mia jurnal

8/19/2019 Mia Jurnal

1/21

Ankle-brachial index measuredby palpation for the diagnosis

of peripheral arterial diseaseAdvisor :

dr. Saugi A. Sp.PD

Chusna Helmia012095853


2/21

den!i!" o# !he $ournal

• Title : Ankle-brachial index measuredby palpation for the diagnosis ofperipheral arterial disease

• Author : Rino Migliacci, RobertoNasorri, Paolo Ricciarini and Paoloresele

• Published : !amily Practice "##$% "&:""$'"(") Access published on "# *une"##$


3/21

A%s!ra&!'a&(ground: The ankle'brachial index +A., i)e)the ratio of the ankle to brachial systolic bloodpressure, is the golden standard for the diagnosisof peripheral arterial disease +PA/. and is a highlyspeci0c method for the assessment of 1ascularrisk in other2ise asymptomatic patients)

patients 2ith an A 3#)4 2ere sho2nto ha1e a substantially increased riskof death and se1ere 1ascular e1ents)


4/21

'a&(ground

• The potential use of the A, as measuredby palpation of the foot arteries, inprimary care has not been properly

assessed and it re5uires 1alidation of itsdiagnostic accuracy% indeed, if 1alidated,the A by palpation could pro1ide asimple to perform nonin1asi1e,

inexpensi1e and rapid method for PA/detection and 1ascular risk strati0cationin primary care)


5/21

'a&(ground

Aim of our study 2as to e1aluate,in a typical primary care setting,

the diagnostic accuracy of the Ameasured by palpation incomparison 2ith the gold

standard A measured by/oppler ultrasound


6/21

)e!hode T2enty-four Ps of the 6al di 7hiana area, Tuscany,7entral taly, participated in the study) n total,

the practices had a population of "# ### patients)Thestudy population comprised patients registered 2iththese practitioners in "##8 and ha1ing the followingcharacteristics:

• age bet2een && and 9& years and one or t2oadditional maor cardio1ascular risk factors +type diabetes mellitus, hypertension, smoking,dyslipidemia. or age bet2een 9& and $# and noadditional risk factors)

• *+&lusion &ri!eria 2ere pre1ious clinicallyapparent ischemic cardio1ascular disease, apre1ious diagnosis of PA/, the concomitantpresence of three or more risk factors, refusal to

gi1e 2ritten, informed consent)


7/21

• ;n the study day, each patientunder2ent the measurement of Abilaterally by pulse detection of the

posterior tibial and dorsalis pedisarteries of the right lo2er limb, of theright and left brachial artery, of theposterior tibial and dorsalis pedisarteries of the left lo2er limb and againof the right and left brachial artery)

• The A 2as calculated from the

a1erage of t2o determinations as theratio bet2een the highest systolicblood pressure of the ankle and thehighest systolic blood pressure of the

upper limbs


8/21

Measurements 2ere carried outsimultaneously by the P, %"

palpa!ion o# !he pos!erior!i%ial ar!er" and by an

experienced angiologist, %"Doppler ul!rasound o# !he

dorsalis pedis using an attachedstethoscope in order to pre1ent

the /oppler signal to be heard by

the P ,the se5uence of themeasurements on the foot arteriesby the P and angiologist 2as

then in1erted


9/21

rachial blood pressures 2ere taken,

again simultaneously by the P andby the angiologist, %" palpa!ion o#!he radial pulse ,-P. and %"

ul!rasound Doppler o# !he%ra&hial ar!er" ,angiologis!/respecti1ely) The angiologist and theP 2ere blinded to one another as

regards the results obtained in eachpatient


10/21

All statistical analyses 2erecarried out using the 7AT-maker

soft2are, according to theinstructions do2nloaded from the7enter for


11/21

R?T• The "8 Ps identi0ed

their respecti1e@#patients to be enrolledin an a1erage time of") days) ;f the "8#

• patients 2ho accepted

to participate, "#& cameback for the study+$&B.) PatientsC meanage 2as 98)& years +&&'$#., &@)9B 2ere female,

– @@B had diabetes

mellitus, – 8(B hypertension,

– @@B 2ere smokers and

– @9B2ere dyslipidemic)


12/21


13/21

• Taking the /oppler measurement of

A as the gold standard, thepalpation method had a sensiti1ity of$$B D4&B con0dence inter1als +7s.

E 9&'@##F, speci0city $"B +'$$.,positi1e predicti1e 1alue @$B +9' "4.,negati1e predicti1e 1alue 44B +4$'

@##., positi1e likelihood ratio 8)4$+()("')8$. and negati1e likelihoodratio #)@& +#)#"'#)4&.


14/21

Dis&ussion

• the 0nding of a pathologic A mayallo2 to identify those cases 2ith a2orse cardio1ascular prognosis) Ge

ha1e sho2n that the A measuredby the P has a sensiti1ity of $$B, aspeci0city of $"B, a positi1e

predicti1e 1alue of @$B and anegati1e predicti1e 1alue of 44B indetecting PA/)


15/21

•

The 1ery lo2 probability of ha1ing PA/ ina patient 2ith an A H#)4 by palpation+posttest probability E #)8&B. allo2s toconsider the test ade5uate as a 0rst

screening for PA/ identi0cation and toexclude the need of further testing) ;nthe other hand, the lo2 positi1epredicti1e 1alue +@$B. does not allo2 touse the test as a conclusi1e diagnostictest


16/21

Pre1ious epidemiologicalstudies

• The pre1alence of PA/ in ourpopula!ion as loer ,.3!han !ha! repor!ed in previous

epidemiologi&al s!udies in primarycare(% ho2e1er, in those studies, thepopulation included patients at high

risk or 2ith pre1ious clinically e1identatherosclerotic disease(


17/21

• pre1ious study, 2ith a design similarto ours, attempted !o valida!e !heaus&ul!a!or" me!hod #or !he

diagnosis o# PAD in &omparisoni!h !he Doppler me!hod, butfound a lo2er positi1e likelihood ratio

as compared 2ith our method +"),7s @)4'()4. and a much lo2erpercentage of assessable patients

+9#)&B. as a compared 2ith ours

Pre1ious epidemiologicalstudies


18/21

• The most important step for thereduction of cardio1ascular morbidityand mortality in patients 2ith PA/ is

disease recognition and an A 3#)4is the main parameter for PA/diagnosis but, PA/ is 1ery

infre5uently diagnosed in primarycare due to the need to performmeasurements re5uiring a

specialiIed e5uipment, an


19/21

• The palpation approach to themeasurement of A should allo2 toreduce substantially the burden of

/oppler ultrasound measurementsre5uired +a $B reduction from ourstudy population.% gi1en the cost of

/oppler measurement in referralcentres in secondary care, this 2ouldimply a substantial cost reduction)


20/21

A simple, fast and inexpensi1e method for themeasurement of A, 2hich re5uires no special

e5uipment or special training, is represented bythe blood pressure measurement in the arm andfoot by palpation of the arterial pulses) Ameasurement by palpation has been pro1en to

be a prognostic factor for ischemiccardio1ascular e1ents in the setting of aprospecti1e clinical trial, but its 1alue in primarycare is not de0ned yet) The 1alidation of its

diagnostic accuracy in primary care, 2ithreference to the golden standard represented byA measurement by /oppler ultrasound, ispreliminary to the e1aluation of its prognostic

role)


21/21

• The possible substantial reduction of costs forthe Jealth 7are =ystem is an argument infa1or of a generaliIed screening of PA/ in

primary care, a procedure recommended byse1eral authorities) The lo2 cost and theinexpensi1e e5uipment re5uired for the

screening of A by palpation may be of

particular

• importance for de1eloping countries 2herethe pre1alence of atherosclerotic disease is in

great expansion) The cost'bene0t ratio of analternati1e strategy, i)e) that of pro1iding allPs 2ith the appropriate e5uipment and the

training for A measurements by /oppler>ltrasound, is likely to be disad1antageous

mia jurnal

Documents