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Int J Endocrinol Metab 2009;4: 229-234

ORIGINAL ARTICLE
CorrelationbetweentheAnkleBrachialandToe
BrachialIndexesandCoronaryArteryDiseasein
PatientswithType2Diabetes

Taghavi M, Mousavi Z, Karbasforushan J

Endocrine Research Center, Mashhad University of Medical Sciences, Mashhad, I.R.Iran

A
therosclerotic coronary vascular disease TBI in identifying diabetic patients with CVD
(CVD) is a major cause of mortality and due to accelerated atherosclerosis.
morbidity among diabetic patients. The
ankle-brachial pressure index (ABI) is a
simple screening procedure used in Key Words: Ankle-brachial index, Toe-brachial
primary care settings for high risk populations, index, Coronary vascular disease, Type 2 diabetes
such as in diabetic patients, in whom medial ar-
terial calcification results in falsely elevated
ABI, which complicates?? the value of ABI in Received: 04.01.2010 Accepted: 02.06.2010
predicting CVD. The aim of this study was to de-
termine whether ABI or Toe-brachial index (TBI)
abnormalities can be used to identify asympto- Introduction
matic type 2 diabetic patients with CVD. Mate- Type 2 diabetes mellitus (DM) is asso-
rials &Methods: In this case control study, 91 pa- ciated with increased cardiovascular risk,
tients with Type 2 DM were selected. All the pa-
tients, who had documented evidence for pres- mostly due to accelerated atherosclerosis.
ence or absence of CVD, completed a question- Recent evidence shows that more aggressive
naire regarding medical history, following preventive strategies may be effective in
which TBI and ABI were measured using a high-risk groups, making it ncessary to
handheld ultrasound Doppler. ABI values less
than 0.9 and TBI less than 0.7 considered abnor- identify diabetic patients with asymptomatic
mal. Results: Forty-four persons (patient group) cardiovascular disease1.
had documented CVD and 47 had normal angio- Ankle-pressure assessment is a simple
graphy (control group). ABI < 0.9 was present in
13.6% of the patient group and in 8.5% of control
and inexpensive procedure that can be
group; TBI < 0.7 was present in 34.1% of the pa- performed in primary care settings. An Ankle
tients group and 23.4% of controls. There was no Brachial Index (ABI) value<0.9 is widely
significant difference between abnormal ABI acknowledged to indicate an abnormally low
and abnormal TBI in the patients or and con-
trols. Sensitivity and specificity of abnormal re-
level2. Low ABI has been associated with
sults in prediction of CVD was 13.6% and 91.4% increased risk of subsequent mortality in
for ABI and 34% and 76.5% for TBI. Conclusion: populations with3 or without48 known cardio-
Our study shows lack of sensitivity of ABI and vascular disease (CVD); low ABI can predict
Correspondence: M. Taghavi, Endocrine Research Cen- increased risk of fatal myocardial infarction9
ter, Mashhad Medical University, Ahmadabad Street- and increased risk of CVD mortality 4-6,8,
Ghaem Hospital, Mashhad, Iran.
E-mail: mortezataghavi2003@yahoo.com ,
independent of conventional risk factors.
taghavimr@mums.ac.ir
230 M Taghavi et al

Although an ABI abnormality can be used rotein (LDLchol) > 100 mg/dL or non high
for screening cardiovascular risk, its capacity density lipoprotein cholesterol>130mg/dL.
to identify asymptomatic atherosclerosis in Height and weight were recorded and body
diabetic patients is unknown. In diabetic mass index calculated. With the patient
subjects, ABI measurement is complicated by placed in a supine position for 15 minutes,
the presence of medial arterial calcification Toe Brachial Index (TBI) and Ankle Brachial
which results in falsely elevated ABI values Index (ABI) were measured using a handheld
in the absence of significant peripheral artery ultrasound doppler device (Atys Medical
disease. To compensate, we also investigated France) by an endocrinologist experienced in
index measurements involving the toe and this procedure.All measurements were perfor-
brachial systolic pressure (toe-brachial index med in a room, maintained at a temperature
[TBI]) in our patients. The aim of this study of 2325C, after at least 30 min of
was to determine whether ABI or TBI acclimatization. The highest systolic pressure
abnormalities, which are bedside indexes of of arm, ankle (tibial or posterior tibial), and
peripheral artery disease, could identify toe pressures for each foot, are divided by the
diabetic patients with obstructive coronary highest brachial systolic pressure to obtain
atherosclerosis. the ABI and TBI for each leg. ABI values
less than 0.9 and TBI less than 0.7 are
Materials & Methods considered abnormal.
In this one-year, case control study, Data are expressed as the mean SD.
conducted in Mashhad, Iran, 91 consecutive Data were analyzed by a Students paired t-
patients with Type 2 DM were selected and test or an unpaired t test. For nonparametric
recruited between September 2007 and data, differences between groups were ana-
September 2008, from the endocrinology or lyzed by the Mann-Whitney U test. A p-value
cardiology in-patient clinics. All of the <0.05 was considered significant.
patients had documented evidence for
presence or absence of coronary heart Results
disease. Of these, 44 patients (patient group) The patient group (diabetic patients with
had documented CVD (defined as a history documented IHD) included 44 patients (26
of myocardial infarction, coronary artery females, 18 males) and the control group
bypass grafting, or an abnormal coronary (diabetic patients with normal angiography)
angiogram) and 47 who were evaluated for included 47 patients (29 females, 18 males).
CVD and had normal angiography made up Mean age of the subjects was 55.59.19
the control group. Smokers and patients with years in the patient group and 54.68 6.85
hepatic or renal failure, rheumatologic years in the controls. There was no
diseases, peripheral edema, chronic obstru- significant difference in mean age, mean
ctive lung disease and thrombophlebitis were body mass indexes (BMI) and durations of
excluded from the study. Participants diabetes in the patient and control groups
completed a questionnaire regarding medical (P=0.51) (Table1); 32 patients in the case
history at the Endocrine Research Center. group and 32 controls had hypertension; 30
Hypertension was defined as use of antihy- patients (case group) and 34 controls had
pertensive medications or blood pressure hyperlipidemia. There was no significant
>130/80 mmHg (mean of 3 measurements). difference between the prevalence of
Hyperlipidemia was defined as serum hypertension (P=0.63) or hyperlipidemia
triglycerides>150 mg/dL, low density lipop- (P=0.66) between the two groups (Table 1).

International Journal of Endocrinology and Metabolism


Ankle and Toe Brachial Indexes in type 2 diabetes 231

Table1. Characteristics of the patient and control groups


Patients (44) Controls (47)
Age (yr) 55.50 9.19* 54.68 6.85
Body mass index (kg/m2) 27.65 4.26 27.59 3.66
Duration of diabetes (yr) 12.27 8.85 11.12 7.85
Mean ABI 1.091 0.12 1.043 0.12
Mean TBI 0.74 0.11 0.74 0.10
ABI < 0.9 (%) 13.6 8.5
TBI < 0.7 (%) 34.1 23.4
*meanSD

In 10 persons with abnormal low ABI (in takes less than 10 to 15 minutes, and can be
both the case and control groups), 5 had done both in the physician's office and in
abnormal TBI. In 78 persons with normal community settings by a suitably trained
ABI, 19 had abnormal TBI. In the remaining nurse or physician16,17. Patient acceptability is
3, ABI was above 1.3; ABI < 0.9 was present high because it is noninvasive and causes no
in 13.6% of patients group and 8.5% of the discomfort.Variability is comparable with that
controls; TBI < 0.7 was observed in 34.1% of of routine blood pressure18,19 and individuals
the patient group and 23.4% of the controls. with borderline results may benefit from a
Mean ABI in the patient group was 1.091 repeated measure at a different visit19. Recent-
0.12, and 1.043 0.12 in the controls. Mean ly guidelines published by the American
TBI in the patient group was 0.74 0.11, Heart Association and the American College
being 0.74 0.10 in the controls. There was of Cardiology20, the Transatlantic Inter-
no significant difference between abnormal Society Consensus Working Group21 and the
ABI (with cut point of 0.9) (P = 0.26) or Fourth Joint European Task Force22 suggest
abnormal TBI (with cut point of 0.7) (P = that ABI should be considered for the
0.46) in patients or controls (Table1). purpose of cardiovascular risk assessment in
Abnormal ABI results had sensitivity and the general population.
specificity of 13.6% and 91.4% and abnormal Abnormal ABI results, reported to have
TBI results had sensitivity and specificity of sensitivity and specificity of 85% and 77%
34% and 76.5% for coronary artery disease. for 3-vessel or left main coronary artery
disease23, are independent predictors of
Discussion CVD12. Other studies document different
Atherosclerotic coronary vascular disease results; ABI was normal in some studies in
(CVD) is a major cause of mortality and many patients who had atherosclerosis12,13,
morbidity among diabetic patients. It is suggesting deficiency of ABI in detecting
desirable to identify diabetic subjects with asymptomatic CVD; in a sub study of 414
coronary atherosclerosis before the onset of participants in the Cardiovascular Health
angina pectoris or myocardial infarction. Study, Newman et al (24) reported a lack of
Targeting aggressive preventive strategies on sensitivity (21%), but moderate specificity
the basis of imaging modalities, clinical (83.5%), of ABI <0.9 in detecting coronary
characteristics and biomarkers can reduce the artery calcification scores >400 in an elderly,
risk of CVD in high risk population including predominantly non-diabetic sample. In another
diabetics 10,11. One approach involves bedside study by Bagheri et al, associations of ABI
tests that predict future CVD, and ABI is abnormalities with coronary artery calcium
potentially a useful tool for this purpose 12-15. (CAC),a measure of coronary atherosclerosis,
Easy and inexpensive, ABI measurement were examined in 589 asymptomatic patients

International Journal of Endocrinology and Metabolism


232 M Taghavi et al

with type 2 DM. Neither ECG nor ABI ABI in diabetic patients with and without
changes predicted CAC after adjusting for CVD was insignificant. The results show
age, gender, and race, and ABI abnormalities lack of sensitivity, but moderate specificity
failed to detect patients with subclinical of ABI to assess asymptomatic CVD in
coronary atherosclerosis 25 patients with diabetes.
ABI interpretation is complicated by the Because medial arterial calcification is
presence of medial arterial calcification and less frequent in the toe than the ankle, we
most patients with an ABI >1.3 have been also measured TBI. The results showed that
shown to have such calcifications 26. In the difference between abnormal TBI in
diabetic patients medial artery calcification diabetic patients with and without CVD was
occurs extensively and decreases the value of insignificant.
ABI; in some studies, index measurements To discuss study limitations, first, the
involving the toe and brachial systolic small sample size of subjects considerably
pressure (TBI) are advocated in diabetic limits the values of results. Further extensive
patients. 26 studies are needed to clarify the relationship
However low ABI can independently pre- between abnormal ABI and CVD. Second,
dict the risk of all cause- and CVD mortality this study is cross sectional and therefore
in patients with type 2 DM; in a study from longitudinal inferences cannot be drawn. A
the Netherlands, investigating the association prospective study should be undertaken to
between ABI and TBI and cardiovascular evaluate role played by high ABI in the
mortality, in diabetic and non diabetic development of atherosclerotic disease.
individuals, it was shown that, although an Our study shows lack of sensitivity of
ABI< 0.9 may underestimate the presence of ABI and TBI in identifying diabetic patients
peripheral artery disease in individuals with with CVD, induced by accelerated subclinical
type 2 diabetes, this measure is a powerful atherosclerosis. Abnormal ABI and TBI
independent predictor of cardiovascular mort- results had low sensitivity but moderate
ality in both diabetic and non-diabetic specificity for coronary artery disease in
subjects27 This result has also been confirmed diabetic patients.
by similar studies conducted in other count-
ries.28,29 Acknowledgement:
Our study compared the ABI values in This study was supported by an investiga-
diabetic patients with documented CVD and tion grant from the Mashhad University. All
with normal coronary vessels. The results authors have contributed significantly and are
showed that the difference between abnormal in agreement with the content of manuscript.

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