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(/* 2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (Updating the 2005 Guideline) (DO NOT EDIT){{cite journal |author= |title=2011 ACCF/AHA Focused Update of the Guideline for the Manageme...) |
(/* 2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (Updating the 2005 Guideline) (DO NOT EDIT){{cite journal |author= |title=2011 ACCF/AHA Focused Update of the Guideline for the Manageme...) |
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*[[ABI]]<0.4: 50% one year mortality rate | *[[ABI]]<0.4: 50% one year mortality rate | ||
== 2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (Updating the 2005 Guideline) (DO NOT EDIT)<ref name="pmid21959305">{{cite journal |author= |title=2011 ACCF/AHA Focused Update of the Guideline for the Management of patients with peripheral artery disease (Updating the 2005 Guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines |journal=[[Circulation]] |volume=124 |issue=18 |pages=2020–45 |year=2011 |month=November |pmid=21959305 |doi=10.1161/CIR.0b013e31822e80c3 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=21959305 |accessdate=2012-10-09}}</ref><ref name="pmid16549646">{{cite journal |author=Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WR, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM, White CJ, White J, White RA, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B |title=ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation |journal=[[Circulation]] |volume=113 |issue=11 |pages=e463–654 |year=2006 |month=March |pmid=16549646 |doi=10.1161/CIRCULATIONAHA.106.174526 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16549646 |accessdate=2012-10-09}}</ref>== | == 2011 Incorporated with 2005 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (Updating the 2005 Guideline) (DO NOT EDIT)<ref name="pmid21959305">{{cite journal |author= |title=2011 ACCF/AHA Focused Update of the Guideline for the Management of patients with peripheral artery disease (Updating the 2005 Guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines |journal=[[Circulation]] |volume=124 |issue=18 |pages=2020–45 |year=2011 |month=November |pmid=21959305 |doi=10.1161/CIR.0b013e31822e80c3 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=21959305 |accessdate=2012-10-09}}</ref><ref name="pmid16549646">{{cite journal |author=Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WR, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM, White CJ, White J, White RA, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B |title=ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation |journal=[[Circulation]] |volume=113 |issue=11 |pages=e463–654 |year=2006 |month=March |pmid=16549646 |doi=10.1161/CIRCULATIONAHA.106.174526 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16549646 |accessdate=2012-10-09}}</ref>== | ||
=== Ankle-Brachial Index, Toe-Brachial Index, and Segmental Pressure Examination (DO NOT EDIT) <ref name="pmid21959305">{{cite journal |author= |title=2011 ACCF/AHA Focused Update of the Guideline for the Management of patients with peripheral artery disease (Updating the 2005 Guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines |journal=[[Circulation]] |volume=124 |issue=18 |pages=2020–45 |year=2011 |month=November |pmid=21959305 |doi=10.1161/CIR.0b013e31822e80c3 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=21959305 |accessdate=2012-10-09}}</ref><ref name="pmid16549646">{{cite journal |author=Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WR, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM, White CJ, White J, White RA, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B |title=ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation |journal=[[Circulation]] |volume=113 |issue=11 |pages=e463–654 |year=2006 |month=March |pmid=16549646 |doi=10.1161/CIRCULATIONAHA.106.174526 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16549646 |accessdate=2012-10-09}}</ref>=== | === Ankle-Brachial Index, Toe-Brachial Index, and Segmental Pressure Examination (DO NOT EDIT) <ref name="pmid21959305">{{cite journal |author= |title=2011 ACCF/AHA Focused Update of the Guideline for the Management of patients with peripheral artery disease (Updating the 2005 Guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines |journal=[[Circulation]] |volume=124 |issue=18 |pages=2020–45 |year=2011 |month=November |pmid=21959305 |doi=10.1161/CIR.0b013e31822e80c3 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=21959305 |accessdate=2012-10-09}}</ref><ref name="pmid16549646">{{cite journal |author=Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WR, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM, White CJ, White J, White RA, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B |title=ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation |journal=[[Circulation]] |volume=113 |issue=11 |pages=e463–654 |year=2006 |month=March |pmid=16549646 |doi=10.1161/CIRCULATIONAHA.106.174526 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16549646 |accessdate=2012-10-09}}</ref>=== | ||
Revision as of 15:39, 1 November 2012
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Peripheral arterial disease Microchapters |
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Differentiating Peripheral arterial disease from other Diseases |
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Diagnosis |
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Treatment |
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Case Studies |
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AHA/ACC Guidelines on Management of Lower Extremity PAD |
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Guidelines for Structured Exercise Therapy for Lower Extremity PAD |
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Guidelines for Minimizing Tissue Loss in Lower Extremity PAD |
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Guidelines for Revascularization of Claudication in Lower Extremity PAD |
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Guidelines for Management of Acute Limb Ischemial in Lower Extremity PAD |
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Guidelines for Longitudinal Follow-up for Lower Extremity PAD |
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Peripheral arterial disease screening On the Web |
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American Roentgen Ray Society Images of Peripheral arterial disease screening |
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Directions to Hospitals Treating Peripheral arterial disease |
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Risk calculators and risk factors for Peripheral arterial disease screening |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Rim Halaby
Synonyms and keywords: Ankle-Brachial index; Ankle Brachial index; ABI
Overview
A resting ankle brachial index is the screening study of choice in a patient who has suspected lower extremity peripheral arterial disease. The ankle brachial index is defined as the ratio of the ankle blood pressure divided by the highest brachial blood pressure. An ankle branchial index should be obtained if a patient has one or more of the following characteristics: 1) exertional claudication; 2) the presence of nonhealing wounds; 3) age over 50 with a history of smoking or diabetes or 4) age over 65.
Ankle Brachial Index (ABI)
- The ABI is a screening test for the assessment for the presence of PAD.
- Studies in 2006 suggests that an abnormal ABI may be an independent predictor of mortality, as it reflects the burden of atherosclerosis[1][2].
Method
- The pressures in the posterior tibial artery and dorsalis pedis artery in the feet and the brachial artery at the elbow are estimated. A Doppler probe is used, through a device called the Pulse Volume Recorder (some variances may apply depending on the physician), to monitor the pulse while a sphygmomanometer (blood pressure cuff) is inflated above the artery. The cuff is deflated and the pressure at which the pulse returns is recorded. The blood pressures are measured after 10 minutes of rest.
ABI Measurement at Rest
- In a normal subject the pressure at the ankle pulses 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 ABI is the ratio of the ankle to the highest brachial blood pressure and an ABPI of greater than 0.9 is considered normal, suggesting that there is no significant peripheral vascular disease affecting the vessels of the legs.
- It should be noted that the ABI varies by ethnicity and gender. [3]. For example, among blacks and women, a normal ABI extends down to 0.85 .
- ABI should be measured in both legs in all new patients with PAD of any severity to confirm the diagnosis and establish a baseline
Interpretation of the ABI results at rest:
- 0.9 to 1.3: Normal
- 0.5 to 0.7: Moderate
- < 0.50: Severe
- ≥ 1.4: Poorly compressible vessels
- A value greater than 1.4 is considered abnormal, and suggests calcification of the walls of the arteries and noncompressible vessels, reflecting severe peripheral vascular disease.
ABI Measurement in Exercise Testing
- The exercise ABI is done by having the patient stand on their toes repeatedly as exercies. The ABI is rechecked after exercise. This test is done if the patient has symptoms with exercise. However, patients with peripheral artery disease can have normal ABI at rest; however, they show abnormal ABI measurements after stress exercise.
- During exercise, the systolic pressure increases causing an increase in the pressure difference beyond the diseased vessel. Hence, the ABI will decrease. An abnormal result is a drop of > 20% on ABI in one minute, despite a normal ABI at rest.
- Patients who can not tolerate the treadmill exercise can do the tip toe exercise as an alternative.
Interpretation of the ABI results at rest:
- 0.5 to 0.9: Mild
- 0.15 to 0.8: Moderate
- <0.15: Severe.[4]
Evaluation of the severity of the arterial occlusive disease based on the tolerance to exercise testing
- Exercise tolerance less than 5 minutes: moderate
- Exercise tolerance less than 3 minutes: severe.[5]
Toe-Brachial Index
- When the vessels are stiff, as in the case of diseases like diabetes, the ABI index is inaccurate in the evaluation of the severity of the arterial occlusive diseases.
- Toe-brachial index is a reliable alternative when the vessels are stiff and non compressible.
- The normal range for the toe-brachial pressure index is values more than 0.70.[6]
Segmental Pressures Examination
- Segmental pressure examinations is basically applying the same ABI principle but on different parts of the extremities.
The Appropriate Management Actions Following Screening with ABI
- Shown below is a table summarizing the interpretation of the ABI values and the appropriate actions to be taken accordingly.
| ABI 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 |
Prognosis Associated with Ankle Brachial Indexes (ABI)
- Normal ABI in the presence of symptoms: no change in the mortality rate
- ABI<0.85: 10% five year mortality rate
- ABI<0.4: 50% one year mortality rate
2011 Incorporated with 2005 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (Updating the 2005 Guideline) (DO NOT EDIT)[7][8]
Ankle-Brachial Index, Toe-Brachial Index, and Segmental Pressure Examination (DO NOT EDIT) [7][8]
| Class I |
| "1. The resting ABI should be used to establish the lower extremity PAD diagnosis in patients with suspected lower extremity PAD, defined as individuals with 1 or more of the following: exertional leg symptoms, nonhealing wounds, age 65 years and older, or 50 years and older with a history of smoking or diabetes.(Level of Evidence: B)" |
| "2. The ABI should be measured in both legs in all new patients with PAD of any severity to confirm the diagnosis of lower extremity PAD and establish a baseline.(Level of Evidence: B)" |
| "3. The toe-brachial index should be used to establish the lower extremity PAD diagnosis in patients in whom lower extremity PAD is clinically suspected but in whom the ABI test is not reliable due to noncompressible vessels (usually patients with long-standing diabetes or advanced age). (Level of Evidence: B)" |
| "4. Leg segmental pressure measurements are useful to establish the lower extremity PAD diagnosis when anatomic localization of lower extremity PAD is required to create a therapeutic plan. (Level of Evidence: B)" |
| "5. ABI results should be uniformly reported with noncompressible values defined as greater than 1.40, normal values 1.00 to 1.40, borderline 0.91 to 0.99, and abnormal 0.90 or less. (Level of Evidence: B)" |
References
- ↑ Feringa HH, Bax JJ, van Waning VH, Boersma E, Elhendy A, Schouten O, Tangelder MJ, van Sambeek MH, van den Meiracker AH, Poldermans D (2006). "The long-term prognostic value of the resting and postexercise ankle-brachial index". Arch Intern Med. 166: 529–535. PMID 16534039.
- ↑ Wild SH, Byrne CD, Smith FB, Lee AJ, Fowkes FG (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. PMID 16505519.
- ↑ Singh S, Bailey KR, Kullo IJ (2011). "Ethnic differences in ankle brachial index are present in middle-aged individuals without peripheral arterial disease". International Journal of Cardiology. doi:10.1016/j.ijcard.2011.05.068. PMID 21652099. Unknown parameter
|month=ignored (help) - ↑ Wennberg PW, Rooke TW. Chapter 109. Diagnosis and Management of Diseases of the Peripheral Arteries and Veins. In: Fuster V, Walsh RA, Harrington RA, eds. Hurst's The Heart. 13th ed. New York: McGraw-Hill; 2011.
- ↑ Feringa HH, Bax JJ, van Waning VH, Boersma E, Elhendy A, Schouten O; et al. (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.
- ↑ Hobbs JT, Yao ST, Lewis JD, Needham TN (1974). "A limitation of the Doppler ultrasound method of measuring ankle systolic pressure". Vasa. 3 (2): 160–2. PMID 4831541.
- ↑ 7.0 7.1 "2011 ACCF/AHA Focused Update of the Guideline for the Management of patients with peripheral artery disease (Updating the 2005 Guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines". Circulation. 124 (18): 2020–45. 2011. doi:10.1161/CIR.0b013e31822e80c3. PMID 21959305. Retrieved 2012-10-09. Unknown parameter
|month=ignored (help) - ↑ 8.0 8.1 Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WR, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM, White CJ, White J, White RA, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B (2006). "ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation". Circulation. 113 (11): e463–654. doi:10.1161/CIRCULATIONAHA.106.174526. PMID 16549646. Retrieved 2012-10-09. Unknown parameter
|month=ignored (help)