Comparison of Accuracy of Two Different Methods to

Determine Ankle-Brachial Index to Predict Peripheral

Arterial Disease Severity Conrmed by Angiography
Vinodh Jeevanantham, MD, Bassem Chehab, MD, Edgar Austria, MD, Rakesh Shrivastava, MD,
Mark Wiley, MD, Peter Tadros, MD, Buddhadeb Dawn, MD, James L. Vacek, MD,
and Kamal Gupta, MD*
Ankle-brachial index (ABI) is conventionally derived as the ratio of higher of the 2 systolic
ankle blood pressures to the higher brachial pressure (HABI method). Alternatively, ABI
may be derived using the lower of the 2 systolic ankle pressures (LABI method). The
objective of this study was to assess the utility and difference between 2 techniques in
predicting peripheral artery disease (PAD). Participants who underwent both ABI measurement and arteriography from July 2005 to June 2010 were reviewed. Angiographic
disease burden was scored semiquantitatively (0 [ <50%, 1 [ 50% to 75%, and 2 [
>75% stenosis of any lower extremity arterial segment), and PAD by angiography was
dened as
>50% stenosis of any 1 lower extremity arterial segment. A combined PAD disease score
was calculated for each leg. A total of 130 patients were enrolled (260 limbs). The ABI was
<0.9 (abnormal) in 68% of patients by HABI method and in 84% by LABI. LABI method
had higher sensitivity and overall accuracy to detect PAD compared with the HABI
method. Regression analysis showed that an abnormal ABI detected by LABI method is
more likely to predict angiographic PAD and total PAD burden compared with HABI.
Moreover, abnormal ABI by LABI method had higher sensitivity and accuracy to detect
PAD in patients with diabetes and below knee PAD compared with the HABI method. In
conclusion, ABI determined by the LABI method has higher sensitivity and is a better
predictor of PAD compared with the conventional (HABI) method.
2014 Elsevier Inc.
All rights reserved. (Am J Cardiol 2014;114:1105e1110)
Peripheral artery disease (PAD) is highly prevalent and
is predicted to increase because of aging of the
1,2
population.
The ankle-brachial index (ABI) is as an easy, reliable
noninvasive test used to screen patients for lower extremity
3e5
PAD and has low interobserver variability.
Conventionally, ABI is calculated as the ratio of the higher of the
systolic blood pressures (SBPs) of the 2 ankle arteries of
that limb (either the dorsalis pedis or posterior tibial) and
the higher of the 2 SBPs of the upper limbs (HABI
3,6,7
method).
ABI calculated by HABI method
underestimates the true preva- lence of PAD, especially in
7e13
the elderly population.
This is important because patients
with PAD are at increased risk for future cardiovascular
14e17
events.
The lack of awareness of signs and symptoms
of PAD and ABI calculation by the HABI method may
18e21
underdiagnose PAD.
Alternatively, ABI can be
calculated using the lower of the 2 ankle pressures (LABI
method), which may improve sensitivity for detecting
7,10e13,22,23
PAD.
However, there are limited data on verication of diagnostic accuracy of this method using angiography. We hypothesized that LABI method would improve
Department of Cardiology, University of Kansas Medical Center,
Kansas City, Kansas. Manuscript received April 13, 2014; revised manuscript received and accepted July 2, 2014.
See page 1110 for disclosure information.
*Corresponding author: Tel: 001-913-588-3827; fax: 001-913-5886010.
E-mail address: kgupta@kumc.edu (K. Gupta).

0002-9149/14/$ - see front matter 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.amjcard.2014.07.023

detection of PAD. Therefore, our study aimed to (1) study

the diagnostic accuracy of these 2 methods in the detection
of PAD and total PAD burden, (2) study the diagnostic
accuracy in patients with diabetes in whom ABI
determined by the HABI method is often falsely elevated
6,24
because of medial calcinosis,
and (3) assess the
diagnostic utility for detect- ing below knee PAD that is
unknown.
Methods
This was a single-center retrospective study performed at
a major tertiary referral academic medical center. All
patients who underwent both ABI measurement and
arteriography of the lower extremities with digital
subtraction angiography (DSA) performed from July 2005
to June 2010 at our insti- tution were reviewed. Only
patients who had an ABI done within 6 months before the
angiogram were included in this study. Exclusion criterion
included previous limb amputa- tions proximal to the heads
of metatarsals or proximal to the elbow in the upper limbs,
previous bypass surgery, stenting, or prosthetic vascular
reconstruction to the lower limbs or of the arteries of lower
limb/abdominal aorta or subclavian or axillary arteries, an
ABI >1.3 in both lower limbs, and any abdominal or
lower extremity vascular surgery or interven- tion between
the time of having the ABI measurement and the rst
available angiography. The study protocol was approved by
the hospital ethics and human subjects committee.
For measurement of ABI, an Unetixs Vascular Incorporated Multilab Series 2-CP (Unetixs Inc, Rhode Island) with
an
www.ajconline.org

The American Journal of Cardiology (www.ajconline.org)

82
Table 1
Patient characteristics
Variable
Mean age (years)
Body mass index (Kg/m2)
Male sex
Symptomatic
Tobacco use
Hypertension
Diabetes
Dyslipidemia
Chronic kidney disease
Cerebrovascular accident
Coronary artery disease
Renal artery stenosis
Carotid artery stenosis
LVEF

All Limbs
(n 260)
68 9
29 6
59%
94%
92%
85%
31%
75%
17%
12%
81%
8%
27%
56 12

HABI <0.9
(n 173)
69
29

9
6
54%
95%
92%
85%
35%
74%
14%
12%
77%
9%
31%
57 12

LABI <0.9
(n 215)
62
30

6
8
57%
94%
92%
85%
31%
74%
15%
12%
79%
9%
29%
61 6

HABI ankle brachial index calculated as the ratio of the higher of the
systolic blood pressures of the 2 ankle arteries of that limb and the higher
of the 2 systolic blood pressures of the upper limbs; LABI ankle
brachial index calculated as the ratio of the lower of the systolic blood
pressures of the 2 ankle arteries of that limb and the higher of the 2
systolic blood pressures of the upper limbs.
Table 2
Diagnostic ability of using higher of the two ankle systolic blood pressures
versus lower of the two ankle ystolic blood pressures in the ratio of ankle
s
brachial index methods to detect at least one arterial segment 50% and
75%
At Least One
At Least One
Segment 50%
Segment 75%

Sensitivity
Specicity
Positive predictive value
Negative predictive value
Overall accuracy

ABI
H

LABI

HABI

LABI

75%
63%
90%
36%
73%

90%
47%
88%
52%
83%

81
57
79
60
73

92
34
74
69
73

HABI ankle brachial index calculated as the ratio of the higher of the
systolic blood pressures of the 2 ankle arteries of that limb and the higher
of the 2 systolic blood pressures of the upper limbs; LABI ankle
brachial index calculated as the ratio of the lower of the systolic blood
pressures of the 2 ankle arteries of that limb and the higher of the 2
systolic blood pressures of the upper limbs.

8- and 5-MHz bidirectional Doppler wave probe device

was used. It also incorporated a calibrated dual-channel
pulse volume recording for denitive quality waveform
assessment. Appropriately sized cuffs were applied on the
lower extrem- ities, just above the malleoli, and on the
arms. These were performed by an experienced examiner
who was blinded to all clinical baseline parameters
assessed. Measurements were performed, after a 5- to 10minute rest, in the supine position with the upper body as
at as possible to minimize the effect of an increased tibial
artery blood pressure because of sitting or semi-sitting
position. ABI values were then calculated applying 2
different methods: the higher ankle pressure (either the
posterior tibial or dorsalis pedis artery) was used as the
numerator for the HABI method and the lower ankle
pressure

Figure 1. ROC curves for the association between LABI values and HABI
values (according to different methods for ABI calculation) and PAD
dened by 50% stenosis in at least 1 arterial segment by angiography.
Table 3
Binary logistic regression analysis showing predictors of peripheral artery
disease

LABI
HABI
Male gender
Age
Body mass index
Hypertension
Hyperlipidemia
Diabetes mellitus
Chronic kidney disease
Smoking

Odds Ratio

95% CI

p Value

5.3
3.4
6
1.02
0.98
1.3
0.8
1.6
1.3
1.4

1.6e16
1.2e10
2.5e14
0.98e1.07
0.92e1.05
0.421e4.03
0.3e1.9
0.58e4.7
0.46e4.08
0.34e6

0.005*
0.022*
<0.001*
0.19
0.737
0.65
0.65
0.33
0.56
0.61

HABI ankle brachial index calculated as the ratio of the higher of the
systolic blood pressures of the 2 ankle arteries of that limb and the higher
of the 2 systolic blood pressures of the upper limbs; LABI ankle
brachial index calculated as the ratio of the lower of the systolic blood
pressures of the 2 ankle arteries of that limb and the higher of the 2
systolic blood pressures of the upper limbs.
* Final predictors of PAD after adjusting for variables age, BMI, DM,
HTN, HLD, CKD, and smoking.

(either posterior tibial or dorsalis pedis artery) was used as

the numerator for the LABI method. An abnormal ABI
was dened as <0.9 for both methods.
Intra-arterial DSA was performed and assessed by
consensus agreement by 2 experienced readers who were
blinded to the clinical and ABI data. Arteriographies were
performed within a 6-month period from the ABI measurements. Appropriate anteroposterior sequential views of
the lower abdomen, pelvis, and lower extremities were obtained. Oblique views were obtained for the iliac and the
proximal femoral arteries. Percentage stenosis was dened
as a >50% diameter reduction determined by visual estimation and by quantitative measurement assessment. Stenosis was calculated as the ratio of the residual target vessel
lumen diameter to the diameter of the reference segment
of artery. Discrepant results between the 2 readers were
assessed by a third experienced reader. All readers were
blinded to the ABI data and measurements.

Figure 2. ROC curves for the association between LABI values and HABI
values (according to different methods for ABI calculation) and PAD
dened by >75% stenosis in at least 1 arterial segment by angiography.

Figure 3. ROC curves for the association between LABI values and HABI
values (according to different methods for ABI calculation) and PAD
dened by >3 segment stenosis in at least 1 segment by angiography.

Table 4
Binary logistic regression analysis showing predictors of peripheral artery
disease by angiography 3 segments

Table 5
Diagnostic ability of using higher of the two ankle systolic blood
pressures versus lower of the two ankle systolic blood pressures in the
ratio of ankle brachial index methods to detect at least one segment 50%
and 75% in
diabetic patients

LABI
HABI
Male gender
Age
Body mass index
Hypertension
Hyperlipidemia
Diabetes mellitus
Chronic kidney disease
Smoking
Left ventricular ejection fraction
<50%

Odds Ratio

95% CI

p Value

5.7
1.2
1.7
1.06
0.97
1.1
1.37
1.3
1.3
4.3
1.6

2.3e14.5
0.4e2.9
0.9e3.2
1.03e1.1
0.91e1.03
0.45e2.7
0.64e2.9
0.6e2.5
0.5e3.3
0.9e21.2
0.6e3.8

<0.001*
0.7
0.1
<0.001
0.34
0.8
0.4
0.46
0.51
0.06
0.3

HABI ankle brachial index calculated as the ratio of the higher of the
systolic blood pressures of the 2 ankle arteries of that limb and the higher
of the 2 systolic blood pressures of the upper limbs; LABI ankle
brachial index calculated as the ratio of the lower of the systolic blood
pressures of the 2 ankle arteries of that limb and the higher of the 2
systolic blood pressures of the upper limbs.
* Final predictors of PAD after adjusting for variables age, BMI, DM,
HTN, HLD, CKD, smoking, and LVEF.

Angiographic disease was scored using the quantitative

coronary assessment method (0 <50%; 1 50% to 75%;
2 >75% occlusion) of any lower extremity arterial
segment. A combined PAD disease score was calculated
based on the total number of segments affected in each leg
separately. Below knee PAD was dened as involvement
(>50%) of at least 1 segment of tibioperoneal trunk, peroneal artery, and anterior tibial and posterior tibial arteries.
Above knee PAD was dened as involvement (>50%) of at
least 1 segment of common iliac artery, external iliac artery,
common femoral artery, supercial femoral artery, and
popliteal artery. Patients with a fasting glucose 126 mg/dl,
with an HbA1C level 6.5%, or on treatment with oral
medications or insulin were dened as patients with
diabetes in our study. Those with an SBP >140 mm
Hg, with

At Least One
Segment 50%

Sensitivity
Specicity
Positive predictive value
Negative predictive value
Overall accuracy

At Least One
Segment 75%

HABI

LABI

HABI

LABI

77%
40%
90%
20%
72%

88%
40%
91%
33%
82%

81%
42%
80%
45%
71%

91%
35%
80%
58%
77%

HABI ankle brachial index calculated as the ratio of the higher of the
systolic blood pressures of the 2 ankle arteries of that limb and the higher fo
the 2 systolic blood pressures of the upper limbs; LABI ankle brachial
index calculated as the ratio of the lower of the systolic blood pressures of
the 2 ankle arteries of that limb and the higher of the 2 systolic blood
pressures of the upper limbs.

a diastolic blood pressure >85 mm Hg, or on treatment for

25
hypertension were dened as patients with hypertension.
Statistical analysis was performed using the Statistical
Program for Social Sciences, version 19.0 (SPSS Inc., Chicago, Illinois). Data were plotted (e.g., histograms and spaghetti plots linking variables) to examine for potential
outliers
and for the necessity of transformation before analysis.
Summary statistics (e.g., mean, SD, minimum, maximum,
proportions) was calculated for all variables. Continuous
variables are expressed as mean
SD. Pearsons
correlation
analysis was performed to calculate correlation between
continuous variables. Chi-square test was used to nd association between categorical variables. An adjusted McNemars statistical test was used to compare the sensitivity
and specicity of the 2 ABI methods, compared with DSA
as the gold standard. Binary regression analysis was
performed to
identify predictors of PAD variables included in the model

were age, gender, diabetes, hypertension, smoking history,

coronary artery disease, LABI, and HABI methods. Linear

Table 6
Diagnostic ability of using higher of the two ankle systolic blood
pressures versus lower of the two ankle systolic blood pressures in the
ratio of ankle brachial index methods to detect at least one segment 50%
and 75% for above knee versus below knee disease
HABI Method

Figure 4. ROC curves for the association between LABI values and HABI
values (according to different methods for ABI calculation) and PAD
dened by 50% stenosis in at least 1 segment by angiography in patients
with diabetes.

At Least One
Segment 50%

At Least One
Segment 75%

Above
Knee

Below
Knee

Above
Knee

Below
Knee

Sensitivity
Specicity
Positive predictive value
Negative predictive value

78
60
85
47

76
37
45
69

87
55
71
76

77
36
40
74

LABI method

At Least One
Segment 50%

At Least One
Segment 75%

Sensitivity
Specicity
Positive predictive value
Negative predictive value

92
41
82
64

96
32
64
86

91
21
35
78

91
21
39
81

HABI ankle brachial index calculated as the ratio of the higher of the
systolic blood pressures of the 2 ankle arteries of that limb and the higher
of the 2 systolic blood pressures of the upper limbs; LABI ankle
brachial index calculated as the ratio of the lower of the systolic blood
pressures of the 2 ankle arteries of that limb and the higher of the 2
systolic blood pressures of the upper limbs.

Figure 5. ROC curves for the association between LABI values and HABI
values (according to different methods for ABI calculation) and PAD
dened by >75% stenosis in at least 1 segment by angiography in patients
with diabetes.

regression analysis was used to identify predictors of total

PAD burden. A p value <0.05 was accepted as indicating
statistical signicance.
Results
Baseline patients characteristics are noted in Table 1. A
total of 130 patients were enrolled (260 limbs). Patients who
underwent angiography were older, were symptomatic, and
had a higher prevalence of hypertension, tobacco use, dyslipidemia, coronary artery disease, and diabetes (Table 1).
Sixty-eight percent were diagnosed with an abnormal ABI
using the HABI method compared with 84% with an
abnormal ABI using the LABI method.
LABI method had a higher sensitivity and overall
accuracy to detect >50% stenosis in one or more arterial
segment
compared with the HABI method (Table 2). McNemars test
demonstrated that differences seen between both methods
were statistically signicant (p <0.0001). Receiver
operating

characteristic (ROC) curve analysis showed that the area

under curve was better for LABI method compared with
the HABI method (Figure 1). Binary logistic regression
analysis indicated that an abnormal ABI by LABI method
is more likely to predict PAD (>50% stenosis in one or
more arterial segment) by angiography compared with the
HABI method after adjusting for confounding factors
(Table 3). LABI method had higher sensitivity but lower
specicity to detect
>75% stenosis in one or more arterial segment compared
with the HABI method (Table 2). ROC analysis showed
that the area under curve for LABI method was better than
the HABI method (Figure 2).
Both LABI and HABI methods had signicant inverse
correlation with total angiographic PAD burden score
(LABI, r 0.48, p <0.001; HABI, r 0.41, p <0.001).
Binary logistic regression analysis showed that an
abnormal ABI detected by LABI is more likely to
predict angiographic PAD in 3 segments compared with HABI after
adjusting for confounding factors (Table 4). Linear regression analysis also showed that an abnormal ABI detected
by the LABI method is more likely to predict total PAD
burden
compared with the HABI method (B 0.38, 95% condence interval [CI] 5.4 to 2.7, p <0.001, vs B 0.04,
95% CI 3.1 to 2.1, p 0.7) after adjusting for confounding factors. ROC analysis showed that the area under
curve for the LABI method was better than the HABI
method for detecting PAD dened by >3 segment stenosis
in at least 1 segment by angiography (Figure 3).
A total of 41 patients had diabetes (82 limbs). Compared
with the HABI method, the LABI method had better

sensitivity and accuracy and similar specicity to detect

PAD by angiography (McNemars test: p <0.01; Table 5).
Binary logistic regression analysis identied an abnormal
ABI by LABI method (odds ratio 12, 95% CI 1.9 to 76, p
0.009) and male gender (odds ratio 6.8, 95% CI 1.1 to 41,
p 0.04) as independent predictors of PAD by
angiography
after adjusting for confounding variables and HABI
method.
Figure 4 shows that ROC was better for LABI method
compared with the HABI method to detect 50% stenosis
in at least 1 arterial segment by arteriography. The area
under curve for LABI method was better than the HABI
method when looking at severe lesions with >75% stenosis
in at least 1 arterial segment by arteriography as shown in
Figure 5.
Abnormal ABI by HABI method had lower sensitivity
and specicity to detect below knee PAD compared with
above knee PAD (Table 6). Abnormal ABI by LABI
method had higher sensitivity and lower specicity to
detect below knee
PAD compared with above knee PAD (Table 6). Both
methods had signicant correlation with angiographic below
knee PAD burden score (LABI, r
0.323, p <0.001;
HABI,
r 0.222, p <0.001). Linear regression analysis showed
that LABI method predicted below knee PAD burden score,
whereas HABI method did not after adjusting for confounding factors (B 0.3, 95% CI 3.3 to 1.4, p <0.001, vs
B 0.11, 95% CI 0.78 to 2.9, p 0.26). However, both
methods signicantly predicted above knee PAD burden
score after adjusting for confounding factors (B 0.26,
95% CI 2.6 to 0.51, p 0.004, vs B 0.22, 95%
CI 2.6 to 0.29, p 0.02). Logistic regression analysis
also showed that LABI method predicted below knee PAD
burden
of
2 segments with >50% stenosis, whereas HABI
method did not after adjusting for confounding factors (B
2.7, 95% CI 1.13 to 6.3, p 0.03, vs B 0.99, 95% CI
0.43 to 2.3,
p 0.98). However, both methods signicantly predicted
above knee PAD burden of
2 segments with >50%
stenosis after adjusting for confounding factors (B 5.7,
95% CI 1.7
to 19.2, p 0.004, vs B 5.5, 95% CI 2.4 to 12.7, p
<0.001).
Discussion
Our study found that the LABI method had a higher
sensitivity and overall diagnostic accuracy than the HABI
method in detecting angiographic lesion >50% diameter
stenosis. LABI method had a signicant correlation to
detect one or more segment with >50% stenosis by
angiography. Furthermore, ABI-determined LABI method
was found to highly correlate with total PAD burden score
and is a better predictor of PAD disease burden compared
with the con- ventional (HABI) method, even after
adjusting for tradi- tional confounding variables.
The increased sensitivity comes with a cost of decreased
specicity in our study. However, in patients with clinical
suspicion of PAD and when ABI using HABI method is reported normal, LABI method might be able to detect
single-

vessel disease and the presence of a vascular

atherosclerotic process that would lead to more
aggressive risk
factor screening and modication
strategies. For example, a dorsalis
pedis occlusion in the presence of no proximal disease and
a patent posterior tibial artery could have a normal ABI by
the HABI method but an abnormal ABI by the LABI
method.

Although intervention for single-vessel below knee PAD

may not change the clinical outcome in patients with
claudication, LABI method might help detect single-vessel
disease and avoid unnecessary tests. Therefore, we propose
to report ABI values for each method or for each artery that
would inform the patient and physician well.
The diagnostic accuracy of HABI has been established
6,26,27
with angiography.
However, there is limited data on
the utility and diagnostic accuracy of LABI method to
13
detect PAD. Previous study by Schroeder et al used
arterial duplex ultrasonography to determine the diagnostic
accu- racies of HABI and LABI method and reported that
LABI method increased the identication of PAD,
suggesting that the LABI method may be a more sensitive
28
indicator of presence of PAD. Also McDermott et al
reported that the prevalence of PAD in a study population
through the LABI method (59%) was higher than the
traditional HABI method (47%). Our study differs from
these studies using gold standard angiography to verify
diagnostic accuracy of LABI method. Our study ndings
12
correlate with previous results by Niazi et al who also
assessed the diagnostic accuracy of
2 methods using angiography.
The lower sensitivity and specicity reported in our
study are because of difference in study population
29
compared with previous studies. Feigelson et al reported
high sensitivity and specicity but only by combining
ABI results with posterior tibialis pressure velocities.
Indeed, the sensitivity of ABI by itself in that report was
only 70%. Therefore, the true sensitivity and specicity of
HABI method may be lower than that commonly reported
in the literature.
Regression analysis from our study shows that an
abnormal ABI by the LABI method is more likely to
predict PAD by angiography and is more likely to predict
angio- graphic PAD in 3 segments compared with the
HABI method after adjusting for the traditional factors.
Thus, LABI method not only increases detection of PAD
but also better predicts disease severity. Future studies are
needed to determine the prognostic implication of using
LABI method to calculate ABI and using this as a screening
tool in a more general population. ABI determined by the
traditional HABI method is often falsely elevated because
6,24
of medial calci- nosis causing noncompressible arteries.
Our study showed that LABI method had better sensitivity
and accu- racy to detect PAD compared with the HABI
method in patients with diabetes. LABI method was an
independent predictor of PAD in patients with diabetes
independent of traditional confounding variables and risk
factors.
Abnormal ABI by the HABI method had lower sensitivity and specicity to detect below knee PAD compared
with above knee PAD. Abnormal ABI by LABI method had
higher sensitivity but lower specicity to detect below knee
PAD compared with the HABI method. Linear regression
analysis showed that LABI method predicted both below
and above knee PAD burden score, whereas HABI method
predicted only above knee PAD and not below knee PAD
after adjusting for confounding factors. Similarly, binary
regression analysis also showed that LABI method
predicted both below and above knee PAD burden of 2
segments with >50% stenosis, whereas HABI method
predicted only above knee and not below knee PAD after
adjusting for confounding factors.

Our study is a retrospective study and has several

limita- tions. It is unclear how the results of ABI would
correlate with angiographic ndings in general population
because the sub- jects in this study were high-risk patients
with a high suspicion index for PAD, and as such, the
study population would be different from the general
population. The angiographic de- nition of stenosis or
PAD, hence, could also be a limitation. However, the
angiographic ndings were reviewed by 3 separate and
experienced readers, thus limiting possible errors in
estimating the degree of stenosis and limiting its effects on
sensitivity and specicity results.

12.
13.

14.

15.

Disclosures
The authors have no conicts of interest to disclose.
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