The ankle brachial index in type 2 diabetes

Czech version

Authors: B. Nussbaumerová ¹; H. Rosolová ¹; J. Ferda ²; P. Šifalda ¹; I. Šípová ¹; F. Šefrna ¹
Authors‘ workplace: Centrum preventivní kardiologie II. interní kliniky Lékařské fakulty UK a FN Plzeň, přednosta prof. MUDr. Jan Filipovský, CSc. ¹; Klinika zobrazovacích metod Lékařské fakulty UK a FN Plzeň, přednosta doc. MUDr. Boris Kreuzberg, CSc. ²
Published in: Vnitř Lék 2011; 57(3): 299-305
Category: 60th birthday of prof. Mudr. Jiřího Vítovce, CSc, FESC

Overview

Introduction:
The ankle brachial index (ABI), i.e. the ratio of systolic blood pressure (SBP) on the ankle and on the arm, is diagnostic for peripheral occlusive artery disease and a marker of cardiovascular (CV) risk. The association between the low ABI < 0.9 and the CV risk in type 2 diabetes (T2DM) subjects was investigated.

Methods:
We examined 253 T2DM subjects (135 males, 118 females, aged 66 ± 9 years). The blood pressures were measured in the supine position with the 2 mm Hg accuracy; Doppler ultrasound was used for the ankle SBP and the mercury sphygnomanometer for the arm SBP. The high CV risk was defined as manifest CV diseases, elevated coronary calcium score (CAC) by Agatston (> 101) or according to the global CV Risk Score ≥ 5% (SCORE).

Statistical method:
Wilcoxon’s unpaired test, χ² test, multiple logistic regression.

Results:
The ABI < 0.9 was found unilateral in 23 T2DM (8%), bilateral in 24 (9%), in older males (71 ± 8 years) with higher CAC (600 ± 707) (p < 0.01), higher total cholesterol (5.4 ± 1.3 mmol/ L) and total homocystein (17.2 ± 7.1 µmol/L) (p < 0.05) in comparison to those with the ABI ≥ 0.9 (age 66 ± 9 years, CAC 234 ± 458, total cholesterol 5.0 ± 0.9, total homocystein 14.3 ± 7.8). Many CV risk factors correlated positively with the low ABI < 0.9; it was significantly independently associated with age (p < 0.001), smoking (p < 0.01), LDL-cholesterol, total homocystein and CAC (p < 0.05). Low ABI < 0.9 predicted ischemic stroke in subjects with T2DM and manifest CV diseases in the further 3 years. There was no correlation between the ABI and the ultrasensitive C-reactive protein.

Conclusion:
Low ABI < 0.9 was in a strong association with the CV risk. The ABI measurement is a simple, noninvasive, time-nonconsuming and inexpensive method for subclinical atherosclerosis detection; the ABI can supply standard methods for the CV risk prediction.

Key words:
ankle-brachial index – diabetes mellitus – atherosclerosis – cardiovascular risk

Sources

1. Murabito JM, D’Agostino RB, Silbershatz H et al. Intermittent claudication: a risk profile from the Framingham Heart Study. Circulation 1997; 96: 44–49.

2. Bernstein EF, Fronek A. Current status of non-invasive tests in the diagnosis of peripheral arterial disease. Surg Clin North Am 1982; 62: 473–487.

3. Criqui MH. Peripheral arterial disease: epidemiological aspects. Vasc Med 2001; 6 (Suppl 3): 3–7.

4. http://www.diab.cz/modules/Standardy/dm2_2009.pdf

5. Wohlfahrt P, Palouš D, Inglischová M et al. Ankle-brachial index is associeated with increased aortic pulse wave velocity. The post-MONICA study. Eur Heart J 2011; přijato k tisku.

6. Bulvas M. Doporučení pro diagnostiku a léčbu ischemické choroby dolních končetin. Cor Vasa 2009; 51: 145–163.

7. Agatston AS, Janowitz WR, Hildner FJ et al. Quantification of coronary artery calcium using ultrafast computed tomography. J Am Coll Cardiol 1990; 15: 827.

8. Vaverková H, Soška V, Rosolová H et al. Doporučení pro diagnostiku a léčbu dyslipidemií v dospělosti, vypracované výborem České společnosti pro aterosklerózu. Vnitř Lék 2007; 53: 181–187.

9. Petrlová B, Rosolová H, Šimon J et al. Kontrola kardiovaskulárních rizikových faktorů u diabetiků 2. typu. Vnitř Lék 2009; 55: 512–818.

10. Mourad JJ, Cacoub P, Collet JP et al. ELLIPSE scientific committee and study investigators. Screening of unrecognized peripheral arterial disease (PAD) using ankle-brachial index in high cardiovascular risk patients free from symptomatic PAD. J Vasc Surg 2009; 50: 572–580.

11. Newman AB, Siscovick SD, Manolio TA et al. Cardiovascular Heart Study (CHS) Collaborative Research Group. Ankle-arm index as a marker of atherosclerosis in the Cardiovascular Health Study. Circulation 1993; 88; 837–845.

12. Lamina C, Meisinger C, Heid IM et al. KORA Study Group. Association of ankle-brachial index and plaques in the carotid and femoral arteries with cardiovascular events and total mortality in a population-based study with 13 years of follow-up. Eur Heart J 2006; 27: 2580–2587.

13. Criqui MH, McClelland RL, McDermott MM et al. The ankle-brachial index and incident cardiovascular events in the MESA (Multi-Ethnic Study of Atherosclerosis). J Am Coll Cardiol 2010; 56: 1506–1512.

14. Liu H, Shi H, Yu J et al. Is Chronic Kidney Disease Associated with a High Ankle Brachial Index in Adults at High Cardiovascular Risk? J Atheroscler Thromb 2010; Nov 25. [Epub ahead of print].

15. Korhonen PE, Syvänen KT, Vesalainen RK et al. Ankle-brachial index is lower in hypertensive than in normotensive individuals in a cardiovascular risk population. J Hypertens 2009; 27: 2036–2043.

16. Tseng CH, Chong CK, Lin BJ et al. Atherosclerotic risk factors for peripheral vascular disease in non-insulin-dependent diabetic patients. J Formos Med Assoc 1994; 93: 663–667.

17. Agnelli G, Cimminiello C, Meneghetti G et al. Polyvascular Atherothrombosis Observational Survey (PATHOS) Investigators. Low ankle-brachial index predicts an adverse 1-year outcome after acute coronary and cerebrovascular events. J Thromb Haemost 2006; 4: 2599–2606.

18. Mostaza JM, Manzano L, Suarez C et al. Different prognostic value of silent peripheral artery disease in type 2 diabetic and non-diabetic subjects with stable cardiovascular disease. Atherosclerosis 2010, 214: 191–195.

19. Králíková E, Býma S, Cífková R et al. Doporučení pro léčbu závislosti na tabáku. Čas Lék Čes 2005; 144: 327–333.

20. Graham IM, Daly LE, Refsum HM et al. Plasma homocysteine as a risk factor for vascular disease. The European Concerted Action Project. JAMA 1997; 277: 1775–1781.

21. Elkeles RS, Godsland IF, Feher MD et al. PREDICT Study Group. Coronary calcium measurement improves prediction of cardiovascular events in asymptomatic patients with type 2 diabetes: the PREDICT study. Eur Heart J 2008; 29: 2244–2251.

22. Clarke R, Halsey J, Lewington S et al. B-Vitamin Treatment Trialists’ Collaboration. Effects of lowering homocysteine levels with B vitamins on cardiovascular disease, cancer, and cause-specific mortality: Meta-analysis of 8 randomized trials involving 37 485 individuals. Arch Intern Med 2010; 170: 1622–1631.

23. Taylor AJ, Cerqueira M, Hodgson JM et al. ACCF/SCCT/ACR/AHA/ASE/ASNC//NASCI/SCAI/SCMR 2010 Appropriate Use Criteria for Cardiac Computed Tomography: A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. Circulation 2010; 122: e525–e555.

24. Budoff MJ, McClelland RL, Nasir K et al. Cardiovascular events with absent or minimal coronary calcification: the Multi-Ethnic Study of Atherosclerosis (MESA). Am Heart J 2009; 158: 554–561.

25. Hendel RC, Berman DS, Di Carli MF et al. American College of Cardiology Foundation Appropriate Use Criteria Task Force; American Society of Nuclear Cardiology; American College of Radiology; American Heart Association; American Society of Echocardiography; Society of Cardiovascular Computed Tomography; Society for Cardiovascular Magnetic Resonance; Society of Nuclear Medicine. ACCF/ASNC//ACR/AHA/ASE/SCCT/SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine. Circulation 2009; 119: e561–e587.

26. Budoff MJ, Achenbach S, Blumenthal RS et al. American Heart Association Committee on Cardiovascular Imaging and Intervention; American Heart Association Council on Cardiovascular Radiology and Intervention; American Heart Association Committee on Cardiac Imaging, Council on Clinical Cardiology. Assessment of Coronary Artery Disease by Cardiac Computed Tomography: A Scientific Statement From the American Heart Association Committee on Cardiovascular Imaging and Intervention, Council on Cardiovascular Radiology and Intervention, and Committee on Cardiac Imaging, Council on Clinical Cardiology. Circulation 2006; 114; 1761–1791.