Use of ankle brachial pressure index to predict cardiovascular events and death: A cohort study

Objective-To determine whether a low ankle brachial pressure index is associated with an increased risk of cardiovascular events and death, and whether the prediction of such events could be improved by including this index. Design-Cohort study. Setting-11 practices in Edinburgh, Scotland. Subjects-1592 men and women aged 55-74 years selected at random from the age-sex registers of 11 general practices and followed up for 5 years. Main outcome measures-Incidence of fatal and non-fatal cardiovascular events and all cause mortality. Results-At baseline 90 (5.7%) of subjects had an ankle brachial pressure index less than or equal to 0.7, 288 (18.2%) had an index less than or equal to 0.9, and 566 (35.6%) less than or equal to 1.0. After five years subjects with an index less than or equal to 0.9 at baseline had an increased risk of non-fatal myocardial infarction (relative risk 1.38, 95% confidence interval 0.88 to 2.16), stroke (1.98, 1.05 to 3.77), cardiovascular death (1.85, 1.15 to 2.97), and all cause mortality (1.58, 1.14 to 2.18) after adjustment for age, sex, coronary disease, and diabetes at baseline. The ability to predict subsequent events was greatly increased by combining the index with other risk factors-for example, hypertensive smokers with normal cholesterol concentrations had a positive predictive value of 25.0%, increasing to 43.8% in subjects with a low index and decreasing to 15.6% in those with a normal index. Conclusion-The ankle brachial pressure index is a good predictor of subsequent cardiovascular events, and improves on predictions by conventional risk factors alone. It is simple and accurate and could be included in routine screening of cardiovascular status.