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Ankle-Brachial Index measurement is often overlooked, despite it being one of the most important measurements from primary care onwards. Read more about the specifics of Ankle-Brachial Index measurement in different fields of healthcare and why timely measurement is so important.

Areas of use – Ankle-Brachial Index

Vascular Surgery

Measurements of the Ankle-Brachial Index (ABI) contribute to correct indications for surgical therapy and are mandatory in the follow up of patients after surgical treatment.

Asymptomatic low ABI has a prognostic value to predict perioperative myocardial damage in vascular surgery patients, incremental to risk factors imbedded in conventional cardiac risk indices.

FURTHER READING:

Goodney  PP, Tarulli  M, Faerber  AE, Schanzer  A, Zwolak  RM.  Fifteen-year trends in lower limb amputation, revascularization, and preventive measures among Medicare patients.  JAMA Surg. 2015;150(1):84-86.

W.-J. Flu, J.-P. van Kuijk, M.T. Vouˆte, R. Kuiper, H.J.M. Verhagen, J.J. Bax, D. Poldermans. Asymptomatic Low Ankle-Brachial Index in Vascular Surgery Patients: A Predictor of Perioperative Myocardial Damage. European Journal of Vascular & Endovascular Srugery, 2010

Elizabeth M. Mahoney, ScD; Kaijun Wang, MS, PhD, ET AL, Vascular hospitalization rates and costs in patients with Peripheral Artery Disease in the United States, Circulation, November, 2010


General practice

There is a clear need for spreading the awareness of the importance of early diagnosis and guideline-directed therapy of PAD, which may promote more timely initiation and optimized secondary prevention strategies to mitigate risk for adverse limb outcomes.

Primary care physicians are in a pivotal position within the healthcare system to improve the standard of care for patients with PAD. This improvement can be achieved if physicians follow the guidelines and perform an Ankle-Brachial Index measurement on all patients in the cardiovascular risk group, regardless of presenting symptoms.

FURTHER READING:

New 2017 ESC Guidelines on PAD

Association of Ankle-Brachial Indices With Limb Revascularization or Amputation in Patients With Peripheral Artery Disease Homam Moussa Pacha, MD1; Vishnu P. Mallipeddi, MBBS1; Naveed Afzal, PhD2; et al, October 17, 2018.

Jill J. F. Belch, MD; Eric J. Topol, MD; Giancarlo Agnelli, MD; et al, Critical issues in Peripheral Arterial Disease detection and management, Arch Intern Med. 2003

C. Diehm, H. Darius, et al, Prognostic value of a low post-exercise Ankle-Brachial Index as assessed by primary care physicians, Atherosclerosis 2011

H. van Langen, J. van Grup, et al, Interobserver variability of Ankle–Brachial Index measurements at rest and post exercise in patients with intermittent claudication, Vascular Medicine, 2009

INTERNATIONAL GUIDELINES:

2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease

2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS)

TASC II  Inter-society consensus for the management of PAD


Cardiology

According to new 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS), “it is the outmost importance that every cardiologist should be sensitive to the diagnosis and management of patients with PADs,…”

The Ankle-Brachial Index (ABI) is a simple, non-invasive, and inexpensive method used in the diagnosis of peripheral arterial disease (PAD) and can identify individuals at risk for cardiovascular disease in other arteries of the body, especially the coronary and carotid arteries. 

FURTHER READING:

Ankle-brachial index combined with Framingham risk score to predict cardiovascular events and mortality: a meta-analysis, JAMA, 2008

De Oliveira, Dinaldo Cavalcanti et al., Association Between Ankle-Brachial Index and Coronary Lesions Assessed by Coronary Angiography. Cardiology research vol. 6,1 (2015): 216-220. doi:10.14740/cr376w

INTERNATIONAL GUIDELINES:

2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS)


Dermatology, Compression therapy and Wound care management

Ankle-Brachial Index is a crucial measurement in wound care management and in compression therapy.

ABI measurement should be performed to:

  • Determine adequate arterial blood flow prior to compression therapy
  • Rule out PAD/LEAD with a lower extremity wound
  • Assess wound healing potential
  • Evaluate therapeutic outcome
  • Determine safe level of compression

FURTHER READING:

Fletcher J. Et al, Wounds UK. Best Practice Statement: Ankle brachial pressure index (ABPI) in practice. London: Wounds UK, 2019

Worldwidewounds.com. (2017). Doppler assessment and ABPI: Interpretation in the management of leg ulceration.

Ankle Brachial Index. (2012). Journal of Wound, Ostomy and Continence Nursing, 39, pp.S21-S29.

Compression for Primary Prevention, Treatment, and Prevention of Recurrence of Venous Leg Ulcers: An Evidence-and Consensus-Based Algorithm for Care Across the Continuum, Journal of Wound Ostomy & Continence Nursing, 2016


Nephrology

Kidney disease is an independent risk factor for the development of PAD and several studies have implicated poor renal function as a factor in increasing cardiovascular events and mortality. According to KDOQI guidelines, all patients should be evaluated for PAD at the time of dialysis. Among CKD patients, those with low ABI have a higher rate of cardiovascular events and mortality and the disease in those patients progresses faster than in patients without kidney disease.

FURTHER READING:

Chronic Kidney disease and blocked arteries? 

DeLoach, S. and Mohler, E. (2007). Peripheral Arterial Disease: A Guide for Nephrologists. Clinical Journal of the American Society of Nephrology

Meng-Chuan Liu, Yen-Wei Lee, Po-Tseng Lee et al, Ankle-Brachial Index Is a Powerful Predictor of Renal Outcome and Cardiovascular Events in Patients with Chronic Kidney Disease, Scientific World Journal. 2012; 2012: 238494. Published online 2012, Jan 4th

INTERNATIONAL GUIDELINES:

K/DOQI Clinical Practice Guidelines for Cardiovascular Disease in Dialysis Patients


Angiology

Ankle-Brachial Index (ABI) is used as a screening tool to determine the possible presence of Peripheral Arterial Disease (PAD) and therefore indicate further management. It is especially useful in the post-operative care of revascularized patients. 

INTERNATIONAL GUIDELINES:

2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease

2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS)

TASC II  Inter-society consensus for the management of PAD


Diabetology

Although PAD is very common in patients with diabetes, it is grossly under-recognized in this type of population. Diagnosis is often difficult when diabetes is associated with peripheral neuropathy (a condition that causes numbness in the feet), because this condition could mask the pain and lead to a big prevalence of wounds, ulcers and amputations in diabetic patients.

Diabetes increases the risk of lower extremity Peripheral-Arterial Disease by 2- to 4-fold and is present in 12% to 20% of persons with lower extremity PAD, so Ankle-Brachial Index should always be the first measurement in diabetic patients, followed by a TBI measurement.

FURTHER READING:

IWGDF guidance on the diagnosis, prognosis and management of peripheral artery disease in patients with foot ulcers in diabetes

X. Jin, J. Ma, Y. Shen, An Analysis of the Relationship Between Ankle–Brachial Index and Estimated Glomerular Filtration Rate in Type 2 Diabetes

INTERNATIONAL GUIDELINES:

2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS)


Neurology

Measurements of the Ankle-Brachial Index are essential in the differential diagnosis of lower extremity pain. In addition, a recurrent ischemia associated with PAD may cause muscle denervation, which may be one of the mechanisms responsible for decreased exercise performance in these patients.

FURTHER READING:

 J. D. England, J. G. Regensteiner, S. P. Ringel, M. R. Carry, W. R. Hiatt, Muscle denervation in Peripheral Arterial Disease, Neurology,  1992

Heidrich, Hermann, Concomitant neurological and orthopaedic diseases in the presence of peripheral arterial disease: A prospective study. VASA, 2013