The association of the ankle-brachial index with incident coronary heart disease: the Atherosclerosis Risk In Communities (ARIC)

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Peripheral arterial disease (PAD), defined by a low ankle-brachial index (ABI), is associated with an increased risk of cardiovascular events, but the risk of coronary heart disease (CHD) over the range of the ABI is not well characterized, nor described for African Americans.


The ABI was measured in 12186 white and African American men and women in the Atherosclerosis Risk in Communities Study in 1987├óÔé¼ÔÇ£89. Fatal and non-fatal CHD events were ascertained through annual telephone contacts, surveys of hospital discharge lists and death certificate data, and clinical examinations, including electrocardiograms, every 3 years. Participants were followed for a median of 13.1 years. Age- and field-center-adjusted hazard ratios (HRs) were estimated using Cox regression models.

Over a median 13.1 years follow-up, 964 fatal or non-fatal CHD events accrued. In whites, the age- and field-center-adjusted CHD hazard ratio (HR, 95% CI) for PAD (ABI<0.90) was 2.81 (1.77├óÔé¼ÔÇ£4.45) for men and 2.05 (1.20├óÔé¼ÔÇ£3.53) for women. In African Americans, the HR for men was 4.86 (2.76├óÔé¼ÔÇ£8.47) and for women was 2.34 (1.26├óÔé¼ÔÇ£4.35). The CHD risk increased exponentially with decreasing ABI as a continuous function, and continued to decline at ABI values > 1.0, in all race-gender subgroups. The association between the ABI and CHD relative risk was similar for men and women in both race groups. A 0.10 lower ABI increased the CHD hazard by 25% (95% CI 17├óÔé¼ÔÇ£34%) in white men, by 20% (8├óÔé¼ÔÇ£33%) in white women, by 34% (19├óÔé¼ÔÇ£50%) in African American men, and by 32% (17├óÔé¼ÔÇ£50%) in African American women.

African American members of the ARIC cohort had higher prevalences of PAD and greater risk of CHD associated with ABI-defined PAD than did white participants. Unlike in other cohorts, in ARIC the CHD risk failed to increase at high (>1.3) ABI values. We conclude that at this time high ABI values should not be routinely considered a marker for increased CVD risk in the general population. Further research is needed on the value of the ABI at specific cutpoints for risk stratification in the context of traditional risk factors.

The ankle-brachial index (ABI) is a simple, non-invasive measure of subclinical atherosclerosis [1]. Prospective studies have found that those with ABI-defined peripheral arterial disease (PAD) are approximately 1.5 to 2 times more likely to have a clinical CVD event than those without PAD [2-4]. The report of the American Heart Association Prevention Conference V concluded that the ABI provides risk information \over and above that provided by traditional risk factors\" and suggested that the test \"might be a useful addition to the assessment of CHD risk in selected populations....\" [1] Recent guidelines for the Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) recommend that an ABI<0.9 be considered a CHD risk equivalent (10-year CHD risk >20%) [5].


  1. Greenland P, Abrams J, Aurigemma GP, Bond MG, Clark LT, Criqui MH, Crouse JR, Friedman L, Fuster V, Herrington DM, Kuller LH, Ridker PM, Roberts WC, Stanford W, Stone N, Swan J, Taubert KA, Wexler L: Prevention Conference V. Beyond secondary prevention: identifying the high-risk patient for primary prevention. Noninvasive tests of atherosclerotic burden. Circulation 2000, 101:e16-e22.
  2. Ogren M, Hedblad B, Isacsson SO, Janzon L, Jungquist G, Lindell SE: Non-invasively detected carotid stenosis and ischaemic heart disease in men with leg arteriosclerosis. Lancet 1993, 342:1138.
  3. Leng GC, Fowkes FG, Lee AJ, Dunbar J, Housley E, Ruckley CV: Use of ankle brachial pressure index to predict cardiovascular events and death: a cohort study. BMJ 1996, 313(7070):1440.
  4. Newman AB, Shemanski L, Manolio TA, Cushman M, Mittelmark M, Polak JF, Powe NR, Siscovick D: Ankle-arm index as a predictor of cardiovascular disease and mortality in the Cardiovascular Health Study. Arteriosclerosis, Thrombosis & Vascular Biology 1999, 19(3):538.
  5. National Cholesterol Education P: Third report of the National Cholesterol Education Program (NCEP) Expert Panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). Final report. Bethesda, MD , National Heart, Lung, and Blood Institute. National Institutes of Health; 2002.
  6. Zheng ZJ, Sharrett AR, Chambless LE, Rosamond WD, Nieto FJ, Sheps DS, Dobs A, Evans GW, Heiss G: Associations of ankle-brachial index with clinical coronary heart disease, stroke and preclinical carotid and popliteal atherosclerosis: the Atherosclerosis Risk in Communities (ARIC) Study. Atherosclerosis 1997, 131(1):115.
  7. Meijer WT, Hoes AW, Rutgers D, Bots ML, Hofman A, Grobbee DE: Peripheral arterial disease in the elderly: The Rotterdam Study. Arteriosclerosis, Thrombosis & Vascular Biology 1998, 18(2):185.
  8. Bots ML, Hofman A, Grobbee DE: Common carotid intima-media thickness and lower extremity arterial atherosclerosis: The Rotterdam Study. Arteriosclerosis & Thrombosis 1994, 14:1885.
  9. Stoffers HEJH, Rinkens PE, Kester AD, Kaiser V, Knottnerus JA: The prevalence of asymptomatic and unrecognized peripheral arterial occlusive disease. International Journal of Epidemiology 1996, 25(2):282.
  10. Manolio TA, Burke GL, Psaty BM, Newman AB, Haan M, Powe N, Tracy RP, O'Leary DH: Black-white differences in subclinical cardiovascular disease among older adults: the Cardiovascular Health Study. CHS Collaborative Research Group. Journal of Clinical Epidemiology 1995, 48(9):1141.
  11. Gofin R, Kark JD, Friedlander Y, Lewis BS, Witt H, Stein Y, Gotsman MS: Peripheral vascular disease in a middle-aged population sample: The Jerusalem Lipid Research Clinic Prevalence Study. Isr J Med Sci 1987, 23:157.
  12. Schroll M, Munck O: Estimation of peripheral arteriosclerotic disease by ankle blood pressure measurements in a population study of 60 year old men and women. J Chronic Dis 1981, 34:261.
  13. Pomrehn P, Duncan B, Weissfeld L, Wallace RB, Barnes R, Heiss G, Ekelund LG, Criqui MH, Johnson N, Chambless LE: The association of dyslipoproteinemia with symptoms and signs of peripheral arterial disease: The Lipid Research Clinic Prevalence Study. Circulation 1986, 73(Suppl 1):100.
  14. Agner E: Natural history of angina pectoris, possible previous myocardial infarction and intermittent claudication during the eighth decade. Acta Med Scand 1981, 210:271.
  15. Kannel WB, Skinner JJ Jr., Schwartz MJ, Shurtleff D: Intermittent claudication: incidence in the Framingham Study. Circulation 1970, 41:875.
  16. Kannel WB, McGhee DL: Update on some epidemiological features of intermittent claudication: the Framingham Study. J Am Ger Soc 1985, 33:13.
  17. Leng GC, Lee AJ, Fowkes FG, Whiteman M, Dunbar J, Housley E, Ruckley CV: Incidence, natural history and cardiovascular events in symptomatic and asymptomatic peripheral arterial disease in the general population. International Journal of Epidemiology 1996, 25(6):1172.
  18. Hiatt WR, Hoag S, Harmnan RF: Effect of diagnostic criteria on the prevalence of peripheral arterial disease. The San Luis Valley Diabetes Study. Circulation 1995, 91:1472.
  19. Fowkes FG, Housley E, Riemersma RA, Macintyre CC, Cawood EH, Prescott RJ, Ruckley CV: Smoking, lipids, glucose intolerance, and blood pressure as risk factors for peripheral atherosclerosis compared with ischemic heart disease in the Edinburgh Artery Study. American Journal of Epidemiology 1992, 135(4):331.
  20. Vogt MT, Cauley JA, Newman AB, Kuller LH, Hulley SB: Decreased ankle/arm blood pressure index and mortality in elderly women. JAMA 1993, 270:465.
  21. Abbott RD, Petrovitch H, Rodriguez BL, Yano K, Schatz IJ, Popper JS, Masaki KH, Ross GW, Curb JD: Ankle/brachial blood pressure in men >70 years of age and the risk of coronary heart disease. Am J Cardiol 2000, 86(3):280-284.
  22. Hooi JD, Stoffers HE, Kester AD, van RJ, Knottnerus JA: Peripheral arterial occlusive disease: prognostic value of signs, symptoms, and the ankle-brachial pressure index. Med Decis Making 2002, 22(2):99-107.
  23. Resnick HE, Lindsay RS, McDermott MM, Devereux RB, Jones KL, Fabsitz RR, Howard BV: Relationship of high and low ankle brachial index to all-cause and cardiovascular disease mortality: the Strong Heart Study. Circulation 2004, 109(6):733-739.
  24. O'Hare AM, Katz R, Shlipak MG, Cushman M, Newman AB: Mortality and cardiovascular risk across the ankle-arm index spectrum. Circulation 2006, 113:388-393.
  25. Wattanakit K, Folsom AR, Duprez DA, Weatherley BD, Hirsch AT: Clinical significance of a high ankle-brachial index: Insights from the Atherosclerosis Risk in Communities (ARIC) Study. Atherosclerosis 2006.
  26. Jones DW, Chambless LE, Folsom ARJ, Heiss G, Hutchinson RG, Sharrett AR, Szklo M, Taylor HA: Risk factors for coronary heart disease in African Americans: the Atherosclerosis Risk in Communities Study, 1987-1997. Arch Int Med 2002, 162:2565-2571.
  27. Jackson SA, Burke GL, Thach C, Cushman M, Ives D, Powe N, Manolio TA: Incidence and predictors of coronary heart disease among older African Americans--the Cardiovascular Health Study. J Natl Med Assoc 2001, 93(11):423-429.
  28. The Atherosclerosis Risk in Communities (ARIC) Study: design and objectives American Journal of Epidemiology 1989, 129:687.
  29. Jackson R, Chambless L, Yang K, Byrne T, Watson R, Folsom A, Shahar E, Kalsbeek W: Differences between respondents and non-respondents in a multi-center community-based study vary by gender and ethnicity. J Clin Epidemiol 1996, 49:1441.
  30. Orchard TJ, Strandness DE: Assessment of peripheral vascular disease in diabetes. Report and recommendations of an international workshop sponsored by the American Diabetes Association and the American Heart Association. September 18-20, 1992, New Orleans, Louisiana. Circulation 1993, 88(2):819.
  31. Weatherley BD, Chambless LE, Heiss G, Catellier DJ, Ellison RC: The reliability of the ankle-brachial index in the Atherosclerosis Risk in Communities (ARIC) study and the NHLBI Family Heart Study (FHS). BMC Cardiovascular Disorders 2006, 6:7.
  32. Friedewald WT, Levy RI, Frederickson DS: Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of preparative centrifuge. Clin Chem 1972, 18:499-502.
  33. Rose GA, Blackburn H: Cardiovascular Survey Methods. Geneva, Switzerland , World Health Organization; 1968.
  34. Riley WA, Barnes RW, Bond MG, Evans G, Chambless LE, Heiss G: High-resolution B-mode ultrasound reading methods in the Atherosclerosis Risk in Communities (ARIC) Cohort. J Neuroimag 1991, 1:168-172.
  35. Rautaharju PM, Warren JW, Jain U, Wolf HK, Nielsen CL: Cardiac infarction injury score: an electrocardiographic coding scheme for ischemic heart disease. Circulation 1981, 64:249-256.
  36. Schoenfeld DA: Partial residuals for the proportional hazards regression model. Biometrika 1982 , 69:239-241.
  37. Stone CJ, Koo CY: Additive splines in statistics. Proc Stat Comp Sect Am Statist Assoc 1985 , 45-48.
  38. Harrell FE: Predicting Outcomes: Applied Survival Analysis and Logistic Regression. Durham, NC , Duke University Medical Center; 1995 :10-11.
  39. Fuller WA: Measurement error models. New York, NY , John Wiley & Sons; 1987.
  40. Carroll RJ, Ruppert D, Stefanski LA: Measurement error in nonlinear models. London , Chapman & Hall ; 1995.
  41. Whittemore AS: Errors-in-variables regression using Stein estimates. The American Statistician 1989, 43(4):226-227.
  42. Heald CL, Fowkes FG, Murray GD, Price JF: Risk of mortality and cardiovascular disease associated with the ankle-brachial index: Systematic review. Atherosclerosis 2006, 189(1):61-69.
  43. Ogren M, Hedblad B, Jungquist G, Isacsson SO, Lindell SE, Janzon L: Low ankle-brachial pressure index in 68-year-old men: prevalence, risk factors and prognosis. Results from prospective population study Men born in 1914", Malmo, Sweden. Eur J Vasc Surg 1993, 7(5):500-506.
  44. Murabito JM, Evans JC, Larson MG, Nieto K, Levy D, Wilson PWF: The ankle-brachial index in the lederly and risk of stroke, coronary disease, and death: the Framingham Study. Arch Int Med 2003, 163:1939-1942.
  45. Lee AJ, Price JF, Russell MJ, Smith FB, van Wijk MC, Fowkes FG: Improved prediction of fatal myocardial infarction using the ankle brachial index in addition to conventional risk factors: the Edinburgh Artery Study. Circulation 2004, 110(19):3075-3080.
  46. van der Meer IM, Bots ML, Hofman A, del Sol AI, van der Kuip DA, Witteman JC: Predictive value of noninvasive measures of atherosclerosis for incident myocardial infarction: the Rotterdam Study. Circulation 2004, 109(9):1089-1094.
  47. Aronow WS: Prevalence of atherothrombotic brain infarction, coronary artery disease and peripheral arterial disease in elderly blacks, Hispanics and whites. Am J Cardiol 1992, 70(13):1212-1213.
  48. Newman AB, Siscovick DS, Manolio TA, Polak J, Fried LP, Borhani NO, Wolfson SK: Ankle-arm index as a marker of atherosclerosis in the Cardiovascular Health Study. Circulation 1993, 88:837.
  49. Kullo IJ, Bailey KR, Kardia SL, Mosley TH Jr., Boerwinkle E, Turner ST: Ethnic differences in peripheral arterial disease in the NHLBI Genetic Epidemiology Network of Arteriopathy (GENOA) study. Vasc Med 2003, 8(4):237-242.
  50. Selvin E, Erlinger TP: Prevalence of and risk factors for peripheral arterial disease in the United States: results from the National Health and Nutrition Examination Survey, 1999-2000. Circulation 2004, 110(6):738-743.
  51. McDermott MM, Liu K, Criqui MH, Ruth K, Goff D, Saad MF, Wu C, Homma S, Sharrett AR: Ankle-brachial index and subclinical cardiac and carotid disease: the multi-ethnic study of atherosclerosis. Am J Epidemiol 2005, 162(1):33-41.
  52. Collins TC, Petersen NJ, Suarez-Almazor M, Ashton CM: The prevalence of peripheral arterial disease in a racially diverse population. Arch Intern Med 2003, 163(12):1469-1474.
  53. Wang JC, Criqui MH, Denenberg JO, McDermott MM, Golomb BA, Fronek A: Exertional leg pain in patients with and without peripheral arterial disease. Circulation 2005 , 112:3501-3508.
  54. Fowkes FG, Housley E, Macintyre CC, Prescott RJ, Ruckley CV: Variability of ankle and brachial systolic pressures in the measurement of atherosclerotic peripheral arterial disease. Journal of Epidemiology & Community Health 1988, 42(2):128.
  55. Flegal CM, Keyl PM, Nieto FJ: Differential misclassification arising from nondifferential errors in exposure measurement. American Journal of Epidemiology 1991, 134(10):1233-1244.