. L, Powell, R. J, Thompson, J. F (2007). The inter-arm blood pressure difference and peripheral vascular disease: cross-sectional study. Fam Pract 24: 420-426 [Abstract] [Full text]  
• Poredos, P., Jug, B. (2007). The Prevalence of Peripheral Arterial Disease in High Risk Subjects and Coronary or Cerebrovascular Patients. ANGIOLOGY 58: 309-315 [Abstract]  
• Feringa, H. H.H., Karagiannis, S. E., Chonchol, M., Vidakovic, R., Noordzij, P. G., Elhendy, A., van Domburg, R. T., Welten, G., Schouten, O., Bax, J. J., Berl, T., Poldermans, D. (2007). Lower Progression Rate of End-Stage Renal Disease in Patients with Peripheral Arterial Disease Using Statins or Angiotensin-Converting Enzyme Inhibitors. J. Am. Soc. Nephrol. 18: 1872-1879 [Abstract] [Full text]  
• Lapolla, A., Piarulli, F., Sartore, G., Ceriello, A., Ragazzi, E., Reitano, R., Baccarin, L., Laverda, B., Fedele, D. (2007). Advanced Glycation End Products and Antioxidant Status in Type 2 Diabetic Patients With and Without Peripheral Artery Disease. Diabetes Care 30: 670-676 [Abstract] [Full text]  
• Bendermacher, B. L.W., Teijink, J. A.W., Willigendael, E. M., Bartelink, M.-L., Peters, R. J.G., de Bie, R. A., Buller, H. R., Boiten, J., Langenberg, M., Prins, M. H. (2007). A clinical prediction model for the presence of peripheral arterial disease -- the benefit of screening individuals before initiation of measurement of the ankle--brachial index: an observational study. Vasc Med 12: 5-11 [Abstract]  
• Murabito, J. M., Guo, C.-Y., Fox, C. S., D'Agostino, R. B. (2006). Heritability of the Ankle-Brachial Index: The Framingham Offspring Study. Am J Epidemiol 164: 963-968 [Abstract] [Full text]  
• Lamina, C., Meisinger, C., Heid, I. M., Lowel, H., Rantner, B., Koenig, W., Kronenberg, F., for the KORA Study Group, (2006). Association of ankle-brachial index and plaques in the carotid and femoral arteries with cardiovascular events and total mortality in a population-based study with 13 years of follow-up. Eur Heart J 27: 2580-2587 [Abstract] [Full text]  
• Golomb, B. A., Dang, T. T., Criqui, M. H. (2006). Peripheral Arterial Disease: Morbidity and Mortality Implications. Circulation 114: 688-699 [Full text]  
• Diehm, C., Lange, S., Darius, H., Pittrow, D., von Stritzky, B., Tepohl, G., Haberl, R. L., Allenberg, J. R., Dasch, B., Trampisch, H. J., for the getABI Study Group, (2006). Association of low ankle brachial index with high mortality in primary care. Eur Heart J 27: 1743-1749 [Abstract] [Full text]  
• Tsakiris, A., Doumas, M., Lagatouras, D., Vyssoulis, G., Karpanou, E., Nearchou, N., Kouremenou, C., Skoufas, P. (2006). Microalbuminuria Is Determined by Systolic and Pulse Pressure Over a 12-Year Period and Related to Peripheral Artery Disease in Normotensive and Hypertensive Subjects: The Three Areas Study in Greece (TAS-GR). ANGIOLOGY 57: 313-320 [Abstract]  
• Feringa, H. H. H., Bax, J. J. J., van Waning, V. H., Boersma, E., Elhendy, A., Schouten, O., Tangelder, M. J., van Sambeek, M. H. R. M., van den Meiracker, A. H., Poldermans, D. (2006). The Long-term Prognostic Value of the Resting and Postexercise Ankle-Brachial Index.. Arch Intern Med 166: 529-535 [Abstract] [Full text]  
• Norman, P. E., Davis, W. A., Bruce, D. G., Davis, T. M.E. (2006). Peripheral arterial disease and risk of cardiac death in type 2 diabetes: the fremantle diabetes study.. Diabetes Care 29: 575-580 [Abstract] [Full text]  
• Wild, S. H., Byrne, C. D., Smith, F. B., Lee, A. J., Fowkes, F. G. R. (2006). Low ankle-brachial pressure index predicts increased risk of cardiovascular disease independent of the metabolic syndrome and conventional cardiovascular risk factors in the edinburgh artery study.. Diabetes Care 29: 637-642 [Abstract] [Full text]  
• Kardys, I., Oei, H.-H. S., van der Meer, I. M., Hofman, A., Breteler, M. M.B., Witteman, J. C.M. (2006). Lipoprotein-Associated Phospholipase A2 and Measures of Extracoronary Atherosclerosis: The Rotterdam Study. Arterioscler. Thromb. Vasc. Bio. 26: 631-636 [Abstract] [Full text]  
• Takahashi, O., Shimbo, T., Rahman, M., Musa, R., Kurokawa, W., Yoshinaka, T., Fukui, T. (2006). Validation of the auscultatory method for diagnosing peripheral arterial disease. Fam Pract 23: 10-14 [Abstract] [Full text]  
• Mangiafico, R. A., Sarnataro, F., Mangiafico, M., Fiore, C. E. (2006). Impaired cognitive performance in asymptomatic peripheral arterial disease: relation to C-reactive protein and D-dimer levels. Age Ageing 35: 60-65 [Abstract] [Full text]  
• Fuster, V., Fayad, Z. A., Moreno, P. R., Poon, M., Corti, R., Badimon, J. J. (2005). Atherothrombosis and High-Risk Plaque: Part II: Approaches by Noninvasive Computed Tomographic/Magnetic Resonance Imaging. J Am Coll Cardiol 46: 1209-1218 [Abstract] [Full text]  
• Doobay, A. V., Anand, S. S. (2005). Sensitivity and Specificity of the Ankle-Brachial Index to Predict Future Cardiovascular Outcomes: A Systematic Review. Arterioscler. Thromb. Vasc. Bio. 25: 1463-1469 [Abstract] [Full text]  
• Carrero, J. J., Lopez-Huertas, E., Salmeron, L. M., Baro, L., Ros, E. (2005). Daily Supplementation with (n-3) PUFAs, Oleic Acid, Folic Acid, and Vitamins B-6 and E Increases Pain-Free Walking Distance and Improves Risk Factors in Men with Peripheral Vascular Disease. J. Nutr. 135: 1393-1399 [Abstract] [Full text]  
• Lee, A.J., Price, J.F., Russell, M.J., Smith, F.B., van Wijk, M.C.W., Fowkes, F.G.R. (2004). Improved Prediction of Fatal Myocardial Infarction Using the Ankle Brachial Index in Addition to Conventional Risk Factors: The Edinburgh Artery Study. Circulation 110: 3075-3080 [Abstract] [Full text]  
• van der Meer, I. M., Bots, M. L., Hofman, A., Iglesias del Sol, A., van der Kuip, D. A.M., Witteman, J. C.M. (2004). Predictive Value of Noninvasive Measures of Atherosclerosis for Incident Myocardial Infarction: The Rotterdam Study. Circulation 109: 1089-1094 [Abstract] [Full text]  
• Resnick, H. E., Lindsay, R. S., McDermott, M. M., Devereux, R. B., Jones, K. L., Fabsitz, R. R., Howard, B. V. (2004). Relationship of High and Low Ankle Brachial Index to All-Cause and Cardiovascular Disease Mortality: The Strong Heart Study. Circulation 109: 733-739 [Abstract] [Full text]  
• Olijhoek, J. K., van der Graaf, Y., Banga, J.-D., Algra, A., Rabelink, T. J., Visseren, F. L. J., for the SMART Study Group, (2004). The Metabolic Syndrome is associated with advanced vascular damage in patients with coronary heart disease, stroke, peripheral arterial disease or abdominal aortic aneurysm. Eur Heart J 25: 342-348 [Abstract] [Full text]  
• Duprez, D. (2004). HOPE brings hope for the use of the ankle-brachial index as cardiovascular risk marker. Eur Heart J 25: 1-2 [Full text]  
• Ostergren, J., Sleight, P., Dagenais, G., Danisa, K., Bosch, J., Qilong, Y., Yusuf, S., for the HOPE study investigators, (2004). Impact of ramipril in patients with evidence of clinical or subclinical peripheral arterial disease. Eur Heart J 25: 17-24 [Abstract] [Full text]  
• Buitron-Granados, L. V., Martinez-Lopez, C., Escobedo-de la Pena, J. (2004). Prevalence of Peripheral Arterial Disease and Related Risk Factors in an Urban Mexican Population. ANGIOLOGY 55: 43-51 [Abstract]  
• Theodoridou, A, Bento, L, D'Cruz, D P, Khamashta, M A, Hughes, G R V (2003). Prevalence and associations of an abnormal ankle-brachial index in systemic lupus erythematosus: a pilot study. Ann Rheum Dis 62: 1199-1203 [Abstract] [Full text]  
• van der Meer, I. M., Iglesias del Sol, A., Hak, A. E., Bots, M. L., Hofman, A., Witteman, J. C.M. (2003). Risk Factors for Progression of Atherosclerosis Measured at Multiple Sites in the Arterial Tree: The Rotterdam Study. Stroke 34: 2374-2379 [Abstract] [Full text]  
• Kallio, M., Forsblom, C., Groop, P.-H., Groop, L., Lepantalo, M. (2003). Development of New Peripheral Arterial Occlusive Disease in Patients With Type 2 Diabetes During a Mean Follow-Up of 11 Years. Diabetes Care 26: 1241-1245 [Abstract] [Full text]  
• Mehler, P. S., Coll, J. R., Estacio, R., Esler, A., Schrier, R. W., Hiatt, W. R. (2003). Intensive Blood Pressure Control Reduces the Risk of Cardiovascular Events in Patients With Peripheral Arterial Disease and Type 2 Diabetes. Circulation 107: 753-756 [Abstract] [Full text]  
• Alkaabi, J. K., Ho, M., Levison, R., Pullar, T., Belch, J. J. F. (2003). Rheumatoid arthritis and macrovascular disease. Rheumatology (Oxford) 42: 292-297 [Abstract] [Full text]  
• van der Meer, I. M., de Maat, M. P.M., Hak, A. E., Kiliaan, A. J., del Sol, A. I., van der Kuip, D. A.M., Nijhuis, R. L.G., Hofman, A., Witteman, J. C.M. (2002). C-Reactive Protein Predicts Progression of Atherosclerosis Measured at Various Sites in the Arterial Tree: The Rotterdam Study. Stroke 33: 2750-2755 [Abstract] [Full text]  
• Coccheri, S., Scondotto, G., Agnelli, G., Palazzini, E., Zamboni, V. (2002). Sulodexide in the treatment of intermittent claudication. Results of a randomized, double-blind, multicentre, placebo-controlled study. Eur Heart J 23: 1057-1065 [Abstract] [Full text]  
• Redberg, R. F., Greenland, P., Fuster, V., Pyorala, K., Blair, S. N., Folsom, A. R., Newman, A. B., O'Leary, D. H., Orchard, T. J., Psaty, B., Schwartz, J. S., Starke, R., Wilson, P. W.F. (2002). Prevention Conference VI: Diabetes and Cardiovascular Disease: Writing Group III: Risk Assessment in Persons With Diabetes. Circulation 105 : e144-e152 [Full text]  
• Hooi, J. D., Stoffers, H. E.J.H., Kester, A. D. M., van Ree, J. W., Knottnerus, J. A. (2002). Peripheral Arterial Occlusive Disease: Prognostic Value of Signs, Symptoms, and the Ankle-Brachial Pressure Index. Med Decis Making 22: 99-107 [Abstract]  
• Coccheri, S, Palareti, G (2002). The cardiovascular risk burden of intermittent claudication. Eur Heart J Suppl 4: B46-B49 [Abstract]  
• Vliegenthart, R., Hollander, M., Breteler, M. M.B., van der Kuip, D. A.M., Hofman, A., Oudkerk, M., Witteman, J. C.M. (2002). Stroke Is Associated With Coronary Calcification as Detected by Electron-Beam CT: The Rotterdam Coronary Calcification Study. Stroke 33: 462-465 [Abstract] [Full text]  
• Tsai, A. W., Folsom, A. R., Rosamond, W. D., Jones, D. W. (2001). Ankle-Brachial Index and 7-Year Ischemic Stroke Incidence: The ARIC Study. Stroke 32: 1721-1724 [Abstract] [Full text]  
• Langlois, M., Duprez, D., Delanghe, J., De Buyzere, M., Clement, D. L. (2001). Serum Vitamin C Concentration Is Low in Peripheral Arterial Disease and Is Associated With Inflammation and Severity of Atherosclerosis. Circulation 103: 1863-1868 [Abstract] [Full text]  
• Hooi, J. D., Kester, A. D. M., Stoffers, H. E. J. H., Overdijk, M. M., van Ree, J. W., Knottnerus, J. A. (2001). Incidence of and Risk Factors for Asymptomatic Peripheral Arterial Occlusive Disease: A Longitudinal Study. Am J Epidemiol 153: 666-672 [Abstract] [Full text]  
• LOWE, G. D O (2001). Who should take aspirin for primary prophylaxis of coronary heart disease?. Heart 85: 245-246 [Full text]  
• Meijer, W. T., Grobbee, D. E., Hunink, M. G. M., Hofman, A., Hoes, A. W. (2000). Determinants of Peripheral Arterial Disease in the Elderly: The Rotterdam Study. Arch Intern Med 160: 2934-2938 [Abstract] [Full text]  
• McDermott, M. M., Fried, L., Simonsick, E., Ling, S., Guralnik, J. M. (2000). Asymptomatic Peripheral Arterial Disease Is Independently Associated With Impaired Lower Extremity Functioning : The Women’s Health and Aging Study. Circulation 101: 1007-1012 [Abstract] [Full text]  
• Ho, M., Veale, D., Eastmond, C., Nuki, G., Belch, J. (2000). Macrovascular disease and systemic sclerosis. Ann Rheum Dis 59: 39-43 [Abstract] [Full text]  
• Gray, W. A., Barrett, D. M., Benge, J. W. (1999). Heart or Head?. NEJM 341: 1458-1462 [Full text]  
• Newman, A. B., Shemanski, L., Manolio, T. A., Cushman, M., Mittelmark, M., Polak, J. F., Powe, N. R., Siscovick, D. (1999). Ankle-Arm Index as a Predictor of Cardiovascular Disease and Mortality in the Cardiovascular Health Study. Arterioscler. Thromb. Vasc. Bio. 19: 538-545 [Abstract] [Full text]  
• Jager, A., Kostense, P. J., Ruhe, H. G., Heine, R. J., Nijpels, G., Dekker, J. M., Bouter, L. M., Stehouwer, C. D. A. (1999). Microalbuminuria and Peripheral Arterial Disease Are Independent Predictors of Cardiovascular and All-Cause Mortality, Especially Among Hypertensive Subjects : Five-year Follow-up of the Hoorn Study. Arterioscler. Thromb. Vasc. Bio. 19: 617-624 [Abstract] [Full text]  
• Tisi, P. V, Shearman, C. P (1998). Biochemical and inflammatory changes in the exercising claudicant. Vasc Med 3: 189-198 [Abstract]  

Rapid Responses:

Read all Rapid Responses

Method of measuring ABPI

Judith Brown
bmj.com, 2 May 2000 [Full text]