Ankle–brachial

pressure index

The ankle-brachial pressure index (ABPI)

or ankle-brachial index (ABI) is the ratio of
the blood pressure at the ankle to the
blood pressure in the upper arm
(brachium). Compared to the arm, lower
blood pressure in the leg suggests blocked
arteries due to peripheral artery disease
(PAD). The ABPI is calculated by dividing
the systolic blood pressure at the ankle by
the systolic blood pressure in the arm.[1]

Ankle–brachial pressure index

Medical diagnostics

Measuring the ankle-brachial index

Synonyms Ankle-brachial index

Purpose Detection of peripheral

artery disease

Method
The patient must be placed supine,
without the head or any extremities
dangling over the edge of the table.
Measurement of ankle blood pressures in
a seated position will grossly overestimate
the ABI (by approximately 0.3).

A Doppler ultrasound blood flow detector,

commonly called Doppler wand or Doppler
probe, and a sphygmomanometer (blood
pressure cuff) are usually needed. The
blood pressure cuff is inflated proximal to
the artery in question. Measured by the
Doppler wand, the inflation continues until
the pulse in the artery ceases. The blood
pressure cuff is then slowly deflated.
When the artery's pulse is re-detected
through the Doppler probe the pressure in
the cuff at that moment indicates the
systolic pressure of that artery.

The higher systolic reading of the left and

right arm brachial artery is generally used
in the assessment. The pressures in each
foot's posterior tibial artery and dorsalis
pedis artery are measured with the higher
of the two values used as the ABI for that
leg.[2]

Where PLeg is the systolic blood

pressure of dorsalis pedis or posterior
 tibial arteries
and PArm is the highest of the left and
right arm brachial systolic blood
pressure

The ABPI test is a popular tool for the non-

invasive assessment of PVD. Studies have
shown the sensitivity of ABPI is 90% with a
corresponding 98% specificity for
detecting hemodynamically significant
(Serious) stenosis >50% in major leg
arteries, defined by angiogram.[3]

However, ABPI has known issues:

ABPI is known to be unreliable on

patients with arterial calcification
(hardening of the arteries) which results
in less or incompressible arteries,[4] as
the stiff arteries produce falsely
elevated ankle pressure, giving false
negatives[5]). This is often found in
patients with diabetes mellitus[6] (41% of
patients with peripheral arterial disease
(PAD) have diabetes[7]), renal failure or
heavy smokers. ABPI values below 0.9
or above 1.3 should be investigated
further regardless.
Resting ABPI is insensitive to mild
PAD.[8] Treadmill tests (6 minute) are
sometimes used to increase ABPI
sensitivity,[9] but this is unsuitable for
patients who are obese or have co-
 morbidities such as Aortic aneurysm,
and increases assessment duration.
Lack of protocol standardisation,[10]
which reduces intra-observer
reliability.[11]
Skilled operators are required for
consistent, accurate results.[12]

When performed in an accredited

diagnostic laboratory, the ABI is a fast,
accurate, and painless exam, however
these issues have rendered ABI unpopular
in primary care offices and symptomatic
patients are often referred to specialty
clinics[13] due to the perceived difficulties.
Technology is emerging that allows for the
oscillometric calculation of ABI, in which
simultaneous readings of blood pressure
at the levels of the ankle and upper arm
are taken using specially calibrated
oscillometric machines.

Interpretation of results
In a normal subject the pressure at the
ankle is slightly higher than at the elbow
(there is reflection of the pulse pressure
from the vascular bed of the feet, whereas
at the elbow the artery continues on some
distance to the wrist).

The ABPI is the ratio of the highest ankle

to brachial artery pressure. An ABPI
between and including 0.90 and 1.29
considered normal (free from significant
PAD), while a lesser than 0.9 indicates
arterial disease.[14] An ABPI value of 1.3 or
greater is also considered abnormal, and
suggests calcification of the walls of the
arteries and incompressible vessels,
reflecting severe peripheral vascular
disease.

Provided that there are no other significant

conditions affecting the arteries of the leg,
the following ABPI ratios can be used to
predict the severity of PAD as well as
assess the nature and best management
of various types of leg ulcers:[2]
ABPI value Interpretation Action Nature of ulcers, if present

Abnormal
1.3 and Refer or measure Toe
Vessel hardening from
above pressure
PVD Venous ulcer
use full compression
1.0 - 1.2 Normal range
None bandaging
0.90 - 0.99 Acceptable

0.80 - 0.89 Some arterial disease Manage risk factors

Mixed ulcers
Moderate arterial
0.50 - 0.79 Routine specialist referral use reduced compression
disease
bandaging

Arterial ulcer
under 0.50 Severe arterial disease Urgent specialist referral no compression bandaging
used

Predictor of atherosclerosis
mortality
Studies in 2006 suggests that an
abnormal ABPI may be an independent
predictor of mortality, as it reflects the
burden of atherosclerosis.[15][16] It thus has
potential for screening for coronary artery
disease,[17] although no evidence-based
recommendations can be made about
screening in low-risk patients because
clinical trials are lacking.[17]

See also
Peripheral vascular examination
Intermittent claudication

References
1. Al-Qaisi, M; Nott, DM; King, DH;
Kaddoura, S (2009). "Ankle brachial
pressure index (ABPI): An update for
practitioners" . Vascular Health and
Risk Management. 5: 833–41.
 doi:10.2147/vhrm.s6759 .
PMC 2762432 . PMID 19851521 .
2. Vowden P, Vowden K (March 2001).
"Doppler assessment and ABPI:
Interpretation in the management of
leg ulceration" . Worldwide Wounds. -
describes ABPI procedure,
interpretation of results, and notes the
somewhat arbitrary selection of "ABPI
of 0.8 has become the accepted
endpoint for high compression
therapy, the trigger for referral for a
vascular surgical opinion and the
defining upper marker for an ulcer of
mixed aetiology"
3. McDermott MM, Criqui MH, Liu K,
Guralnik JM, Greenland P, Martin GJ,
Pearce W (December 2000). "Lower
ankle/brachial index, as calculated by
averaging the dorsalis pedis and
posterior tibial arterial pressures, and
association with leg functioning in
peripheral arterial disease". J Vasc
Surg. 32 (6): 1164–71.
doi:10.1067/mva.2000.108640 .
PMID 11107089 .
4. Allison MA, Hiatt WR, Hirsch AT, Coll
JR, Criqui MH (April 2008). "A high
ankle-brachial index is associated with
increased cardiovascular disease
morbidity and lower quality of life". J
 Am Coll Cardiol. 51 (13): 1292–8.
doi:10.1016/j.jacc.2007.11.064 .
PMID 18371562 .
5. American Diabetes Association
(December 2003). "Peripheral Arterial
Disease in People with Diabetes".
Diabetes Care. 26 (12): 3333–3341.
doi:10.2337/diacare.26.12.3333 .
PMID 14633825 .
6. Aboyans V, Ho E, Denenberg JO, Ho LA,
Natarajan L, Criqui MH (November
2008). "The association between
elevated ankle systolic pressures and
peripheral occlusive arterial disease in
diabetic and nondiabetic subjects". J
 Vasc Surg. 48 (5): 1197–203.
doi:10.1016/j.jvs.2008.06.005 .
PMID 18692981 .
7. Novo S (March 2002). "Classification,
epidemiology, risk factors, and natural
history of peripheral arterial disease".
Diabetes Obes Metab. 4: S1–6.
doi:10.1046/j.1463-
1326.2002.0040s20s1.x .
PMID 12180352 .
8. Stein R, Hriljac I, Halperin JL,
Gustavson SM, Teodorescu V, Olin JW
(February 2006). "Limitation of the
resting ankle-brachial index in
symptomatic patients with peripheral
 arterial disease". Vasc Med. 11 (1):
29–33.
doi:10.1191/1358863x06vm663oa .
PMID 16669410 .
9. Montgomery PS, Gardner AW (June
1998). "The clinical utility of a six-
minute walk test in peripheral arterial
occlusive disease patients". J Am
Geriatr Soc. 46 (6): 706–11.
doi:10.1111/j.1532-
5415.1998.tb03804.x .
PMID 9625185 .
10. Jeelani NU, Braithwaite BD, Tomlin C,
MacSweeney ST (July 2000).
"Variation of method for measurement
 of brachial artery pressure significantly
affects ankle-brachial pressure index
values". Eur J Vasc Endovasc Surg. 20
(1): 25–8.
doi:10.1053/ejvs.2000.1141 .
PMID 10906293 .
11. Caruana MF, Bradbury AW, Adam DJ
(May 2005). "The validity, reliability,
reproducibility and extended utility of
ankle to brachial pressure index in
current vascular surgical practice". Eur
J Vasc Endovasc Surg. 29 (5): 443–51.
doi:10.1016/j.ejvs.2005.01.015 .
PMID 15966081 .
12. Kaiser V, Kester AD, Stoffers HE,
Kitslaar PJ, Knottnerus JA (July 1999).
"The influence of experience on the
reproducibility of the ankle-brachial
systolic pressure ratio in peripheral
arterial occlusive disease". Eur J Vasc
Endovasc Surg. 18 (1): 25–9.
doi:10.1053/ejvs.1999.0843 .
PMID 10388635 .
13. Hirsch AT, Criqui MH, Treat-Jacobson
D, Regensteiner JG, Creager MA, Olin
JW, Krook SH, Hunninghake DB,
Comerota AJ, Walsh ME, McDermott
MM, Hiatt WR (Sep 2001). "Peripheral
arterial disease detection, awareness,
and treatment in primary care". JAMA.
 286 (11): 1317–24.
doi:10.1001/jama.286.11.1317 .
PMID 11560536 .
14. Rooke, TW; Hirsch, AT; Misra, S;
Sidawy, AN; Beckman, JA; Findeiss, LK;
Golzarian, J; Gornik, HL; Halperin, JL;
Jaff, MR; Moneta, GL; Olin, JW; Stanley,
JC; White, CJ; White, JV; Zierler, RE;
Society for Cardiovascular
Angiography and, Interventions;
Society of Interventional, Radiology;
Society for Vascular, Medicine; Society
for Vascular, Surgery (Nov 1, 2011).
"2011 ACCF/AHA Focused Update of
the Guideline for the Management of
Patients With Peripheral Artery
 Disease (updating the 2005 guideline):
a report of the American College of
Cardiology Foundation/American
Heart Association Task Force on
Practice Guidelines" . Journal of the
American College of Cardiology. 58
(19): 2020–45.
doi:10.1016/j.jacc.2011.08.023 .
PMC 4714326 . PMID 21963765 .
15. Feringa HH, Bax JJ, van Waning VH, et
al. (March 2006). "The long-term
prognostic value of the resting and
postexercise ankle-brachial index".
Arch. Intern. Med. 166 (5): 529–35.
doi:10.1001/archinte.166.5.529 .
PMID 16534039 .
16. Wild SH, Byrne CD, Smith FB, Lee AJ,
Fowkes FG (March 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 (3): 637–42.
doi:10.2337/diacare.29.03.06.dc05-
1637 . PMID 16505519 .
17. Desai, Chintan S.; Blumenthal, Roger
S.; Greenland, Philip (2014). "Screening
low-risk individuals for coronary artery
disease". Current Atherosclerosis
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 doi:10.1007/s11883-014-0402-8 .
ISSN 1534-6242 . PMID 24522859 .

External links
medical test information form (PDF) at
webMD
Ankle Brachial Index at Stanford
Medicine 25

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