European Heart Journal Advance Access originally published online on June 16, 2006
European Heart Journal 2006 27(14):1743-1749; doi:10.1093/eurheartj/ehl092
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Association of low ankle brachial index with high mortality in primary care
1 Department of Internal Medicine/Vascular Medicine, SRH-Klinikum Karlsbad-Langensteinbach, Affiliated Teaching Hospital, University of Heidelberg, Guttmannstr. 1, D-76307 Karlsbad, Germany
2 Department of Medical Informatics, Biometry and Epidemiology, University of Bochum, Bochum, Germany
3 Department of Medicine I, Vivantes Neukölln Medical Center, Berlin, Germany
4 Department for Clinical Pharmacology, Medical Faculty, Technical University of Dresden, Dresden, Sachsen, Germany
5 Medical Department, Sanofi-Aventis, Berlin, Germany
6 Vascular Medicine, Munich, Germany
7 Department of Neurology, Hospital Harlaching, Munich, Germany
8 Department of Vascular Surgery, Ruprecht-Karls University of Heidelberg, Heidelberg, Germany
Received 28 March 2006; revised 23 May 2006; accepted 26 May 2006; online publish-ahead-of-print 16 June 2006.
* Corresponding author. Tel: +49 7202 61 3340; fax: +49 7202 61 6167. E-mail address: curt.diehm{at}kkl.srh.de
Aims We aimed to assess the increased risk of death and severe vascular events in elderly individuals with subclinical or manifest peripheral arterial disease (PAD), evidenced by low ankle brachial index (ABI < 0.9) in primary care.
Methods and results In this monitored prospective observational study, 6880 representative unselected patients aged 
65 years were followed up over 3 years by 344 primary care physicians. Main outcome measures were mortality or a combined endpoint of mortality and severe vascular events. In total, 20 127 patient-years were observed. In the group of PAD patients (n=1230), 134 patients died; in the group without PAD (n=5591), 237 patients died [multivariate hazard ratio (HR) 2.0; 95% confidence interval 1.6–2.5, P<0.001]. Compared with an ABI1.1, the risk of death increased linearly in the lower ABI categories: ABI 0.7–0.89, HR 1.7 (1.2–2.4, P<0.001); ABI<0.5, HR 3.6 (2.4–5.4, P<0.001).
Conclusion Patients with a low ABI (PAD), who can be readily identified in a primary care setting, have a substantially increased risk of death and severe vascular events. Patients with an ABI between 1.1 and 0.9 should be considered and followed up as borderline PAD cases. Particular attention should be paid to patients with PAD and previous vascular events, as their risk is markedly increased.
Key Words: Peripheral arterial disease • Risk stratification • Cardiovascular death • Prognosis • Primary care • Screening
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