Jennifer S. Lin, MD, MCR; Carin M. Olson, MD, MS; Eric S. Johnson, PhD; Evelyn P. Whitlock, MD, MPH
Note: AHRQ staff provided oversight for the project and assisted in external review of the draft evidence synthesis. USPSTF liaisons helped to resolve issues around the scope of the review but were not involved in the conduct of the review.
Disclaimer: The authors of this report are responsible for its content. Statements in the report should not be construed as endorsement by AHRQ or the U.S. Department of Health and Human Services.
Acknowledgment: The authors thank Daphne Plaut, MLS, for conducting the literature searches; Kevin Lutz, MFA, for his editorial support; Caitlyn Senger, MPH, and Clara Soh, MPA, for their assistance in conducting the evidence review; Tracy Wolff, MD, MPH, and Aileen Buckler, MD, MPH, for their assistance at AHRQ; Timothy Wilt, MD, MPH, Al Siu, MD, MSPH, Kirsten Bibbins-Domingo, MD, PhD, and Jessica Herzstein, MD, for their work as our USPSTF leads; and Josh Beckman, MD, MS, Nancy Cook, ScD, Gerry Fowkes, PhD, David Goff, MD, PhD, and Al Hirsch, MD, our expert reviewers, for their review of our full evidence report.
Financial Support: This review was conducted by the Kaiser Permanente Research Affiliates Evidence-based Practice Center under contract to AHRQ (contract HHSA 290-2007-10057-I, task order 13).
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-0658.
Requests for Single Reprints: Reprints are available from the AHRQ Web site (www.ahrq.gov).
Current Author Addresses: Drs. Lin, Olson, Johnson, and Whitlock: Center for Health Research, Kaiser Permanente Northwest, 3800 North Interstate Avenue, Portland, OR 97227.
Author Contributions: Conception and design: J.S. Lin, E.P. Whitlock.
Analysis and interpretation of the data: J.S. Lin, C.M. Olson, E.S. Johnson, E.P. Whitlock.
Drafting of the article: J.S. Lin, C.M. Olson, E.P. Whitlock.
Critical revision of the article for important intellectual content: J.S. Lin, C.M. Olson, E.S. Johnson, E.P. Whitlock.
Final approval of the article: J.S. Lin, C.M. Olson, E.S. Johnson, E.P. Whitlock.
Statistical expertise: E.S. Johnson.
Obtaining of funding: E.P. Whitlock.
Collection and assembly of data: J.S. Lin, C.M. Olson.
Lin JS, Olson CM, Johnson ES, Whitlock EP. 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;159:333-341. doi: 10.7326/0003-4819-159-5-201309030-00007
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Published: Ann Intern Med. 2013;159(5):333-341.
Screening for peripheral artery disease (PAD) may reduce morbidity and mortality.
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.
MEDLINE and the Cochrane Central Register of Controlled Trials (1996 to September 2012), clinical trial registries, reference lists, and experts.
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.
Dual quality assessment and abstraction of relevant study details.
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.
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.
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.
Agency for Healthcare Research and Quality.
Summary of evidence search and selection.
ABI = ankle–brachial index.
* Available at www.uspreventiveservicestaskforce.org.
Table 1. Characteristics of Included Risk Prediction Studies
Appendix Table. Summary of Results for Risk Prediction Studies Reporting Outcomes of Independent Association of ABI and CVD Morbidity and Mortality Independent of FRS and/or Measures of Discrimination of ABI Compared With FRS
Table 2. Risk Reclassification of ABI When Added to FRS in the ABI Collaboration Cohorts*, by Sex
Table 3. Risk Reclassification of ABI When Added to FRS in the ABI Collaboration Cohorts* Using a Traditional Reference Group, by Sex
Table 4. Summary of NRI Results for Risk Prediction Studies
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