Ankle brachial index as a surrogate to vascular imaging in evaluation of peripheral artery disease in patients with type 2 diabetes

Ejiofor Ugwu,Anthony Anyanwu,Michael Olamoyegun

doi:10.1186/s12872-020-01821-6

Abstract

BackgroundPeripheral artery disease (PAD) is common in persons with type 2 diabetes (T2DM) and contributes significantly to cardiovascular morbidity and mortality. Controversy exists regarding the utility of ankle brachial index (ABI) for clinical diagnosis of PAD in persons with diabetes. The aim of this study was to evaluate the reliability of ABI for diagnosis of PAD in patients with T2DM using duplex ultrasonography (DUS) as the gold standard.ResultsA total of 319 legs from 163 patients comprising of 156 subjects with intact legs and 7 patients who had undergone unilateral lower limb amputations were studied. The mean age of the participants was 56.1 ± 17.3 years. One hundred and ninety-five legs (61.1%) had sonographically confirmed PAD which was mild, moderate and severe in 40%, 41.5% and 18.5% respectively. The accuracy of ABI in detecting PAD was 76.7% for mild stenosis, 91.7% for moderate stenosis and 93.1% for severe stenosis. The sensitivity of ABI improved with increasing severity of arterial stenosis, reaching 100% in severe cases. ABI demonstrated good agreement with DUS [kappa = 0.65 (95% CI 0.49–0.88), P < 0.001].ConclusionIn comparison to DUS, the ABI demonstrated good reliability for diagnosis of PAD in high risk T2DM patients. The utility of this simple and non-invasive procedure should therefore be maximized in clinical practice.

Highlights

Peripheral artery disease (PAD) is common in persons with type 2 diabetes (T2DM) and contributes significantly to cardiovascular morbidity and mortality
The inclusion criteria were subjects aged 30–80 years, who had been diagnosed with type 2 diabetes mellitus (T2DM) according to the 1999 World Health Organization criteria [18], and who have clinical suspicion of lower extremity PAD based on history of intermittent claudication and/ or diminished/absent peripheral pulses on manual palpation
In the year 2012, and updated in 2018, the National Institute for Health and Care Excellence stated that diagnosis of PAD should not be ruled out in people with diabetes on the basis of a normal ankle brachial index (ABI), pointing out that such people are more prone to arterial calcification and may have falsely elevated ankle pressures [13]

Summary

Introduction

Peripheral artery disease (PAD) is common in persons with type 2 diabetes (T2DM) and contributes significantly to cardiovascular morbidity and mortality. The risk factors of PAD are those of cardiovascular diseases generally and include older age, hypertension, diabetes mellitus, cigarette smoking and hypercholesterolemia [4]. Individuals with type 2 diabetes mellitus (T2DM) are three times more likely to develop PAD than those without [5]. Lower limb PAD is reported in 35–60% of T2DM patients with diabetic foot ulcer (DFU) and contributes significantly to its development, progression and outcome [6]. Lower limb PAD is an independent risk factor for lower extremity amputation (LEA) in patients with DFU [6, 9]. Foot ulcer recurrence is reportedly five times more likely in diabetic patients with PAD than those without [6]. Peripheral artery disease is an important morbidity requiring serious attention in persons living with diabetes

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