Risk factors and haemodynamic variables in patients with low toe-brachial index but normal ankle-brachial index

Høyer, Christian; Høgh, Annette; Sandermann, Jes; Petersen, Lars Jelstrup

doi:10.1016/j.atherosclerosis.2019.08.005

Cited by 9 publications

(6 citation statements)

References 21 publications

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“…24 However, our data show that TBI also detects PAD in an even higher proportion of limbs (70%), even when ABI is within normal limits. Other studies have also observed that between 14% and 27% of patients referred for distal pressure measurements including diabetes patients have a low TBI, with a normal ABI, referred to as “isolated low TBI.” 25,26 This is in keeping with our observation, although the prevalence of low TBI within our cohort of diabetes patients was much higher at 70% and a significant proportion had an associated ulceration. Thus, the terminology of “isolated low TBI” may not be as benign as it might seem.…”

Section: Discussionsupporting

confidence: 90%

Peripheral Arterial Disease Located in the Feet of Patients With Diabetes and Foot Ulceration Demands a New Approach to the Assessment of Ischemia

Manu

Freedman

Rashid

et al. 2020

The International Journal of Lower Extremity Wounds

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Peripheral arterial disease (PAD) is common below the knee in diabetes but arteries in the foot are controversially said to be spared of occlusive disease. This is relevant to the convenient site of vascular assessment that is recommended in guidelines. Should assessment be distal at toe/forefoot to detect foot disease or only proximal to detect disease at ankle level? The objective was to determine frequency of PAD at foot and ankle level. This was a cross-sectional observational study, evaluating arterial disease proximally by palpation of pedal pulses and Ankle Brachial Index (ABI), and distally by Toe Brachial Index (TBI), and forefoot transcutaneous oxygen tension (tcpO2), in consecutive patients presenting with foot ulceration. We assessed 301 limbs in 154 patients: 59% of limbs were ulcerated. PAD in the foot was detected in 70% and 74% of limbs by TBI and forefoot tcpO2, respectively, but PAD at ankle level only in 51% and 34% by pulse palpation and ABI, respectively. In limbs with “normal” ABI, PAD was present in the foot in 70% as indicated by low TBI, and in 73% by low tcpO2, with 70% to 64% having associated ulceration, respectively. When compared with arterial waveforms, as a measure of PAD, TBI gave an excellent AUC (area under the curve of the receiver operating characteristic curve) of 0.81 (95% confidence interval: 0.73-0.89), but ABI gave a poor AUC of 0.65 (95% confidence interval: 0.55-0.76). In conclusion, arterial disease is important in the foot and can be detected by TBI, which should be performed even when ABI is normal. Guidelines that recommend TBI only if ABI is artificially raised need updating.

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Section: Discussionsupporting

confidence: 90%

Peripheral Arterial Disease Located in the Feet of Patients With Diabetes and Foot Ulceration Demands a New Approach to the Assessment of Ischemia

Manu

Freedman

Rashid

et al. 2020

The International Journal of Lower Extremity Wounds

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“…This difference in the prevalence of PAD could be explained by the exclusion of patients with schizophrenia having comorbidities such as diabetes, hypertension, or coronary artery disease, contrary to our study in which patients were not excluded due to comorbidities. Furthermore, ABI have been considered to underestimate the diagnosis of PAD which could also explain the difference between the prevalence rate found in Ünsal et al [19] compared to this study [19,20].…”

Section: Prevalence Rates Of Pad and Current Literaturementioning

confidence: 53%

Peripheral artery disease in patients with schizophrenia as compared to controls

Jørgensen

Hegtmann

Straszek

et al. 2023

BMC Cardiovasc Disord

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Background Patients with schizophrenia have an increased prevalence of risk factors for peripheral artery disease (PAD) and is expected to have an increased prevalence of PAD. PAD can be detected utilizing toe–brachial index (TBI) which screens for vascular pathology proximal to the toes. Methods Using a cross-sectional design, we defined the subpopulations: (1) Patients diagnosed with schizophrenia less than 2 years before inclusion (SCZ < 2), (2) Psychiatric healthy controls matched to subpopulation 1 on sex, age, and smoking status, and (3) Patients diagnosed with schizophrenia 10 or more years before inclusion (SCZ ≥ 10). TBI was calculated by dividing toe pressures by systolic brachial blood pressure, and PAD was defined by TBI < 0.70. Logistic regression analysis with PAD as outcome and sex, age, smoking status, BMI, skin temperature, diagnosis of schizophrenia, and comorbidities as explanatory variables was conducted. Results PAD was present in 26.2% of patients diagnosed with SCZ < 2 (17 of 65) and in 18.5% of psychiatric healthy controls (12 of 65) with no statistically significant difference in prevalence rates (p = 0.29). PAD was present in 22.0% of patients diagnosed with SCZ ≥ 10 (31 of 141). In logistic regression, patients diagnosed with SCZ < 2 had an increased odds of PAD with psychiatric healthy controls as reference (Odds ratio = 2.80, 95% confidence interval 1.09–7.23, p = 0.03). The analysis was adjusted for age, sex, smoking status, BMI and comorbidities such as hypertension, diabetes and heart disease. Conclusions This study did not find statistically significant increased prevalence rates of PAD in patients with schizophrenia even though patients with SCZ were compared to psychiatric healthy controls using TBI. Utilizing logistic regression PAD was associated with schizophrenia diagnosis within the last 2 years, age and skin temperature. As PAD is initially asymptomatic, screening could be relevant in patients with schizophrenia if other risk factors are prevalent. Further large-scale multicenter studies are warranted to investigate schizophrenia as a potential risk factor for PAD. Trial registration: Clinicaltrials.gov identifier NCT02885792.

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“…In this regard, TBI measurements presumably have more information than ABI for predicting poor prognosis (26). To date, the association between TBI and prognosis has been less frequently studied in elderly populations with diabetes or chronic kidney disease, which are known to have high rates of PAD and medial artery calcification (27)(28)(29)(30). Therefore, we conducted additional subgroup analysis in stroke patients with a normal ABI range and found that low TBI was still independently associated with worse outcomes in the subgroup.…”

Section: Discussionmentioning

confidence: 97%

Low Toe–Brachial Index Is Associated With Stroke Outcome Despite Normal Ankle–Brachial Index

Han

Lee

et al. 2021

Front. Neurol.

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Introduction: We investigated whether the toe–brachial index (TBI) is associated with stroke prognosis and evaluated this association in patients with normal ankle–brachial index (ABI).Methods: Acute ischemic stroke patients who underwent TBI measurements were enrolled. Poor functional outcome was defined as modified Rankin Scale score ≥3. Major adverse cardiovascular event (MACE) was defined as stroke recurrence, myocardial infarction, or death. Normal ABI was defined as 0.9 ≤ ABI ≤ 1.4.Results: A total of 1,697 patients were enrolled and followed up for a median 39.7 (interquartile range, 25.7–54.6) months. During the period, 305 patients suffered MACE (18.0%), including 171 (10.1%) stroke recurrences. TBI was associated with hypertension, diabetes, atrial fibrillation, aortic plaque score, ABI, and brachial–ankle pulse wave velocity (all p < 0.05). In multivariable logistic regression, TBI was inversely associated with poor functional outcome in all patients [odds ratio (OR) 0.294, 95% confidence interval (CI) 0.114–0.759], even in patients with normal ABI (OR 0.293, 95% CI 0.095–0.906). In multivariable Cox regression, TBI < 0.6 was associated with stroke recurrence [hazard ratio (HR) 1.651, 95% CI 1.135–2.400], all-cause mortality (HR 2.105, 95% CI 1.343–3.298), and MACE (HR 1.838, 95% CI 1.396–2.419) in all patients. TBI < 0.6 was also associated with stroke recurrence (HR 1.681, 95% CI 1.080–2.618), all-cause mortality (HR 2.075, 95% CI 1.180–3.651), and MACE (HR 1.619, 95% CI 1.149–2.281) in patients with normal ABI.Conclusions: Low TBI is independently associated with poor short- and long-term outcomes in acute ischemic stroke patients despite normal ABI.

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Risk factors and haemodynamic variables in patients with low toe-brachial index but normal ankle-brachial index

Cited by 9 publications

References 21 publications

Peripheral Arterial Disease Located in the Feet of Patients With Diabetes and Foot Ulceration Demands a New Approach to the Assessment of Ischemia

Peripheral Arterial Disease Located in the Feet of Patients With Diabetes and Foot Ulceration Demands a New Approach to the Assessment of Ischemia

Peripheral artery disease in patients with schizophrenia as compared to controls

Low Toe–Brachial Index Is Associated With Stroke Outcome Despite Normal Ankle–Brachial Index

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