Prevalence of Peripheral Artery Disease by Abnormal Ankle-Brachial Index in Atrial Fibrillation

Q: What are the key findings of this study?

Ankle-brachial index (ABI) ≤0.90 was present in 21% of nonvalvular atrial fibrillation patients, increasing total vascular disease prevalence from 17.3% to 33% when added to CHA2DS2-VASc.

Q: What is the clinical evidence from this study?

Study design: Cross-Sectional. Population: Nonvalvular atrial fibrillation (NVAF) (n=2027). Intervention: Ankle-brachial index (ABI) ≤0.90 measurement vs. ABI 0.91-1.39 / history-based CHA2DS2-VASc vascular disease definition alone. Primary outcome: Prevalence of peripheral artery disease defined by ABI ≤0.90 (and resulting total prevalence of vascular disease when added to CHA2DS2-VASc) (OR 1.85 for association of CHA2DS2-VASc including ABI ≤0.90 with previous stroke, 95% CI 1.41-2.44, p=<0.0001).

Q: What question did this study set out to answer?

To evaluate the prevalence of peripheral artery disease defined by an abnormal ankle-brachial index (ABI ≤0.90) in patients with nonvalvular atrial fibrillation and determine its impact on vascular risk classification.

Francesco Violi; Giovanni Davı̀; William Robert Hiatt; Gregory Y.H. Lip; Gino Roberto Corazza; Francesco Perticone; Marco Proietti; Pasquale Pignatelli; Anna Rita Vestri; Stefania Basili

doi:10.1016/j.jacc.2013.07.035

August 14, 2013Journal of the American College of CardiologyOpen Access

Prevalence of Peripheral Artery Disease by Abnormal Ankle-Brachial Index in Atrial Fibrillation

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Key result

Adding low ankle-brachial index to CHA2DS2-VASc is linked to ~85% higher prior stroke odds in AF.

OR 1.85 for association of CHA2DS2-VASc including ABI ≤0.90 with previous stroke
95% CI 1.41-2.44
P<0.0001
n=2,027

Why the study?

What is the prevalence of peripheral artery disease defined by an abnormal ankle-brachial index (ABI ≤0.90) in patients with nonvalvular atrial fibrillation, and how does its inclusion affect CHA2DS2-VASc vascular disease prevalence?

Key Points

To evaluate the prevalence of peripheral artery disease defined by an abnormal ankle-brachial index (ABI ≤0.90) in patients with nonvalvular atrial fibrillation and determine its impact on vascular risk classification.
Conducted a multicenter study (ARAPACIS registry, NCT01161251) across Italian internal medicine wards enrolling consecutive patients aged 18 years or older with nonvalvular atrial fibrillation.
Assessed bilateral ankle-brachial index measurements in a planned cohort halted early after an interim analysis, yielding a final sample of N=2,027 patients.
Calculated stroke risk categories using the CHA2DS2-VASc score and determined the change in vascular disease classification upon incorporating ABI ≤0.90.
An abnormal ABI ≤0.90 was identified in 21% of patients (428 of 2,027), while 69% (1,381 patients) had an ABI of 0.91–1.39 and 10% (204 patients) had an ABI ≥1.40.
ABI ≤0.90 was significantly associated with smoking (OR 1.99; 95% CI, 1.48–2.66; p<0.0001), diabetes (OR 1.93; 95% CI, 1.51–2.46; p<0.0001), age ≥75 years (OR 3.12; 95% CI, 2.16–4.61; p<0.0001), and previous TIA/stroke (OR 1.64; 95% CI, 1.20–2.24; p=0.002).
Incorporating ABI ≤0.90 increased the documented prevalence of vascular disease from 17.3% to 33%, and the updated score correlated more strongly with prior stroke (OR 1.85; 95% CI, 1.41–2.44; p<0.0001).

Study Design

Type

Cross-Sectional (n=2,027)

Multicenter

Yes

Structured PICO

What is the prevalence of peripheral artery disease defined by an abnormal ankle-brachial index (ABI ≤0.90) in patients with nonvalvular atrial fibrillation, and how does its inclusion affect CHA2DS2-VASc vascular disease prevalence?

P

Population

2,027 adults (age ≥18 years) with nonvalvular atrial fibrillation referred to Italian internal medicine wards, excluding those with valvular AF, active cancer, life expectancy <3 years, hyperthyroidism, or pregnancy.

E

Exposure

Ankle-brachial index (ABI) measurement (specifically ABI ≤0.90) incorporated into the CHA2DS2-VASc vascular disease assessment

C

Comparator

Standard history-based vascular disease assessment in CHA2DS2-VASc score alone or normal ABI (0.91-1.39)

O

Outcome

Prevalence of peripheral artery disease defined by ABI ≤0.90 in NVAF patientssurrogate

Main Result

Odds Ratio: 1.85 (95% CI 1.41–2.44)

p-value: p=<0.0001

Limitations

Cross-sectional baseline analysis requiring a prospective study to validate the prognostic risk score of the new vascular disease definition
ABI recorded in only one leg was excluded from the analysis (n=14)
Early interruption of patient enrollment at 2,027 of the planned 3,000 patients after interim analysis showed higher than expected prevalence of low ABI
Prospective study is necessary to validate the risk score of this new definition of vascular disease
Enrollment was stopped early at 2,027 patients (originally planned 3,000) following an interim analysis by the Data and Safety Monitoring Board
14 patients with ABI recorded in only one leg were excluded from the ABI distribution analysis

Key expert perspectives

Captured external expert commentary on this paper, strongest first. Original sources are linked where available.

FV Francesco VioliProfessor of internal medicine, Sapienza University of Rome

“This study provides the first evidence that one-fifth of NVAF patients had an ABI?0.90, indicating that it may represent a simple and cheap method to better define the prevalence of vascular disease in NVAF”

Sapienza University of RomeNews Coverage

Implication

Routine ankle-brachial index measurement identifies subclinical peripheral artery disease (ABI ≤0.90) in 21% of nonvalvular atrial fibrillation patients, nearly doubling the detected prevalence of vascular disease from 17.3% to 33% and potentially upgrading CHA2DS2-VASc stroke risk stratification.

Abstract

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Discussion

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Cite This Study

Violi et al. (2013) conducted a cross-sectional in Nonvalvular atrial fibrillation (NVAF) (n=2,027). Ankle-brachial index (ABI) ≤0.90 measurement vs. ABI 0.91-1.39 / history-based CHA2DS2-VASc vascular disease definition alone was evaluated on Prevalence of peripheral artery disease defined by ABI ≤0.90 (and resulting total prevalence of vascular disease when added to CHA2DS2-VASc) (OR 1.85 for association of CHA2DS2-VASc including ABI ≤0.90 with previous stroke, 95% CI 1.41-2.44, p=<0.0001). Ankle-brachial index (ABI) ≤0.90 was present in 21% of nonvalvular atrial fibrillation patients, increasing total vascular disease prevalence from 17.3% to 33% when added to CHA2DS2-VASc.

synapsesocial.com/papers/6ada28977c74d94e4bf719a0 https://doi.org/10.1016/j.jacc.2013.07.035

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Prevalence of Peripheral Artery Disease by Abnormal Ankle-Brachial Index in Atrial Fibrillation

Key Points

Study Design

Structured PICO

Main Result

Limitations

Key expert perspectives

Implication

Abstract

Discussion

Cite This Study

Prevalence of Peripheral Artery Disease by Abnormal Ankle-Brachial Index in Atrial Fibrillation

Key Points

Study Design

Structured PICO

Main Result

Limitations

Key expert perspectives

Implication

Abstract

Discussion

Cite This Study

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