Ankle–brachial pressure index

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Ankle–brachial pressure index
Medical diagnostics

Measuring the ankle-brachial index

Synonyms Ankle-brachial index
Purpose Detection of peripheral artery disease

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]

Contents

 1 Method
 2 Interpretation of results
 3 Predictor of atherosclerosis mortality
 4 See also
 5 References
 6 External links
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