Arteriosclerosis, Thrombosis, and Vascular Biology. 1999;19:538-545
© 1999 American Heart Association, Inc.
Original Contributions |
Ankle-Arm Index as a Predictor of Cardiovascular Disease and Mortality in the Cardiovascular Health Study
From the University of Pittsburgh, Pittsburgh, Pa (A.B.N.); University of Washington, Seattle (L.S., D.S.); National Heart, Lung, and Blood Institute, Bethesda, Md (T.A.M.); University of Vermont, Colchester (M.C.); University of Bergen, Bergen, Norway (M.M.); Harvard University, Boston, Mass (J.F.P.); and Johns Hopkins University, Baltimore, Md (N.R.P.).
Correspondence to Anne B. Newman, MD, MPH, University of Pittsburgh School of Medicine, Department of Medicine, Division of Geriatric Medicine, 3520 Fifth Ave, Suite 300, Pittsburgh, PA 15213. E-mail anewman+{at}pitt.edu
Abstract—Peripheral
arterial disease (PAD) in the legs, measured noninvasively
by the ankle-arm index (AAI) is associated with clinically manifest
cardiovascular disease (CVD) and its risk factors. To
determine risk of total mortality, coronary heart disease, or
stroke mortality and incident versus recurrent CVD associated with a
low AAI, we examined the relationship of the AAI to subsequent CVD
events in 5888 older adults with and without CVD. The AAI was measured
in 5888 participants 
65 years old at the baseline examination of the
Cardiovascular Health Study. All participants had a
detailed assessment of prevalent CVD and were contacted every 6 months
for total mortality and CVD events (including CVD mortality, fatal and
nonfatal myocardial infarction, congestive heart failure, angina,
stroke, and hospitalized PAD). The crude mortality rate at 6 years was
highest (32.3%) in those participants with prevalent CVD and a low AAI
(P<0.9), and it was lowest in those with neither of
these findings (8.7%, P<0.01). Similar patterns
emerged from analysis of recurrent CVD and incident CVD. The
risk for incident congestive heart failure (relative risk
[RR]=1.61) and for total mortality (RR=1.62) in those without CVD at
baseline but with a low AAI remained significantly elevated after
adjustment for cardiovascular risk factors.
Hospitalized PAD events occurred months to years after the AAI was
measured, with an adjusted RR of 5.55 (95% CI, 3.08 to 9.98) in those
at risk for incident events. A statistically significant decline in
survival was seen at each 0.1 decrement in the AAI. An AAI of <0.9 is
an independent risk factor for incident CVD, recurrent CVD, and
mortality in this group of older adults in the
Cardiovascular Health Study.
Key Words: peripheral vascular diseases • ankle-arm index • ankle-brachial pressure index • cardiovascular diseases, epidemiology
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A. M. O'Hare, R. A. Rodriguez, and P. Bacchetti Low Ankle-Brachial Index Associated With Rise in Creatinine Level Over Time: Results From the Atherosclerosis Risk in Communities Study Arch Intern Med, July 11, 2005; 165(13): 1481 - 1485. [Abstract] [Full Text] [PDF]
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A. V. Doobay and S. S. Anand Sensitivity and Specificity of the Ankle-Brachial Index to Predict Future Cardiovascular Outcomes: A Systematic Review Arterioscler Thromb Vasc Biol, July 1, 2005; 25(7): 1463 - 1469. [Abstract] [Full Text] [PDF]
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D. G. Federman, D. C. Ranani, R. S. Kirsner, and D. M. Bravata Lipid-Lowering Therapy in Patients With Peripheral Arterial Disease: Are Guidelines Being Met? Mayo Clin. Proc., April 1, 2005; 80(4): 494 - 498. [Abstract] [PDF]
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G. I. Parameswaran, K. Brand, and J. Dolan Pulse Oximetry as a Potential Screening Tool for Lower Extremity Arterial Disease in Asymptomatic Patients With Diabetes Mellitus Arch Intern Med, February 28, 2005; 165(4): 442 - 446. [Abstract] [Full Text] [PDF]
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C. L. Leibson, J. E. Ransom, W. Olson, B. R. Zimmerman, W. M. O'Fallon, and P. J. Palumbo Peripheral Arterial Disease, Diabetes, and Mortality Diabetes Care, December 1, 2004; 27(12): 2843 - 2849. [Abstract] [Full Text] [PDF]
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A.J. Lee, J.F. Price, M.J. Russell, F.B. Smith, M.C.W. van Wijk, and F.G.R. Fowkes Improved Prediction of Fatal Myocardial Infarction Using the Ankle Brachial Index in Addition to Conventional Risk Factors: The Edinburgh Artery Study Circulation, November 9, 2004; 110(19): 3075 - 3080. [Abstract] [Full Text] [PDF]
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E. R Mohler III, D. Treat-Jacobson, M. P Reilly, K. E Cunningham, M. Miani, M. H Criqui, W. R Hiatt, and A. T Hirsch Utility and barriers to performance of the ankle brachial index in primary care practice Vascular Medicine, November 1, 2004; 9(4): 253 - 260. [Abstract] [PDF]
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Y. Aso, K.-i. Okumura, S. Wakabayashi, K. Takebayashi, S. Taki, and T. Inukai Elevated Pregnancy-Associated Plasma Protein-A in Sera from Type 2 Diabetic Patients with Hypercholesterolemia: Associations with Carotid Atherosclerosis and Toe-Brachial Index J. Clin. Endocrinol. Metab., November 1, 2004; 89(11): 5713 - 5717. [Abstract] [Full Text] [PDF]
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 R. Ebrahimi, J. R. Saleh, E. J. Toggart, B. Hayatdavoudi, C. J. Wolf, N. N. Wadhani, and A. P. Shah Lipid-Lowering Therapy in Patients with Peripheral Arterial Disease Journal of Cardiovascular Pharmacology and Therapeutics, October 1, 2004; 9(4): 271 - 277. [Abstract] [PDF]
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E. Selvin and T. P. Erlinger Prevalence of and Risk Factors for Peripheral Arterial Disease in the United States: Results From the National Health and Nutrition Examination Survey, 1999-2000 Circulation, August 10, 2004; 110(6): 738 - 743. [Abstract] [Full Text] [PDF]
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A. R. Brady, S. G. Thompson, F. G. R. Fowkes, R. M. Greenhalgh, J. T. Powell, and on behalf of the UK Small Aneurysm Trial Participa Abdominal Aortic Aneurysm Expansion: Risk Factors and Time Intervals for Surveillance Circulation, July 6, 2004; 110(1): 16 - 21. [Abstract] [Full Text] [PDF]
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 H. Sillesen What does the future hold for the patient with peripheral arterial disease? Eur. Heart J. Suppl., July 1, 2004; 6(suppl_C): C43 - C48. [Abstract] [Full Text] [PDF]
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Y. Aso, K.-i. Okumura, T. Inoue, R. Matsutomo, N. Yoshida, S. Wakabayashi, K. Takebayashi, and T. Inukai Results of Blood Inflammatory Markers Are Associated More Strongly With Toe-Brachial Index Than With Ankle-Brachial Index in Patients With Type 2 Diabetes Diabetes Care, June 1, 2004; 27(6): 1381 - 1386. [Abstract] [Full Text] [PDF]
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I. M. van der Meer, M. L. Bots, A. Hofman, A. Iglesias del Sol, D. A.M. van der Kuip, and J. C.M. Witteman Predictive Value of Noninvasive Measures of Atherosclerosis for Incident Myocardial Infarction: The Rotterdam Study Circulation, March 9, 2004; 109(9): 1089 - 1094. [Abstract] [Full Text] [PDF]
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H. E. Resnick, R. S. Lindsay, M. M. McDermott, R. B. Devereux, K. L. Jones, R. R. Fabsitz, and B. V. Howard Relationship of High and Low Ankle Brachial Index to All-Cause and Cardiovascular Disease Mortality: The Strong Heart Study Circulation, February 17, 2004; 109(6): 733 - 739. [Abstract] [Full Text] [PDF]
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D. Duprez HOPE brings hope for the use of the ankle-brachial index as cardiovascular risk marker Eur. Heart J., January 1, 2004; 25(1): 1 - 2. [Full Text] [PDF]
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J. Ostergren, P. Sleight, G. Dagenais, K. Danisa, J. Bosch, Y. Qilong, S. Yusuf, and for the HOPE study investigators Impact of ramipril in patients with evidence of clinical or subclinical peripheral arterial disease Eur. Heart J., January 1, 2004; 25(1): 17 - 24. [Abstract] [Full Text] [PDF]
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H.-H. S. Oei, R. Vliegenthart, A. Hofman, M. Oudkerk, and J. C.M. Witteman Risk factors for coronary calcification in older subjects: The Rotterdam Coronary Calcification Study Eur. Heart J., January 1, 2004; 25(1): 48 - 55. [Abstract] [Full Text] [PDF]
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L. V. Buitron-Granados, C. Martinez-Lopez, and J. Escobedo-de la Pena Prevalence of Peripheral Arterial Disease and Related Risk Factors in an Urban Mexican Population Angiology, January 1, 2004; 55(1): 43 - 51. [Abstract] [PDF]
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J. Amighi, S. Sabeti, O. Schlager, W. Mlekusch, M. Exner, W. Lalouschek, R. Ahmadi, E. Minar, and M. Schillinger Low Serum Magnesium Predicts Neurological Events in Patients With Advanced Atherosclerosis Stroke, January 1, 2004; 35(1): 22 - 27. [Abstract] [Full Text] [PDF]
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 A Theodoridou, L Bento, D P D'Cruz, M A Khamashta, and G R V Hughes Prevalence and associations of an abnormal ankle-brachial index in systemic lupus erythematosus: a pilot study Ann Rheum Dis, December 1, 2003; 62(12): 1199 - 1203. [Abstract] [Full Text] [PDF]
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E. R. Mohler III Peripheral Arterial Disease: Identification and Implications Arch Intern Med, October 27, 2003; 163(19): 2306 - 2314. [Abstract] [Full Text] [PDF]
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J. M. Murabito, J. C. Evans, M. G. Larson, K. Nieto, D. Levy, and P. W. F. Wilson The Ankle-Brachial Index in the Elderly and Risk of Stroke, Coronary Disease, and Death: The Framingham Study Arch Intern Med, September 8, 2003; 163(16): 1939 - 1942. [Abstract] [Full Text] [PDF]
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P. Holvoet, T. B. Harris, R. P. Tracy, P. Verhamme, A. B. Newman, S. M. Rubin, E. M. Simonsick, L. H. Colbert, and S. B. Kritchevsky Association of High Coronary Heart Disease Risk Status With Circulating Oxidized LDL in the Well-Functioning Elderly: Findings From the Health, Aging, and Body Composition Study Arterioscler Thromb Vasc Biol, August 1, 2003; 23(8): 1444 - 1448. [Abstract] [Full Text] [PDF]
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E. Suzuki, K. Egawa, Y. Nishio, H. Maegawa, M. Tsuchiya, M. Haneda, H. Yasuda, S. Morikawa, T. Inubushi, and A. Kashiwagi Prevalence and Major Risk Factors of Reduced Flow Volume in Lower Extremities With Normal Ankle-Brachial Index in Japanese Patients With Type 2 Diabetes Diabetes Care, June 1, 2003; 26(6): 1764 - 1769. [Abstract] [Full Text] [PDF]
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