Is the Ankle Brachial Pressure Index an Independent Predictor for Cardiovascular Morbidity and Death in the Asymptomatic Population? A Systematic Review and Meta-analysis.

Abstract

This study aimed to assess whether the ankle brachial pressure index (ABPI) is independently associated with cardiovascular morbidity and mortality in the asymptomatic general population. Ovid MEDLINE, Embase, CINAHL, and Cochrane databases. Studies assessing ABPI in a general population with > 30 days follow up were included. A random effects meta-analysis was completed following PRISMA guidelines (PROSPERO: CRD42022383573). Study quality was assessed using the Newcastle-Ottawa Scale, and certainty was assessed through Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Outcomes included major cardiovascular events, cardiovascular death, coronary events, cerebrovascular events, and all cause death. Twenty-five studies from 23 cohorts were included (20 prospective, four retrospective, and one propensity matched), representing 181 598 individuals. An ABPI < 0.9 was statistically significantly associated with higher cardiovascular mortality (hazard ratio [HR] 2.04, 95% confidence interval [CI] 1.70 - 2.44, p < .001; GRADE, low certainty), major cardiovascular events (HR 1.74, 95% CI 1.56 - 1.94, p < .001; GRADE, very low certainty), coronary events (HR 2.80, 95% CI 2.11 - 3.70, p < .001; GRADE, low certainty), cerebrovascular events (HR 1.75, 95% CI 1.34 - 2.30, p < .001; GRADE, low certainty), and all cause mortality (HR 1.90, 95% CI 1.71 - 2.10, p < .001; GRADE, very low certainty) compared with a normal ABPI. An ABPI > 1.3 was statistically significantly associated with higher cardiovascular mortality (HR 2.39, 95% CI 2.02 - 2.83, p < .001; GRADE, low certainty) and all cause mortality (HR 1.92, 95% CI 1.54 - 2.39, p < .001; GRADE, very low certainty) compared with a normal ABPI. An ABPI > 1.3 was not statistically significant for major cardiovascular events (HR 1.07, 95% CI 0.74 - 1.55, p = .70; GRADE, low certainty) or cerebrovascular events (HR 1.80, 95% CI 0.91 - 3.58, p = .090; GRADE, very low certainty). An abnormal ABPI is associated with higher cardiovascular and all cause mortality rates. Randomised evidence is needed to assess the cost effectiveness, efficacy, and benefits of screening.