The ankle-brachial

pressure index:
An under-used tool in primary care?

18
Calculating a patient’s ankle-brachial pressure index (ABPI) is a simple, low-cost and non-invasive way
of detecting peripheral artery disease in the lower limbs. Atherosclerosis is the most frequent cause of
peripheral artery disease and the patient’s atherosclerotic burden is reflected by the degree to which
their ABPI is reduced. Measuring ABPI therefore provides a useful window into what is happening in the
cardiovascular system and an additional prognostic tool to that provided by more frequently used surrogate
markers of cardiovascular risk. Targeted testing of ABPI for people most at risk of developing peripheral
artery disease and its complications, in combination with routine cardiovascular risk assessments, will lead
to earlier and more appropriate treatment of all types of atherosclerotic disease.

Is your Practice measuring ankle-brachial involving over 48 000 patients without a history of coronary
pressure indices? artery disease, found that when ABPI indicated the presence
of peripheral artery disease the risk of cardiovascular mortality
Peripheral artery disease is a significant risk factor for increased by over four times for males and approximately 3.5
cardiovascular events and lower limb amputation. The times for females, compared with people with an ABPI in the
prevalence of peripheral artery disease is increased among normal range.2
older people, people who smoke and people who have
diabetes. In New Zealand there is limited epidemiological data The majority of General Practitioners do not currently perform
on peripheral artery disease. However, it is likely that Māori and routine ABPI measurements – presumably because they do
Pacific peoples are more severely affected by peripheral artery not have access to the necessary equipment. When combined
disease compared with European New Zealanders, as they are with a focused vascular examination, the ABPI is a useful tool
known to have significantly higher rates of cardiovascular in primary care for stratifying a patient’s cardiovascular risk,
disease in general. and improving their management.

The ankle-brachial pressure index (ABPI) is a non-invasive Ankle-brachial pressure index testing has multiple uses
method for detecting or ruling-out the presence of peripheral A pedal pulse that is easily felt on examination effectively
artery disease. ABPI is a calculation of the ratio of the patient’s excludes peripheral artery disease. However, measuring
systolic blood pressure at their ankle to the systolic pressure in ABPI to detect peripheral artery disease is a more sensitive
their arm. ABPI is generally between 1.0 – 1.4 in healthy people, and replicable test compared to palpation of a pedal pulse,
i.e. the systolic pressure at the ankle is greater than the systolic especially in patients who are obese or who have significant
pressure at the arm. An abnormally low ABPI value (i.e. < 0.9) oedema.1 Measurement of the ABPI can also provide valuable
has a sensitivity of 79 – 95% and a specificity of approximately clinical information without the need to refer the patient to a
95% for peripheral artery disease.1 vascular laboratory.

Between one-third and one-half of patients with peripheral ABPI is recommended for all patients who present with signs
artery disease will have some evidence of coronary artery and symptoms suggestive of peripheral artery disease. The
or cerebrovascular disease.1 A meta-analysis of 16 studies physical examination of a patient with peripheral artery disease

BPJ  Issue 60  19

may reveal reduced or absent pedal pulses on palpation, skin people who are at risk of developing artery disease (see
that is cool, shiny, hairless or thin, thickening of the nails, below), be offered a clinical assessment that includes an ABPI
abnormal capillary refill time, pallor of distal extremities measurement.3, 5
on elevation, leg pain and tissue ulceration or necrosis.3
The classical initial symptom of peripheral artery disease is Risk factors for peripheral artery disease include:3, 5
intermittent claudication. This is a tight cramp-like pain in the Older age
muscles of the calf, thigh or buttock that is reproduced with
Smoking, past and present
exercise and relieved within ten minutes of rest.3 However,
only 10% of patients with peripheral artery disease present Diabetes
with classical claudication and approximately 50% have Hyperlipidaemia
atypical leg pain; the remainder of patients are asymptomatic.3 Hypertension
Venous claudication, neurogenic claudication (spinal stenosis),
Reduced renal function (eGFR < 60 mL/min/1.73 m2)
popliteal artery entrapment, Raynaud’s phenomenon and
other vasospastic problems are differential diagnoses that may
need to be considered in patients with symptoms suggestive In particular, international guidelines recommend targeted
of claudication. Therefore ABPI testing is not only useful for testing for peripheral artery disease for the following groups:6
detecting the presence of peripheral artery disease, it is also All people aged between 50 and 69 years who smoke or
helpful for ruling-out peripheral artery disease as a cause of have diabetes
symptoms in the lower limbs, particularly in older patients.
All people from age 70 years regardless of risk-factor
status
ABPI provides an indication of disease severity and the
urgency of referral. The presence of ischaemic rest pain All people with a Framingham risk score > 10%
suggests increased severity of peripheral artery disease and
an increased risk to the limb. Patients with ischaemic rest pain Current smokers are estimated to be almost four times as likely
often present with a burning pain in the arch or distal foot that to develop peripheral artery disease as non-smokers.5 Over
occurs when their feet are elevated, e.g. in bed, and resolves half of all amputations due to peripheral artery disease are
when they place their feet on the floor. An ABPI < 0.4 indicates reported to occur in patients with diabetes.5
the patient has critical limb ischaemia.4 This is a potentially
life-threatening condition characterised by severely reduced Performing ankle-brachial pressure index
circulation, ischaemic rest pain and tissue loss due to ulceration testing
and/or gangrene.5 Due to severely impaired circulation, 5 – 10%
of patients with peripheral artery disease will require surgical The following equipment is recommended for measuring the
revascularisation to reduce the risk of amputation.5 ankle-brachial pressure index:8
A hand-held portable Doppler device with a frequency
ABPI is used to assess the safety of compression treatment of 8 – 10 MHz, although 5 MHz probes may be better
when considering compression hosiery and bandaging for for patients with significant ankle oedema. Devices can
patients with venous disease or ulceration. ABPI may still be purchased for under $700 and training is generally
be performed as a confirmatory measure in patients with a provided by the supplier. More expensive devices with
palpable pedal pulse, before applying compression hosiery or LCD screen and printing options are also available.
compression bandages, because of the risk of complications
A sphygmomanometer
developing in patients with undiagnosed peripheral artery
disease. Ultrasound transmission gel

ABPI is used to exclude peripheral artery disease in patients

How to measure the ankle-brachial pressure index
who are undergoing treatment that may result in vascular
complications, e.g. patients undergoing leg or foot surgery.5 For the purposes of excluding peripheral artery disease it is
sufficient to perform only one ABPI measurement, i.e. by
Targeted use of ABPI in asymptomatic patients dividing the systolic pressure detected at a single posterior
There is currently insufficient evidence to recommend tibial artery by the systolic brachial pressure of one arm (see
population screening for peripheral artery disease using below). The diastolic pressure is not measured and is not
ABPI.3 However, international guidelines recommend that required when measuring the ABPI.

20  BPJ  Issue 60

With the patient in a supine position (Figure 1): If the patient’s ABPI is < 0.9 then this indicates they have
peripheral artery disease and additional measurements are
1. Place the blood pressure cuff approximately two to
recommended to increase the accuracy of the assessment of
three centimetres above the antecubital fossa for the
the disease severity:
brachial pressure and approximately five centimetres
above the medial malleolus for the ankle pressure 5. Divide the highest ankle systolic pressure in each of the
posterior tibial and dorsalis pedis arteries* in both feet
2. The Doppler probe should detect a clear arterial pulse
by the highest brachial systolic pressure from each arm;
before the cuff is inflated
the lowest resulting value is the patient’s overall ABPI.
3. Inflate the cuff slowly until the systolic pressure is
indicated by the disappearance of the Doppler sound. * This measurement may not be possible in all patients as 12% of the
general population has a congenital absence of the dorsalis pedis
N.B. This does not need to be highly precise as the ratio
pulse.8
is calculated to a single decimal point.

4. Divide the ankle systolic pressure detected at the The ABPI procedure may cause discomfort for patients with
posterior tibial artery by the brachial pressure lower leg pain or cellulitis. If ulcers or wounds are present on
the ankle then a protective barrier, e.g. a plastic wrap, should
be placed over the affected area before the cuff is applied.8

B Systolic pressure recorded in

the brachial artery of the arm

A Ultrasound device
amplifies the sound of
arterial blood flow
Blood pressure cuff

D Systolic pressure
sequentially recorded in
the arteries of the ankle
Brachial Artery after each arterial flow is
located
Dorsalis Pedis Artery

C Sound of arterial blood

Posterior Tibial Artery
flow located in ankle
Ultrasound Device

Figure 1: Sequentially measuring the brachial systolic pressure and ankle systolic pressure in the posterior tibial and dorsalis pedis
arteries with a single hand-held Doppler ultrasound device

BPJ  Issue 60  21

 Interpreting the ankle-brachial index

An ABPI between 1.0 – 1.4 (Table 1) is sufficient to exclude

ABPI can be used as a marker of
peripheral artery disease in most patients (see: “Limitations of
cardiovascular risk
ankle-brachial pressure index” on opposite page). Referral to a
A low ABPI, i.e. < 0.9, is an independent predictor of vascular laboratory should be considered for patients with an
cardiovascular risk and measuring ABPI has been widely ABPI > 1.4, as this result is clinically inconclusive. In a patient
suggested for the detection of subclinical disease in with a borderline APBI, i.e. 0.9, where there are additional
order to prevent cardiovascular mortality and stroke.1, 2, 7 reasons to suspect peripheral artery disease, e.g. symptoms
For some patients detection of a low ABPI may allow a and risk factors, consider discussing the result with a vascular
more accurate estimation of cardiovascular risk than is surgeon as further investigations, such as exercise testing, may
provided solely by traditional risk assessment tools, e.g. be recommended.
patients with no other history of cardiovascular disease.7
A meta-analysis involving over 48 000 patients found that An ABPI of < 0.9 indicates significant occlusion in the arteries
an ABPI ≤ 0.9 approximately doubled the risk of total supplying the patient’s lower extremities and is diagnostic for
mortality, cardiovascular mortality and major coronary peripheral artery disease. The lower the patient’s ABPI, the
events across all Framingham risk categories assessed.2 more severe the disease, with an ABPI < 0.4 indicating critical
For example, the overall ten-year rate of cardiovascular limb ischaemia.4
mortality was 7.3% for males with an ABPI between 0.91
and 1.1, but 18.7% in males with an ABPI ≤ 0.9.2 In patients with an ABPI > 0.8 compression hosiery is
considered safe.9 However, in patients with an ABPI < 0.8, high
compression hosiery (i.e. 30 – 40 mmHg at the ankle) is not
recommended when treating lower limbs, e.g. non-healing
leg ulcers in patients with diabetes, due to the increased risk
of skin necrosis.8 If ABPI is < 0.5, compression hosiery should
not be used.8

Table 1: Clinical interpretation of the ankle-brachial index

(ABPI)1, 4, 5

Ankle-brachial
pressure index (ABPI) Clinical interpretation

Inconclusive due to non-

> 1.4
compressible blood vessels

Normal; peripheral artery

1.0 – 1.4 disease can be excluded in
most patients

Borderline; discussion with

a vascular surgeon may be
0.9 appropriate depending on the
patients symptoms and risk
factors

Abnormal and diagnostic of

< 0.9
peripheral artery disease

< 0.4 Critical limb ischaemia

22  BPJ  Issue 60

What to do when a patient is diagnosed with
peripheral artery disease
The limitations of ankle-brachial pressure
After performing a vascular examination, criteria that would index testing
indicate an increased urgency of referral to a vascular surgeon
1. The Doppler device that is used in the measurement
include:
of ABPI indicates the velocity of blood flow and
An ABPI < 0.5
although this is related to blood volume, it is not
Known peripheral artery disease presenting with a new a measure of the amount of blood that peripheral
ulcer or area of necrotic tissue tissues are receiving.
An ulcer that is not responding to treatment 2. The technique is unable to determine the exact
Intermittent claudication when walking for less than location of a patient’s arterial stenosis or occlusion.
200 m 3. ABPI can be falsely elevated in patients with
Young and otherwise healthy patients with claudication calcification of the medial arteries, e.g. in some
to rule-out rare causes, e.g. popliteal artery entrapment patients with diabetes, renal dysfunction or
rheumatoid arthritis.8
Discussion with a vascular surgeon should also be considered 4. Some patients with arterial stenosis may present
when: with intermittent claudication and normal ankle
There is doubt concerning the patient’s diagnosis pressures at rest.8 Referral for vascular testing may
There is uncertainty around the significance of an ABPI be required for patients where there is reason to
result suspect the presence of peripheral artery disease
despite a normal or elevated ABPI being recorded.
There is doubt about the need for treatment or what
treatment options are available

Treatment of peripheral artery disease

The treatment of peripheral artery disease focuses on:

1. Improving quality of life in symptomatic patients
2. Reducing overall cardiovascular risk, which may have
a small disease-modifying effect on peripheral artery
disease

All patients with an ABPI < 0.9 have peripheral artery disease
and are clinically assumed to have a 5-year cardiovascular risk
> 20%.10 Therefore the use of cardiovascular risk charts when
performing routine cardiovascular risk assessments in these
patients is not necessary and management of cardiovascular
risk factors should be intensive.10 The modifiable and non-
modifiable risk factors for peripheral artery disease are the
same as those for other forms of cardiovascular disease.5

Patients with peripheral artery disease will often have co-

morbidities. An Australian study of patients in general practice
from 2008 – 2012 found that the prevalence of managed, i.e.
known, co-morbidities in patients with peripheral artery
disease was: hypertension (10.7%), diabetes (8.0%), lipid
disorders (3.9%) and ischaemic heart disease (3.7%).11

BPJ  Issue 60  23

Lifestyle advice is the first-line treatment for peripheral Pharmacological treatment of peripheral artery disease
artery disease itself is unproven
Some patients with peripheral artery disease may not associate There is little evidence supporting the pharmacological
their symptoms with their lifestyle, e.g. smoking or a lack of treatment of peripheral artery disease itself. However,
exercise. Give patients lifestyle advice to address modifiable emerging evidence suggests that angiotensin converting
risk factors, which in turn is likely to improve the symptoms of enzyme (ACE) inhibitors may improve walking ability in patients
peripheral artery disease:5 with intermittent claudication. A meta-analysis of six studies
Smoking cessation comprising over 800 patients found that treatment with an ACE
inhibitor improved the maximum walking distance of patients
Regular exercise
with intermittent claudication by approximately 120 metres
Weight loss and improved pain-free walking distance by approximately
Eating a healthy and balanced diet 75 metres.14 However, the ACE inhibitor with the greatest
evidence of benefit is ramipril, which is not currently available
in New Zealand. It is unknown if the improvement in walking
Smoking cessation advice and support should be given to all distance associated with ramipril is due to a class effect of ACE
patients with peripheral artery disease who smoke.5 There are inhibitors or whether it is specific to this medicine. The use of
relatively few robust studies investigating the direct benefits ACE inhibitors has not been shown to have a significant effect
of smoking cessation on peripheral artery disease. There is on ABPI, although this may be due to the limitations of ABPI
observational evidence suggesting that smoking cessation will testing.14 Additional guidance on this issue will be published
improve mobility in patients with peripheral artery disease. 5 when more evidence is available.
However, the strongest evidence for the benefits of smoking
cessation in patients with peripheral artery disease comes Pentoxifylline (oxypentifylline) is a vasoactive medicine
from cardiovascular outcomes. The excess cardiovascular risk that has been used to improve blood flow in patients with
of people who smoke is reported to be halved within one year peripheral artery disease by decreasing blood viscosity. It is
of cessation and be the same as non-smokers within five years.5 partially subsidised in New Zealand, but is rarely used. In the
It can also be explained to patients that continued smoking United Kingdom the use of pentoxifylline is not recommended
will decrease the effectiveness of other interventions such as for the treatment of intermittent claudication in patients with
exercise programmes or surgery. peripheral artery disease, on the basis of lack of evidence of
clinical and cost-effectiveness.15
Patients are recommended to walk for twenty minutes per
day and encouraged to exercise to the point of maximal pain.5
Improvement, e.g. towards the goal of pain-free walking in Pharmacological reduction of cardiovascular risk is
patients with intermittent claudication, should be assessed recommended for all patients
after three months and regularly thereafter.5 Patients with Patients with peripheral artery disease require pharmacological
peripheral artery disease require a structured programme of treatments to reduce their cardiovascular risk:
regular walking because people who participate in exercise Antiplatelet treatment with either aspirin or clopidogrel
programmes have been found to benefit from improved (depending on the patient’s cardiovascular history
limb function and general health. This is likely to be due to and presence of co-morbidities) is recommended for
improved distal blood flow following the creation of new prevention of vascular ischaemic events. Antiplatelet
collateral blood vessels stimulated by the production of treatment reduces the risk of serious vascular events by
growth factors, e.g. vascular endothelial growth factor, and approximately one-quarter in patients with peripheral
the release of vasodilating compounds, e.g. nitric oxide.12 artery disease.16
Compliance with an exercise programme is likely to be
improved by supervision. Supervised exercise programmes Statins are recommended for all patients with peripheral
involving walking three times a week on a treadmill have been artery disease, unless contraindicated. NICE guidelines
shown to provide greater benefit to patients with peripheral report a 17.6% reduction in cardiovascular events for
artery disease compared with unsupervised programmes.13 patients with peripheral artery disease taking simvastatin
Where supervised programmes are not accessible, suggesting with a total cholesterol > 3.5 mmol/L.5 Statin use may
that patients participate in group exercise programmes may also result in atherosclerotic plaque stabilisation and
improve compliance and replicate the benefits of supervised even plaque regression independently of their lipid-
exercise programmes. lowering ability.

24  BPJ  Issue 60

 Hypertension should be treated to a target of 130/80 References
mmHg.10 Dietary salt intake should be restricted. 1. Kim E, Wattanakit K, Gornik H. Using the ankle-brachial index to
diagnose peripheral artery disease and assess cardiovascular risk.
HbA1c target for patients with diabetes and peripheral Cleve Clin J Med 2012;79:651–61.
artery disease should be ≤ 50 – 55 mmol/L (or as
2. Ankle Brachial Index Collaboration. Ankle brachial index combined
individually agreed, depending on other clinical with Framingham Risk Score to predict cardiovascular events and
factors).10 mortality: a meta-analysis. JAMA 2008;300:197–208.

Renal function should be monitored regularly, e.g. 3. Hennion DR, Siano KA. Diagnosis and treatment of peripheral arterial
disease. Am Fam Physician 2013;88:306–10.
annually, in patients with peripheral artery disease.
Microalbuminuria is the earliest sign of diabetic kidney 4. Blecha MJ. Critical limb ischemia. Surg Clin North Am 2013;93:789–812,
disease.10 viii.

5. National Institute for Health and Care Excellence (NICE). Lower limb
peripheral arterial disease: Diagnosis and management. NICE, 2012.
Beta-blockers may be cautiously continued in patients with
Available from: http://guidance.nice.org.uk/CG147 (Accessed Apr,
peripheral artery disease where they are clinically indicated.
2014).
Contrary to historical concern, a Cochrane review of six studies
6. Norgren L, Hiatt WR, Dormandy JA, et al. Inter-society consensus for
with a small sample of 119 patients found no evidence that the
the management of peripheral arterial disease (TASC II). J Vasc Surg
use of beta-blockers adversely affected walking distance, calf
2007;45 Suppl S:S5–67.
blood flow or vascular resistance in patients with peripheral
7. Doobay AV, Anand SS. Sensitivity and specificity of the ankle-brachial
artery disease.17
index to predict future cardiovascular outcomes: a systematic review.
Arterioscler Thromb Vasc Biol 2005;25:1463–9.
  For further information on pharmacological treatment 8. WOCN Clinical Practice Wound Subcommittee. Ankle Brachial Index:
recommendations for hypertension and diabetes, see:
quick reference guide for clinicians. J Wound Ostomy Continence Nurs
“Hypertension in adults: the silent killer”, BPJ 54 (Aug, 2013) and 2012;39(2 Suppl):S21–9.
“Improving glycaemic control in people with type 2 diabetes”,
9. Vicaretti M. Compression therapy for venous disease. Austr Prescr
BPJ 53 (Jun, 2013). 2010;33:186–90.

10. New Zealand Guidelines Group (NZGG). New Zealand primary care
handbook 2012. NZGG, 2012.
Referral may be required if interventions are
unsuccessful 11. Henderson J, Pollack A, Harrison C, et al. Peripheral arterial disease.
Aust Fam Physician 2013;42:363.
Vascular surgeons can provide advice and suggestions of
12. Hamburg NM, Balady GJ. Exercise rehabilitation in peripheral artery
additional treatment options at any stage during the patient’s
disease: functional impact and mechanisms of benefits. Circulation
management. If smoking cessation, exercise, weight loss and
2011;123:87–97.
pharmacological reduction of CVD risk have not been effective
13. Fokkenrood H, Bendermacher B, Lauret G, et al. Supervised exercise
in improving the patient’s symptoms within six months, then
therapy versus non-supervised exercise therapy for intermittent
patients with peripheral artery disease should be referred claudication. Cochrane Database Syst Rev 2013;8:CD005263.
to a vascular surgeon to discuss ongoing management of
14. Shahin Y, Barnes R, Barakat H, et al. Meta-analysis of angiotensin
their condition, including a tailored exercise programme.
converting enzyme inhibitors effect on walking ability and ankle
Surgical procedures are performed on relatively few patients brachial pressure index in patients with intermittent claudication.
compared to the number of people diagnosed with peripheral Atherosclerosis 2013;231:283–90.
artery disease. Vascular imaging, functional testing and 15. National Institute for Health and Clinical Excellence (NICE). Cilostazol,
surveillance programmes may be considered before more naftidrofuryl oxalate, pentoxifylline and inositol nicotinate for the
invasive procedures such as angioplasty, stent placement or treatment of intermittent claudication in people with peripheral
revascularisation are considered. arterial disease. NICE, 2011. Available from: http://publications.nice.
org.uk/cilostazol-naftidrofuryl-oxalate-pentoxifylline-and-inositol-
nicotinate-for-the-treatment-of-ta223 (Accessed Apr, 2014).

ACKNOWLEDGEMENT Thank you to Professor Andre 16. Antithrombotic Trialists’ Collaboration. Collaborative meta-analysis
van Rij, Vascular Surgeon, Ralph Barnett Professor of of randomised trials of antiplatelet therapy for prevention of
death, myocardial infarction, and stroke in high risk patients. BMJ
Surgery, Department of Surgical Sciences, Dunedin
2002;324:71–86.
School of Medicine, University of Otago for expert
17. Paravastu SCV, Mendonca DA, Da Silva A. Beta blockers for peripheral
review of this article.
arterial disease. Cochrane Database Syst Rev 2013;9:CD005508.

BPJ  Issue 60  25