The Use of Ankle Brachial Index (ABI) as the Early Detection of Left

Ventricular Diastolic Dysfunction

Background

Heart Failure (HF) has been one of the major health problems worldwide due
to lifestyle (education, diet, exercise, smoking, and socioeconomic) and poor quality
of life. According to Indonesias National Cardiovascular Center, HF is the most
common diagnosis with high mortality rate. Other than that, the number of
hospitalized heart failure patents is increasing in year 2007 to 2008, from 1409 to
1476 patients, in NCVC Jakarta.1 These numbers are estimated to increase
continuously throughout the coming years. Patients admitted to hospital are usually in
poor condition. The lack of awareness to heart failure diseases is due to ignorance, not
much of health insurance, and being far from hospital. There are several types and
numerous etiologies of HF, whereas Left Ventricular Diastolic Heart Failure
(LVDHF) is the most progressive ones.2,3
Left Ventricular Diastolic Heart Failure currently accounts for 40-50% of all
HF cases.4 This type of HF is a progressive disorder characterized by impaired left
ventricular (LV) relaxation, increased LV stiffness, escalated interstitial deposition of
collagen, and modified extracellular matrix proteins. Thus, blood pumped from the
left ventricle will be less than its normal capability. The onset of LVDHF is usually
asymptomatic (left ventricle myocardial remodeling causing diastolic dysfunction)
because of the compensation that the human body does. However, symptoms will
arise when the human body can no longer endure the problem and at this state it
becomes LVDHF. Since, the process of left ventricle myocardial remodeling starts
before the onset of symptoms, recent studies has emphasized on the detection of
subclinical LV diastolic dysfunction, as one of the earliest and most common cardiac
abnormalities which will develop into diastolic HF, and identification through risk
factors for HF.5
As described in the previous paragraph, LV diastolic dysfunction is a predictor
for cardiovascular disease6 and all-cause mortality7. According to a study in Europe,
specifically in Northern Belgium, on 539 randomly selected residents aged 37-68
years (mean aged 52.5) showed that the prevalence of LV diastolic dysfunction was

high, 27.3%.5 On another recent study researching into 692 Japanese adult patients
with sinus rhythm, referred for a transthoracic echocardiography between JulyDecember 2007 (mean 59 15 years old; 50% women, 48% hypertension, 16%
diabetes, 26% overweight, 8% obese), showed that 78% of the population had
abnormal LV diastolic dysfunction.8 Both studies showed diastolic dysfunction is
common in older populations and often unaccompanied by overt congestive heart
failure.5,8
Formerly, cardiac catheterization was the gold standard to demonstrate
impaired relaxation and filling by making direct measurements. However,
echocardiography has replaced it as the most clinically used tool. Echocardiographic
techniques to assess early subclinical changes in diastolic LV function evolved
rapidly over the past 10 years. By evaluating mitral inflow pulmonary venous flow
Doppler, color M-mode velocity propagation, tissue Doppler imaging, and speckle
tracking, echocardiography is considered an accurate method for diagnosis and
grading diastolic dysfunction, despite of its high cost.9
Recent findings showed a significant association between LV diastolic
dysfunction and arterial stiffness using different markers, such as augmentation index
(AIx), brachio-ankle Pulse Wave Velocity (ba-PWV), carotid-femoral pulse wave
velocity, and cardio-ankle vascular index.10-13 Increased arterial stiffness results in
higher transmission velocities of both forward and reflected arterial pulse waves
causing the reflected waves to arrive earlier in the central aorta and augment pressure
in late systole. The augmentation of central aortic systolic pressure is typically
quantified as the increase of pressure from the first systolic shoulder to the systolic
pressure peak of the aortic pressure waveform and is expressed as a percentage of
central aortic pulse pressure (AIx).10 Beside that, the arterial stiffness also can be
expressed by another kind of marker called the PWV. PWV is simple and noninvasive in determining arterial stiffness. All arterial sites have potential interest.
Indeed, the forearm circulation is where blood pressureis commonly measured, and
the lower limb arteries are specifically altered by atherosclerosis. Measurement
oflocal carotid stiffness may also provide important prognosticinformation, since the
carotid artery is a frequent site ofatheroma formation. Oscillometric technique is used
in obtaining baPWV and the result has shown strong correlation with increased
cardiovascular events. Aside from that, carotid-femoral PWV has also been used in
the epidemiological studies demonstrating the predictive value of aortic stiffness for

cardiovascular events events. Another marker is the noninvasive cardioankle vascular

index (CAVI) which can measure the stiffness of the aorta, femoral artery, and tibial
artery with monitoring of the electrocardiogram and phonocardiogram. All markers
described above demand the use of advance instruments.14
Decreased arterial compliance is one of the earliest detectable manifestations
of adverse structural and functional changes in the vessel wall. Stiffening in both
medium-sized and large elastic arteries is associated with multiple cardiovascular risk
factors, including hypertension, dyslipidemia, obesity, smoking, diabetes, and aging.
Another marker used to diagnose arterial stiffness is the Ankle-Brachial Index.13
The Ankle-Brachial Index (ABI) is a commonly used variable to assess the
occurrence of peripheral artery disease in epidemiological studies, as well as in
clinical setting. Repetitiously, a low ABI has been shown to predict future
cardiovascular events. Usually, 0.90 is used as a cut-off limit in ABI. The latest
investigations showed that lower ABI was independently associated with arterial
stiffness, an early subclinical marker of LV diastolic dysfunction. Nonetheless,
research indicates the association of the variables, to the best of our knowledge, has
not been conducted.15
This method uses Doppler as the instrument in assessing ABI. However, a
research in 2008 has found that the use of simple instruments such as stethoscope and
sphygmomanometer is nearly as accurate as Doppler.16,17 Noted that, lower ABI in
asymptomatic patients has a correlation to AIx, which is one of the markers for
diastolic dysfunction.18
Conclusively, early detection for Left Ventricular Diastolic Dysfunction thats
low cost is needed to prevent the increasing incidence of heart failure each year. ABI
method is one of the low cost methods, which can be applied as an early detection
method. Our general purpose of this research is to investigate the association between
ABI and LV diastolic dysfunction. In this study, we hypothesize that lower ABI is
associated with LV diastolic dysfunction.

Materials and Methods

Study Subjects and Design
National Cardiovascular Center Harapan Kita medical check-up database
stores the medical check-up records that are done in the National Cardiovascular
Center Harapan Kita, approximately 700 records a year. Using the National
Cardiovascular Center Harapan Kita advanced medical check-up database, we
consecutively selected 30 subjects with diastolic dysfunction and 30 subjects with
normal diastolic function. Advanced medical check-up consists of : physical
examination, laboratory test (hematology-hemoglobin, leukocyte, erythrocyte,
differential count, blood sedimentation rate, hematocrit, fibrinogen, and platelet
aggregation, liver function test-SGOT and SGPT, lipid profile-total cholesterol, high
density lipid, low density lipid, triglyceride and Lp(a), fasting blood glucose-fasting
glucose, postprandial blood glucose and HbA1C, kidney function-creatinine, ureum,
uric acid, complete urine test), Electrocardiography (ECG), Treadmill Test,
Echocardiography, and interpretation from cardiologist. Subjects with normal
diastolic function were enrolled as control group. We only included patients with
preserved ejection fraction (EF>50%), without history of heart failure and lived in
Jakarta, Indonesia. Participants with known organic heart disease (hypertrophic
cardiomyopathy-diagnosed using ECG, atrial fibrillation-diagnosed using ECG,
ischemic heart disease-diagnosed using Treadmill Test, valvular heart diseasediagnosed using Echocardiography, and dilated cardiomyopathy-diagnosed using
Echocardiography) were excluded. Data collection was obtained through complete
review of medical records from January 2011 until December 2011.
We performed a cross-sectional study comparing the Ankle Brachial Index
(ABI) on these diastolic dysfunction group to control group. All participants were
given written, informed consent before participating in the study.
Demographic and laboratory parameters
Data collection for subjects in both diastolic dysfunction and normal diastolic
function was identical. Subjects in both group completed a questionnaire, provided a
blood sample, and underwent an echocardiogram. The questionnaire included
identical questions pertaining to HF symptoms, cardiovascular risk factors, and

medication usage. Demographic characteristics were recorded. Presence of the

following traditional cardiovascular risk factors according to Framingham Heart
Study General Cardiovascular Disease (10-year risk)19 was ascertained : age (years),
body mass index (BMI, kg/m), smoking status (no history of smoking, former
smoker-ceased smoking for at least 1 year, or current smoker), hyperlipidemia (based
on clinically obtained elevated fasting lipid values of low-density cholesterol 160
mg/dL, triglycerides 200 mg/dL or high-density cholesterol <40 mg/dL and/or
documented use of lipid lowering agents), diabetes (based on clinical history and/or
documented use of antidiabetic drugs), and hypertension (systolic blood pressure
(SBP) 140mmHg or diastolic blood pressure (DBP) 90mmHg, or both and/or
documented use of antihypertension agents). Data on history of ischemic heart disease
(IHD) (presence of angina pectoris, coronary artery disease, myocardial infarction
(MI) were also gathered.
Echocardiography Measurements
All echocardiograms were performed by registered diagnostic cardiac
sonographers using Philips HD 15 system (Philips, Bothell, WA) and Sonos 4500
interfaced with a 2.5- to 3.5-MHz phased-array probe and interpreted in the National
Cardiovascular Center Harapan Kita. The following echocardiographic parameters
were measured and/or estimated in each subject: The LV ejection fraction (LVEF was
derived automatically from the equipment. The peak velocity of early trans-mitral
flow (E velocity) and the peak velocity of atrial flow (A velocity) were recorded. E/A
was the ratio of E velocity to A velocity. The deceleration time was the interval from
the E-wave peak to the decline of the velocity to baseline. An E/A ratio of

1.0 was

considered as indicating of diastolic dysfunction.2 All subjects had a normal LVEF

(EF > 50%) and no subject in this study had a pseudonormal diastolic function (E/A
ratio of 1.0 to 1.5 and deceleration time > 240 ms). The physicians who performed the
assessments above were blinded to other information.
Assessment of ABI
Each test was done by trained medical students. All examiners used the same
methodology. At the outset, patients were asked to rest in the supine position for 10
minutes, after which the radial arteries were palpated bilaterally. After confirmation

that the pulsations in the bilateral radial arteries were similar, the right brachial artery
sistole blood pressure was measured. In order to measure the posterior tibial and
dorsalis pedis artery sistole blood pressure, a 12 cm-wide standard cuff for the upper
extremity was applied to the ankle, with the lower end of the cuff being placed about
3 cm above the malleoli and the contour adjusted to the conical shape of the lower
leg. The higher systolic pressure of the two inferior arteries was divided by the higher
systolic pressure of the arms to obtain the ABI. A mercury sphygmamometer and a
stethoscope were used.