Risk factors and haemodynamic variables in patients with low toe-brachial index but normal ankle-brachial index


      • Solitary use of ankle-brachial index (ABI) underestimated the prevalence of peripheral arterial disease (PAD).
      • Patients with low ABI have increased risk of cardiovascular morbidity and mortality.
      • Patients with low toe-brachial index  (TBI) but normal ABI share risk factors with patients with low ABI.


      Background and aims

      Classically, peripheral arterial disease (PAD) is diagnosed by a low ankle-brachial index (ABI), but the diagnosis can also be made based on toe-brachial index (TBI) measurements. The objective of this study was to characterize patients with low TBI but normal ABI, and chart potential underestimation of PAD prevalence by solitary use of ABI.


      A total of 3739 consecutive patients with known or suspected PAD referred for ABI and TBI measurements in a four-year period were compared to an age- and gender matched control group (n = 17,340).


      In the patient cohort, 65.0% had low ABI, 20.5% had low TBI but normal ABI, and 14.5% had normal indices. When comparing the frequencies of comorbidities related to atherosclerotic disease (myocardial infarction, congestive heart failure, cerebrovascular disease, diabetes mellitus, chronic kidney failure), there were no significant differences among patients with low ABI or low TBI with normal ABI in any of the variables (all p > 0.06). Of the patients with low TBI and normal ABI, 18.7% were diagnosed with diabetes mellitus type I or II, and 8.2% with chronic kidney disease.


      Patients with low TBI but normal ABI represented 20.5% of patients referred with the suspicion of PAD. Furthermore, patients with low TBI but normal ABI presented similar comorbid characteristics to patients with low ABI, who have a well-described increased risk of cardiovascular morbidity and mortality. The solitary use of ABI underestimated the prevalence of PAD in the population, and PAD screening could potentially be improved by routine application of TBI.

      Graphical abstract


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Atherosclerosis
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Norgren L.
        • Hiatt W.R.
        • Dormandy J.A.
        • Nehler M.R.
        • Harris K.A.
        • Fowkes F.G.
        • et al.
        Inter-society consensus for the management of peripheral arterial disease (TASC II).
        Eur. J. Vasc. Endovasc. Surg. 2007; 33: S1-S75
        • Ankle Brachial Index Collaboration
        • Fowkes F.G.
        • Murray G.D.
        • Butcher I.
        • Heald C.L.
        • Lee R.J.
        • et al.
        Ankle brachial index combined with Framingham Risk Score to predict cardiovascular events and mortality: a meta-analysis.
        J. Am. Med. Assoc. 2008; 300: 197-208
        • Leskinen Y.
        • Salenius J.P.
        • Lehtimaki T.
        • Huhtala H.
        • Saha H.
        The prevalence of peripheral arterial disease and medial arterial calcification in patients with chronic renal failure: requirements for diagnostics.
        Am. J. Kidney Dis. 2002; 40: 472-479
        • Bonham P.
        Measuring toe pressures using a portable photoplethysmograph to detect arterial disease in high-risk patients: an overview of the literature.
        Ostomy/Wound Manag. 2011; 57: 36-44
        • Hoyer C.
        • Sandermann J.
        • Petersen L.J.
        Randomised diagnostic accuracy study of a fully automated portable device for diagnosing peripheral arterial disease by measuring the toe-brachial index.
        Eur. J. Vasc. Endovasc. Surg. 2013; 45: 57-64
        • Hoyer C.
        • Sandermann J.
        • Paludan J.P.
        • Pavar S.
        • Petersen L.J.
        Diagnostic accuracy of laser Doppler flowmetry versus strain gauge plethysmography for segmental pressure measurement.
        J. Vasc. Surg. 2013; 58: 1563-1570
        • Andersen T.F.
        • Madsen M.
        • Jorgensen J.
        • Mellemkjoer L.
        • Olsen J.H.
        The Danish National Hospital Register. A valuable source of data for modern health sciences.
        Dan. Med. Bull. 1999; 46: 263-268
        • Thygesen S.K.
        • Christiansen C.F.
        • Christensen S.
        • Lash T.L.
        • Sorensen H.T.
        The predictive value of ICD-10 diagnostic coding used to assess Charlson comorbidity index conditions in the population-based Danish National Registry of Patients.
        BMC Med. Res. Methodol. 2011; 11 (2288-11-83)
        • Charlson M.E.
        • Pompei P.
        • Ales K.L.
        • MacKenzie C.R.
        A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.
        J. Chronic Dis. 1987; 40: 373-383
        • Deyo R.A.
        • Cherkin D.C.
        • Ciol M.A.
        Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases.
        J. Clin. Epidemiol. 1992; 45: 613-619
        • Arveschoug A.K.
        • Vammen B.
        • Yoshinaka E.
        • Sorensen D.
        • Jodal L.
        • Brochner-Mortensen J.
        Reference data for distal blood pressure in healthy elderly and middle-aged individuals measured with the strain gauge technique. Part I: resting distal blood pressure.
        Scand. J. Clin. Lab. Investig. 2008; 68: 249-253
        • Clark C.E.
        • Taylor R.S.
        • Shore A.C.
        • Ukoumunne O.C.
        • Campbell J.L.
        Association of a difference in systolic blood pressure between arms with vascular disease and mortality: a systematic review and meta-analysis.
        Lancet. 2012; 379: 905-914
        • Viera A.J.
        • Garrett J.M.
        Understanding interobserver agreement: the kappa statistic.
        Fam. Med. 2005; 37: 360-363
        • Aboyans V.
        • Ricco J.B.
        • Bartelink M.E.L.
        • Bjorck M.
        • Brodmann M.
        • Cohnert T.
        • et al.
        Editor's choice - 2017 ESC guidelines on the diagnosis and treatment of peripheral arterial diseases, in collaboration with the european society for vascular surgery (ESVS).
        Eur. J. Vasc. Endovasc. Surg. 2018; 55: 305-368
        • Suominen V.
        • Uurto I.
        • Saarinen J.
        • Venermo M.
        • Salenius J.
        PAD as a risk factor for mortality among patients with elevated ABI--a clinical study.
        Eur. J. Vasc. Endovasc. Surg. 2010; 39: 316-322
        • Hoyer C.
        • Sandermann J.
        • Petersen L.J.
        The toe-brachial index in the diagnosis of peripheral arterial disease.
        J. Vasc. Surg. 2013; 58: 231-238
        • Hyun S.
        • Forbang N.I.
        • Allison M.A.
        • Denenberg J.O.
        • Criqui M.H.
        • Ix J.H.
        Ankle-brachial index, toe-brachial index, and cardiovascular mortality in persons with and without diabetes mellitus.
        J. Vasc. Surg. 2014; 60: 390-395
        • Wickstrom J.E.
        • Laivuori M.
        • Aro E.
        • Sund R.T.
        • Hautero O.
        • Venermo M.
        • et al.
        Toe pressure and toe brachial index are predictive of cardiovascular mortality, overall mortality, and amputation free survival in patients with peripheral artery disease.
        Eur. J. Vasc. Endovasc. Surg. 2017; 53: 696-703
        • Zobel E.H.
        • von Scholten B.J.
        • Reinhard H.
        • Persson F.
        • Hansen T.W.
        • Parving H.H.
        • et al.
        Toe-brachial index as a predictor of cardiovascular disease and all-cause mortality in people with type 2 diabetes and microalbuminuria.
        Diabetologia. 2017; 60: 1883-1891
        • Suominen V.
        • Rantanen T.
        • Venermo M.
        • Saarinen J.
        • Salenius J.
        Prevalence and risk factors of PAD among patients with elevated ABI.
        Eur. J. Vasc. Endovasc. Surg. 2008; 35: 709-714
        • Spreen M.I.
        • Gremmels H.
        • Teraa M.
        • Sprengers R.W.
        • Martens J.M.
        • Verhaar M.C.
        • et al.
        High and immeasurable ankle-brachial index as predictor of poor amputation-free survival in critical limb ischemia.
        J. Vasc. Surg. 2018; 67 (e3): 1864-1871
        • Weinberg I.
        • Giri J.
        • Calfon M.A.
        • Hawkins B.M.
        • Weinberg M.D.
        • Margey R.
        • et al.
        Anatomic correlates of supra-normal ankle brachial indices.
        Cathet. Cardiovasc. Interv. 2013; 81: 1025-1030
        • Paravastu S.C.
        • Mendonca D.A.
        • Da Silva A.
        Beta blockers for peripheral arterial disease.
        Cochrane Database Syst. Rev. 2013; 9 (doi:CD005508): CD005508
        • Potier L.
        • Halbron M.
        • Bouilloud F.
        • Dadon M.
        • Le Doeuff J.
        • Ha Van G.
        • et al.
        Ankle-to-brachial ratio index underestimates the prevalence of peripheral occlusive disease in diabetic patients at high risk for arterial disease.
        Diabetes Care. 2009; 32: e44-2015
        • Emanuele M.A.
        • Buchanan B.J.
        • Abraira C.
        Elevated leg systolic pressures and arterial calcification in diabetic occlusive vascular disease.
        Diabetes Care. 1981; 4: 289-292
        • Criqui M.H.
        • Browner D.
        • Fronek A.
        • Klauber M.R.
        • Coughlin S.S.
        • Barrett-Connor E.
        • et al.
        Peripheral arterial disease in large vessels is epidemiologically distinct from small vessel disease. An analysis of risk factors.
        Am. J. Epidemiol. 1989; 129: 1110-1119