The Ankle Brachial Index

Measurement, Calculation, and

Interpretation
Limitations
Ivan Casserly MD

Denver VA Medical Center

University of Colorado Hospital
Ankle Brachial Index

• Ankle brachial index (ABI)

• Ankle brachial pressure index (ABPI)
• Ankle arm index (AAI)
Ankle Brachial Index
Why should we care?

• In clinical practice
– Aids in diagnosis and assessment of
patients with symptoms suggestive of
PAD
– Role in primary prevention since PAD is a
powerful independent predictor of CV
morbidity and mortality regardless of
symptomatic status of PAD.
Ankle Brachial Index
How good is it at diagnosing PAD?

• Using gold standard of DSA angiography

– >50% stenosis in lower extremity vessel
Ankle Brachial Index
Diagnosis of PAD

90
80
70
60
50
40 HAP
30
20
10
0
Sensitivity Specificity Accuracy

Niazi et al, Cath Cardiovasc Interv 2006;68:788-792

Ankle Brachial Index
Role in Primary Prevention – Low incidence of classic
claudication

PAD

Asymptomatic Atypical Symptoms Claudication

Stable
PAD Rest Pain Tissue Loss

CLI
Peripheral Arterial Disease
Prevalence

• PARTNERS Program (PAD Awareness, Risk, and

Treatment: New Resources for Survival)
– 350 Primary care sites
– Patients (n=~7,000)
• >70 yrs
• 50-69 yrs with history DM or smoking
– PVD diagnosis
• ABI <0.9
• Previous documentation
• Abnormal vasc studies
• Prior revascularization
Hirsch AT, JAMA 2001;286:1317-1324
Peripheral Arterial Disease
Prevalence

25

20
24%

15
% 16%
10 13%
5

0
PVD CVD PVD + CVD

Hirsch AT, JAMA 2001;286:1317-1324

Peripheral Arterial Disease
Under-diagnosis in Primary Care Practice / Influence of assoc.
diagnosis of CVD

12

10

8
10%
New
% 6 7%
Prior
4 6% 6%
2

0
PVD PVD + CVD

Hirsch AT, JAMA 2001;286:1317-1324

Peripheral Arterial Disease
Impact of Diagnosis on Survival

1.00

Normal Subjects
0.75
Survival

Asymptomatic PAD
0.50
Symptomatic PAD

0.25
Severe Symptomatic PAD

0.00
0 2 4 6 8 10 12

Year
Adapted from Criqui MH, et al. N Engl J Med. 1992;326:381-386.
Peripheral Arterial Disease
Impact of Diagnosis on Survival

Resnick et al. Circulation 2004;109;733-739

Peripheral Arterial Disease
Impact of Diagnosis on Survival – Polyvascular Disease

PAD alone PAD +CVD PAD + CHD PAD + CHD + CVD

30

25

20
%

15

10

0
All-cause Mortality CV death Nonfatal MI CV death, MI,
stroke, or
hospitalization

Adapted from PG Steg et al. JAMA.2007;297:1197-1206.

ABI and Primary Prevention
Algorithm

Doobay AV et al. Arterioscler Thromb Vasc Biol.2005;25:1463-1469.

Ankle Brachial Index

• Performance
• Calculation
• Interpretation
Ankle Brachial Index
Performance - Equipment
Ankle Brachial Index
Performance

Hiatt WR, N Engl J Med 2001;344:1608-1621

Ankle Brachial Index
Performance

• CLINICAL DEMONSTRATION
Ankle Brachial Index
Performance - Review

• Patient Position
– No activity for 4-5 minutes
– Supine position
Ankle Brachial Index
Performance – Arm Pressure

• Arm
– Appropriate cuff size
– Doppler over brachial artery
• NOT STETHESCOPE (underestimate SBP)
• NOT OVER RADIAL ARTERY
– Record right AND left arm brachial
pressures
• Why?
Ankle Brachial Index
Performance – Ankle Pressure

• Cuff
– Appropriate size
– Appropriate location
• Lower leg above malleoli
• NOT OVER BULK OF CALF MUSCLES
• Doppler over DP AND PT
– NOT STETHESCOPE
Ankle Brachial Index
Calculation

• ABI
– Numerator – Ankle pressures
• Higher of the two pedal pressures
• Brachial
– Denominator – Brachial pressure
– Higher of the two arm pressures
– Best reflects aortic pressure
Ankle Brachial Index
Calculation - Rationale

• Patient
– DP 100, PT 150, Highest brachial 150

• Method 1. • Method 2.
– Higher of the two – Lower of the two
pressures pressures
– ABI 150/150 = 1 – ABO 100/150 = 0.66
• Sensitivity ↓ • Sensitivity ↑
• Specificity ↑ • Specificity ↓
Ankle Brachial Index
High versus Low Ankle Pressure (HAP vs LAP)

90
80
70
60
50
HAP
40 LAP
30
20
10
0
Sensitivity Specificity Accuracy

Niazi et al, Cath Cardiovasc Interv 2006;68:788-792

Ankle Brachial Index
Interpretation

• What is a normal ABI?

Ankle Brachial Index
Interpretation

• Normal ankle pressure is 8-15% higher than

arm pressure
• Epidemiological studies have used ABI of
0.9 as cutoff of normal from abnormal for
diagnosis of PAD.
Ankle Brachial Index
Interpretation – High ABI – Non-compressible vessels
Ankle Brachial Index
Interpretation

ABI Interpretation
>1.3 Non-compresssible
1.00 - 1.29 Normal
0.91 - 0.99 Equivocal
0.41 - 0.90 Mild-to-moderate PVD
0.00 - 0.40 Severe PVD

Hirsch AT et al, J Am Coll Cardiol 2006;47:1239-1312

Study

• 17 volunteers
– 1st year n=10
– 2nd year n=4
– 3rd year n=3
Feedback from Study
Part A – Performance of ABI

• Measure ABI for right

leg on patient
Measure Right ABI
Feedback – Arm Measurement

100 N=15

80

60
% Correct
40
N=2
20 N=1
0
Cuff size Rt and Lt Brachial Doppler
Measure Right ABI
Feedback – Leg Measurement

100

80
N=9 N=8
60
%
40 Correct
N=3
20 N=1
0
Cuff size Cuff DP and PT Doppler*
Location

* Obtained accurate Doppler signal from DP and PT

Feedback from Study
Part B – Calculation of ABI

• Right 150mmHg •A
brachial
140mmHg •B
• Left •C
100mmHg
brachial
130mmHg •D
• Right PT
120mmHg •E
• Right DP
105mmHg •F
• Left PT
• Left DP
Right ABI = D/A
Left ABI = E/A
ABI Calculation
Feedback

• Errors

100 – Brachial:Ankle index

– Same leg/arm
80
• Right ankle/right arm
60
%
Correct • Left ankle/left arm
40
N=1 – Lower brachial
20 pressure
0 – Use of DP alone
ABI calculation
– Use of PT alone
Feedback from Study
Part C – Interpretation of ABI

• ABI
– 1.6 • A – non-compressible
– 1.2 • B – normal
– 1.0 • C – mild
– 0.8 • D – Moderate
– 0.4 • E - Severe
ABI Interpretation
Feedback

100

80

60 N=7
%
40 Correct

20

0
ABI
interpretation
Ankle Brachial Index
Interpretation

ABI Interpretation
>1.3 Non-compresssible
1.00 - 1.29 Normal
0.91 - 0.99 Equivocal
0.41 - 0.90 Mild-to-moderate PVD
0.00 - 0.40 Severe PVD
Ankle Brachial Index
Limitations

• Localization of disease
• Non-compressible ABI
• Pseudo-normal ABI
• Resting versus exercise ABI
• Role in diagnosis of critical limb ischemia
(CLI)
• Hypertensive patient
ABI and Localization of Disease
Segmental Limb Pressures

Brachial
Aorto-Iliac, CFA, Prox SFA
Upper Thigh
Mid/distal SFA and Popliteal
Upper Calf
Tibial
Ankle
Small Vessel Disease
Toe
ABI and Localization of Disease
Pulse Volume Recordings

• Measures volume change

in limb with each pulsation
• Volume of tissue and
venous blood relatively
constant
• Change in volume due to
arterial inflow
• Cuffs inflated to ~60mmHg
• Volume change presented
on spectral display
• Similar to arterial pulse
wave tracing
• Stenosis indicated by loss
of amplitude during systole
Non-Compressible ABI
 Non-Compressible ABIs
Role of Toe Pressure

• Toe Pressure
– Great toe
32mHg
– 2nd toe 35mmHg
– 3rd toe
17mmHg
– 4th toe 19mmHg
– 5th toe absent

•Normal toe-brachial index > 0.7

Non-invasive Hemodynamic Evaluation
Toe Pressure
Pseudonormal ABI

PAD

Vessel Ca 2+
ABI
 Resting versus Exercise ABI
Exercise Testing

• Exercise
– ABI at baseline
– 2 mph at 12% grade, 5
minutes
– ABI post-exercise, 1
minute, then q 2 minutes
• Post-exercise ankle systolic
pressure
– Falls >20% from baseline
– Takes longer than 3
minutes to recover
 Resting versus Exercise ABI
Exercise Testing

Resting ABI Exercise ABI

100
100
80
80
60 Exercise
60 Normal
% ABI %
40 40 Exercies
Abnormal
20 20

0 0
Normal Abnormal Non-
compressible

N=396 symptomatic patients with PAD.

Resting versus Exercise ABI
Exercise Testing

• 58 year old male

• Right buttock
claudication
– Classic description
Non-invasive Hemodynamic Evaluation
Exercise Testing
ABI in Patients with Critical Limb
Ischemia
Limitation

Delete n=49

ABI

Delete
 ABI in Patients with Critical Limb
Ischemia
Importance of Indication for Assessment
Lower Extremities Test DEC 14,2005@14:00
SEGMENTAL LIMB PRESSURE (mm Hg) PVR (CATEGORY-AMPLITUDE)

RIGHT LEFT RIGHT LEFT

RESTING LEVELS
142 138 BRACHIAL 1-92 1-49
160 170 THIGH 1-50 1-50
152 150 CALF 1-60 1-78
140 (0.99) 160 (1.13) ANKLE 2-16 1-35
TM 2.5 2-26 2-21
92 110 TOE 5.0

Ankle Pressure 140mmHg

ABI 0.99
Toe Pressure 92mmHg
Right Heel
Popliteal and Tibial Angiography

AT
PT

Peroneal
AT

PT
Peroneal
Conclusions

• ABI
– Helpful in diagnosis and assessment of
patients with symptomatic PAD
– Useful in primary prevention of CV
morbidity and mortality, especially in
asymptomatic patients or patients with
atypical symptoms.
– Requires training in order to perform
correctly and calculate ABI
– Has limitations that should be understood