Current utility of the ankle-brachial index (ABI) in general practice: implications for its use in cardiovascular disease screening

Duplex ultrasound and pedal acceleration time as tools to evaluate foot perfusion: a literature review

Currently, the standard non-invasive test for diagnosing Peripheral Arterial Disease is the Ankle-Brachial Index. However, this test becomes unfeasible in a certain population. New evidence proposes the pedal acceleration time, an ultrasound index, as an alternative test. An integrative bibliographic review was carried out between June 3, 2022 and January 8, 2023, to investigate this new index as a tool to assess foot perfusion. Papers published in English, Portuguese, or Spanish between 2012 and 2022 were searched on PubMed, Google Scholar, and Scielo, using the keywords "Peripheral Arterial Disease" AND "Acceleration Time" AND (Pedal OR Plantar). Research that didn't assess foot perfusion using the methods of interest or did not present human data and also case series or reports were excluded. Seven out of the sixty-six articles identified in the searches were selected for the review, all of which had notable methodological limitations. Pedal acceleration time seems to be able to diagnose and stratify and may reflect prognosis.

COVID-19 Pivoted Virtual Skills Teaching Model: Project ECHO Ontario Skin and Wound Care Boot Camp

OBJECTIVE

To describe a virtual, competency-based skin and wound care (SWC) skills training model. The ECHO (Extension for Community Healthcare Outcomes) Ontario SWC pivoted from an in-person boot camp to a virtual format because of the COVID-19 pandemic.

METHODS

An outcome-based program evaluation was conducted. Participants first watched guided commentary and videos of experts performing in nine SWC multiskills videos, then practiced and video-recorded themselves performing those skills; these recordings were assessed by facilitators. Data were collected using pre-post surveys and rubric-based assessments. Descriptive statistics and thematic analysis were applied to data analysis.

RESULTS

Fifty-five healthcare professionals participated in the virtual boot camp, measured by the submission of at least one video. A total of 216 videos were submitted and 215 assessment rubrics were completed. Twenty-nine participants completed the pre-boot camp survey (53% response rate) and 26 responded to the post-boot camp survey (47% response rate). The strengths of the boot camp included the applicability of virtual learning to clinical settings, boot camp supplies, tool kits, and teaching strategies. The analysis of survey responses indicated that average proficiency scores were greater than 80% for three videos, 50% to 70% for three of the videos, and less than 50% for three of the videos. Participants received lower scores in local wound care and hand washing points of contact. The barriers of the boot camp included technical issues, time, level of knowledge required at times, and lack of equipment and access to interprofessional teams.

CONCLUSIONS

This virtual ECHO SWC model expanded access to practical skills acquisition. The professional development model presented here is generalizable to other healthcare domains.

Prognostic and predictive value of ultrasound-based estimated ankle brachial pressure index at early follow-up after endovascular revascularization of chronic limb-threatening ischaemia: a prospective, single-centre, service evaluation

Background

Ankle brachial pressure index can be estimated (eABPI) using cuffless ankle Doppler ultrasound. We evaluated the prognostic value of eABPI measured during pre- and post-procedural ultrasound exams to predict the clinical outcome after endovascular revascularisations.

Methods

In this prospective, single-centre, service evaluation, consecutive patients with symptomatic peripheral artery disease undergoing lower limb endovascular revascularisations between July, 26 2018 and January, 13 2022 at Surrey and Sussex Healthcare NHS Trust (Redhill, UK) were analysed. eABPI was determined using the higher acceleration index measured with angle-corrected duplex ultrasound in ankle arteries before and ≤1 month post-procedure. Clinical outcomes (mortality, major amputations, amputation-free survival [AFS], clinically driven target lesion revascularization [cdTLR], major adverse limb events [MALE; cdTLR and major amputation], wound healing) were assessed over 1 year.

Findings

Of 246 patients treated, for 219 patients (median 75 [IQR 66-83] years) pre- and post-procedural eABPI (0.50 [0.33-0.59] and 0.90 [0.69-1.0], p < 0.0001) were available, respectively. In n = 199 patients with chronic limb-threatening ischaemia (CLTI) Kaplan-Meier survival analyses showed that higher post-procedural, but not pre-procedural, eABPI was associated with favourable AFS, MALE, cdTLR, and wound healing. This was confirmed in Cox regression analysis and remained significant with adjustment for pre-procedural eABPI, age, sex, co-morbidities, treated levels, wound score, and foot infection. Whereas all clinical outcomes, except for survival, were significantly better at ≥0.7 vs <0.7, wound healing (unadjusted: HR 1.7 (95% CI 1.2-2.6), adjusted: HR 2.1 (95% CI 1.3-3.1), cdTLR, and MALE (unadjusted: HR 0.41 (95% CI 0.18-0.93), adjusted: HR 0.28 (95% CI 0.11-0.74) were significantly improved at ≥0.9 vs <0.9.

Interpretation

Post-procedural eABPI can provide valid, clinically important prognostic and predictive information. Our data indicate that revascularisations should target values of at least 0.9 to achieve optimal outcomes. Future studies need to confirm generalisability and cost-effectiveness in a wider context.

Funding

European Partnership on Metrology, co-financed from European Union's Horizon Europe Research and Innovation Programme and UK Research and Innovation.

Ankle-Brachial Index: Diagnostic Tool of Peripheral Arterial Disease and Predictor of Cardiovascular Risk-An Update of Current Knowledge

The ankle-brachial index (ABI) was introduced as a screening method for the diagnosis of lower extremity peripheral arterial disease (PAD). Later findings recognized ABI as a prognostic marker of adverse cardiovascular events due to its relation to atherosclerosis in other vascular territories. This narrative review aims to appraise the validity, reliability, and utility of ABI in the detection of PAD and the determination of global atherosclerotic cardiovascular risk. While the ABI value can be influenced by different physiological characteristics including age, sex, body position, and techniques used for ABI determination, it has high specificity and reproducibility in the assessment of vascular patients. In conclusion, when used correctly, the ABI remains a reliable and invaluable indicator of lower-limb perfusion and a useful tool for predicting the risk of future cardiovascular events. However, its underutilization in clinical settings is noteworthy.

Prospective Assessment of the Diagnostic Accuracy of Multi-site Photoplethysmography Pulse Measurements for Diagnosis of Peripheral Artery Disease in Primary Care

Peripheral arterial disease (PAD) is associated with cerebral and coronary artery disease. Symptomatic PAD affects about 5% of people over 55 years; many more have asymptomatic PAD. Early detection enables modification of arterial disease risk factors. Diagnostically, assessment of symptoms or signs can be unreliable; ankle brachial pressure index (ABPI) testing is time-consuming and few healthcare professionals are properly trained. This study assessed the diagnostic accuracy of multi-site photoplethysmography (MPPG), an alternative non-invasive test for PAD, in primary care. PAD patients identified from general practice registers were age- and sex-matched with controls. Participants were assessed using MPPG, ABPI and duplex ultrasound (DUS). Outcome measures were sensitivity and specificity of MPPG and ABPI (relative to DUS) and concordance. MPPG test results were available in 249 of 298 eligible participants from 16 practices between May 2015 and November 2016. DUS detected PAD in 101/249 (40.6%). MPPG sensitivity was 79.8% (95% confidence interval [CI] 69.9-87.6%), with specificity 71.9% (95% CI 63.7-79.2%). ABPI sensitivity was 80.2% (95% CI 70.8-87.6%), with specificity 88.6% (95% CI 82-93.5%). With comparable sensitivity to ABPI, MPPG is quick, automated and simpler to do than ABPI; it offers the potential for rapid and accessible PAD assessments in primary care.

Evaluation of the lower extremity blood supply in no-option critical limb ischemia patients with stem cell transplantation by time maximum intensity projection CT perfusion: A single-centre prospective study

OBJECTIVES

Cell therapy has had satisfactory safety and efficacy outcomes for no-option critical limb ischaemia (NO-CLI) patients. In the current study, we aimed to compare the image quality of ischaemic lower limb blood vessels shown on volumetric CT-based time maximum intensity projection CT perfusion (t-MIP CTP) versus single-phase CTA (sCTA). We also tried to quantify the blood flow of the ischaemic lower extremity based on the t-MIP technique, not only to precisely show the dynamic change in blood flow from before to after cell therapy but also to detect any relationship between this change and patient prognosis.

METHODS

A total of 31 patients with thromboangiitis obliterans (TAO)-induced NO-CLI who had been referred from the department of vascular surgery to undergo autologous stem cell transplantation into a single limb from January 2020 to March 2021 were prospectively enrolled in this study. Preoperative sCTA or t-MIP CTP and postoperative 1-month t-MIP CTP were performed in all patients. Clinical outcomes, including the 1-month ankle-brachial index (ABI) and 3-month CLI status, were also analysed. Image quality, including objective scores (attenuation, signal-to-noise ratio [SNR] and contrast-to-noise ratio [CNR]), subjective scores and collateral scores, was compared between preoperative sCTA and t-MIP CTP. Vascular volume was calculated as the total volume (mL) of lower limb arteries within the scanning range. All images and calculations were performed by 2 separate radiologists. Receiver operating characteristic curves were drawn to reveal the sensitivity and specificity of vascular volume and ABI in predicting prognosis.

RESULTS

Both sCTA and t-MIP CTP images exhibited good quality for diagnosis. t-MIP CTP images showed significantly higher attenuation, SNR and CNR in all arterial segments (popliteal artery, anterior tibial artery, posterior tibial artery and peroneal artery). In subjective and collateral score evaluations, t-MIP CTP images were also significantly better than sCTA images (both p < .05). At 1 month after transplantation, both vascular volume and ABI showed significant improvement (both p < .01). At 3 months after transplantation, 38.71% of patients (12/31) achieved CLI relief (Rutherford class < 4). Through the receiver operating characteristic (ROC) curve, the 1-month vascular volume increase ratio showed better ability to predict the 3-month prognosis (radiologist 1: AUC, 0.757; sensitivity, 0.750; specificity, 0.840; radiologist 2: AUC, 0.803; sensitivity, 0.500; specificity, 1.000) than the 1-month ABI increase ratio (AUC, 0.607; sensitivity, 0.230; specificity, 0.820) or 1-month ABI (AUC, 0.410; sensitivity, 0.080; specificity, 0.580).

CONCLUSION

t-MIP CTP showed significantly higher-quality images of ischaemic limb vascularity than sCTA. t-MIP CTP can reveal the anatomical information of collaterals more accurately, which is of great importance for NO-CLI patients undergoing cell transplantation. The 1-month vascular volume increase ratio can predict the 3-month prognosis more precisely on this basis.

Diagnosis and Treatment of Lower Extremity Arterial Disease-A Survey among Family Medicine Trainees in Poland

Guidelines point to the ankle-brachial index (ABI) as a non-invasive tool for the initial diagnosis of lower extremity artery disease (LEAD). Questions have been raised whether primary practices should perform ABI. An online questionnaire was distributed among family medicine trainees in two academic centers in Poland. The questionnaire aimed to establish their knowledge about LEAD management and their opinion on the usefulness of ABI measurement and other LEAD diagnostic methods in primary care. ABI measurement was found either very or moderately useful in LEAD diagnosis by 94.5% of the respondents. Among the three most important elements of LEAD management, lifestyle changes, secondary prevention of atherosclerosis and exercise treatment were chosen, respectively, by 98.6%, 83.6% and 72.6% of them. ABI was seen as a useful diagnostic method at the primary care by 74% of the participants; however, 82.2% of them do not have access to ABI measurement in their workplace. The residents have good knowledge of the diagnostic methods of LEAD and consider ABI measurement as useful in LEAD diagnosis. However, most of them do not have access to ABI measurements in their clinical practices. Future discussion and potential financial changes will be needed for the introduction of ABI measurements into Polish primary care.

Validating fatty acid binding protein 3 as a diagnostic and prognostic biomarker for peripheral arterial disease: A three-year prospective follow-up study

BACKGROUND

Patients with peripheral arterial disease (PAD) often remain undiagnosed and therefore suboptimally managed. Here, we investigated the diagnostic and prognostic potential of fatty acid binding protein 3 (FABP3) in patients with PAD.

METHODS

In the discovery phase, 374 PAD and 184 non-PAD patients were recruited from vascular surgery ambulatory clinics at St. Michael's Hospital (Toronto, Ontario, Canada) between October 4, 2017 to October 29, 2018. The diagnostic ability of baseline FABP3 level was investigated through receiver operator characteristic (ROC) curves to determine two cutoff points: 1) an exclusionary "rule out" cutoff point, and 2) a confirmatory "rule in" cutoff point. Next, these cutoff points were confirmed in the external validation phase using a separate cohort of 312 patients (180 PAD and 132 non-PAD) recruited from ambulatory vascular surgery clinics at St. Michael's Hospital (Canada) between November 6, 2018-July 30, 2019. Cox regression analyses were used to explore the independent association between FABP3 and major adverse limb events (MALE - defined as need for arterial revascularization or major amputation) and decrease in ankle-brachial index (ABI -defined as drop ≥0.15) during 3 years of follow-up.

FINDINGS

In the discovery phase, FABP3 levels were significantly elevated in patients with PAD compared to non-PAD patients. ROC analysis demonstrated that FABP3 had an AUC of 0.83 (95% CI: 0.81-0.86, p-value < 0.001). FABP3 exclusionary cutoff was <1.55 ng/ml (sensitivity = 96%; specificity = 40%), whereas FABP3 confirmatory cutoff was >3.55 ng/ml (sensitivity = 43%; specificity = 95%) - values that were confirmed in the external validation phase. Cox regression analysis demonstrated FABP3 to be an independent predictor of increase in MALE [HR = 1.14 (1.03-1.29); p-value = 0.010] and worsening PAD status (drop in ABI >0.15 [HR = 1.11 (1.02-1.19); p-value = 0.009]).

INTERPRETATION

Our findings suggested that FABP3 levels can be used as both a diagnostic and prognostic biomarker for PAD, and may facilitate risk stratification in select individuals for purposes of vascular evaluation or intensive medical management.

FUNDING

Funding for this study was provided by the Bill and Vicky Blair Foundation.

Transmetatarsal amputations in patients with diabetes mellitus: A contemporary analysis from an academic tertiary referral centre in a developing community

Transmetatarsal amputation (TMA) involves the surgical removal of the distal portion of metatarsals in the foot. It aims to maintain weight-bearing and independent ambulation while eliminating the risk of spreading soft tissue infection or gangrene. This study aimed to explore the risk factors and surgical outcomes of TMA in patients with diabetes at an academic tertiary referral center in Jordan. Medical records of all patients with diabetes mellitus who underwent TMA at King Abdullah University Hospital, Jordan, between January 2017 and January 2019 were retrieved. Patient characteristics along with clinical and laboratory findings were analyzed retrospectively. Pearson’s chi-square test of association, Student’s t-test, and multivariate regression analysis were used to identify and assess the relationships between patient findings and TMA outcome. The study cohort comprised 81 patients with diabetes who underwent TMA. Of these, 41 (50.6%) patients achieved complete healing. Most of the patients were insulin-dependent (85.2%). Approximately half of the patients (45.7%) had severe ankle-brachial index (ABI). Thirty patients (37.1%) had previous revascularization attempts. The presence of peripheral arterial disease (P<0.05) exclusively predicted poor outcomes among the associated comorbidities. Indications for TMA included infection, ischemia, or both. The presence of severe ABI (≤0.4, P<0.01) and a previous revascularization attempt (P<0.05) were associated with unfavorable outcomes of TMA. Multivariate analysis that included all demographic, clinical, and laboratory variables in the model revealed that insulin-dependent diabetes, low albumin level (< 33 g/L), high C-reactive protein level (> 150 mg/L), and low score of Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC, <6) were the main factors associated with poor TMA outcomes. TMA is an effective technique for the management of diabetic foot infection or ischemic necrosis. However, attention should be paid to certain important factors such as insulin dependence, serum albumin level, and LRINEC score, which may influence the patient’s outcome.

Diagnostic Accuracy of Ankle-Brachial Pressure Index Compared with Doppler Arterial Waveforms for Detecting Peripheral Arterial Disease: A Systematic Review

GENERAL PURPOSE

To present the results of a research study evaluating the diagnostic accuracy of the ankle-brachial pressure index (ABPI) compared with that of Doppler arterial waveforms (DAWs) to detect peripheral arterial disease (PAD).

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After completing this continuing education activity, the participant will:1. Summarize the evidence the authors considered when comparing the diagnostic accuracy of the ABPI with that of Doppler arterial waveforms to detect PAD.2. Select the characteristics of the participants in the studies the authors analyzed.3. Identify the results of the authors' study comparing the diagnostic accuracy of the ABPI with that of Doppler arterial waveforms to detect PAD.4. Distinguish the authors' conclusions about the advantages of using Doppler arterial waveforms to detect PAD.

Automated Measurements of Ankle-Brachial Index: A Narrative Review

Peripheral artery disease (PAD) is an atherosclerotic disease that causes obstruction in lower limb arteries. It increases cardiovascular risk even in asymptomatic patients. Accurate diagnostic tools for identification of affected individuals are needed. Recently, there have been attempts to establish a reliable method of automated ankle-brachial index (ABI) identification. A search of PubMed database to identify studies assessing automatic ABI measurements in agreement with standard PAD diagnosis methods was conducted in December 2020. A total of 57 studies were analyzed in the review. The majority of analyzed studies found ABI measured by automatic oscillometric devices to be potentially feasible for use. Some note that, even though the Doppler and oscillometric methods are not fully interchangeable, the oscillometric devices could be used in screening. Significantly fewer publications are available on automatic plethysmographic devices. For photoplethysmography, most studies reported either good or moderate agreement with reference standards. For air plethysmography, poorer agreement with Doppler ABI is suggested. It is noted that pulse volume recording (PVR) function may improve the diagnostic accuracy of the devices.

Perceptions of primary care and hospital clinicians on the use of the Ankle Brachial Pressure Index in general practice

INTRODUCTION Peripheral arterial disease is an increasingly prevalent chronic illness globally. The Ankle Brachial Pressure Index (ABPI) is a well-established, simple, relatively quick and non-invasive assessment useful in diagnosing and quantifying peripheral arterial disease. ABPIs may be currently underutilised in general practice. AIM To explore perspectives of health professionals on the role of the ABPI. METHODS One-to-one interviews were conducted with health professionals using snowball sampling. Questions centred around interviewees' education on, experience with and view on the usefulness of the ABPI in general practice. Interviews were recorded and used for thematic analysis. RESULTS Participants consisted of 13 health-care professionals: nine general practitioners, two vascular surgeons and two allied health professionals. Most general practitioners interviewed identified benefits of ABPIs use in primary care, including aiding peripheral arterial disease diagnostics, management, referral and triage. No general practitioners stated they had ever had formal training in undertaking ABPIs. Two of the nine general practitioners stated regular ABPI use in their practice. Participants who did not use ABPIs identified practical barriers to its use in general practice, including cost of equipment, length of time needed and perceived low patient need to justify cost. All interviewees agreed that there was a role for ABPI use in the community if barriers were overcome. DISCUSSION There was consensus among general practitioners that ABPI use is beneficial. Many general practitioners named similar practical barriers to more common use of ABPIs in general practice. They saw a role for ABPIs in primary care, although it may be more practical as a tool for specialised individual clinicians to use for communities, given practical barriers of cost, time and perceived low patient need. Formal training could be considered, as none of the interviewed general practitioners had ever had any.

Fatty acid binding protein 3 is associated with peripheral arterial disease

Background

Peripheral arterial disease (PAD) affects more than 150 million people worldwide and is associated with high rates of lower extremity amputation, myocardial infarction, stroke and death. Fatty acid binding protein 3 (FABP3) is released into circulation in patients with skeletal muscle injury. In this pilot study, we investigated a possible association between PAD and blood levels of FABP3.

Methods

Blood samples were collected from patients with clinical symptoms and diagnostic findings indicative of PAD (PAD group; ankle-brachial index [ABI] <0.9; n = 75) and in those without clinical or diagnostic features of PAD (non-PAD group; ABI >0.9; n = 75) presenting to vascular surgery ambulatory clinics at St. Michael's Hospital. Plasma samples were analyzed by protein multiplex to quantify FABP3 levels.

Results

PAD patients were found to have higher blood levels of FABP3 compared to patients without PAD (mean 3.90 ± 1.69 vs 2.03 ± 0.78; P < .001). A subgroup analysis demonstrated that the FABP3 levels were increased by almost two-fold in patients with PAD, independent of coronary artery disease (P < .001) or diabetes mellitus status (P < .001). Moreover, a significant negative correlation between FABP3 and the ABI was observed in PAD and patients without PAD matched groups (r = –0.51; P = .001). Last, immunohistochemistry demonstrated elevated expressions of FABP3 within skeletal muscle obtained from patients with the most severe form of PAD, chronic limb-threatening ischemia, when compared with patients without PAD.

Conclusions

Patients with PAD have elevated plasma levels of FABP3. An increasing severity of PAD is associated with higher FABP3 levels.

There is a pressing need for a simple, readily accessible, blood-based biomarker for PAD. In this study, we found elevated levels of FABP3 in patients with PAD. This increase in FABP3 was irrespective of history of coronary artery disease or diabetes. Furthermore, our data suggest that an increasing severity of PAD is associated with higher FABP3 levels. Subsequently, FABP3 may be a potential diagnostic biomarker for PAD. However, further studies are needed to confirm the capability of FABP3 to serve as a valid and reliable biomarker for PAD.

Perceived Challenges to Routine Uptake of the Ankle Brachial Index within Primary Care Practice

(1) Introduction: The ankle-brachial index (ABI) is the most widely used method of diagnosing peripheral arterial disease (PAD). However, the uptake of ABIs has been reported to be low in primary care settings across different various healthcare settings; however, this is yet to be investigated within the Canadian context. (2) Objective: Therefore, we sought to assess the rates of ABI usage as well as perceived barriers among primary care practitioners (PCPs) in Toronto, Canada. (3) Methods: A modified questionnaire was electronically sent to 257 PCPs in the Greater Toronto Area (GTA). Questions pertained to frequency, feasibility, utility, and barriers associated with ABI usage in clinical practice. Responses were collected and tallied. (4) Results: A total of 52 PCPs completed the questionnaire. 79% of PCPs did not routinely perform ABIs within their clinical practice, and 56% deemed ABI usage as unfeasible. Constraints in time and staff personnel, as well as complexity of ABI result interpretation, were cited as the major perceived barriers to ABI usage. The overwhelming majority of PCPs viewed alternative forms of diagnosis, such as a blood test for PAD, as being preferable to ABI, as such an approach would enhance diagnostic simplicity and efficiency. (5) Conclusion: ABI usage rates are poor within primary care practices in Toronto, Canada. Alternative approaches for diagnosing PAD may result in greater adoption rates among PCPs and therefore improve the identification of patients with PAD.

Peripheral Artery Disease as a Predictor of Coronary Artery Disease in Patients Undergoing Coronary Angiography

Background

Peripheral artery disease (PAD) may be a useful tool to predict coronary artery disease (CAD) in patients undergoing coronary angiography. If proven that PAD can be a good predictor of CAD, it can help in early and cost-effective diagnosis of CAD.

Methodology

This observational study was conducted from January 2020 to February 2021 in the cardiology unit of a tertiary care hospital. Participants older than 40 years, with a history of uncontrolled hypertension and unstable angina, who warranted the need of angiography were enrolled in study. After enrollment and recording history, these cases were assessed for the presence of PAD based on ankle brachial index (ABI). ABI values less than 0.9 were labelled as participants with PAD. Then these cases underwent coronary angiography at the same institute, and the presence of greater than 50% stenosis of any coronary vessel on angiography was taken as positive CAD.

Results

In this study, PAD was identified in 152 (62.8%) participants. A total of 165 (68.1%) participants had greater than 50% stenosis on angiography. Out of 152 participants with ABI less than 0.9, 140 had greater than 50% stenosis on angiography. In total, 90 participants had ABI more than 0.9, of which 35 participants had greater than 50% stenosis. Sensitivity of PAD in predicting coronary artery stenosis was 80.0% (95% confidence interval [CI]: 73.30%-85.66%), specificity was 82.09% (95% CI: 70.80%-90.39%), and accuracy was 80.58% (95% CI: 75.02%-85.37%).

Conclusions

Our study demonstrated that the sensitivity, specificity, and accuracy of PAD in predicting coronary artery stenosis were significant. Hence, we conclude that PAD can be an excellent predictor of CAD by helping in early and cost-effective diagnosis of CAD.

Nurses' and patients' experiences and preferences of the ankle-brachial pressure index and multi-site photoplethysmography for the diagnosis of peripheral arterial disease: A qualitative study

Peripheral arterial disease is a global health problem, affecting around 20% of people aged over 60 years. Whilst ankle-brachial pressure index (ABPI) is regularly used for diagnosis, it has a number of limitations, which have presented a need for alternative methods of diagnosis. Multi-site photoplethysmography (MPPG) is one such method, but evidence of acceptability of both methods is lacking. This study aims to describe and compare preferences and experiences amongst nurses and patients of ABPI and MPPG use in primary care. We used qualitative research methods in the context of a clinical diagnostic study comparing ABPI with MPPG. Use of ABPI and MPPG by 13 nurses were observed with 51 patients across general practice surgeries in North-East England in 2015/16. Follow-up semi-structured interviews were conducted with 12 nurses and 27 patients. Data were thematically analysed. Two major themes were identified: (1) device preferences; (2) test discomfort and anxiety. There was a compelling preference for MPPG due to ease of use, speed of the test, patient comfort, and perceived device accuracy/objectivity. However some patients struggled to identify a preference, describing ambivalence to medical testing. ABPI was deemed uncomfortable and painful, particularly when the blood pressure cuff was inflated at the lower limbs. There was also evidence of anxiety amongst patients when their foot pulses were not identified using ABPI. Whilst ABPI is a non-invasive and routine procedure it was associated with a number of drawbacks in clinical practice. Nurses required considerable dexterity to employ the test, and it resulted in anxiety amongst some patients. Conversely, MPPG was deemed to be easier and quicker to use, and perceived to be less subjective. Should diagnostic accuracy and cost be comparable to ABPI, then the findings of this study suggest MPPG would be preferable to ABPI for patients as well as nurses.

Screening of peripheral arterial disease in primary health care

Background and purpose

The screening tool for diagnosing lower extremity arterial disease is the assessment of the ankle-brachial index (ABI), which is widely used in general practice. However, resting ABI can easily produce a false negative result. In light of this, our goal was to determine the proportion of definitive diagnoses (peripheral arterial disease [PAD] confirmed or refuted) among patients screened in general practice, and the rate of cases in which the need for further specialized examination is necessary, with special attention to groups having non-compressible arteries and ABI negative symptomatic status. The aim of our work is to improve the efficiency of primary health care screening in PAD and reduce the extremely high domestic amputation ratio.

Patients and methods

Eight hundred and sixteen patients were screened. We used the Edinburgh Questionnaire and recorded medical histories, major risk factors, current complaints, and medication. Physical examinations were performed, including ABI testing.

Results

Thirty-three percent complained about lower extremity claudication; 23% had abnormal ABI values; 13% of the patients within the normal ABI range had complaints of dysbasia; and 12% were in the non-compressible artery group. The ABI-negative symptomatic group’s risk factor profile showed a close similarity to the clear PAD-positive and non-compressible artery groups.

Conclusion

The percentage of PAD could be higher than the number of patients diagnosed by ABI screening. Nearly a quarter of the population fell into the non-compressible artery and ABI-negative symptomatic groups, together defined as the “murky zone”. When screening purposely for PAD, these patients deserve special attention due to the insufficient selectivity and sensitivity of measurements. If there is high clinical suspicion of PAD in spite of normal ABI values, further assessment may be considered.

Measurement of Blood Pressure in Humans: A Scientific Statement From the American Heart Association

The accurate measurement of blood pressure (BP) is essential for the diagnosis and management of hypertension. This article provides an updated American Heart Association scientific statement on BP measurement in humans. In the office setting, many oscillometric devices have been validated that allow accurate BP measurement while reducing human errors associated with the auscultatory approach. Fully automated oscillometric devices capable of taking multiple readings even without an observer being present may provide a more accurate measurement of BP than auscultation. Studies have shown substantial differences in BP when measured outside versus in the office setting. Ambulatory BP monitoring is considered the reference standard for out-of-office BP assessment, with home BP monitoring being an alternative when ambulatory BP monitoring is not available or tolerated. Compared with their counterparts with sustained normotension (ie, nonhypertensive BP levels in and outside the office setting), it is unclear whether adults with white-coat hypertension (ie, hypertensive BP levels in the office but not outside the office) have increased cardiovascular disease risk, whereas those with masked hypertension (ie, hypertensive BP levels outside the office but not in the office) are at substantially increased risk. In addition, high nighttime BP on ambulatory BP monitoring is associated with increased cardiovascular disease risk. Both oscillometric and auscultatory methods are considered acceptable for measuring BP in children and adolescents. Regardless of the method used to measure BP, initial and ongoing training of technicians and healthcare providers and the use of validated and calibrated devices are critical for obtaining accurate BP measurements.

Tips and tricks for facilitating teaching of Doppler waveforms and ankle-brachial index in undergraduate level: A practical guide

Although the measurement of ankle-brachial index (ABI) is considered a fundamental skill in assessment and diagnosis of peripheral arterial disease and a predictive tool for cardiovascular events, real-world practice shows that the experience of many health professionals is far from ideal. Not only teaching and practice of ABI measurement in undergraduate medical curricula are limited but various mistakes in the process of calculation, estimation, and interpretation of ABI results in the postgraduate practice have also been documented. Because vascular surgery is a core subject in our medical school, we deal with the difficulties and challenges that undergraduate medical students and nurses face to measure and comprehend ABI. We came up with useful tips and maneuvers to overcome these difficulties. Accordingly, this article provides twelve easy-to-follow useful tips to enhance and facilitate the teaching and comprehension of ABI. Moreover, it favors the simultaneous teaching of Doppler arterial waveform examination as a means to facilitate accurate interpretation and validation of ABI results.

Lower extremity arterial disease in patients with diabetes: a contemporary narrative review

Lower-extremity arterial disease (LEAD) is a major endemic disease with an alarming increased prevalence worldwide. It is a common and severe condition with excess risk of major cardiovascular events and death. It also leads to a high rate of lower-limb adverse events and non-traumatic amputation. The American Diabetes Association recommends a widespread medical history and clinical examination to screen for LEAD. The ankle brachial index (ABI) is the first non-invasive tool recommended to diagnose LEAD although its variable performance in patients with diabetes. The performance of ABI is particularly affected by the presence of peripheral neuropathy, medial arterial calcification, and incompressible arteries. There is no strong evidence today to support an alternative test for LEAD diagnosis in these conditions. The management of LEAD requires a strict control of cardiovascular risk factors including diabetes, hypertension, and dyslipidaemia. The benefit of intensive versus standard glucose control on the risk of LEAD has not been clearly established. Antihypertensive, lipid-lowering, and antiplatelet agents are obviously worthfull to reduce major cardiovascular adverse events, but few randomised controlled trials (RCTs) have evaluated the benefits of these treatments in terms of LEAD and its related adverse events. Smoking cessation, physical activity, supervised walking rehabilitation and healthy diet are also crucial in LEAD management. Several advances have been achieved in endovascular and surgical revascularization procedures, with obvious improvement in LEAD management. The revascularization strategy should take into account several factors including anatomical localizations of lesions, medical history of each patients and operator experience. Further studies, especially RCTs, are needed to evaluate the interest of different therapeutic strategies on the occurrence and progression of LEAD and its related adverse events in patients with diabetes.

The perfusion index is a useful screening tool for peripheral artery disease

The number of people with peripheral artery disease (PAD) has been increasing globally; therefore, it is important to explore more options to screen patients who are at a risk of developing PAD. The perfusion index (PI) represents the degree of circulation through the peripheral tissues and is measured noninvasively. We investigated the correlation between the PI and ankle-brachial index (ABI) to explore whether the PI could be used a screening tool for PAD. This cross-sectional study included 390 patients. We measured the ABI and PI for all patients. The median ABI value was 1.06 (0.92-1.13); the PI was 1.7% (0.9-3.5). The PI was higher in men than in women (P < 0.0001). The PI was positively correlated with the estimated glomerular filtration rate and ABI in both men and women. The sensitivity and specificity of the PI to predict PAD (ABI ≤0.9) were 90.0% and 80.3%, respectively, and the cutoff PI value was 1.5% in men. The sensitivity and specificity of the PI to predict PAD were 82.1% and 79.2%, respectively, and the cutoff PI value was 1.1% in women. PI could be a reliable screening tool for diagnosing PAD because it does not restrict the patient's mobility, can be completed in a short time period, and is associated with reduced costs.

Increase in the Arterial Velocity Pulse Index of Patients with Peripheral Artery Disease

Background

Recently, a simple parameter calculated from the brachial pressure waveform recorded using an oscillometric device (arterial velocity pulse index [AVI]: ratio of the forward/reflected pressure wave amplitudes) has become available to assess the pathophysiological abnormalities associated with vascular damage. Peripheral artery disease (PAD) represents one of the disease entities associated with the advanced stages of atherosclerotic vascular damage. The present study was conducted to examine whether an increase in the AVI might be influenced by the presence of PAD.

Methods and Results

The AVI was measured from oscillometric recordings of the brachial pressure waveform, and the ankle-brachial pressure index (ABPI) was determined by an oscillometric method. Study 1: In 341 consecutive patients admitted for the management of cardiovascular disease and/or cardiovascular risk factors, the ABPI and the AVI were measured simultaneously. An ABPI ≤0.90 was observed in 19 subjects, and logistic regression analysis revealed a significant association between AVI and ABPI ≤0.90 (odds ratio = 1.81; 95% confidence interval = 1.15-2.84; p = 0.01). Study 2: In another 19 patients with PAD, percutaneous transluminal angioplasty resulted in a decrease in the AVI from 31 ± 8 to 27 ± 8 (p < 0.01).

Conclusion

Possible presence of PAD must be taken into account while applying the AVI for the assessment of vascular damage.

Investigation and analysis of lower extremity arterial disease in hospitalized elderly type 2 diabetic patients

BACKGROUND

The risk of lower extremity arterial disease (LEAD) is increased in diabetic patients. LEAD in diabetic patients occurs earlier and is often more severe and diffuse; however, it is largely underdiagnosed and untreated. The purposes of this study were to investigate and analyze LEAD situation of hospitalized elderly type 2 diabetic patients.

METHODS

The ankle-brachial index (ABI) was used to screen LEAD in hospitalized elderly type 2 diabetic patients. The patients were divided into 5 groups based on the screening results: non-LEAD group and LEAD group; the LEAD group was divided into mild stenosis group, moderate stenosis group, and severe stenosis group.

RESULTS

The percentage of patients who had LEAD was 43%. Significant difference in age, diabetes duration, peak velocity, microalbuminuria, and vibratory sensory neuropathy was observed between patients with and without LEAD; regression analysis showed that urinary albumin and vibratory sensory neuropathy were independent risk factors for LEAD. Significant difference in age, body mass index (BMI), peak velocity, urinary albumin, and high-density lipoprotein cholesterol (HDL-C) was observed between mild stenosis group, moderate stenosis group, and severe stenosis group; regression analysis showed that urinary albumin, BMI, and HDL-C were independent risk factors for accelerating vascular stenosis.

CONCLUSIONS

The incidence of LEAD in hospitalized elderly type 2 diabetic patients is high; age, diabetes duration, peak velocity, BMI, urinary microalbumin, vibratory sensory neuropathy, and HDL-C are the major risk factors for LEAD. Active control of risk factors is helpful to reduce or delay LEAD.

Subjecting the ankle-brachial index to timely scrutiny: is it time to say goodbye to the ABI?

Although the ankle-brachial index (ABI) has been used as an indicator of peripheral artery disease and vascular supply to the foot for over 50 years, it is now associated with reservations and qualifying empirical evidence to the extent that the provocative step of abandoning it totally might be advisable. In this article, the results of three publications concerning the ABI are initially described in some depth and the results from eight additional publications are then summarized more briefly. Cumulatively, the research indicates that ABIs that seem to be normal, as well as those in the subnormal range, are often inflated by medial arterial calcification and can therefore produce a high proportion of false-negative screening test results for arterial disease as well as a misleadingly high impression of vascular sufficiency to the lower extremity. The toe-brachial index is suggested as being likely to overcome the problems associated with the ABI, and other alternatives to the ABI and TBI are acknowledged.

Primary care screening for peripheral arterial disease: a cross-sectional observational study

Background

Early identification of peripheral arterial disease (PAD) and subsequent instigation of risk modification strategies could minimise disease progression and reduce overall risk of cardiovascular (CV) mortality. However, the feasibility and value of primary care PAD screening is uncertain.

Aim

This study (the PIPETTE study — Peripheral arterial disease In Primary carE: Targeted screening and subsequenT managEment) aimed to determine the value of a proposed primary care PAD screening strategy. Outcomes assessed were: prevalence of PAD and agreement of ankle– brachial index (ABI)-defined PAD (ABI ≤0.9) with QRISK^®2-defined high CV risk (≥20).

Design and setting

A cross-sectional observational study was undertaken in a large general practice in Merthyr Tydfil, Wales.

Method

In total, 1101 individuals with ≥2 pre-identified CV risk factors but no known CV disease or diabetes were invited to participate. Participants underwent ABI measurement and QRISK2 assessment, and completed Edinburgh Claudication Questionnaires.

Results

A total of 368 people participated in the study (participation rate: 33%). Prevalence of PAD was 3% (n = 12). The number needed to screen (NNS) to detect one new case of PAD was 31. Refining the study population to those aged ≥50 years with a smoking history reduced the NNS to 14, while still identifying 100% of PAD cases. Of participants with PAD, 33% reported severe lifestyle-limiting symptoms of intermittent claudication that warranted subsequent endovascular intervention, yet had not previously presented to their GP. The QRISK2 score predicted high CV risk in 92% of participants with PAD.

Conclusion

The low PAD yield and the fact that QRISK2 was largely comparable to the ABI in predicting high CV risk suggests that routine PAD screening may be unwarranted. Instead, strategies to improve public awareness of PAD are needed.

Automated oscillometric blood pressure and pulse-wave acquisition for evaluation of vascular stiffness in atherosclerosis

OBJECTIVE

Evaluation of diagnostic accuracy of an oscillometry-based device (VascAssist) combining fully automated ankle-brachial index (ABI) and pulse-wave velocity (PWV) assessment for detection of peripheral arterial disease (PAD).

SUBJECTS AND METHODS

110 consecutive subjects including symptomatic PAD patients (n = 41) and healthy PAD-free participants (n = 69) were recruited. All subjects underwent standard manual Doppler-based ABI (sABI) and oscillometry-based automated ABI (aABI) measurements (VascAssist). Oscillometry by the VascAssist included central and peripheral PWV assessment. Additionally, arterial stiffness (AS) was evaluated by flow-mediated vasodilation (FMD) of the brachial artery in all patients. All symptomatic PAD patients underwent catheter angiography for endovascular intervention and post-interventional acquisition of sABI, aABI, PWV and FMD.

RESULTS

Sensitivity, specificity, PPV and NPV of aABI for detecting PAD was 73%, 100%, 100%, and 86% as compared to 80%, 96%, 92%, and 89% for sABI. Pearson-correlation for diabetics was r = 0.81; (P < .001) and for non-diabetics r = 0.77; (P < .001). Bland-Altman-analysis revealed a difference (95% CI) for diabetics of 0.09 (-0.22-0.4] and non-diabetics 0.022 [-0.25-0.295]. Weak correlation exists for FMD/AS analysis (pre-interventional R = 0.386, P = .043; post-interventional R = -0.06; P = .76) and significant increase of pre-/post-interventional PWV analysis (P < .001).

CONCLUSION

Combined automatic ABI and PWV acquisition with the VascAssist device showed excellent diagnostic accuracy for detection of PAD. Compared to FMD, AS analysis may serve as an investigator-independent (screening) tool for determination of functional vascular damage in atherosclerosis.

Ankle-brachial index and brachial-ankle pulse wave velocity are risk factors for ischemic stroke in patients with Type 2 diabetes

The incidence of ischemic stroke in patients with diabetes is increasing. While brachial-ankle pulse wave velocity (BaPWV) and ankle-brachial index (ABI) are known to be associated with ischemic cardiovascular and cerebrovascular diseases, whether these measures predict the risk of ischemic cerebrovascular disease in diabetic patients remains unclear. 117 patients with type 2 diabetes were enrolled in this study. According to the results of head magnetic resonance imaging, the patients were divided into a diabetes-only group (n = 55) and a diabetes and ischemic stroke group (n = 62). We then performed ABI and BaPWV examinations for all patients. Compared with the diabetes-only group, we found decreased ABI and increased BaPWV in the diabetes and ischemic stroke group. Multivariate logistic regression analyses revealed that BaPWV and ABI were risk factors for ischemic stroke in patients with type 2 diabetes. Our findings indicate that decreased ABI and increased BaPWV are objective indicators of increased risk of ischemic stroke in patients with type 2 diabetes.

Non-invasive assessment of peripheral arterial disease: Automated ankle brachial index measurement and pulse volume analysis compared to duplex scan

Objectives:

This cross-sectional study aimed to individually and cumulatively compare sensitivity and specificity of the (1) ankle brachial index and (2) pulse volume waveform analysis recorded by the same automated device, with the presence or absence of peripheral arterial disease being verified by ultrasound duplex scan.

Methods:

Patients (n=205) referred for lower limb arterial assessment underwent ankle brachial index measurement and pulse volume waveform recording using volume plethysmography, followed by ultrasound duplex scan. The presence of peripheral arterial disease was recorded if ankle brachial index <0.9; pulse volume waveform was graded as 2, 3 or 4; or if haemodynamically significant stenosis >50% was evident with ultrasound duplex scan. Outcome measure was agreement between the measured ankle brachial index and interpretation of pulse volume waveform for peripheral arterial disease diagnosis, using ultrasound duplex scan as the reference standard.

Results:

Sensitivity of ankle brachial index was 79%, specificity 91% and overall accuracy 88%. Pulse volume waveform sensitivity was 97%, specificity 81% and overall accuracy 85%. The combined sensitivity of ankle brachial index and pulse volume waveform was 100%, specificity 76% and overall accuracy 85%.

Conclusion:

Combining these two diagnostic modalities within one device provided a highly accurate method of ruling out peripheral arterial disease, which could be utilised in primary care to safely reduce unnecessary secondary care referrals.

Subclinical Vascular Disease and Subsequent Erectile Dysfunction: The Multiethnic Study of Atherosclerosis (MESA)

BACKGROUND

The association between subclinical cardiovascular disease and subsequent development of erectile dysfunction (ED) remains poorly described.

HYPOTHESIS

Among multiple subclinical atherosclerosis and vascular dysfunction measurements, coronary artery calcium (CAC) score best predicts ED.

METHODS

After excluding participants taking ED medications at baseline, we studied 1862 men age 45 to 84 years free of known cardiovascular disease from the Multi-Ethnic Study of Atherosclerosis (MESA) with comprehensive baseline subclinical vascular disease phenotyping and ED status assessed at MESA visit 5 (9.4 ± 0.5 years after baseline) using a standardized question on ED symptoms. Multivariable logistic regression was used to assess the associations between baseline measures of vascular disease (atherosclerosis domain: CAC, carotid intima-media thickness, carotid plaque, ankle-brachial index; vascular stiffness/function domain: aortic stiffness, carotid stiffness, brachial flow-mediated dilation) and ED symptoms at follow-up.

RESULTS

Mean baseline age was 59.5 ± 9 years, and 839 participants (45%) reported ED symptoms at follow-up. Compared with symptom-free individuals, participants with ED had higher baseline prevalence of CAC score >100 (36.4% vs 17.2%), carotid intima-media thickness Z score >75th percentile (35.3% vs 16.6%), carotid plaque score ≥2 (39% vs 21.1%), carotid distensibility <25th percentile (34.6% vs 17.1%), aortic distensibility <25th percentile (34.2% vs 18.7%), and brachial flow-mediated dilation <25th percentile (28.4% vs 21.3%); all P < 0.01. Only CAC >100 (odds ratio: 1.43, 95% confidence interval: 1.09-1.88) and carotid plaque score ≥2 (odds ratio: 1.33, 95% confidence interval: 1.02-1.73) were significantly associated with ED.

CONCLUSIONS

Subclinical vascular disease is common in men who later self-report ED. Early detection of subclinical atherosclerosis, particularly advanced CAC and carotid plaque, may provide opportunities for predicting the onset of subsequent vascular ED.

The clinical relevance of the percentage flow-mediated dilation index

In 2010, the American College of Cardiology Foundation and American Heart Association could not recommend brachial artery percentage flow-mediated dilation (FMD%) for risk assessment of coronary artery disease (CAD) in asymptomatic adults. We aimed to scrutinise past and recently published findings regarding FMD% in this same context of clinical utility and conclude that (1) the question of whether brachial FMD% is a suitable substitute for coronary vasodilation is addressed by method agreement statistics rather than the correlation coefficients that have been reported in past studies. Also, the much-repeated view that brachial FMD% and coronary vasodilation are "closely related" is not entirely justified, even before the influence of baseline lumen diameters on this relationship is accounted for; (2) along with the specialist training and the considerable time (≥1 h) that is required for the FMD% protocol, the error in individual measurements and population reference ranges is too large for clinical decisions to be robust on individual patients; (3) many interventions that are proposed to change FMD% also change baseline artery diameter, which can bias estimates of any intervention effects on the flow-mediated response per se, and (4) the FMD% index generates spurious correlations between shear rate, artery diameter and endothelial function, which may help to explain the apparent paradoxes of FMD% being higher in obese people and lower in athletes. In conclusion, the clinical relevance of brachial artery flow-mediated dilation is unclear at present. The dependence of the chosen index, FMD%, on initial artery size has contributed to this lack of clarity.

Ankle-Brachial Index Testing at the Time of Stress Testing in Patients Without Known Atherosclerosis

BACKGROUND

Individuals referred for stress testing to identify coronary artery disease may have nonobstructive atherosclerosis, which is not detected by stress tests. Identification of increased risk despite a negative stress test could inform prevention efforts. Abnormal ankle-brachial index (ABI) is associated with increased cardiovascular risk.

HYPOTHESIS

Routine ABI testing in the stress laboratory will identify unrecognized peripheral arterial disease in some patients.

METHODS

Participants referred for stress testing without known history of atherosclerotic disease underwent ABI testing (n = 451). Ankle-brachial index was assessed via simultaneous arm and leg pressure using standard measurement, automated blood-pressure cuffs at rest. Ankle-brachial index was measured after exercise in 296 patients and 30 healthy controls. Abnormal postexercise ABI was defined as a >20% drop in ABI or fall in ankle pressure by >30 mm Hg.

RESULTS

Overall, 2.0% of participants had resting ABI ≤0.90, 3.1% had ABI ≥1.40, and 5.5% had borderline ABI. No patient with abnormal or borderline ABI had an abnormal stress test. Participants who met peripheral arterial disease screening criteria (age ≥65 or 50-64 with diabetes or smoking) tended toward greater frequency of low ABI (2.9% vs 1.0%; P = 0.06) and were more likely to have borderline ABI (0.91 to 0.99; 7.8% vs 2.9%; P = 0.006). Postexercise ABI was abnormal in 29.4% of patients and 30.0% of controls (P not significant).

CONCLUSIONS

Ankle-brachial index screening at rest just before stress testing detected low ABI in 2.0% of participants, all of whom had negative stress tests.

Vascular assessment techniques of podiatrists in Australia and New Zealand: a web-based survey

Background

Podiatrists play a central role in conducting non-invasive vascular assessment in the lower extremity. This involves screening for signs and symptoms of peripheral arterial disease (PAD) and ongoing monitoring of the condition. Podiatric vascular assessment practices in Australia and New Zealand are currently unclear. Determining the clinical habits of Podiatrists is essential in identifying if there is a need for further education or support in performing accurate vascular assessments.

Methods

A web-based, secure, anonymous questionnaire was conducted of registered Podiatrists in Australia and New Zealand between 1 April and 31 July 2013. The questions examined clinician’s regular practices in vascular assessment, clinical indicators to perform and barriers in completing vascular assessment. Nominal logistic regression was performed to further examine years of experience and practice setting on clinical indicators to perform vascular assessment and types of assessment performed.

Results

Four hundred forty-seven podiatrists participated in the survey. Clinical indicators for vascular assessment, along with barriers and available equipment were examined and the results varied depending on the podiatrists’ geographical location, practice setting, and experience. Palpation of pedal pulses was the most frequently reported assessment (97 %) along with Doppler assessment (74 %). Pressure measurement was the least frequently reported vascular assessment method, with only 34 % undertaking ankle-brachial indices and 19 % completing toe-brachial indices. Public podiatrists reported more varied and complete vascular assessment compared to those in private practice. Lack of time was identified as the most frequently reported barrier (66 %) in performing vascular assessment, followed by lack of equipment (28 %). In New Zealand podiatrists, lack of equipment was much more of an issue than in Australian podiatrists.

Conclusion

Large variations exist in vascular assessment methods amongst Australian and New Zealand podiatrists. Some assessments being undertaken are potentially inadequate for accurate screening for PAD. There is a need for continuing education in vascular assessment to address the deficiencies in technique reported by some Podiatrists. A podiatry-relevant summary of broad international guidelines for PAD screening may be of use to improve utilisation and accuracy of screening methods to improve patient management.

Electronic supplementary material

The online version of this article (doi:10.1186/s13047-015-0130-5) contains supplementary material, which is available to authorized users.

Atypical leg symptoms: does routine measurement of the ankle brachial pressure index (ABPI) in primary care benefit patients?

Background : Managing patients with atypical leg symptoms in primary care can be problematic. Determining the ankle brachial pressure index (ABPI) may be readily performed to help diagnose peripheral arterial disease, but is often omitted where signs and symptoms are unclear. Question: Does routine measurement of ABPI in patients with atypical leg symptoms aid management increase satisfaction and safely reduce hospital referral? Methodology: Patients with atypical leg symptoms but no skin changes or neurological symptoms underwent clinical review and Doppler ABPI measurement (suspicious finding ≤ 1.0). Testing was performed by the same doctor (study period: 30 months). Patient outcomes were determined from practice records, hospital letters and a telephone survey. Results : The study comprised 35 consecutive patients (males: N = 15), mean age 64 years (range: 39-88). Presentation included pain, cold feet, cramps, irritation and concerns regarding circulation. Prior to ABPI measurement, referral was considered necessary in 10, not required in 22 and unclear in 3. ABPI changed the referral decision in 10 (29%) and confirmed the decision in 25 (71%). During the study, 10 (29%) patients were referred (9 vascular, 1 neurology). Amongst the vascular referrals, significant peripheral arterial disease has been confirmed in six patients. A further two patients are under review and one did not attend. To date, lack of referral in patients with atypical leg symptoms but a normal ABPI has not increased morbidity. Current status was assessed by telephone review in 16/35 (46% contact rate; mean 18 months, range 2-28). Fifteen patients (94%) appreciated that their symptoms had been quickly and conveniently assessed, 8/11 (73%) with a normal ABPI were reassured by their result and in 8/11 symptoms have resolved. Discussion/Conclusion: APBI conveniently aids management of atypical leg symptoms by detecting unexpected peripheral arterial disease, avoids /confirms the need for referral, reassures patients and guides reassessment. This study suggests ABPI should be used more widely.

Increased pulsatility of the intracranial blood flow spectral waveform on transcranial Doppler does not point to peripheral arterial disease in stroke patients

BACKGROUND

Peripheral arterial disease (PAD) is common in patients with acute cerebral ischemia. Indexes of resistance derived from the systolic and diastolic velocities are routinely used in diagnostic transcranial Doppler (TCD) to detect intracranial arterial disease. We sought to explore whether these indexes can predict the presence of PAD in acute cerebral ischemia.

METHODS

We prospectively evaluated consecutive patients with acute cerebral ischemia. On TCD, peak-systolic and end-diastolic velocities in both middle cerebral and basilar arteries were manually measured to calculate pulsatility index (PI) and resistance index (RI). Increased resistance was defined as PI equal to 1.2 or more and RI equal to .75 or more. Ankle-brachial index (ABI) measurements were performed and an ABI equal to .9 or more was considered predictive of definite PAD.

RESULTS

We included 95 patients (45 male, 50 female) aged 66 ± 9 years with a median National Institutes Health Stroke Scale score of 3 (interquartile range, 8) points. The ABI was abnormal and consistent with definite PAD in 24 of 95 (25.3%; 95% confidence interval [CI], 16.4-34.2) patients. Increased PI did not differ among patients with and without PAD (20.8% vs. 28.2%, P = .60). Only 1 patient with PAD had increased RI as opposed to 4 patients without PAD (4.2% vs. 5.6%, P = 1.0). Increased PI was not found to be an independent predictor of PAD (odds ratio [OR], .68; 95% CI, .22-2.12; P = .51). Increases in both PI and RI independently predicted arterial hypertension (OR, 1.62; 95% CI, 1.19-2.21; P = .002 and OR, 3.20; 95% CI, 1.51-6.77; P = .002, respectively).

CONCLUSIONS

Our findings indicate that PAD cannot be inferred from intracranial flow parameters predictive of arterial disease and risk factors such as hypertension among patients with acute cerebral ischemia.