Ankle Brachial Index Combined with Framingham Risk Score to Predict Cardiovascular Events and Mortality: A Meta-analysis

By F. Fowkes, G. Murray, I. Butcher, C. Heald, Lee Rj, L. Chambless, A. Folsom, A. Hirsch, M. Dramaix, G. Debacker and 37 more. Journal of the American Medical Association (JAMA), 2008

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Context Prediction models to identify healthy individuals at high risk of cardiovascular disease have limited accuracy. A low ankle brachial index is an indicator of atherosclerosis and has the potential to improve prediction. Objective To determine if the ankle brachial index provides information on the risk of cardiovascular events and mortality independently of the Framingham Risk Score and can improve risk prediction. Data Sources Relevant studies were identified by collaborators. A search of MEDLINE (1950 to February 2008) and EMBASE (1980 to February 2008), was conducted using common text words for the term ‘ABI’ combined with text words and Medical Subject Headings to capture prospective cohort designs. Review of reference lists and conference proceedings, and correspondence with experts was conducted to identify additional published and unpublished studies. Study Selection Studies were included if (1) participants were derived from a general population (2) ankle brachial index was measured at baseline and (3) subjects were followed up to detect total and cardiovascular mortality. Data Extraction Pre-specified data on subjects in each selected study were extracted into a combined dataset and an individual participant data meta-analysis conducted on subjects who had no previous history of coronary heart disease. Results Sixteen population cohort studies fulfilling the inclusion criteria were included. During 480,325 person years of follow up of 24,955 men and 23,339 women, the risk of death by ankle brachial index had a reverse J shaped distribution with a normal (low risk) ankle brachial index of 1.11 to 1.40. The 10-year cardiovascular mortality (95% CI) in men with a low ankle brachial index (≤ 0.90) was 18.7% (13.3% to 24.1%) and with normal ankle brachial index (1.11 to 1.40) was 4.4% (3.2% to 5.7%), hazard ratio (95% CI) 4.2 (3.5 to 5.4). Corresponding mortalities in women were 12.6% (6.2% to 19.0%) and 4.1% (2.2% to 6.1%), hazard ratio 3.5 (2.4 to 5.1). The hazard ratios remained elevated on adjusting for Framingham Risk Score, 2.9 (2.3 to 3.7) for men and 3.0 (2.0 to 4.4) for women. A low ankle brachial index (≤0.90) was associated with approximately twice the 10-year total mortality, cardiovascular mortality and major coronary event rate compared with the overall rate in each Framingham category. Inclusion of the ankle brachial index in cardiovascular risk stratification using the Framingham Risk Score would result in reclassification of the risk category and modification of treatment recommendations in approximately 19% of men and 36% of women. Conclusion Measurement of the ankle brachial index may improve the accuracy of cardiovascular risk prediction beyond the Framingham Risk Score. Development and validation of a new risk equation incorporating the ankle brachial index is warranted.

Subfields: Cardiology and Cardiovascular Medicine, Surgery

View Paper: https://www.semanticscholar.org/paper/c80f012169f25edabdb259574e9321abf73cf7e3

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Citations in the corpus

The 2015 Canadian Hypertension Education Program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension. (2013, background): “Furthermore, even asymptomatic PAD, as detected by a low ABI, has prospectively been found to be associated in men with an incidence of CV morbid and fatal events approaching 20% in 10 years [198,199].”
ESH / ESC Guidelines for the management of arterial hypertension (2013, background): “9) signals PAD and, in general, advanced atherosclerosis,(197) has predictive value for CV events,(198) and was associated with approximately twice the 10-year CV mortality and major coronary event rate, compared with the overall rate in each Framingham category.(198) Furthermore, even asymptomatic ”
2016 European Guidelines on cardiovascular disease prevention in clinical practice (2017, positive): “The ABI is inversely related to CV risk [132], but there is controversy regarding its potential to reclassify patients into different risk categories [131, 143].”
2007 Guidelines for the Management of Arterial Hypertension: The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) (2007, background): “Furthermore, even asymptomatic PAD, as detected by a low ABI, has prospectively been found to be associated in men with an incidence of CV morbid and fatal events approaching 20% in 10 years [198,199].”