Diagnosis of Peripheral Arterial Disease in General Practice
Background: Despite its validity as a screening test for peripheral arterial disease (PAD), and its prognostic value, the ankle-brachial index (ABI) is infrequently used in primary care, probably because a Doppler device is required, along with the requisite skill for its use. We hypothesized that ABI could be accurately measured either by pulse palpation (pABI) or automatic blood pressure devices (autoABI) instead of Doppler method (dABI).
Design and methods: In 54 subjects, we compared the results and the intra-observer reproducibility of pABI to dABI, as well as the inter-observer reproducibility of both pABI and autoABI to dABI. Arm and ankle systolic pressures were measured by the three methods by two observers. The first observer repeated pABI and dABI measurements. The results were compared by the Student paired t-test. Reproducibility was assessed by the intra-class correlation coefficient of agreement (R) and the Bland and Altman method.
Results: The mean dABI obtained by the first observers was 1.03 ± 0.26 vs. a pABI of 0.85 ± 0.44 (p < 0.0001) and an autoABI of 1.09 ± 0.31 (p < 0.05). The intra-observer R-coefficient was at 0.89 for dABI vs. 0.60 for pABI (p < 0.05). The inter-observer R-coefficients were 0.79 for dABI vs. 0.40 for pABI (p < 0.05) and 0.44 for autoABI (p < 0.05).
Conclusion: Neither pulse palpation nor automatic oscillometric devices can be recommended as reliable methods for ABI measurement.
What's known: Ankle-brachial index (ABI) is the easiest accurate method to detect peripheral arterial disease (PAD), and it is therefore highly recommended in general practice. However, ABI is rarely used in routine clinical practice, possibly since a Doppler device is required for its measurement. It has been suggested that automatic blood pressure (BP) devices or pulse palpation be used to assess limbs BPs, but a thorough comparison of these alternate methods has received little attention.
What's new: Our data show that ABI determination by pulse palpation or automatic BP devices are poorly reliable compared with Doppler, and may lead to ABI underestimation for the former and overestimation for the latter. The use of a (portable) Doppler is required for accurate ABI determination.
Peripheral arterial disease (PAD), a manifestation of atherosclerotic disease, has a high prevalence in the general population in western countries. It is well known that a majority of those suffering from PAD are asymptomatic. Even at the subclinical level, the diagnosis of PAD is of public health importance as both clinical and subclinical PAD are strong prognostic markers for future cardiovascular disease (CVD) events. Hence, knowledge of the presence of PAD should influence the implementation of preventive care. Unfortunately, only a fraction of patients suffering from PAD are adequately diagnosed by their general practitioners. The presence or absence of lower limb pulses cannot solely make the diagnosis, as not only the reliability of pulse palpation is poor, but also a present pulse cannot definitely exclude the presence of PAD.
The easiest accurate non-invasive method for the diagnosis of PAD is the measurement of ankle-brachial index (ABI). A low ABI (≤ 0.90) defines the presence of PAD with good sensitivity and excellent specificity. Besides its measurement ease, requiring only a pneumatic pressure cuff and a (pocket) Doppler device, its use in general practice remains uncommon. Reasons include the expense of Doppler devices and/or the lack of training to use them appropriately in primary care offices.
The reliability of ABI measured by automatic blood pressure cuffs has been studied with conflicting results. A recent report employed pulse palpation instead of a Doppler device for the measurement of the systolic pressures of the limbs. However, the reliability and the reproducibility of this method are unknown. Compared with the Doppler method traditionally used, these methods are more accessible in primary care offices and would therefore be more likely to be utilised. In this study, we assessed the validity and reliability of these two alternative modes of ABI measurement, compared with the traditional Doppler method, in a group of patients.
Background: Despite its validity as a screening test for peripheral arterial disease (PAD), and its prognostic value, the ankle-brachial index (ABI) is infrequently used in primary care, probably because a Doppler device is required, along with the requisite skill for its use. We hypothesized that ABI could be accurately measured either by pulse palpation (pABI) or automatic blood pressure devices (autoABI) instead of Doppler method (dABI).
Design and methods: In 54 subjects, we compared the results and the intra-observer reproducibility of pABI to dABI, as well as the inter-observer reproducibility of both pABI and autoABI to dABI. Arm and ankle systolic pressures were measured by the three methods by two observers. The first observer repeated pABI and dABI measurements. The results were compared by the Student paired t-test. Reproducibility was assessed by the intra-class correlation coefficient of agreement (R) and the Bland and Altman method.
Results: The mean dABI obtained by the first observers was 1.03 ± 0.26 vs. a pABI of 0.85 ± 0.44 (p < 0.0001) and an autoABI of 1.09 ± 0.31 (p < 0.05). The intra-observer R-coefficient was at 0.89 for dABI vs. 0.60 for pABI (p < 0.05). The inter-observer R-coefficients were 0.79 for dABI vs. 0.40 for pABI (p < 0.05) and 0.44 for autoABI (p < 0.05).
Conclusion: Neither pulse palpation nor automatic oscillometric devices can be recommended as reliable methods for ABI measurement.
What's known: Ankle-brachial index (ABI) is the easiest accurate method to detect peripheral arterial disease (PAD), and it is therefore highly recommended in general practice. However, ABI is rarely used in routine clinical practice, possibly since a Doppler device is required for its measurement. It has been suggested that automatic blood pressure (BP) devices or pulse palpation be used to assess limbs BPs, but a thorough comparison of these alternate methods has received little attention.
What's new: Our data show that ABI determination by pulse palpation or automatic BP devices are poorly reliable compared with Doppler, and may lead to ABI underestimation for the former and overestimation for the latter. The use of a (portable) Doppler is required for accurate ABI determination.
Peripheral arterial disease (PAD), a manifestation of atherosclerotic disease, has a high prevalence in the general population in western countries. It is well known that a majority of those suffering from PAD are asymptomatic. Even at the subclinical level, the diagnosis of PAD is of public health importance as both clinical and subclinical PAD are strong prognostic markers for future cardiovascular disease (CVD) events. Hence, knowledge of the presence of PAD should influence the implementation of preventive care. Unfortunately, only a fraction of patients suffering from PAD are adequately diagnosed by their general practitioners. The presence or absence of lower limb pulses cannot solely make the diagnosis, as not only the reliability of pulse palpation is poor, but also a present pulse cannot definitely exclude the presence of PAD.
The easiest accurate non-invasive method for the diagnosis of PAD is the measurement of ankle-brachial index (ABI). A low ABI (≤ 0.90) defines the presence of PAD with good sensitivity and excellent specificity. Besides its measurement ease, requiring only a pneumatic pressure cuff and a (pocket) Doppler device, its use in general practice remains uncommon. Reasons include the expense of Doppler devices and/or the lack of training to use them appropriately in primary care offices.
The reliability of ABI measured by automatic blood pressure cuffs has been studied with conflicting results. A recent report employed pulse palpation instead of a Doppler device for the measurement of the systolic pressures of the limbs. However, the reliability and the reproducibility of this method are unknown. Compared with the Doppler method traditionally used, these methods are more accessible in primary care offices and would therefore be more likely to be utilised. In this study, we assessed the validity and reliability of these two alternative modes of ABI measurement, compared with the traditional Doppler method, in a group of patients.
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