Low Ankle Brachial Indices Reflect Left Ventricular Systolic Dysfunction: A Potential Explanation for Co-Existing Heart Failure and Peripheral Artery Disease?
Muzammil Rehman, Shabnam Seydafkan, Jonathan Daich, Muhammad Afzal Khan, Louis Salciccioli and Jason M Lazar*
Division of Cardiovascular Medicine, State University of New York Downstate Medical Center, USA
Submission: February 24, 2018; Published: March 19, 2018
*Corresponding author: Jason M Lazar, Director, Non-Invasive Cardiology, State University of New York Downstate Medical Center, 450 Clarkson Avenue, MSC 1199, Brooklyn, New York 11203-2098, USA, Tel: 718-221-5222; Fax: 718-221-5220; Email: email@example.com
How to cite this article: Muzammil Rehman, Shabnam Seydafkan, Jonathan Daich, Muhammad Afzal Khan, Louis Salciccioli, et al. Low Ankle Brachial Indices Reflect Left Ventricular Systolic Dysfunction: A Potential Explanation for Co-Existing Heart Failure and Peripheral Artery Disease?. J Cardiol & Cardiovasc Ther 2018; 9(5): 555774. DOI: 10.19080/JOCCT.2018.09.555774.
Peripheral artery disease (PAD) is a growing health concern in the United States due to its rising prevalence, negative impact on functional disability and increased risk for cardiovascular and cerebrovascular events. Less widely appreciated is that PAD is associated with nearly double the prevalence of congestive heart failure (CHF) and that 17% of heart failure patients have co-existing PAD. Multiple reasons may account for co-existing PAD and CHF. The prevalence of each disorder rises with age and they share common risk factors as well as metabolic disturbances. In addition, while ankle brachial index (ABI) testing has long been the primary modality used to detect PAD, there is accumulating evidence that low ABI values may reflect left ventricular (LV) systolic dysfunction and reduced ejection fraction (EF). The low ABI-low EF relation appears independent of CAD and may in part explain the prognostic value of low ABI for predicting increased mortality. Accordingly ABI values should be interpreted in the context of LV systolic function.
Keywords: Ankle brachial index; Peripheral artery disease; Congestive heart failure; Left ventricular function
Peripheral artery disease (PAD) is a growing health concern in the United States due its rising prevalence, its impact on functional disability and increased risk for cardiovascular and cerebrovascular events. A recent review by Basgoz et al.  summarized the importance of screening for PAD and its association with coronary artery disease (CAD). Importantly, the authors delved into the less widely appreciated association between PAD and congestive heart failure (CHF). The presence of PAD has been found associated with nearly a doubling the prevalence of CHF . Conversely, an earlier study showed a high prevalence of PAD in heart failure patients as 17.1% of CHF patients with low left ventricular (LV) ejection fraction (EF)≤ 40% enrolled in disease management programs in Louisiana and Florida had PAD . In another study of more than 18,000 subjects, aimed at deriving a clinical risk score derived to predict PAD, heart failure conferred a higher likelihood of a low ABI among the general population .
These prior studies measured the ankle brachial systolic blood pressure index (ABI), which is the most common method used to assess for PAD [5-7]. While multiple reasons may account for co-existing PAD and CHF including age dependence, common risk factors and similar metabolic disturbances, ABI determination may play a role as well. The ABI is essentially ratio of lower extremity systolic blood pressure (BP) to brachial artery BP measured by Doppler or sphygmo manometry. Normal values range from 1.2 to 1.4, indicating that systolic BP is normally higher in the lower than the upper extremities. Systolic BP increases with increasing distance from the heart as the arterial pressure waveform changes shape from the central aorta to the periphery due to arterial pressure amplification resulting from vascular branching and tapering as well as peripheral arterial wave reflections [8-11].
Values of ABI <0.9 in either lower extremity is considered evidence of PAD and numerous studies have found low ABI values to be an independent predictor of cardiovascular events including myocardial infarction, stroke and death [12,13]. More than 2 decades ago, Fine et al first suggested that lowered ABI values may reflect LV function upon finding LV systolic dysfunction present in 20% of diabetic patients found to have low ABI . In 2010, our group hypothesized that LV systolic dysfunction would attenuate BP amplification and we demonstrated that ABI values were directly correlated with LVEF in patients suspected of PAD . The ABI-LVEF relation appeared independent of the presence of CAD, suggesting that coexisting CAD and PAD did not account for the association. Since then, other studies have similarly found ABI values related to LVEF in a variety of patients including: elderly with ischemic heart disease, those with and without diabetes, atrial fibrillation and hemodialysis [16-21].
While the exact mechanism(s) underlying this relation remains unknown, similar correlations between LVEF and ABI were found in patients with and without significant CAD and higher LVEF was associated with higher ABI values . Moreover, we observed a strong ABI-LVEF correlation observed in a species of non-human primates that generally do not develop atherosclerosis . These findings would implicate that LV systolic function directly affects the step up in systolic BP from upper to lower extremities, known as pressure amplification. Given that LV systolic dysfunction is often accompanied by increased arterial stiffness and lower arterial pressure wave reflections and that these arterial properties may influence systolic BP amplification along the arterial tree, dampened arterial pressure wave reflections could be expected to lower ABI values [23,24]. Whether LVEF simply reflects lowered LV stroke volume or a diminished contractile force that in turn dampens SBP amplification that normally occurs along the arterial tree because of arterial branching and tapering merits further study.
Moreover, lower ABI values have also been found to be associated with cardiac structural abnormalities including: LV wall thickening and cavity dilation that predispose to LV dysfunction and CHF as well as to left atrial dilation [24,25]. Similar findings have been reported for patients with borderline low ABI values . Of note, ABI values were found to increase in response to low dose dobutamine, which predominantly increases ventricular contractility, but to decrease at higher doses sufficient to cause systemic vasodilation in patients without PAD .
Therefore, despite growing evidence relating ABI to LV structure and function, low ABI values are generally deemed to be indicative of PAD. Depressed LV function has been seldom considered. These studies suggest ABI values to reflect functional and structural properties related to ventriculo-arterial coupling . We believe that there is ample evidence to support that low ABI values may not reflect PAD but rather LV systolic dysfunction. The predictive value of low ABI values for cardiovascular events and mortality may in part relate to depressed LV systolic function rather than atherosclerosis alone. Accordingly, ABI values should be interpreted in the context of LV systolic function.
- Basgoz BB, Musa, Aykan B, Tasc I (2017) An ignored disease of cardiovascular system: peripheral arterial disease. J Cardiol & Cardiovasc Ther 8(3): 1-4.
- Anand RG, Ventura HO, Mehra MR (2007) Is heart failure more prevalent in patients with peripheral arterial disease? A meta-analysis. Congest Heart Fail 13(6): 319-322.
- Hebert K, Lopez B, Michael C, Franco E, Dias A, et al. (2010) The prevalence of peripheral arterial disease in patients with heart failure by race and ethnicity. Congest Heart Fail 16(3): 118-121.
- Duval S, Massaro JM, Jaff MR, Boden WE, Alberts MJ, et al. (2012) An evidence-based score to detect prevalent peripheral artery disease (PAD). Vasc Med 17(5): 342-351.
- Hirsch AT, Criqui MH, Treat-Jacobson D, Regensteiner JG, Creager MA, et al. (2001) Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA 286(11): 1317-1324.
- Aboyans V, Criqui MH, Abraham P, Allison MA, Creager MA, et al. (2012) Measurement and interpretation of the ankle-brachial index: a scientific statement from the American Heart Association. Circulation 126(24): 2890-2909.
- Bertino RE, Grassi CJ, Bluth EI, Cardella JF, Frates M, et al. (2007) Practice guideline for the performance of physiologic evaluation of extremity arteries. J Vasc Interv Radiol 18(10): 1203-1206.
- Merillon JP, Lebras Y, Chastre J, Lerallut JF, Motte G, et al. (1983) Forward and backward waves in the arterial system, their relationship to pressure waves form. Eur Heart J 4(Suppl G): 13-20.
- Bortolotto LA, Safar ME (2006) Blood pressure profile along the arterial tree and genetics of hypertension. Arq Bras Cardiol 86(3): 166-169.
- Benetos A, Thomas F, Joly L, Blacher J, Pannier B, et al. (2010) Pulse pressure amplification a mechanical biomarker of cardiovascular risk. J Am Coll Cardiol 55(10): 1032-1037.
- Segers P, Mahieu D, Kips J, Rietzschel E, De Buyzere M, et al. (2009) Amplification of the pressure pulse in the upper limb in healthy, middle-aged men and women. Hypertension 54(2): 414-420.
- Zheng ZJ, Sharrett AR, Chambless LE, Rosamond WD, Nieto FJ, et al. (1997) Associations of ankle-brachial index with clinical coronary heart disease, stroke and preclinical carotid and popliteal atherosclerosis: the Atherosclerosis Risk in Communities (ARIC) Study. Atherosclerosis 131(1): 115-125.
- McKenna M, Wolfson S, Kuller L (1991) The ratio of ankle and arm arterial pressure as an independent predictor of mortality. Atherosclerosis 87(2-3): 119-128.
- Fine JJ, Hopkins CB, Hall PA (2005) Abnormal ankle brachial indices may predict cardiovascular disease among diabetic patients without known heart disease. Circ J 69(7): 798-801.
- Rizvi S, Kamran H, Salciccioli L, Saiful F, Lafferty J, et al. (2010) Relation of the ankle brachial index to left ventricular ejection fraction. Am J Cardiol 105(1): 129-132.
- Santo Signorelli S, Anzaldi M, Fiore V, Catanzaro S, Simili M, et al. (2010) Study on unrecognized peripheral arterial disease (PAD) by ankle/brachial index and arterial comorbidity in Catania, Sicily, Italy. Angiology 61(6): 524-529.
- Abbasnezhad M, Aliasgarzadeh A, Aslanabadi H, Habibzadeh A, Zamani B (2011) Relation of ankle brachial index to left ventricular ejection fraction in non-diabetic individuals. J Cardiovasc Thorac Res 3(4): 109112.
- Masanauskien E, Naudziunas A (2011) Comparison of ankle-brachial index in patients with and without atrial fibrillation. Medicina (Kaunas) 47(12): 641-645.
- Abbasnezhad M, Asgarzadeh AA, Aslanabadi H, Habibzadeh A (2012) Relation of ankle brachial index to left ventricular ejection fraction in diabetic patients. J Endocrin Metabol 2(6): 228-231.
- Amer MS, Tawfik HM, Maamoun, MMMA, Abd Elmoteleb AM (2013) Relationship between peripheral artery disease and cardiac function in elderly patients with ischemic heart disease. Egyptian Jrnl Hosp Med 51: 285-288.
- Tayebi Khosroshahi H, Abbasnejad M, Gojazade M, Mansouri S, Ahadi HR, et al. (2015) Relationship between ankle-brachial index and left ventricle ejection fraction in patients on hemodialysis. Iran J Kidney Dis 9(6): 463-468.
- Liu Y, Bapat M, Kamran H, Salciccioli L, Rozenboym A, et al. (2015) The ankle-brachial index is related to left ventricular ejection fraction in bonnet macaques. Cardiology 130(2): 91-95.
- Weber T, Auer J, Lamm G, O'Rourke MF, Eber B (2007) Arterial stiffness, central blood pressures, and wave reflections in cardiomyopathy- implications for risk stratification. J Card Fail 13(5): 353-359.
- Denardo SJ, Nandyala R, Freeman GL, Pierce GL, Nichols WW (2010) Pulse wave analysis of the aortic pressure waveform in severe left ventricular systolic dysfunction. Circ Heart Fail 3(1): 149-156.
- Fu W, Ye C, Mei C, Rong S, Wang W (2006) Reverse correlation between ankle-brachial index and left ventricular hypertrophy in patients on maintenance haemodialysis. Nephrology (Carlton) 11(1): 9-14.
- Maldonado J, Pereira T, Resende M, Simoes D, Carvalho M (2008) Usefulness of the ankle-brachial index in assessing vascular function in normal individuals. Rev Port Cardiol 27(4): 465-476.
- Tanaka S, Kaneko H, Kano H, Matsuno S, Suzuki S, et al. (2016) The predictive value of the borderline ankle-brachial index for long-term clinical outcomes: An observational cohort study. Atherosclerosis 250: 69-76.
- Wysokinski WE, Spittell PC, Pellikka PA, Miller WL, Seward JB (1998) Dobutamine effect on ankle-brachial pressure index in patients with peripheral arterial occlusive disease. New noninvasive test for evaluation of peripheral circulation? Int Angiol 17(3): 201-207.
- Nichols WW, Pepine CJ (1992) Ventricular/vascular interaction in health and heart failure. Compr Ther 18(7): 12-19.
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