Relationship of High and Low Ankle Brachial Index to All-Cause and Cardiovascular Disease Mortality

TLDR

Low (<0.90) and high (>1.40) ankle‑brachial index (ABI) levels have not been studied for all‑cause or cardiovascular mortality risk in a population‑based cohort. This study examined all‑cause and cardiovascular mortality associated with low and high ABI among 4,393 American Indians in the Strong Heart Study. Participants underwent baseline bilateral ABI measurements and were followed for an average of 8.3 years, with Cox regression used to compare mortality rates relative to normal ABI (0.90–1.40). Both low and high ABI were linked to markedly higher all‑cause (HR ≈ 1.7) and cardiovascular mortality (HR ≈ 2.5 for low, 2.1 for high), revealing a U‑shaped association and suggesting the upper normal ABI limit should not exceed 1.40.

Abstract

Background— The associations of low (&lt;0.90) and high (&gt;1.40) ankle brachial index (ABI) with risk of all-cause and cardiovascular disease (CVD) mortality have not been examined in a population-based setting. Methods and Results— We examined all-cause and CVD mortality in relation to low and high ABI in 4393 American Indians in the Strong Heart Study. Participants had bilateral ABI measurements at baseline and were followed up for 8.3±2.2 years (36 589 person-years). Cox regression was used to quantify mortality rates among participants with high and low ABI relative to those with normal ABI (0.90 ≤ABI ≤1.40). Death from all causes occurred in 1022 participants (23.3%; 27.9 deaths per 1000 person-years), and of these, 272 (26.6%; 7.4 deaths per 1000 person-years) were attributable to CVD. Low ABI was present in 216 participants (4.9%), and high ABI occurred in 404 (9.2%). Diabetes, albuminuria, and hypertension occurred with greater frequency among persons with low (60.2%, 44.4%, and 50.1%) and high (67.8%, 49.9%, and 45.1%) ABI compared with those with normal ABI (44.4%, 26.9%, and 36.5%), respectively ( P &lt;0.0001). Adjusted risk estimates for all-cause mortality were 1.69 (1.34 to 2.14) for low and 1.77 (1.48 to 2.13) for high ABI, and estimates for CVD mortality were 2.52 (1.74 to 3.64) for low and 2.09 (1.49 to 2.94) for high ABI. Conclusions— The association between high ABI and mortality was similar to that of low ABI and mortality, highlighting a U-shaped association between this noninvasive measure of peripheral arterial disease and mortality risk. Our data suggest that the upper limit of normal ABI should not exceed 1.40.