The ankle-brachial index as a biomarker of cardiovascular risk: it's not just about the legs.

The ankle-brachial index (ABI) is widely accepted as a diagnostic test used to evaluate the presence of lower extremity peripheral artery disease (PAD) in patients with symptoms of intermittent claudication or rest ischemia.1–3 However, the majority of patients with PAD are asymptomatic; therefore, measurement of the ABI only when prompted by symptoms will result in most cases of PAD going unrecognized.4 Article see p 2053 The measurement of the ABI in patients without symptoms of PAD is controversial. In 2005, the United States Preventative Services Task Force assigned a “D” recommendation to screening for PAD, a grade indicating minimal benefit and possible harm.5 This recommendation was based on evaluation of limb outcomes such as claudication, amputation, and impaired ambulation. However, most patients with PAD do not go on to have major adverse limb outcomes.1 They do, however, have an excessively high burden of cardiovascular morbidity and mortality. In this issue of Circulation , Diehm and colleagues6 make an important contribution to the mounting evidence that screening for PAD in asymptomatic individuals be considered in terms of cardiovascular and not limb outcomes.7 They report 5-year outcomes in the German Epidemiological Study on Ankle Brachial Index (getABI), an ongoing prospective observational cohort study on the prognosis of elderly (aged ≥65 years) individuals with a low ABI compared with those with a normal ABI. Twenty-one percent of subjects screened had PAD, and the presence of PAD was associated with a >2-fold adjusted risk of death or severe vascular events. In persons with PAD, the risk of death or a severe coronary or cerebral vascular event was 3-fold that of a peripheral vascular event. Their findings reinforce the concept that the measurement of the ABI in selected patients as part of primary care practice would identify a significant …

[1]  Harald Darius,et al.  Mortality and Vascular Morbidity in Older Adults With Asymptomatic Versus Symptomatic Peripheral Artery Disease , 2009, Circulation.

[2]  Barbara P. Yawn,et al.  Using nontraditional risk factors in coronary heart disease risk assessment: U.S. Preventive Services Task Force recommendation statement. , 2009, Annals of internal medicine.

[3]  M. Criqui,et al.  Aspirin and secondary prevention in peripheral artery disease: a perspective for the early 21st century. , 2009, JAMA.

[4]  M. Criqui,et al.  Atherosclerotic Peripheral Vascular Disease Symposium II: screening for atherosclerotic vascular diseases: should nationwide programs be instituted? , 2008, Circulation.

[5]  P. Macfarlane,et al.  The prevention of progression of arterial disease and diabetes (POPADAD) trial: factorial randomised placebo controlled trial of aspirin and antioxidants in patients with diabetes and asymptomatic peripheral arterial disease , 2008, BMJ : British Medical Journal.

[6]  A Hofman,et al.  Ankle brachial index combined with Framingham Risk Score to predict cardiovascular events and mortality: a meta-analysis. , 2008, JAMA.

[7]  T. Holland-Letz,et al.  Reproducibility and reliability of the ankle—brachial index as assessed by vascular experts, family physicians and nurses , 2007, Vascular medicine.

[8]  D. Morrow,et al.  Benchmarks for the Assessment of Novel Cardiovascular Biomarkers , 2007, Circulation.

[9]  W. Howard.  Randomized trial of the effects of cholesterol-lowering with simvastatin on peripheral vascular and other major vascular outcomes in 20,536 people with peripheral arterial disease and other high-risk conditions. , 2007, Journal of vascular surgery.

[10]  L. Norgren,et al.  Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). , 2007, Journal of vascular surgery.

[11]  Rodney A. White,et al.  ACC/AHA Guidelines for the Management of Patients with Peripheral Arterial Disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Associations for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Intervent , 2006, Journal of vascular and interventional radiology : JVIR.

[12]  J. Beckman,et al.  The United States Preventive Services Task Force Recommendation Statement on Screening for Peripheral Arterial Disease: More Harm Than Benefit? , 2006, Circulation.

[13]  R. Vasan,et al.  Biomarkers of Cardiovascular Disease: Molecular Basis and Practical Considerations , 2006, Circulation.

[14]  Rodney A. White,et al.  ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography , 2006, Circulation.

[15]  A. Panju,et al.  Does the clinical examination predict lower extremity peripheral arterial disease? , 2006, JAMA.

[16]  Sonia S. Anand,et al.  Sensitivity and Specificity of the Ankle–Brachial Index to Predict Future Cardiovascular Outcomes: A Systematic Review , 2005, Arteriosclerosis, thrombosis, and vascular biology.

[17]  J. Knottnerus,et al.  Asymptomatic peripheral arterial occlusive disease predicted cardiovascular morbidity and mortality in a 7-year follow-up study. , 2004, Journal of clinical epidemiology.

[18]  P. Mehler,et al.  Intensive Blood Pressure Control Reduces the Risk of Cardiovascular Events in Patients With Peripheral Arterial Disease and Type 2 Diabetes , 2003, Circulation.

[19]  A. Connor,et al.  The way I see it: House officers need formal career development , 2002 .

[20]  A. Mattioli,et al.  Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients , 2002, BMJ : British Medical Journal.

[21]  Catherine Sudlow,et al.  Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients , 2002, BMJ : British Medical Journal.

[22]  D. DeMets,et al.  Biomarkers and surrogate endpoints: Preferred definitions and conceptual framework , 2001, Clinical pharmacology and therapeutics.

[23]  M. Criqui,et al.  Peripheral arterial disease detection, awareness, and treatment in primary care. , 2001, JAMA.