Ankle Brachial Index as a Screening Test in Suspected Coronary Artery Disease Patients

Ankle Brachial Index as a Screening Test in Suspected Coronary Artery Disease Patients.




Authors
Tariq Waseem. FCPS Allama Iqbal Medical College/ Jinnah Hospital Lahore.
Naveed Rashid. MBBS Mayo Hospital Lahore.
Abbas Raza. FCPS Allama Iqbal Medical College/ Jinnah Hospital Lahore.


Institute
Departments of Medicine & Cardiology Mayo Hospital Lahore


Correspondence.
Dr. Tariq Waseem
34- Neelum Block Allama Iqbal Town Lahore.
Cell: 0300 8401474
Email: tariqwaseem_59@hotmail.com


Abstract
The resting ankle- brachial index (ABI) is a non-invasive method to assess the patency of lower extremity arterial system and to screen for the presence of peripheral occlusive arterial disease. Diagnostic efficacy of ABI to predict atherosclerosis is well documented and low ABI levels (<>0.9), 2 (1.3%) with mild ABI (0.7- 0.89), and 1 (0.7%) with moderate ABI (0.4- 0.69). In patients with normal ABI 34 (22.7%) patients had normal coronary angiogram, 43 (28.7%) patients had single vessel disease, 33 (22%) patients had two vessels disease, 35 (23.3%) patients had three vessels disease, and 2 (1.3%) patients had four vessel disease. In patients with mild ABI (0.7- 0.89) there was 1(0.7%) patient who had single vessel disease, and 1 (0.7%) patient with four vessel disease. In the moderate ABI category (0.4 – 0.69) there was 1 (0.7%) patient of two vessel disease.

Conclusion: Ninety eight percent of the studied population with otherwise symptomatic coronary artery disease had normal ABI. On the other hand 77% of patients with normal ABI had abnormalities on coronary angiogram. ABI lacks the sensitivity to screen atheromatous CAD and cannot be recommended as such.
Key Words: Ankle brachial index, coronary artery disease, coronary angiography.


Introduction
Patients already having evidence of atheromatous vascular disease are at higher risk of another vascular event and can be offered a variety of primary and secondary preventive measures to improve their outcome.1 Patients with peripheral arterial disease (PAD) have a high prevalence of coexistent coronary artery disease (CAD).2 They are at triple the risk of all cause morality and at more than six times the risk of death from coronary artery disease as compared to those without the disease.3 Under-diagnosis of peripheral arterial disease in primary care practice may be a barrier to effective secondary prevention of high ischaemic cardiovascular risk associated with peripheral arterial disease.4
Ankle brachial pressure index (ABI) being simple and easy to perform technique should be included early in the clinical consideration of patients with symptoms suggesting coronary artery disease.3,5 Ankle brachial index is the ratio of ankle and brachial systolic pressures measured with the help of a hand held Doppler. Normal value of ABI is >0.9 and <1.406. or =" 0.90)">0.9.14 These data demonstrate that low ABI levels, particularly those of <0.9,>0.9 (normal), 2 (1.3%) patients of ABI of 0.7-0.89 (mild), 1 (0.7%) patient of ABI of 0.4-0.69 (moderate) and no patients of severe ABI (Table 5).
In the CAD findings, there were 34 (22.7%) normal finding, 44 (29.3%) patients of single vessel disease, 34 (22.7%) patients of two vessels disease, 35 (23.3%) patients of three vessels disease and 3 (2%) patients of four vessels disease (Table 6).
In the relationship between ABI and extent of coronary artery disease, in the normal ABI (>0.9) there were 34 (22.7%) patients of normal CAD, 43 (28.7%) patients of single vessel disease, 33 (22%) patients of two-vessel disease, 35 (23.3%) patients of three vessels disease and 2 (1.3%) patients of four vessel disease. In the mild ABI (0.7-0.89) there was 1 (0.7%) patient of single vessel disease and 1 (0.7%) patients of four vessels disease. In the moderate ABI (0.4-0.69) there was 1 (0.7%) patient of two vessels disease (Table 7).



Table 1
Distribution of patients by Age
(n=150)

Age (Years) No. Percentage
<50>50 95 63.3
Mean±SD 51.23±10.23

Key:
SD Standard deviation
<> Equal to or more than



Table 2
Distribution of patients by sex
(n=150)

Sex No. Percentage
Male 118 78.7
Female 32 21.3
Total 150 100.0




Table 3
Distribution of patients by symptoms
(n=150)

Symptoms No. Percentage
Dyspnea 20 13.3
Chest pain 112 74.7
Palpitation 3 2.0
Arm pain 5 3.3
Epigastric pain 4 2.7
Chest heaviness 6 4.0





Table 4
Frequency of Major CVD risk factors
(n=150)

Risk Factor No. Percentage
Smoking 66 44.0
Hypertension 63 42.0
Diabetes 37 24.7
Dyslipidemia 9 6.0




Table 5
Distribution of patients by ABI
(n=150)

ABI No. Percentage
>0.9 147 98.0
0.7-0.89 2 1.3
0.4-0.69 1 0.7
<0.4>0.9 Normal
0.7-0.89 Mild
0.4-0.69 Moderate
<0.4 n="150)" n="150)">0.9 34 43 33 35 2 147
0.7-0.89 0 1 0 0 1 2
0.4-0.69 0 0 1 0 0 1
<0.4>0.9), 1.3% patients of mild ABI (0.7-0.89), 0.7% patient of moderate ABI (0.4-0.69) and no patient of severe ABI (<0.4).>0.9) patients, 22.7% patients had normal angiography, 28.7% patients had single vessel disease, 22% patients had two vessel disease, 23.3% patients had three vessel disease and 1.3% patients had four vessel disease. In the mild ABI (0.7-0.89), 0.7% patient has single vessel disease and 0.7% patient had four-vessel disease. In the moderate ABI (0.4-0.69) 0.7% patient had two-vessel disease.
The ABI is a simple, noninvasive, and reliable test that can be complementary to conventional vascular risk factor profiles to identify individuals from the general population who are at high risk of developing cardiovascular disease and could benefit from preventive measures.23 After adjusting for conventional cardiovascular risk factors and prevalent cardiovascular disease, a low ABI (<0.90) is an independent predictor of cardiovascular risk. A low ABI is also highly specific (88%-93%) for predicting future cardiovascular events (ie, a low ABI helps to "rule in" a high-risk patient), with likelihood ratios of about 2.5 for coronary heart disease, 2.4 for stroke, and 5.6 for cardiovascular death. However, because the sensitivity of a low ABI to predict future cardiovascular outcomes is low (i.e., a normal ABI does not "rule out" a high-risk patient), the ABI lacks usefulness as a screening test for CAD in the general population. Further clarification of the role of ABI awaits evaluation of its incremental predictive value over conventional methods of risk assessment in patients who may be at increased risk of cardiovascular disease.23 Its optimal application may be as part of the vascular risk assessment among selected individuals without established vascular disease but older than 70 years or among those who are aged 50 to 69 years and have 1 or more cardiovascular risk factors i.e., elevated serum cholesterol level, hypertension, dysglycemia, tobacco exposure, or a family history of atherosclerotic disease.24
Our patients were younger with a mean age of 51 years when compared with those of Doobay and Anand23 who were 50-69 years old and had one or more cardiovascular risk factors. Perhaps this is the reason of finding a lower frequency of low ABI and hence lower PAD in our patients who otherwise comprised of symptomatic patients having significant abnormalities on coronary angiography. Despite its documented usefulness to predict peripheral vascular disease ABI remains insensitive to predict CAD in younger patients. Peripheral vascular disease may be lagging behind CAD by a decade to become manifest in our patients.

Conclusion
ABI cannot be recommended as a screening tool for atheromatous CAD in our population. 98% the studied population with otherwise symptomatic coronary artery disease had normal ABI. On the other hand 77% of patients with normal ABI had abnormalities on coronary angiogram. A low ABI helps to "rule in" a high-risk patient but a normal ABI does not "rule out" a high-risk patient. The ABI lacks usefulness as a screening test for CAD in the general population.

References
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My CV

Curriculum Vitae

Dr.Tariq Waseem
34 – Neelum block Allama Iqbal Town Lahore Pakistan.
Phone 92- 42- 5417934. Cell. 0300- 8401474

Date of birth. February 09, 1959

Marital status. Married with two sons aged 18 & 16 years.

Academic Qualifications

MBBS. Punjab University (Quaid-e-Azam Medical College Bahawalpur). Nov. 1983
FCPS. College of Physicians & Surgeons Pakistan May 1991

Honors & Awards.

Best Graduate Quaid-e-Azam Medical college Bahawalpur. Session 1976-81 (Gold Medal)
Second position in The Punjab University. Final professional MBBS.
Distinction in Surgery
Distinction in Community Medicine
First Position in Medicine (Silver Medal)
First position in Pharmacology (Silver Medal)

Professional Experience

Position Specialty Institution Period

Associate professor
Medicine

Allama Iqbal Medical College Lahore.
Feb 22, 2007 –to- date.
Associate Professor Medicine King Edward Medical College Lahore. Jan 06, 2001 – Feb 22, 2007
Assistant Professor Medicine K.E.M.C. Lahore. July 1996 - Jan 06, 2001
Senior Registrar Medicine Mayo Hospital Lahore. May 1991 – July 1996
Resident Medical Officer Medicine Mayo Hospital Lahore Dec 1986 – May 1991
Resident Medical officer Pulmonary medicine Lahore General Hospital Lahore. Nov 1985 – Dec 1986
Demonstrator Pathology Nishter Medical College Multan. March 1985 – Nov 1985
House Physician Medicine Lahore General hospital Lahore. Jan 1984 – Jan 1985


Personal Profile.

After qualifying FCPS I joined Mayo Hospital Lahore (MHL) as Senior Registrar in May 1991. My duties included helping the team of residents in day to day care of patients admitted to the unit, attending two out patients clinic each week, regular ward rounds and supervising the on call team in the emergency department, in addition to regular teaching sessions and assisting the administration of the unit. During that period I developed echocardiography & stress test labs in the unit providing this facility to the whole medical floor of the hospital.

I was promoted as Assistant Professor in 1996 and joined King Edward Medical College (K.E.M.C.) Lahore. My job involved attending out patient clinics twice a week, three ward rounds per week and both bedside as well as lecture hall teaching sessions. I also participated in postgraduate resident training program of the unit. I was also consultant in-charge of the 8 bedded Medical ICU. The facilities for assisted ventilation, diagnostic and therapeutic Endoscopy, Echocardiography, Stress test lab and Ultrasonography were available within the unit. I got actively involved in quite a few clinical research projects during that period.

From January 2001 to February 2007 I served as Associate Professor at K.E.M.C. on acting charge in own pay scale when I was promoted on regular basis and transferred to A.I.M.C. & Jinnah Hospital Lahore.

Since February 2007 I am working as an Associate Professor at Allama Iqbal Medical College Lahore and Medical Unit III Jinnah Hospital Lahore. Our unit is 48 Bedded teaching unit and houses all the necessary diagnostic and therapeutic facilities including GI endoscopy on the floor. I attend two out patient clinics per week, four ward rounds per week. Besides that I have one echocardiography session per week. My responsibilities also include regular teaching of medical students both at the bedside as well as in lecture halls. I am involved in various research activities and participate in weekly clinico-pathological conferences and mortality reviews.

I am on the approved register of College of Physician & Surgeons of Pakistan (CPSP) as supervisor for FCPS II in subject of Medicne. At present I am supervisor to ten postgraduate trainees. I am paper assessor & examiner for FCPS Part II medicine of CPSP. I have also been examiner for the final year MBBS examinations for the Punjab University, University of Health
Sciences.

I have contributed in research & publication of 25 original research articles in various international & national scientific journals. I also presented my research work in national & international medical conferences. I am on peer review panel of JCPSP and also an assessor for dissertation by CPSP.


Fields of Interest
Echocardigraphy
Non invasive Cardiology
Critical Care Medicine
Publications

1. Tariq Waseem, Asif Mahmood, Malik Asif Humayun, Abbas Raza, Nadia Sultan.

Measuring Partial pressure of Ammonia in Arterial or Venous Blood vs Total Ammonia

Levels in hepatic encephalopathy: JAIMC; Vol. 7, April- June 2009.

2. Malik Asif Humayun, Tariq Waseem, Asif Mahmood, Abbas Raza, et al.

Frequency of Risk factors for Stroke and In-Hospital Care Pathways For Stroke at a Tertiary

Care Hospital in Pakistan: JAIMC; Vol. 7, April- June 2009.

3. Sameena Saeed, Tariq Waseem, Hamid Khalil.

Frequency of Silent Myocardial Ischemia in Patients with Eastablished coronary artery

Disease: Journal of Fatima Jinnah Medical College; Vol. 1, Issue 3 & 4 Jul – Dec. 2007.

4. Hamid Khalil, Sameena Saeed, Tariq Waseem.

Effects of Dobutamine Infusion Following Volume Loading Compared With Volume

loading Alone to Improve Hemodynamics in Right Ventricular Infarction. Journal of Fatima

Jinnah Medical College; Vol. 1, Issue 3 & 4 Jul – Dec. 2007.

5. M. Arif Nadeem, Tariq Waseem, S Mohsin Ali shah and Abdul Hafeez khan.

Comparison of In-Hospital course of patients having First Acute Myocardial Infarction with

or without Pre-Infarct Angina. Esculapio; Vol. 03, Issue 03, October-December 2007.

6. S. Mohsin Ali Shah, M. Arif Nadeem, Tariq Waseem, Abdul Hafeez Khan.

A Comparison of Early Echocardiographic Findings in patients having First Acute

Myocardial Infarction with or without Pre-Infarct Angina. Esculapio; Vol. 03, Issue 02, July-

September 2007

7. Tariq Waseem, M A Nadeem, Razi Sohail, A R Butt, A H Khan.

Gender, Age of the Patient and Killip Class at presentation as Predictive Factors for the

Occurrence of Left Ventricular Thrombus in First Acute Myocardial Infarction. Annals of

K.E.M.C. 2003; vol. 9, No. 2: 154-156.

8. Tariq Waseem, M A Nadeem, Turab Ali, A H Khan.

Left Ventricular Hypertrophy (LVH): Sensitivity of Different Electrocardiographic Criteria

To diagnose LVH in Patients Having Increased left ventricular Mass Index on

Echocardiography.Annals of K.E.M.C. 2003; vol. 9, No. 2: 101-104.

9. M A Nadeem, Tariq Waseem, A M Sheikh, N Ghuman, K, Irfan, S S Hasnain.

Hepatitis C Virus: An Alarmingly Increasing Cause of Liver Cirrhosis in Pakistan. The

Pakistan Journal of Gastroentrology. 2000; vol.16, No.1: 3-8

10. M A Nadeem, Tariq Waseem, M ayub, F Mujib, T Naveed, S s Hasnain.

Effects of Octreotide Infusion Prior to Sclerotherapy in esophageal Varices. JCPSP. 2001;

vol.11, No.11: 689- 92.

11. M A Nadeem, M Latif, Tariq Waseem, A H Khan.

Comparison of Clinical Vs CT scan localization of Intracerebral Hemorrhage. Pakistan

Journal of Neurology. 2001; vol. 7, No.1: 10-17.

12. M A Nadeem, Tariq Waseem, R Sohail, AH Khan.

The Effects of Thrombolysis on Left Ventricular thrombus formation after first Acute

Myocardial Infarction. Annals of K.E.M.C. 2001; vol. 7, No. 2: 96-98.

13. M A Nadeem, K Irfan, K A I waheed, Tariq Waseem, A H Khan.

Structural CNS diseases (Non – Traumatic) Causing Coma and their Prognostic Significance.

Pakistan Journal of Neurology. 2000; vol. 6, No.1: 8-12.

14. Rizwan Iqbal, Iffat Shabbir, Tariq Waseem.

Screening for AFB in sputum by concentration or direct smear method. Pakistan J. Medical

Res. 2000; 39; 1: 35-36

15. K Irfan, M A Nadeem, K Ahmed I Waheed, Tariq Waseem, AH Khan.

The Etiology of Non Traumatic Coma. Annals of K.E.M.C. 2000; vol.6, No.3: 285-288.

16. Tariq Waseem, M A Nadeem, Mohsin Mahmood, S S Hasnain,

Atypical chest pain, Endoscopic abnormalities in patients with normal resting and post

exercise EKG. The Pakistan Journal of Gastroentrology.2000; vol. 14, No.1: 16-18.

17. M Haroon, Tariq Waseem.

Chronic Rheumatic Endocarditis An Echocardiographic Study. Annals of K.E.M.C. 2000;

Vol. 6, no. 2: 207-210

18. M A Nadeem, Tariq Waseem, Waseem Ahmed, Faisal Mujib, M Abass raza, A H Khan.

Usefulness of SAAG in Evaluation of Ascites. The Pakistan Journal of Gastroentrology 1999;

Vol. 13: 22-28

19. M A Nadeem, Tariq Waseem, K Mahmood, S F Imam, A H Khan

Differences in Clinical Profile & echocardiographic findings in patients with valvular Vs non-

valvular origin of atrial fibrillation. Annals of K.E.M.C. 1999; vol 5: 44-47

20. M Ayub, Tariq Waseem, M A Nadeem, irshad Hussain, A W Khalid, S F Imam, A H Khan.

Risk Stratification of patients with first myocardial infarction using cardiac Troponin-T.

Pakistan Journal of Cardiology. 1999; vol.10, No. 4: 63-67

21. Faisal Mujib, M A Nadeem, Tariq Waseem, M T M K Niazi, A W Khalid, A H Khan.

Non Invasive Markers of Reperfusion following thrombolysis in acute myocardial infarction.

Pakistan Journal of Cardiology.1999; vol.10, No. : 108-114

22. M T M K Niazi, Tariq Waseem, M A Nadeem, F Mujib, S F Imam, A H Khan.

Delay in Presentation in Patients with Acute myocardial infarction. Annals of K.E.M.C.

1998; Vol. 4, No. : 33-37

23. Tariq Waseem, Naveed Bari Bhatti, T h Raza, Najam un Nasir, A H Khan.

Myocardial damage after suicidal ingestion of wheat preservative Aluminiun Phosphophide.

Pakistan Journal of Cardiology. 1997; Vol. 8, No. : 3-4

24. Tanzeem Haider Raza, Tariq Waseem, Naveed Bari Bhatti, T H mahmud, A H Khan.

Cough induced by Angiotensin Converting Enzyme Inhibitors. Pakistan Postgraduate

Journal. 1996; vol. 8, No. : 1-4

25. Naveed Bari Bhatti, T H Mahmud, T H Raza, Tariq Waseem, A H Khan.

Right Ventricular involvement in Patients with Inferior wall Myocardial Infarction V4R- A

prognostic Indicator. Pakistan Postgraduate Journal . 1996; vol. 7 No. : 33-36

26. T H Mahmud, Naveed Bari Bhatti, S T H Raza, Tariq Waseem, Najam un Nasir, A H Khan.

Left Ventricular Thrombus in Patients with Anterior Wall Myocardial Infarction. Effect of

Thrombolysis. Pakistan Postgraduate Medical Journal. 1996; vol. 7, No. : 5-9

27. Tariq Waseem, Tanzeem Haider Raza, Naveed Bari Bhatti, Abdul Hafeez Khan.

Cerebral Malaria, Clinical presentation in Adults at Mayo Hospital Lahore Pakistan. Bio-

Medica. 1996; vol. 12, No. : 43-45

28. Tariq Waseem, A H Khan.

Intracardiac Schwanoma. A Case Report. Pakistan Journal of Cardiology. 1995; vol. 6: 57-60