Peripheral Artery Disease

(PAD) & Ankle Brachial Index

(ABI)
 Peripheral arterial disease (PAD), salah
satu bentuk dari peripheral vascular disease
(PVD)

 PAD mrpkn penyakit aterosklerotik oklusif

pada arteri yg menyuplai ekstremitas bawah

 PAD mrpkn faktor resiko mayor pada

amputasi ektremitas bawah
Systemic Manifestations of
Atherosclerosis
• TIA
• Ischemic stroke

• Myocardial Infarction
• Unstable angina pectoris

• Renovascular hypertension

• Erectile dysfunction

• Claudication
• Critical limb ischemia, rest pain,
gangrene, amputation
ATHEROSCLEROSIS,
A MULTIFACTORIAL DISEASE
LIPIDS
OBESITY HYPERTENSION

DIABETES
ENVIRONMENTAL FACTORS

DIET
VASCULAR
DISEASE

GENETIC FACTORS
AGE
SMOKING
GENDER
SEDENTARY FAMILY HISTORY
LIFESTYLE
THROMBOGENIC
FACTORS
 Defining a Population “At Risk” for Lower
Extremity P.A.D.
• Age > than 40 years with one additional risk
factor (e.g., diabetes, smoking, dyslipidemia,
hypertension, or hyperhomocysteinemia)
• Age 50 (male) 60 (female) with risk factor
• Age 70 years and older
• Leg symptoms with exertion (suggestive of
claudication) or ischemic rest pain
• Abnormal lower extremity pulse examination
• Known atherosclerotic coronary, carotid, or renal
artery disease
Canadian Cardiovascular Consensus: PAD Executive Summary; Can J Cardiol 2005;
21(12):997-1006
 How Is PAD Diagnosed?

• History and physical

examination

• ABI

• Vascular lab

Adapted American Diabetes Association. Diabetes Care. 2003:26;3333-3341.

Questions to Ask Patients
Presenting with Symptoms of PAD
1.Do you have pain in either
leg when you walk?
2. Do you have a similar pain
when you are bending, sitting
or lying down?
3. How far can you walk
without stopping?
4. What stops you when
you are walking?

5. Do you walk?

6. Why not?
Olson, KWP, et al. J of Vascular Nursing. 2004:22;72-77.
Physical Exam Findings of PAD
The Physical Exam Should Be
Performed With Patient’s Pants/Shoes Off

Limb examination (and comparison with the opposite limb)

findings might include:
• Absent or diminished femoral or pedal pulses (especially after
exercising the limb)
• Hair loss
• Poor nail growth (brittle nails)
• Dry, scaly, atrophic skin
• Dependent rubor
• Pallor with leg elevation after 1 minute at 60 degrees (normal
color should return in 10 to 15 seconds; longer than 40
seconds indicates severe ischemia)
• Ischemic tissue ulceration (punched-out, painful, with little
bleeding), gangrene
• Arterial bruits

Lesho EP, et al. Am Fam Physician. 2004; 69:525-533.

Concept of ABI
The systolic blood pressure in the leg should be
approximately the same as the systolic blood pressure
in the arm.

Therefore, the
Leg pressure

÷
ratio of systolic
blood pressure in
the leg vs the arm
≈1
should be
approximately 1 Arm pressure
or slightly higher.

ABI has been found to be 95% sensitive and 99%

specific for angiographically diagnosed PAD.

Adapted from Weitz JI, et al. Circulation. 1996;94:3026-3049.

 Measuring the Ankle-Brachial Index (ABI)
Step 1: Gather Equipment Needed

Equipment needed:

1. Blood Pressure
Cuff

2. Hand-held 5-10
MHz Doppler
probe

3. Ultrasound Gel

American Diabetes Association. Diabetes Care 2003: 26; 3333–3341.

Stabilizing hand
Calculating the ABI
Example Calculation

Right Leg ABI Left Leg ABI

60 mm Hg 66 mm Hg
= 0.50 = 0.55
120 mm Hg 120 mm Hg

ABI Interpretation
≤ 0.90 is diagnostic of peripheral arterial
disease
Hiatt WR. N Engl J Med. 2001;344:1608-1621.
 Interpreting the Ankle–Brachial
Index: ABI
ABI Interpretation

• 1.0-1.4 Normal

• 0.91-0.99 Borderline

• <0.90 Abnormal

• >1.4 Non-compressible

• 2011 ACCF/AHA Focused Update of the Guideline for the Management of

Patients With Peripheral Artery Disease (Updating the 2005 Guideline)
 A 65 year male, heavy smoker, hypertensive presents
with right gangrenous toe and rest pain:
Calculate the ABI

R Brachial Pressure: L/Brachial Pressure:

_160____ __156___

Dorsalis Pedis SBP : __60_____ Dorsalis Pedis SBP: ___140____

Posterior Tibial SBP : __58____ Posterior Tibial SBP: ___138_____

R/ ABI= _____ L/ ABI= _____

ABI Interpretation:
Normal, Borderline, Mild, Moderate, Severe, Noncompressible
Correct answers are: R/ABI= 0.37 L/ABI= 0.87
Severe PAD R/Side, mild PAD L/side
 A 76 year old male, heavy smoker, hypertensive &
previous MI presents with right calf pain after 2 blocks:
Calculate the ABI

R Brachial Pressure: L/Brachial Pressure:

_130____ __134___

AT SP: ___140____
AT SBP: __90_____
PT SP: ___138_____
PT SBS: __96_____

R ABI= _____ L ABI= _____

ABI Interpretation:
Normal, Borderline, Mild, Moderate, Severe, Noncompressible
Correct answers are: R/ABI= 0.71 L/ABI= 1.04
Mild PAD R/ leg