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The Ankle Brachial Pressure Index (ABPI) is the ratio of the blood pressure in the lower legs to the blood pressure in the arms. Compared to the arm, lower blood pressure in the leg is a symptom of blocked arteries (peripheral vascular disease). The ABPI is calculated by dividing the systolic blood pressure in the arteries at the ankle and foot by the higher of the two systolic blood pressures in the arms.



A Doppler ultrasound blood flow detector, commonly called Doppler Wand or Doppler probe, is used to register the peripheral pulse while a sphygmomanometer (blood pressure cuff) is inflated over the artery until the pulse ceases, proximal to the doppler probe. The cuff is slowly deflated, and the corresponding sphygmomanometer pressure at the instant the pulse returns provides the systolic blood pressure reading, for the given artery.

The higher of the left and right arm brachial artery pressure is generally used in the assessment. The pressures in each foot's posterior tibial artery and dorsalis pedis artery are measured with the higher of the two values used as the ABPI for that leg.[1]

ABPI_{Leg} = \frac { P_{Leg} }{ P_{Arm} }
Where PLeg is the systolic blood pressure of dorsalis pedis or posterior tibial arteries
and PArm is the highest of the left and right arm brachial systolic blood pressure

The ABPI test is a popular tool for the non-invasive assessment of PVD. Studies have shown the sensitivity of ABPI is 90% with a corresponding 98% specificity for detecting hemodynamically significant (Serious) stenosis >50% in major leg arteries, defined by angiogram[2].

However, ABPI has known issues:

  • ABPI is known to be unreliable on patients with arterial calcification (Hardening of the arteries) which results in less or incompressible arteries[3], as the stiff arteries produce falsely elevated ankle pressure, giving false negatives[4]). This is often found in patients with diabetes melitus[5] (41% of PAD patients have diabetes[6]), renal failure or heavy smokers. ABPI values >1.3 should be investigated further regardless.
  • Performing ABPI is time consuming[7].
  • Resting ABPI is insensitive to mild PAD[8]. Treadmill tests (6 minute) are sometimes used to increase ABPI sensitivity[9], but this is unsuitable for patients who are obese or have co-morbidities such as Aortic aneurysm, and increases assessment duration.
  • Lack of protocol standardisation[10], which reduces intra-observer reliability[11].
  • Skilled Operators are required for consistent, accurate results[12].

Interpretation of results

In a normal subject the pressure at the ankle is slightly higher than at the elbow (there is reflection of the pulse pressure from the vascular bed of the feet, whereas at the elbow the artery continues on some distance to the wrist). The ABPI is the ratio of the highest ankle to brachial artery pressure and an ABPI of greater than 0.9 is considered normal (Free from significant PAD).

However, an ABPI value greater than 1.3 is considered abnormal, and suggests calcification of the walls of the arteries and incompressible vessels, reflecting severe peripheral vascular disease.

Provided that there are no other significant conditions affecting the arteries of the leg, the following ABPI ratios can be used to predict the severity of PAD as well as assess the nature and best management of various types of leg ulcers:[1]

ABPI value Interpretation Action Nature of ulcers, if present
above 1.2 Abnormal
Vessel hardening from PVD
Refer routinely Venous ulcer
use full compression bandaging
1.0 - 1.2 Normal range None
0.9 - 1.0 Acceptable
0.8 - 0.9 Some arterial disease Manage risk factors
0.5 - 0.8 Moderate arterial disease Routine specialist referral Mixed ulcers
use reduced compression bandaging
under 0.5 Severe arterial disease Urgent specialist referral Arterial ulcers
no compression bandaging used

Predictor of atherosclerosis mortality

Studies in 2006 suggests that an abnormal ABPI may be an independent predictor of mortality, as it reflects the burden of atherosclerosis.[13][14]

See also


  1. ^ a b Vowden P, Vowden K (March 2001). "Doppler assessment and ABPI: Interpretation in the management of leg ulceration". Worldwide Wounds.   - describes ABPI procedure, interpretation of results, and notes the somewhat arbitrary selection of "ABPI of 0.8 has become the accepted endpoint for high compression therapy, the trigger for referral for a vascular surgical opinion and the defining upper marker for an ulcer of mixed aetiology"
  2. ^ McDermott MM, Criqui MH, Liu K, Guralnik JM, Greenland P, Martin GJ, Pearce W (December 2000). "Lower ankle/brachial index, as calculated by averaging the dorsalis pedis and posterior tibial arterial pressures, and association with leg functioning in peripheral arterial disease". JJ Vasc Surg. 32 (6): 1164–71. doi:10.1067/mva.2000.108640. PMID 11107089.  
  3. ^ Allison MA, Hiatt WR, Hirsch AT, Coll JR, Criqui MH (April 2008). "A high ankle-brachial index is associated with increased cardiovascular disease morbidity and lower quality of life". J Am Coll Cardiol. 51 (13): 1292–8. doi:10.1016/j.jacc.2007.11.064. PMID 18371562.  
  4. ^ American Diabetes Association (December 2003). "Peripheral Arterial Disease in People with Diabetes". Diabetes Care 26 (12): 3333–3341. doi:10.2337/diacare.26.12.3333. PMID 14633825.  
  5. ^ Aboyans V, Ho E, Denenberg JO, Ho LA, Natarajan L, Criqui MH (November 2008). "The association between elevated ankle systolic pressures and peripheral occlusive arterial disease in diabetic and nondiabetic subjects". J Vasc Surg. 48 (5): 1197–203. doi:10.1016/j.jvs.2008.06.005. PMID 18692981.  
  6. ^ Novo S (March 2002). "Classification, epidemiology, risk factors, and natural history of peripheral arterial disease". Diabetes Obes Metab. 4: S1–6. doi:10.1046/j.1463-1326.2002.0040s20s1.x. PMID 12180352.  
  7. ^ Doubeni CA, Yood RA, Emani S, Gurwitz JH (March-April 2006). "Identifying unrecognized peripheral arterial disease among asymptomatic patients in the primary care setting". Angiology 57 (2): 171–80. doi:10.1177/000331970605700206. PMID 16518524.  
  8. ^ Stein R, Hriljac I, Halperin JL, Gustavson SM, Teodorescu V, Olin JW (February 2006). "Limitation of the resting ankle-brachial index in symptomatic patients with peripheral arterial disease". J Vasc Med. 11 (1): 29–33. doi:10.1191/1358863x06vm663oa. PMID 16669410.  
  9. ^ Montgomery PS, Gardner AW, (June 1998). "The clinical utility of a six-minute walk test in peripheral arterial occlusive disease patients". J Am Geriatr Soc. 46 (6): 706–11. PMID 9625185.  
  10. ^ Jeelani NU, Braithwaite BD, Tomlin C, MacSweeney ST (July 2000). "Variation of method for measurement of brachial artery pressure significantly affects ankle-brachial pressure index values". Eur J Vasc Endovasc Surg. 20 (1): 25–8. doi:10.1053/ejvs.2000.1141. PMID 10906293.  
  11. ^ Caruana MF, Bradbury AW, Adam DJ (May 2005). "The validity, reliability, reproducibility and extended utility of ankle to brachial pressure index in current vascular surgical practice". Eur J Vasc Endovasc Surg. 29 (5): 443–51. doi:10.1016/j.ejvs.2005.01.015. PMID 15966081.  
  12. ^ Kaiser V, Kester AD, Stoffers HE, Kitslaar PJ, Knottnerus JA (July 1999). "The influence of experience on the reproducibility of the ankle-brachial systolic pressure ratio in peripheral arterial occlusive disease". Eur J Vasc Endovasc Surg. 18 (1): 25–9. doi:10.1053/ejvs.1999.0843. PMID 10388635.  
  13. ^ Feringa HH, Bax JJ, van Waning VH, et al. (March 2006). "The long-term prognostic value of the resting and postexercise ankle-brachial index". Arch. Intern. Med. 166 (5): 529–35. doi:10.1001/archinte.166.5.529. PMID 16534039.  
  14. ^ Wild SH, Byrne CD, Smith FB, Lee AJ, Fowkes FG (March 2006). "Low ankle-brachial pressure index predicts increased risk of cardiovascular disease independent of the metabolic syndrome and conventional cardiovascular risk factors in the Edinburgh Artery Study". Diabetes Care 29 (3): 637–42. doi:10.2337/diacare.29.03.06.dc05-1637. PMID 16505519.  


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