Ankle–brachial blood pressure in elderly men and the risk of stroke: The Honolulu Heart Program

doi:10.1016/S0895-4356(01)00373-0

Journal of Clinical Epidemiology

Volume 54, Issue 10, October 2001, Pages 973-978

https://doi.org/10.1016/S0895-4356(01)00373-0 Get rights and content

Abstract

Although low ankle/brachial blood pressure index (ABI) is a marker of generalized atherosclerosis in the elderly, it has not been identified as a risk factor for stroke. The purpose of this report is to examine the relation between ABI and stroke in elderly men. ABI was measured from 1991 to 1993 in 2767 men aged 71 to 93 years in the Honolulu Heart Program without a history of stroke and coronary heart disease. Subjects were followed for 3 to 6 years for fatal and nonfatal thromboembolic and hemorrhagic stroke. During follow-up, there were 91 strokes. There was an age-adjusted 2-fold excess in men with an ABI < 0.9 (6.0%) versus men with an ABI ⩾ 0.9 (2.9%, P < 0.01). Thromboembolic events occurred in 4.6% of men with an ABI < 0.9 and in 2.0% in those with an ABI ⩾ 0.9 (P < 0.01). Hemorrhagic stroke was also more frequent in men with a low ABI (< 0.9) versus a higher ABI (1.9 vs. 0.8%, respectively). After adjusting for other factors, the risk of total and thromboembolic strokes increased with declining ABI (P = 0.019 and P = 0.004, respectively). The relation between ABI and stroke was similar and statistically significant in the presence and absence of diabetes and hypertension (P < 0.05). Findings suggest that ABI is inversely related to the incidence of stroke. Simple measurement of ABI in an outpatient setting could be an important tool for assessing the risk of stroke in the elderly.

Introduction

The ankle/brachial blood pressure index (ABI) is a measure of asymptomatic peripheral artery disease that is known to coexist with a variety of cardiovascular risk factors when it falls below 0.9 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14. Although relatively uncommon in middle-adulthood, low ABI prevalence (< 0.9) rises rapidly with age from under 4% for ages less than 70 to more than 25% in individuals aged 85 years and older 1, 2, 3, 4.

While evidence suggests that individuals with a low ABI have an increased risk of death from cardiovascular disease 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, an association with incident stroke in the elderly has not been identified 6, 7. Effects of ABI in individuals with other underlying cardiovascular risk factors are also unknown. The purpose of this report is to examine the relation between ABI and the risk of thromboembolic and hemorrhagic stroke in a sample of clinically healthy elderly men.

Section snippets

Materials and methods

From 1965 to 1968, the Honolulu Heart Program began following 8006 men of Japanese ancestry living on the island of Oahu, Hawaii, for the development of coronary heart disease and stroke 15, 16. At the time of study enrollment, participants received a complete physical examination when they were aged 45 to 68 years. Procedures were in accordance with institutional guidelines and approved by an institutional review committee. Informed consent was obtained from the study participants.

The first

Results

In the 2767 men considered in this report, the average ABI was 1.04 ± 0.16. Among the men, 11.6% (322) had an ABI < 0.9. Nine men, without a detectable ankle blood pressure, had an ABI of zero. Table 1 shows the percent distribution of an ABI < 0.9 according to age. Among the men, the percent with an ABI < 0.9 increased significantly from 6.3% (53/836) in men aged 71 to 74 years to 25.4% (72/283) in those who were 85 years and older (P < 0.001). Men with an ABI < 0.9 were on average 80 years

Discussion

Low ABI ( < 0.9) was consistently related to an increased risk of total and thromboembolic stroke before and after risk factor adjustment. Findings further suggest that the risk of hemorrhagic stroke is also increased in men with a low ABI as compared to those whose ABI is higher. Although ABI has been shown to be an important risk factor for total mortality, total cardiovascular disease, cardiac failure, and peripheral artery disease 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, this may be the first

Acknowledgements

Supported by the National Heart, Lung, and Blood Institute (contract NO1-HC-05102 and grant U01-HL-56274), the National Institute on Aging (contract NO1-AG-4-2149), by a Research Centers in Minority Institutions Award from the National Institutes of Health (P20 RR 11091), Bethesda, Maryland, and by the American Heart Association of Hawaii (grant HIGS-16-97).

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Ankle-brachial index and the risk of hemorrhagic stroke
2021, European Journal of Internal Medicine
Ankle-brachial index and subsequent risk of incident and recurrent cardiovascular events in older adults: The Atherosclerosis Risk in Communities (ARIC) study
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Citation Excerpt :
The addition of ABI beyond traditional predictors significantly improved the risk prediction of CHD/stroke and HF in participants with and without ASCVD, but the improvement was most evident for CHD in those without ASCVD and for HF in those with ASCVD. Our findings on the contemporary associations between ABI and incident CHD/stroke in the older adult population without history of ASCVD are consistent with earlier studies from the 1980s–1990s [7–9]. Since the medical environment has changed substantially in the last few decades (e.g. increased statin use and prevalence of diabetes and general improvements in medical therapy), our contemporary study is of value in the era of modern medicine [10,24,25].
The ankle-brachial index (ABI) is a diagnostic test for screening and detecting peripheral artery disease (PAD), as well as a risk enhancer in the AHA/ACC guidelines on the primary prevention of atherosclerotic cardiovascular disease (ASCVD). However, our understanding of the association between ABI and cardiovascular risk in contemporary older populations is limited. Additionally, the prognostic value of ABI among individuals with prior ASCVD is not well understood.
Among 5,003 older adults at ARIC visit 5 (2011–2013) (4,160 without prior ASCVD [median age 74 years, 38% male], and 843 with ASCVD [median age 76 years, 65% male]), we quantified the association between ABI and the risk of heart failure (HF), and composite coronary heart disease and stroke (CHD/stroke) using multivariable Cox regression models.
Over a median follow-up of 5.5 years, we observed 400 CHD/stroke events and 338 HF cases (242 and 199 cases in those without prior ASCVD, respectively). In participants without a history of ASCVD, a low ABI ≤0.9 (relative to ABI 1.11–1.20) was associated with both CHD/stroke and HF (adjusted hazard ratios 2.40 [95% CI: 1.55–3.71] and 2.23 [1.40–3.56], respectively). In those with prior ASCVD, low ABI was not significantly associated with CHD/stroke, but was with HF (7.12 [2.47–20.50]). The ABI categories of 0.9–1.2 and > 1.3 were also independently associated with increased HF risk. Beyond traditional risk factors, ABI significantly improved the risk discrimination of CHD/stroke in those without ASCVD and HF, regardless of baseline ASCVD.
Low ABI was associated with CHD/stroke in those without prior ASCVD and higher risk of HF regardless of baseline ASCVD status. These results support ABI as a risk enhancer for guiding primary cardiovascular prevention and suggest its potential value in HF risk assessment for older adults.
Co-existence of vascular disease in different arterial beds: Peripheral artery disease and carotid artery stenosis - Data from Life Line Screening<sup>®</sup>
2015, Atherosclerosis
Atherosclerosis is a systemic vascular disorder, involving multiple arterial territories. This project sought to investigate the relationship between lower extremity peripheral artery disease (PAD) and carotid artery stenosis (CAS) in a large self-referred population.
Data from the ankle brachial index (ABI) and carotid duplex ultrasound were analyzed from 3.67 million US subjects in the Life Line Screening program between 2004 and 2008. PAD was defined by ABI<0.9 and CAS was defined by greater than 50% stenosis. Multivariate logistic regression analysis was used to estimate odds of CAS by PAD status and severity.
Mean age of the population was 63.7 ± 10.6 years and 64% were women. The prevalence of PAD and CAS was 4.1% and 3.9%, respectively. Subjects with PAD had a higher prevalence of CAS than those without PAD (18.8% vs. 3.3%, P < 0.0001). In multivariate analysis, PAD was associated with greater odds of CAS (OR 3.28, 95% CI 3.22–3.34). Both symptomatic (OR 3.66, 95% CI 3.58–3.75) and asymptomatic PAD (OR 2.91, 95% CI 2.84–2.98) was associated with CAS. Increasing severity of PAD was associated with greater odds of CAS (OR 2.32, 3.61, 4.19, 5.14, and 7.59 for ABI categories 0.81–0.90, 0.71–0.80, 0.61–0.70, 0.41–0.60, ≤0.40, respectively).
Presence and severity of PAD was associated with prevalence of CAS in the large self-referred and self-paying Life Line cohort, regardless of lower extremity symptoms.
ABI and stroke: Action at a distance and a call to action
2014, Atherosclerosis
Ankle-brachial index and neurologic deterioration in acute ischemic stroke
2014, Journal of Stroke and Cerebrovascular Diseases
Citation Excerpt :
ABI has been used as a diagnostic and prognostic tool for the management of patients with PAD.15 Furthermore, several studies have indicated that an abnormal ABI can be a good predictor of initial or recurrent stroke.1,9,16,17 High prevalence of a low ABI in patients with ischemic stroke has been reported previously, with most studies indicating that the prevalence of low ABI ranges from 24%-51% among patients with AIS or transient ischemic attack.6-10
Few studies have examined the relationship between abnormal ankle-brachial index (ABI) and short-term outcome in patients with acute ischemic stroke (AIS).
We included 209 consecutive patients with AIS admitted to our hospital and divided them into abnormal ABI (≤.9) and normal ABI (>.9) groups. We defined neurologic deterioration (ND) as an increase of 1 or more points in the National Institutes of Health Stroke Scale score within 7 days of stroke onset. Clinical characteristics were compared between the 2 groups. Then, we performed a multiple logistic regression analysis to identify independent predictors of ND. In the multivariate analysis, the ABI values were used separately as binary variables in different cutoff thresholds (.9, 1.0, and 1.1).
Of the 209 patients, 24 (11.5%) had an abnormal ABI. The patients in abnormal and normal ABI groups showed significant differences in carotid arterial stenosis (37.5% versus 18.9%; P = .040), intracranial artery stenosis (54.2% versus 18.9%; P < .001), and previous use of antiplatelet drugs (58.3% versus 29.2%; P = .004). According to the multivariate analysis, ABIs of .9 or less and 1.0 or less were positively associated with ND (odds ratio [OR], 1.74; 95% confidence interval [CI], 1.03-2.89; P = .034 and OR, 1.63; 95% CI, 1.05-2.54; P = .027, respectively), whereas an ABI value of 1.1 or less was not an independent predictor of ND (OR, 1.17; 95% CI, 0.79-1.74; P = .43).
Not only an ABI of .9 or less but also an ABI of 1.0 or less can be a predictor of ND in patients with AIS.
Low ankle-brachial index and risk of stroke
2013, Atherosclerosis
Citation Excerpt :
The qualities of the included studies are listed in Table 2. Six studies [5,8,9,11–13] reported low ABI and total strokes. The total number of participants included in this meta-analysis was 23,171 with 712 total strokes patients.
Many studies have evaluated the association between a low ankle-brachial index (ABI) and the risk of stroke events; however, their results are inconsistent. The aim of the present study was to determine the association between a low ABI (ABI < 0.9) and the risk of stroke events by conducting a meta-analysis.
Electronic literature databases (Medline, and Embase) were searched for relevant prospective observational studies published prior to December 2012. Only prospective studies that detected stroke events for participants with low ABI in general population during the follow-up period were selected. The results were presented as relative risk (RR) and the 95% confidence interval (CI) comparing low ABI (ABI < 0.9) to the ABI (≥0.9) category.
After the initial search, we identified 10 studies with a total of 22,355 participants that met our inclusion criteria. Overall, low ABI was associated with an increased risk of subsequent stroke (RR 1.43; 95% CI 1.23–1.65), and ischemic stroke (RR 1.83; 95% CI 1.29–2.58). In addition, a low ABI was also associated with an increased risk of recurrent strokes (RR 3.02; 95% CI 1.26–7.25). However, a low ABI was not associated with an increased risk of hemorrhagic stroke (RR 1.55; 95% CI 0.34–7.08).
Our results suggest that a low ABI appears to be an independent predictor for ischemic and recurrent stroke events. The low ABI provides supplemental information on subjects who are at increased risk of subsequent stroke events.

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Original articleAnkle–brachial blood pressure in elderly men and the risk of stroke: The Honolulu Heart Program

Abstract

Introduction

Section snippets

Materials and methods

Results

Discussion

Acknowledgements

J Clin Epidemiol

Atherosclerosis

Atherosclerosis

Atherosclerosis

J Chron Dis

Am J Cardiol

J Clin Epidemiol

J Clin Epidemiol

Ankle-arm index as a marker of atherosclerosis in the Cardiovascular Health Study

Circulation

Peripheral artery disease and cardiovascular risk factors in the elderlyThe Honolulu Heart Program

Arterioscler Thromb Vasc Biol

The prevalence of peripheral vascular disease in a defined population

Circulation

Ankle-arm index as a predictor of cardiovascular disease and mortality in the Cardiovascular Health Study

Arterioscler Thromb Vasc Biol

Mortality over a period of 10 years in patients with peripheral arterial disease

N Engl J Med

Deceased ankle/arm blood pressure index and mortality in elderly women

JAMA

Original article
Ankle–brachial blood pressure in elderly men and the risk of stroke: The Honolulu Heart Program