Correlation between type 2 diabetes mellitus and ankle-brachial index in a geographically specific Greek population without peripheral arterial disease

Main Article Content

G. Koufopoulos
K. Pafili
N. Papanas


Background. Diabetes mellitus (DM) remains one of the fastest growing and most challenging medical diseases today. The Ankle-Brachial Index (ABI) is the ratio of ankle systolic blood pressure divided by brachial systolic pressure. Generally, ABI has a high specificity and sensitivity for the diagnosis of peripheral arterial disease (PAD). In DM, ABI measurement is recommended by the American Diabetes Association for all subjects > 50 years old. The prevalence of an abnormal ABI is high in type 2 DM. An ABI ≥ 1.3 is associated with increased risk of cardiovascular disease and mortality in the general population, as well as with all-cause mortality in DM. The purpose of the study was to assess the potential association of a high ankle-brachial index with diabetes mellitus in a specific Greek population free from peripheral arterial disease. Materials and methods. Between July 2017 and August 2018, people over 30 years old with and without type 2 DM were examined. We included 240 subjects (118 men) with mean age 64.5 ± 14.6 years from Naxos island in Greece who did not have peripheral arterial disease (PAD). Of these, 144 had DM and 96 did not. DM duration was 10.6 ± 7.4 years. ABI was measured in all subjects. ABI was measured in the supine position after 5–10 minutes of rest, in normal room temperature (25 °C) after patients had taken off their shoes and socks. Results. We grouped ABI measurements into 4 groups: ABI 0.90–1.29; ABI 1.30–1.39; ABI 1.40–1.49; ABI > 1.50. ABI > 1.30 was seen in 44 % of participants with DM vs. 3.1 % of those without DM. There was a significant correlation (p < 0.001) between diabetes duration and ABI. Among participants with DM, those with ABI > 1.30 had DM duration of 14.2 ± 8.2 years, while those with ABI < 1.30 had DM duration of 8 ± 5 years. ABI was 0.21 (19 %) higher in DM vs. non-DM subjects (1.28 ± 0.20 vs. 1.07 ± 0.11, p < 0.001). Conclusions. A high ABI is more frequent in DM, PAD-free, Greek participants, especially among subjects with long-standing DM.

Article Details

How to Cite
Koufopoulos, G., K. Pafili, and N. Papanas. “Correlation Between Type 2 Diabetes Mellitus and Ankle-Brachial Index in a Geographically Specific Greek Population Without Peripheral Arterial Disease”. INTERNATIONAL JOURNAL OF ENDOCRINOLOGY (Ukraine), vol. 15, no. 7, Dec. 2019, pp. 517-22, doi:10.22141/2224-0721.15.7.2019.186053.
Original Researches


Cho N H, Shaw J E, Karuranga S, et al. IDF Diabetes Atlas: Global estimates of diabetes prevalence for 2017 and projections for 2045. Diabetes Res Clin Pract. 2018 Apr;138:271-281. doi: 10.1016/j.diabres.2018.02.023.

Norgren L, Hiatt W R, Dormandy J A, et al. Inter-society consensus for the management of peripheral arterial disease. J Vasc Surg. 2007 Jan;45 Suppl S:S5-67. doi: 10.1016/j.jvs.2006.12.037.

Dachun X, Jue L, Liling Z, et al. Sensitivity and specificity of the ankle-brachial index to diagnose peripheral artery disease: a structured review. Vasc Med. 2010 Oct;15(5):361-9. doi: 10.1177/1358863X10378376.

Nicolai SP, Kruidenier LM, Rouwet EV, Bartelink ML, Prins MH, Teijink JA. Ankle brachial index measurement in primary care: are we doing it right? Br J Gen Pract. 2009 Jun;59(563):422-7. doi: 10.3399/bjgp09X420932.

Georgakarakos E, Papadaki E, Vamvakerou V, et al. Training to measure ankle-brachial index at the undergraduate level: can it be successful? Int J Low Extrem Wounds. 2013 Jun;12(2):167-71. doi: 10.1177/1534734613483768.

Papanas N, Symeonidis G, Mavridis G, et al. Ankle-brachial index: a surrogate marker of microvascular complications in type 2 diabetes mellitus? Int Angiol. 2007 Sep;26(3):253-7.

Daskalopoulou SS, Pathmarajah M, Kakkos SK, et al. Association between ankle-brachial index and risk factor profile in patients newly diagnosed with intermittent claudication. Circ J. 2008 Mar;72(3):441-8. doi: 10.1253/circj.72.441.

Tziomalos K, Athyros V G, Karagiannis A, Mikhailidis DP. The role of ankle brachial index and carotid intima-media thickness in vascular risk stratification. Curr Opin Cardiol. 2010 Jul;25(4):394-8. doi: 10.1097/hco.0b013e328338c109.

Manfredini F, Malagoni AM, Mandini S, et al. Near-infrared spectroscopy assessment following exercise training in patients with intermittent claudication and in untrained healthy participants. Vasc Endovascular Surg. 2012 May;46(4):315-24. doi: 10.1177/1538574412443318.

Paraskevas KI, Kotsikoris I, Koupidis SA, Giannoukas AD, Mikhailidis DP. Ankle-brachial index: a marker of both peripheral arterial disease and systemic atherosclerosis as well as a predictor of vascular events. Angiology. 2010 Aug;61(6):521-3. doi: 10.1177/0003319710371620.

American Diabetes Association. Standards of medical care in diabetes-2018 Abridged for Primary Care Providers. Clin Diabetes. 2018 Jan;36(1):14-37. doi: 10.2337/cd17-0119.

Li X, Wang YZ, Yang XP, Xu ZR. Prevalence of and risk factors for abnormal ankle-brachial index in patients with type 2 diabetes. J Diabetes. 2012 Jun;4(2):140-6. doi: 10.1111/j.1753-0407.2011.00171.x.

Allison MA, Hiatt WR, Hirsch AT, Coll JR, Criqui MH. A high ankle-brachial index is associated with increased cardiovascular disease morbidity and lower quality of life. J Am Coll Cardiol. 2008 Apr 1;51(13):1292-8. doi: 10.1016/j.jacc.2007.11.064.

Aboyans V, Ho E, Denenberg JO, Ho LA, Natarajan L, Criqui MH. The association between elevated ankle systolic pressures and peripheral occlusive arterial disease in diabetic and nondiabetic subjects. J Vasc Surg. 2008 Nov;48(5):1197-203. doi: 10.1016/j.jvs.2008.06.005.

Signorelli S S, Fiore V, Catanzaro S, Simili M, Torrisi B, Anzaldi M. Prevalence of high ankle-brachial index (ABI) in general population of Southern Italy, risk factor profiles and systemic cardiovascular co-morbidity: an epidemiological study. Arch Gerontol Geriatr. 2011 Jul-Aug;53(1):55-9. doi: 10.1016/j.archger.2010.05.020.

Ix JH, Katz R, Peralta CA, et al. A high ankle brachial index is associated with greater left ventricular mass MESA (Multi-Ethnic Study of Atherosclerosis). J Am Coll Cardiol. 2010 Jan 26;55(4):342-9. doi: 10.1016/j.jacc.2009.11.010.

Potier L, Roussel R, Labreuche J, et al. Interaction between diabetes and a high ankle-brachial index on mortality risk. Eur J Prev Cardiol. 2015 May;22(5):615-21. doi: 10.1177/2047487314533621.

Lilly S M, Jacobs D R, Jr., Kronmal R, et al. Arterial compliance across the spectrum of ankle-brachial index: the Multiethnic Study of Atherosclerosis. Atherosclerosis. 2014 Apr;233(2):691-696. doi: 10.1016/j.atherosclerosis.2014.01.029.

Young MJ, Adams JE, Anderson GF, Boulton AJ, Cavanagh PR. Medial arterial calcification in the feet of diabetic patients and matched non-diabetic control subjects. Diabetologia. 1993 Jul;36(7):615-21. doi: 10.1007/bf00404070.

Everhart JE, Pettitt DJ, Knowler WC, Rose FA, Bennett PH. Medial arterial calcification and its association with mortality and complications of diabetes. Diabetologia 1988;31:16-23. doi: 10.1007/bf00279127.

Suominen V, Uurto I, Saarinen J, Venermo M, Salenius J. PAD as a risk factor for mortality among patients with elevated ABI ─ a clinical study. Eur J Vasc Endovasc Surg. 2010 Mar;39(3):316-22. doi: 10.1016/j.ejvs.2009.12.003.

Ix JH, Katz R, De Boer IH, et al. Association of chronic kidney disease with the spectrum of ankle brachial index the CHS (Cardiovascular Health Study). J Am Coll Cardiol. 2009 Sep 22;54(13):1176-84. doi: 10.1016/j.jacc.2009.06.017.

Sutton-Tyrrell K, Venkitachalam L, Kanaya AM, et al. Relationship of ankle blood pressures to cardiovascular events in older adults. Stroke. 2008 Mar;39(3):863-9. doi: 10.1161/STROKEAHA.107.487439.

Novo S, Coppola G, and Milio G. Critical limb ischemia: definition and natural history. Curr Drug Targets Cardiovasc Haematol Disord. 2004 Sep;4(3):219-25. doi: 10.2174/1568006043335989.

Adam DJ, Bradbury AW. TASC II document on the management of peripheral arterial disease. Eur J Vasc Endovasc Surg. 2007 Jan;33(1):1-2. doi: 10.1016/j.ejvs.2006.11.008.

Greenland P, Abrams J, Aurigemma GP, et al. Beyond secondary prevention: identifying the high-risk patient for primary prevention: noninvasive tests of atherosclerotic burden: Writing Group III. Circulation. 2000 Jan 4;101(1):E16-22. doi: 10.1161/01.cir.101.1.e16.

Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003 May 21;289(19):2560-72. doi: 10.1001/jama.289.19.2560.

Reaven PD, Sacks J; Investigators for the VADT. Coronary artery and abdominal aortic calcification are associated with cardiovascular disease in type 2 diabetes. Diabetologia. 2005 Feb;48(2):379-85. doi: 10.1007/s00125-004-1640-z.

O'Hare AM, Katz R, Shlipak MG, Cushman M, Newman AB. Mortality and cardiovascular risk across the ankle-arm index spectrum: results from the Cardiovascular Health Study. Circulation. 2006 Jan 24;113(3):388-93. doi: 10.1161/CIRCULATIONAHA.105.570903.

Resnick HE, Lindsay RS, McDermott MM, et al. Relationship of high and low ankle brachial index to all-cause and cardiovascular diseasemortality: the Strong Heart Study. Circulation. 2004 Feb 17;109(6):733-9. doi: 10.1161/01.CIR.0000112642.63927.54.

Young MJ, Adams JE, Anderson GF, Boulton AJ, Cavanagh PR. Medial arterial calcification in the feet of diabetic patients and matched non-diabetic control subjects. Diabetologia. 1993 Jul;36(7):615-21. doi: 10.1007/bf00404070.

Goss DE, de Trafford J, Roberts VC, Flynn MD, Edmonds ME, Watkins PJ. Raised ankle/brachial pressure index in insulin-treated diabetic patients. Diabet Med. 1989 Sep-Oct;6(7):576-8. doi: 10.1111/j.1464-5491.1989.tb01231.x.

Maser RE, Wolfson SK Jr, Ellis D, et al. Cardiovascular disease and arterial calcification in insulin-dependent diabetes mellitus: interrelations and risk factor profiles. Pittsburgh Epidemiology of Diabetes Complications Study-V. Arterioscler Thromb. 1991 Jul-Aug;11(4):958-65. doi: 10.1161/01.atv.11.4.958.

Thiruvoipati T, Kielhorn CE, Armstrong EJ. Peripheral artery disease in patients with diabetes: Epidemiology, mechanisms, and outcomes. World J Diabetes. 2015 Jul 10;6(7):961-9. doi: 10.4239/wjd.v6.i7.961.

American Diabetes Association. Peripheral arterial disease in people with diabetes. Diabetes Care. 2003 Dec;26(12):3333-41. doi: 10.2337/diacare.26.12.3333.

Nam SC, Han SH, Lim SH, et al. Factors affecting the validity of ankle-brachial index in the diagnosis of peripheral arterial obstructive disease. Angiology. 2010 May;61(4):392-6. doi: 10.1177/0003319709348295.

Potier L, Halbron M, Bouilloud F, et al. Ankle-to-brachial ratio index underestimates the prevalence of peripheral occlusive disease in diabetic patients at high risk for arterial disease. Diabetes Care. 2009 Apr;32(4):e44. doi: 10.2337/dc08-2015.

Suominen V, Rantanen T, Venermo M, Saarinen J, Salenius J. Prevalence and risk factors of PAD among patients with elevated ABI. Eur J Vasc Endovasc Surg. 2008 Jun;35(6):709-14. doi: 10.1016/j.ejvs.2008.01.013.

Alnaeb ME, Crabtree VP, Boutin A, Mikhailidis DP, Seifalian AM, Hamilton G. Prospective assessment of lower-extremity peripheral arterial disease in diabetic patients using a novel automated optical device. Angiology. 2007 Oct-Nov;58(5):579-85. DOI: 10.1177/0003319707305685.

Espinola-Klein C, Rupprecht HJ, Bickel C, et al. Different calculations of ankle-brachial index and their impact on cardiovascular risk prediction. Circulation. 2008 Aug 26;118(9):961-7. doi: 10.1161/CIRCULATIONAHA.107.763227.

Clairotte C, Retout S, Potier L, Roussel R, Escoubet B. Automated ankle-brachial pressure index measurement by clinical staff for peripheral arterial disease diagnosis in nondiabetic and diabetic patients. Diabetes Care. 2009 Jul;32(7):1231-6. doi: 10.2337/dc08-2230.

Brooks B, Dean R, Patel S, Wu B, Molyneaux L, Yue DK. TBI or not TBI: that is the question. Is it better to measure toe pressure than ankle pressure in diabetic patients? Diabet Med. 2001 Jul;18(7):528-32. doi: 10.1046/j.1464-5491.2001.00493.x.

Janssen A. Pulsatility index is better than ankle-brachial doppler index for non-invasive detection of critical limb ischaemia in diabetes. Vasa. 2005 Nov;34(4):235-41. doi: 10.1024/0301-1526.34.4.235.

Williams DT, Harding KG, Price P. An evaluation of the efficacy of methods used in screening for lower-limb arterial disease in diabetes. Diabetes Care. 2005 Sep;28(9):2206-10. doi: 10.2337/diacare.28.9.2206.

Sergis MG. Laografika kai Ethnografika apo to Glinado Naxou. Proodeftikos Omilos Glinadou Naxou, 1994, Athens.

Gouveri E, Papanas N, Marakomichelakis G, et al. Post-exercise ankle-brachial index is not an indispensable tool for the detection of peripheral arterial disease in an epidemiological survey. A post-hoc analysis of the Athens Study. Int Angiol. 2013 Oct;32(5):518-25.

Tsivgoulis G, Bogiatzi C, Heliopoulos I, et al. Low ankle-brachial index predicts early risk of recurrent stroke in patients with acute cerebral ischemia. Atherosclerosis. 2012 Feb;220(2):407-12. doi: 10.1016/j.atherosclerosis.2011.11.009.