The ankle-brachial index for peripheral artery disease screening and cardiovascular disease prediction among asymptomatic adults: a systematic evidence review for the U.S. Preventive Services Task Force

Ann Intern Med. 2013 Sep 3;159(5):333-41. doi: 10.7326/0003-4819-159-5-201309030-00007.


Background: Screening for peripheral artery disease (PAD) may reduce morbidity and mortality.

Purpose: To review the evidence on the ability of the ankle-brachial index (ABI) to predict cardiovascular disease (CVD) morbidity and mortality independent of Framingham Risk Score (FRS) factors in asymptomatic adults and on the benefits and harms of treating screen-detected adults with PAD.

Data sources: MEDLINE and the Cochrane Central Register of Controlled Trials (1996 to September 2012), clinical trial registries, reference lists, and experts.

Study selection: English-language, population-based prognostic studies evaluating the ABI in addition to the FRS and treatment trials or studies of treatment harms in screen-detected adults with PAD.

Data extraction: Dual quality assessment and abstraction of relevant study details.

Data synthesis: One large meta-analysis (n = 43 919) showed that the ABI could reclassify 10-year risk for coronary artery disease (CAD), but it did not report measures of appropriate reclassification (the net reclassification improvement [NRI]). Four heterogeneous risk prediction studies showed that the magnitude of the NRI was probably small when the ABI was added to the FRS to predict CAD or CVD events. Of 2 treatment trials meeting inclusion criteria, 1 large trial (n = 3350) showed that low-dose aspirin did not prevent CVD events in persons with a screen-detected low ABI but may have increased the risk for major bleeding events.

Limitations: Most prognostic studies did not allow for calculation of a bias-corrected NRI. Evidence on treatment benefits and harms was limited to aspirin and was scant.

Conclusion: Adding the ABI to the FRS probably has limited value for predicting CAD or CVD. Treatment benefits for asymptomatic individuals with screen-detected PAD are not established.

Primary funding source: Agency for Healthcare Research and Quality.

Publication types

  • Research Support, U.S. Gov't, P.H.S.
  • Review
  • Systematic Review

MeSH terms

  • Adult
  • Ankle Brachial Index*
  • Aspirin / adverse effects
  • Aspirin / therapeutic use
  • Asymptomatic Diseases
  • Cardiovascular Diseases / epidemiology*
  • Cardiovascular Diseases / mortality
  • Fibrinolytic Agents / adverse effects
  • Fibrinolytic Agents / therapeutic use
  • Hemorrhage / chemically induced
  • Humans
  • Mass Screening / methods*
  • Peripheral Arterial Disease / diagnosis*
  • Peripheral Arterial Disease / drug therapy
  • Predictive Value of Tests
  • Risk Assessment
  • Risk Factors


  • Fibrinolytic Agents
  • Aspirin