Reliability of Two Ankle-Brachial Index Methods to Predict Silent Lacunar Infarcts: A Population-Based Study in Stroke-Free Older Adults (the Atahualpa Project)

Abstract

Individuals with an abnormal ankle-brachial index (ABI) are four times more likely to have a silent lacunar infarct (SLI), but reliability of ABI in predicting the presence of these lesions has not been estimated yet.

We compared two methods of calculating ABI to assess their reliability in predicting SLIs.

Stroke-free Atahualpa residents aged ≥ 60 years underwent MRI of the brain and ABI determinations. Persons with ABI ≥ 1.4 were excluded. Using receiver operator characteristic curve analysis, we calculated the reliability of the traditional as well as an alternative ABI method to identify individuals with SLI. The traditional ABI uses the higher systolic pressure of either the dorsalis pedis or the posterior tibial arteries as the numerator, whereas the alternative ABI uses the lower pressure.

Of the 247 participants, 38 (15%) had traditional and 95 (38%) had alternative ABIs ≤ 0.9. Twenty-one individuals had SLI. Traditional and alternative ABIs ≤ 0.9 identified 9 and 13 individuals with SLI, respectively. The traditional ABI had sensitivity of 42.9% (22.6–65.6%) and specificity of 87.2% (81.9–91.1%). The alternative ABI had sensitivity of 61.9% (38.6–81%) and specificity of 63.7% (57–69.9%). The area under the curve for the predictive value of SLI was 0.65 (0.54–0.76) for the traditional and 0.63 (0.52–0.74) for the alternative ABI ≤ 0.9.

The ABI is moderately reliable for identifying candidates for MRI screening in studies assessing the burden of SLI in older adults. The traditional ABI seems to be more suitable for this purpose.

Keywords

ankle-brachial index - alternative ankle-brachial index - peripheral artery disease - silent lacunar infarcts - magnetic resonance imaging - population-based studies - developing countries

• References

• 1 Strong K, Mathers C, Bonita R. Preventing stroke: saving lives around the world. Lancet Neurol 2007; 6 (2) 182-187
• 2 Saposnik G, Del Brutto OH ; Iberoamerican Society of Cerebrovascular Diseases. Stroke in South America: a systematic review of incidence, prevalence, and stroke subtypes. Stroke 2003; 34 (9) 2103-2107
• 3 Tshikwela ML, Londa FB, Tongo SY. Stroke subtypes and factors associated with ischemic stroke in Kinshasa, Central Africa. Afr Health Sci 2015; 15 (1) 68-73
• 4 Wardlaw JM, Smith EE, Biessels GJ , et al; STandards for ReportIng Vascular changes on nEuroimaging (STRIVE v1). Neuroimaging standards for research into small vessel disease and its contribution to ageing and neurodegeneration. Lancet Neurol 2013; 12 (8) 822-838
• 5 Yatsu FM, Shaltoni HM. Implications of silent strokes. Curr Atheroscler Rep 2004; 6 (4) 307-313
• 6 Del Brutto OH, Sedler MJ, Mera RM , et al. The association of ankle-brachial index with silent cerebral small vessel disease: results of the Atahualpa Project. Int J Stroke 2015; 10 (4) 589-593
• 7 Fowkes FG, Murray GD, Butcher I , et al; Ankle Brachial Index Collaboration. Ankle brachial index combined with Framingham risk score to predict cardiovascular events and mortality: a meta-analysis. JAMA 2008; 300 (2) 197-208
• 8 Gronewold J, Hermann DM, Lehmann N , et al; Heinz Nixdorf Recall Study Investigative Group. Ankle-brachial index predicts stroke in the general population in addition to classical risk factors. Atherosclerosis 2014; 233 (2) 545-550
• 9 Aboyans V, Criqui MH, Abraham P , et al; American Heart Association Council on Peripheral Vascular Disease; Council on Epidemiology and Prevention; Council on Clinical Cardiology; Council on Cardiovascular Nursing; Council on Cardiovascular Radiology and Intervention, and Council on Cardiovascular Surgery and Anesthesia. Measurement and interpretation of the ankle-brachial index: a scientific statement from the American Heart Association. Circulation 2012; 126 (24) 2890-2909
• 10 Schröder F, Diehm N, Kareem S , et al. A modified calculation of ankle-brachial pressure index is far more sensitive in the detection of peripheral arterial disease. J Vasc Surg 2006; 44 (3) 531-536
• 11 Nead KT, Cooke JP, Olin JW, Leeper NJ. Alternative ankle-brachial index method identifies additional at-risk individuals. J Am Coll Cardiol 2013; 62 (6) 553-559
• 12 Del Brutto OH, Santamaría M, Ochoa E , et al. Population-based study of cardiovascular health in Atahualpa, a rural village of coastal Ecuador. Int J Cardiol 2013; 168 (2) 1618-1620
• 13 Del Brutto OH, Tettamanti D, Del Brutto VJ, Zambrano M, Montalván M. Living alone and cardiovascular health status in residents of a rural village of coastal Ecuador (the Atahualpa Project). Environ Health Prev Med 2013; 18 (5) 422-425
• 14 Lloyd-Jones D, Hong Y, Labarthe D , et al; American Heart Association Strategic Planning Task Force and Statistics Committee. Defining and setting national goals for cardiovascular health promotion: The American Heart Association's strategic impact goal through 2020 and beyond. Circulation 2010; 121: 586-613
• 15 Del Brutto OH, Mera RM, Del Brutto VJ, Zambrano M, Lama J. White matter hyperintensities of presumed vascular origin: a population-based study in rural Ecuador (the Atahualpa Project). Int J Stroke 2015; 10 (3) 372-375
• 16 Bouchi R, Babazono T, Takagi M , et al. Non-linear association between ankle-brachial pressure index and prevalence of silent cerebral infarction in Japanese patients with type 2 diabetes. Atherosclerosis 2012; 222 (2) 490-494
• 17 McDermott MM, Criqui MH, Liu K , et al. Lower ankle/brachial index, as calculated by averaging the dorsalis pedis and posterior tibial arterial pressures, and association with leg functioning in peripheral arterial disease. J Vasc Surg 2000; 32 (6) 1164-1171
• 18 Niazi K, Khan TH, Easley KA. Diagnostic utility of the two methods of ankle brachial index in the detection of peripheral arterial disease of lower extremities. Catheter Cardiovasc Interv 2006; 68 (5) 788-792
• 19 Domanski MJ, Davis BR, Pfeffer MA, Kastantin M, Mitchell GF. Isolated systolic hypertension: prognostic information provided by pulse pressure. Hypertension 1999; 34 (3) 375-380
• 20 de Virgilio C, Toosie K, Arnell T , et al. Asymptomatic carotid artery stenosis screening in patients with lower extremity atherosclerosis: a prospective study. Ann Vasc Surg 1997; 11 (4) 374-377
• 21 Chung JW, Kim BJ, Sohn CH, Yoon BW, Lee SH. Branch atheromatous plaque: a major cause of lacunar infarction (high-resolution MRI study). Cerebrovasc Dis Extra 2012; 2 (1) 36-44