January 26, 2008

Ankle-Brachial Index: a Surrogate Marker of Microvascular Complications in Type 2 Diabetes Mellitus?

By Papanas, N Symeonidis, G; Mavridis, G; Georgiadis, G S; Papas, T T; Lazarides, M K; Maltezos, E

Aim. The aim of this study was to investigate the potential role of ankle-brachial index (ABI) as a marker of microvascular disease in patients with type 2 diabetes mellitus. Methods. This study included 126 type 2 diabetic patients (64 male and 62 female) with an age of 66.6+-5.3 years (mean+-SD) and diabetes duration of 13.2+- 4.1 years. ABI was measured with a Doppler device. The exclusion criterion was the medial arterial calcification. Patients were also examined for microalbuminuria, retinopathy and peripheral neuropathy.

Results. ABI was significantly lower in patients with microalbuminuria than in those without microalbuminuria (0.91 +- 0.17 vs 1.05+-0.13, P=0.004), in patients with retinopathy than in those without retinopathy (0.91 +-0.18 vs 1.06+-0.1, P=0.005), as well as in patients with neuropathy than in those without neuropathy (0.94+-0.17 vs 1.06+-0.11, P=0.001). Sensitivity and specificity of ABI

Conclusion. ABI is significantly lower in patients with than in those without microvascular complications of type 2 diabetes. An ABI

[Int Angiol 2007;26:253-7]

Key words: Ankle-Brachial Index - Diabetes mellitus - Ultrasonography, Doppler, Duplex - Microvasculature.

Ankle-brachial index (ABI) is a widely used, standardized diagnostic test for peripheral arterial disease (PAD).1-3 It has been validated in large epidemiological studies 4-7 and has been found to have a high reproducibility.8-9 Its use in patients with diabetes mellitus has been criticized, because medial arterial calcification may cause spuriously elevated ankle pressures.1 3, 10- 12 Nonetheless, it has been shown that ABI may be reliably used in diabetic patients, with the exception of those with ABI higher than a critical value, suggestive of medial calcification.13,14

Several studies have also established ABI as a marker of cardiovascular morbidity.4-5, 15-17 This is mainly attributed to ischemic heart disease, prompting some authors to suggest that a low ABI is a diagnostic tool for coronary artery disease (CAD).18-22 The association between PAD and CAD is particularly relevant in patients with diabetes.23-25 Interestingly, not only is a low ABI a marker of CAD, but it is also a predictor of its angiographic severity, both in diabetic and in non-diabetic patients.26-27

However, while ABI is an accepted marker of atherosclerotic macrovascular disease in diabetic patients, its role as a marker of microvascular disease has, to the best of our knowledge, not been investigated. Thus, the aim of the present study was to examine the potential role of ABI as a marker of microvascular disease in patients with type 2 diabetes mellitus.

Materials and methods

This study included 126 type 2 diabetic patients (64 male, 62 female) with an age of 66.6+-5.3 years (mean+-SD) and diabetes duration of 13.2+-4.1 years. These were recruited from the Diabetic Department of the O Agios Dimitrios General Hospital of Thessaloniki, Greece. Patient characteristics are shown in Table I. The study was performed in accordance with the Helsinki Declaration of Human Rights and all patients gave their informed consent.

ABI was measured using a Doppler device (PROGETTI 2000). Systolic pressure was measured both in the dorsalis pedis and in the posterior tibial artery. The higher value of these pressures was divided by the higher value of the two brachial systolic pressures to calculate ABI. ABI was measured in both limbs and the lower of the two values was used for the analysis.1-3 Patient examination was performed in normal room temperature (25 [degrees]C) after patients had taken off their shoes and socks and had been allowed a 10-min rest. Doppler examination was conducted by an operator who was blinded to the patients' characteristics and to the presence or absence of microvascular complications. PAD was diagnosed in patients with an ABI

The exclusion criterion was the presence of medial arterial calcification, defined as ABI >/=1.3 or visible arterial calcification on plain X-rays.3-4

Patients were also evaluated for microalbuminuria, retinopathy and peripheral neuropathy. Microalbuminuria was defined as an albumin excretion rate >/=20 [mu]g/min, in the absence of uncontrolled hypertension and/or urinary tract infection.29 Retinopathy was defined as at least two microaneurysms and/or retinal hemorrhage and/or other signs of retinal damage.30 Diabetic neuropathy was diagnosed by the neuropathy disability score (NDS).31 This is a standardized clinical examination of ankle reflexes as well as 128 Hz tuning fork, pin-prick and temperature (cold tuning fork) sensation at the hallux, as described earlier.31 Diagnosis of neuropathy was defined as an NDS >/=6.31,32

Statistical analysis

Statistical analysis was conducted using the SPSS (Statistical Package for Social Sciences) 11.0. In univariate analysis, normally distributed quantitative variables were analysed by unpaired t- test. Multivariate logistic regression analysis, using each of the microvascular complications (neuropathy, microalbuminuria and neuropathy) separately as a dependent variable, was also performed. Significance was defined at the 5% level (P


ABI was significantly lower in patients with microalbuminuria than in those without microalbuminuria (0.91 +-0.17 vs 1.05+-0.13, P=0.004) (mean+-SD), in patients with retinopathy than in those without retinopathy (0.91 +-0.18 vs 1.06+-0.1, P=0.005), as well as in patients with neuropathy than in those without neuropathy (0.94+- 0.17 vs 1.06+-0.11, P=0.001). Longer duration of diabetes (>10 years) was also significantly associated with lower ABI as compared to shorter duration of diabetes (=10 years) (0.97+-0.17 vs 1.07+- 0.1, P=0.005).

PAD was diagnosed in 21/43 (48.8%) patients with microalbuminuria and 10/83 (32.3%) patients without microalbuminuria. Sensitivity and specificity of ABI

Significant predictors of microvascular complications, as identified by multivariate logistic regression analysis, are shown in Table II.


The present study demonstrated that ABI was significantly lower in type 2 diabetic patients with microalbuminuria than in those without microalbuminuria. An ABI

Similarly, retinopathy was associated with a significantly lower ABI. An ABI

Moreover, neuropathy was associated with a significantly lower ABI. An ABI

The practical implications of our findings may be summarized as follows. An ABI


In conclusion, ABI is significantly lower in patients with than in those without microvascular complications of type 2 diabetes. An ABI

These results suggest a potential role for ABI as a surrogate marker of microvascular complications in type 2 diabetic patients.

Received on October 4, 2006; acknowledged on November 15, 2006; accepted for publication on January 5, 2007.


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1 Second Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis, Greece

2 Diabetic Department, O Agios Dimitrios General Hospital, Thessaloniki, Greece

3 Department of Vascular Surgery, Democritus University of Thrace, Alexandroupolis, Greece

Address reprint requests to: Dr. N. Papanas, Ethnikis Antistasis 44, Alexandroupolis 68100, Greece.

E-mail to: [email protected]

Copyright Edizioni Minerva Medica Sep 2007

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