Menoufia Medical Journal

ORIGINAL ARTICLE
Year
: 2021  |  Volume : 34  |  Issue : 1  |  Page : 174--179

Ankle brachial index in patients with type II diabetes mellitus undergoing coronary angiography


Ahmed A Reda1, Ahmed M El-Kersh1, Eslam M El-Habashy2,  
1 Department of Cardiology, Faculty of Medicine, Menoufia University, Cairo, Egypt
2 Department of Cardiology, National Institute of Diabetes and Endocrinology, Cairo, Egypt

Correspondence Address:
Eslam M El-Habashy
National Institute of Diabetes and Endocrinology, Cairo
Egypt

Abstract

Objective The aim was to determine the relation between ankle-brachial index (ABI) with angiographic stenosis and major cardiovascular risk factors in type II diabetes mellitus (DM) patients. Background The role of DM in relation to coronary artery disease (CAD) was believed to be as important as CAD itself. Patients with DM were frequently combined with peripheral arterial disease. ABI is a noninvasive tool for identifying atherosclerosis, CAD. Patients and methods Patients under study were those admitted to Menoufia University Hospital and who had undergone coronary angiography. A total of 80 patients over 35 years of age with suspected CAD had been enrolled. All patients were subjected to ABI measurements and coronary angiography and risk factor. Patients had been divided into four groups according to ABI measurements and type II DM. Results ABI is a simple, inexpensive method for diagnosing patients with peripheral arterial disease. ABI is a sensitive, noninvasive predictor of CAD in diabetic patients. Conclusion ABI is a sensitive, noninvasive predictor of CAD in diabetic patients. It needs other markers for better specificity for predicting CAD.



How to cite this article:
Reda AA, El-Kersh AM, El-Habashy EM. Ankle brachial index in patients with type II diabetes mellitus undergoing coronary angiography.Menoufia Med J 2021;34:174-179


How to cite this URL:
Reda AA, El-Kersh AM, El-Habashy EM. Ankle brachial index in patients with type II diabetes mellitus undergoing coronary angiography. Menoufia Med J [serial online] 2021 [cited 2021 Dec 5 ];34:174-179
Available from: http://www.mmj.eg.net/text.asp?2021/34/1/174/312030


Full Text



 Introduction



Atherosclerosis, the most common cause of mortality and morbidity worldwide, is considered a generalized process which affects coronary, cerebral, and peripheral arteries of the lower extremities [1]. The onset of coronary artery disease (CAD) starts as early as the first decade of life and progresses eventually to the formation of atherosclerotic plaques. Unstable or obstructive plaques lead to clinical manifestations of atherosclerosis and CAD [2].

Patients with diabetes mellitus (DM) have an over tenfold risk for cardiovascular (CV) disease in their lifetime [3]. A key feature of diabetes contributing to this is the development of an accelerated atherosclerosis [4].

The ankle-brachial index (ABI) is a noninvasive tool that is useful for the diagnosis and surveillance of peripheral vascular diseases. It is also a strong marker of generalized atherosclerosis and CV risk. An ankle-brachial index (ABI) less than 0.90 is associated, on average, with a twofold to threefold increased risk of total and CV death. An ankle-brachial index (ABI) greater than 1.40 represents arterial stiffening and is associated with a higher risk of CV events and mortality [5],[6].

The study aimed to determine the relation between ankle-brachial index (ABI) with angiographic stenosis and major CV risk factors in type II DM patients.

 Patients and methods



The study was conducted at Menoufia University Hospital, Egypt, from June 2018 to December 2018. The study protocol was approved by the Ethics Committee of Menoufia University. Patients were admitted to Menoufia University Hospital who had undergone coronary angiography with written informed consents. A total of 80 patients over 35 years of age with suspected CAD had been enrolled. All patients were subjected to ankle-brachial index (ABI) measurements and coronary angiography and risk factor. Patients had been divided into four groups according to ankle-brachial index (ABI) measurements and type II DM: Group A had an ankle-brachial index (ABI) value greater than or equal to 0.9 no DM (A−/D−); group B had ankle-brachial index (ABI) value greater than or equal to 0.9 and DM (A−/D+); group C had an ankle-brachial index (ABI) less than or equal to 0.9 no DM (A+/D−); group D had an ankle-brachial index (ABI) value less than or equal to 0.9 and DM (A+/D+) with inclusion criteria which include that all patients with suspected CAD were subjected to coronary angiography and ankle-brachial index (ABI) measurements to determine the relation between ankle-brachial index (ABI) and angiographic findings and major CV risk factors in patients with suspected CAD in type II DM patients and exclusion criteria which include lower limb trauma, lower limb deep vein thrombosis, lower limb surgery, lower limb filariasis, or swelling due to other causes and type I DM.

Medical history was elicited including age, sex, and major documented risk factors for CAD (hypertension, DM, smoking, dyslipidaemia, family history of CAD) and a physical examination was done. The patients were subjected to routine laboratory testing, including urea and creatinine levels, lipid profile, and A1C.

The full procedure was explained to the patient. No anesthesia or sedation was used as it may affect the blood pressure measurement. Ankle-brachial index (ABI) was measured using a Doppler device in a supine position. The brachial systolic pressures of both arms were obtained. Anterior tibial and posterior tibial systolic pressures of the extremity were measured, and the higher of the two ankle pressures was divided by the higher brachial pressure to obtain the ankle-brachial index (ABI) . Then coronary angiography was done. The patients were instructed to withhold oral intake for 6 h before the procedure. Medications were to be continued, except for hypoglycemic agents. Oral hypoglycemic agents were held the day of the procedure. Doses of long-acting insulin were halved and regular insulin should be held. Ultra-long-acting insulin was administered as usual.

An intravenous access line was established before angiography. Access to the arterial vasculature was accomplished by the percutaneous Seldinger technique. The skin and subcutaneous tissues about the artery were infiltrated with a local anesthetic. The common femoral artery was punctured with a thin-walled needle. The puncture site should be ∼5 cm inferior to the line at the site of the pulse. After the artery is punctured, a flexible guidewire with a 'J' tip passed through the needle into the arterial lumen hemostatic sheath is advanced into the vessel. Coronary lesions are best evaluated in at least two orthogonal projections in which the lesion can be seen well in both projections without foreshortening or overlap.

Data were statistically described in terms of range, mean ± SD, median, frequencies (number and percentages of cases) when appropriate. Comparison of numerical variables between the study groups was done using Mann–Whitney U-test for independent samples when comparing two groups and a Kruskal–Wallis test with post hoc multiple two-group comparisons when comparing more than two groups. To compare categorical data, Pearson's χ2 test was performed. Fisher's exact two-tailed probability test was used instead when the expected frequency is less than 5.

Correlation between various variables was done using Spearman's rank correlation equation for non-normal variables. P values less than 0.05 was considered significant. All calculations were done using SPSS computer programs (SPSS Inc., Chicago, Illinois, USA), version 23.

 Results



In all, 80 patients were included in this study; patients with noncoronary lesions were 34 with a mean age of 57.52 ± 6.29 years and with coronary lesion were 46 patients with a mean age of 59.17 ± 7.62 years.

There were 16 (47.1%) men and 18 (52.9%) were women in the noncoronary lesion group. There were 16 (34.8%) men and 30 (65.2%) women in the coronary lesion group. There was no statistical significance between both groups as regards age and sex (P = 0.05).

The most frequent risk factors was diabetes (60.9%) the other risk factors being smoking, hypertension, and dyslipidemia. Mean ankle-brachial index (ABI) was1.09 ± 0.11 and 0.84 ± 0.09 with noncoronary lesions and coronary lesions patients respectively, with high statistical significance between both groups (P = 0.001). A comparison between the means of ankle-brachial index (ABI) between coronary lesion and noncoronary lesions showed a high statistically significant difference (P = 0.05) [Table 1].{Table 1}

Coronary lesions were present in 46 (57.5%) patients with high prevalence in groups II and IV. The presence of coronary lesion shows a statistical significance between groups (P = 0.002). Left main coronary artery (LMCA) and left anterior descending artery (LAD) lesions were prevalent in groups III and IV with statistically significant differences between groups [Table 2].{Table 2}

Characteristic features of angiographic lesion as regards site were at the middle and were prevalent in groups 2 and 4 with statistically significant difference between groups (P = 0.042). The complex morphology was prevalent in groups II and IV with high statistically significant difference between groups (P = 0.001) [Table 3].{Table 3}

The receiver operating characteristic curve was calculated for the presence of angiographic coronary lesions in the studied patients. The AUC for ankle-brachial index (ABI) to predict coronary lesions was 96 and 83% at ankle-brachial index (ABI) cutoff values of 0.87 and 0.90, respectively, with a confidence interval of 0.927–1.00 and 0.742–0.924, respectively. The optimal cutoff ankle-brachial index (ABI) value was 0.87 with a sensitivity of 76% and specificity of 97% with a P value of 0.001 [Table 4] and [Figure 1].{Table 4}{Figure 1}

 Discussion



CAD is the single most common cause of death in men and women [7]. The WHO estimates that by 2020 the global number of deaths from CAD will have risen from 7.1 million in 2002 to 11.1 million [8]. Peripheral arterial disease (PAD) remains too often ignored, although it is a strong predictor of CV events and mortality [9]. Diabetes markedly increases the risk of atherosclerosis and PAD [10]. Ankle-brachial index (ABI) is a simple, noninvasive, and reproducible quantitative measurement which has high sensitivity and specificity for the detection of PAD. It may also be an indicator of atherosclerotic disease in other vascular areas and of increased CV morbidity and mortality [11].

The study aimed to determine the relation between ankle-brachial index (ABI) and angiographic findings and major CV risk factors in patients with suspected CAD in type II DM patients.

In this study, 80 patients were included; patients with noncoronary lesions were 34 with a mean age of 57.52 ± 6.29 years and with coronary lesions were 46 patients with a mean age of 59.17 ± 7.62 years.

There were 16 (47%) women and 18 (53%) men in the noncoronary lesion group. Men were 30 (65.2%) and 16 (34.8%) were women in the coronary lesion group. There was no statistical significance between both groups as regards age (P = 0.30) and sex (P = 0.26). The most frequent risk factors were diabetes (60.9%), other risk factors being smoking, hypertension, and dyslipidemia. Our study shows the role of risk factors in coronary diseases which is in line with several studies.

In this study, the complex morphology was prevalent in groups that had diabetes and an ankle-brachial index (ABI) of less than 0.9 with high statistically significant difference between groups (P = 0.001). This was in agreement with Lamina et al. [12] who found the importance of DM in predicting CAD and CAD severity for patients with ankle-brachial index (ABI) values of less than 0.9.The results of their study confirm and extend the findings of other researchers, implying that the ankle-brachial index (ABI) in DM patients with suspected CAD is valuable for identifying those at risk for high-grade CAD severity. Similarly, in a study in Taiwan, Chang ST et al. [13] studied the usefulness of ankle-brachial index (ABI) to predict the complex and diffuse coronary lesions in patients undergoing coronary angiography. Compared with the control group the ankle-brachial index (ABI) (+) patients had more critical and significant lesions which were difficult to manipulate. Accordingly, they recommended using this simple, inexpensive, and well-established index not only for diagnosing PAD, but also for predicting diffuse and complex lesion subtypes. Papamichael et al. [13] reported similar findings regarding the use of ankle-brachial index (ABI) as the main variables for predicting the extent and severity of CAD with diabetes.

On the other hand, Al-Thani et al. [14] and Franzone et al. [15] reported that the severity of PVD is not yet used to help stratify the CAD complexity despite the strong association with fatal and nonfatal CV events. Also, studies comparing the ankle-brachial index (ABI) value with the severity of stable CAD have found a negative relationship between Sebastianski et al. [16], Aykan et al. [17], and Tripathi et al. [14]. This difference may be related to patients with ACS in these studies and to the small sample size in the current study.

In this study, coronary lesions were present in 46 (57.5%) patients with a high prevalence in groups II and IV who were diabetics. The presence of coronary lesions shows a statistical significance between groups (P = 0.002). Left main coronary artery (LMCA) and left anterior descending artery (LAD) lesions were prevalent in groups III and IV with statistically significant differences between groups.

Sukhija et al. [18] reported that coexisting PAD is correlated with the prevalence of multivessel CAD and obstructive CAD and coronary revascularization. The present study found that patients with a low ankle-brachial index (ABI) value had more CAD target vessel involvement and higher mean lesion numbers than those with a normal ankle-brachial index (ABI) value. These results were compatible with the findings of the study of Chang et al. [12].

The Fremantle Diabetes Study showed that in T2D an ankle-brachial index (ABI) less than 0.9 increased the risk of cardiac death by 67%. Norman et al. and Li et al. [19],[20] reported that an ankle-brachial index (ABI) lower than 0.9 increased significantly the adjusted relative risk of CV mortality in a Chinese population of T2D; additionally, the risk was inversely correlated to the decrease in ankle-brachial index (ABI).

In this study, the predictability of ABI for coronary lesions was 96 and 83% at ankle-brachial index (ABI) cutoff values of 0.87 and 0.90, respectively. The optimal cutoff ankle-brachial index (ABI) value was 0.87 with a sensitivity of 76% and specificity of 97% with P value less than 0.001. ankle-brachial index (ABI) values less than or equal to 0.87 showed high specificity to predict significant CAD. The current findings are in line with Li et al. [21] who reported that patients with ankle-brachial index (ABI) less than 0.90 present an increased risk of CV events and low ankle-brachial index (ABI) was an independent predictor of risk of fatal myocardial infarction even after adjustment for traditional risk factors for CAD. However, when indexes less than or equal to 0.87 were considered, the specificity was 95.4%. Li et al. [21] stated that ankle-brachial index (ABI) is not fully validated for detecting CAD when used as a single diagnostic method; ankle-brachial index (ABI) does not have good sensitivity for predicting CAD. Also, Sabedotti et al. [22] demonstrated that three-vessel arterial disease or left main CAD can be predicted by the ITB with a sensitivity and specificity of 85 and 77%, respectively.

Similarly, Otah et al. [23] determined the sensitivity and specificity of ankle-brachial index (ABI) in predicting future CV events. They concluded that though ankle-brachial index (ABI) less than or equal to 0.9 is highly specific but not sensitive in this regard, it is considered a useful CV event risk prediction tool especially in selected populations due to its simple assessment.

This study results do not agree with Doobay and Anand [24], who aimed to correlate ankle-brachial index (ABI), a marker of PAD, with the severity of CAD as assessed by coronary angiogram. They did not find a significant correlation between low ankle-brachial index (ABI) and the presence or severity of CAD. All patients with an abnormal ankle-brachial index (ABI) less than 0.9 had CAD; however, not all patients with CAD demonstrated angiographically an abnormal ankle-brachial index (ABI). No significant correlation was found between the severity of ankle-brachial index (ABI) impairment and extent of CAD (P = 0.2). Also, in Dsouza and Bhat [25] study, only three (13.6%) patients out of the 22 patients who had triple vessel disease had ankle-brachial index (ABI) less than 0.9 (P = 0.07). Dsouza and Bhat [25] found that abnormalities in coronary angiogram are not reflected in ankle-brachial index (ABI) ranges. The difference may be due to the low sample volume in our study, difference in some patients selection and the aim was to correlate with the presence or absence of CAD not the severity.

 Conclusion



Ankle-brachial index (ABI) should be added to the physical examination, as a useful method to stratify the risk of CAD. Early detection of CAD enables the initiation of earlier intervention for hypertension and dyslipidemia, leading to an improved prognosis in patients with type II DM at high risk for CV events. However, we need further studies in large sample sizes of general population and using more modern diagnostic techniques may corroborate our findings.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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