ABI-LOW was independently associated with all-cause mortality in hypertensive individuals (HR 1.87; 95% CI 1.63-2.16), but provided limited incremental predictive value over clinical predictors.
Cohort (n=21,875)
Do alternative ABI assessments (ABI-LOW and multivessel scoring) improve mortality risk prediction compared to standard ABI in hypertensive individuals?
Alternative ABI calculations identify more PAD cases and are associated with mortality in hypertensive patients, but offer limited incremental value for mortality risk prediction over standard clinical predictors.
Hazard Ratio: 1.87 (95% CI 1.63–2.16)
Objective: Lower-extremity peripheral arterial disease (PAD), assessed via the ankle–brachial index (ABI), is a recognized form of hypertension-mediated organ damage by the recent European Society of Hypertension guidelines. While alternative ABI calculations have shown improved sensitivity for PAD detection, their prognostic utility in hypertensive populations remains unclear. Design and method: In this prospective cohort study of 21,875 hypertensive individuals (ÉRV Study), we compared the prognostic performance of three ABI-based approaches: (1) standard ABI using the higher ankle and higher brachial pressure (ABI-HIGH), (2) ABI using the lower ankle higher brachial pressure (ABI-LOW), and (3) multivessel ABI scoring (number of vessels with ABI =< 0.90). The primary endpoint was all-cause mortality, assessed over a median follow-up of 5 years using interval-censored Cox regression. Results: PAD prevalence was 14.4% using ABI-HIGH and 28.3% using ABI-LOW, with 13.9% of patients identified only by the latter. All PAD definitions were independently associated with mortality. ABI-LOW as a continuous variable demonstrated the strongest association (HR 1.87; 95% CI, 1.63–2.16). Multivessel ABI showed a dose–response relationship with mortality. However, overall discrimination was modest: time-dependent AUCs ranged from 0.608 to 0.635 for ABI-based models alone. When added to clinical predictors, ABI metrics improved the AUC to a range from 0.763 to 0.780, with added predictive value between 6–11%. Conclusions: In hypertensive individuals, ABI-LOW and multivessel scoring identify more PAD cases and are independently associated with mortality. However, their incremental value in mortality risk prediction is limited. Alternative ABI methods may assist in identifying higher-risk subgroups warranting further vascular assessment.
Jarai et al. (2026) conducted a cohort in Hypertension (n=21,875). ABI-LOW (ankle-brachial index using the lower ankle higher brachial pressure) vs. Standard ABI (ABI-HIGH) was evaluated on All-cause mortality (HR 1.87, 95% CI 1.63-2.16). ABI-LOW was independently associated with all-cause mortality in hypertensive individuals (HR 1.87; 95% CI 1.63-2.16), but provided limited incremental predictive value over clinical predictors.