Ankle brachial index combined with Framingham risk score to predict cardiovascular events and mortality

A meta-analysis

F. G. R. Fowkes, G. D. Murray, I. Butcher, C. L. Heald, R. J. Lee, L. E. Chambless, A. R. Folsom, A. T. Hirsch, M. Dramaix, G. deBacker, J-C. Wautrecht, M. Kornitzer, A. B. Newman, M. Cushman, K. Sutton-Tyrrell, Amanda Jane Lee, J. F. Price, R. B. d'Agostino, J. M. Murabito, P. E. Norman & 28 others K. Jamrozik, J. D. Curb, K. H. Masaki, B. L. Rodriquez, J. M. Dekker, L. M. Bouter, R. J. Heine, G. Nijpels, C. D. A. Stehouwer, L. Ferrucci, M. M. McDermott, H. E. Stoffers, J. D. Hooi, J. A. Knottnerus, M. Ogren, B. Hedblad, J. C. Witteman, M. M. B. Breteler, M. G. M. Hunink, A. Hofman, M. H. Criqui, R. D. Langer, A. Fronek, W. R. Hiatt, R. Hamman, H. E. Resnick, J. Guralnik, Ankle Brachial Index Collaboration

Research output: Contribution to journalLiterature review

1089 Citations (Scopus)

Abstract

Context Prediction models to identify healthy individuals at high risk of cardiovascular disease have limited accuracy. A low ankle brachial index ( ABI) is an indicator of atherosclerosis and has the potential to improve prediction.

Objective To determine if the ABI provides information on the risk of cardiovascular events and mortality independently of the Framingham risk score ( FRS) and can improve risk prediction.

Data Sources Relevant studies were identified. A search of MEDLINE ( 1950 to February 2008) and EMBASE ( 1980 to February 2008) was conducted using common text words for the term ankle brachial index combined with text words and Medical Subject Headings to capture prospective cohort designs. Review of reference lists and conference proceedings, and correspondence with experts was conducted to identify additional published and unpublished studies.

Study Selection Studies were included if participants were derived from a general population, ABI was measured at baseline, and individuals were followed up to detect total and cardiovascular mortality.

Data Extraction Prespecified data on individuals in each selected study were extracted into a combined data set and an individual participant data meta- analysis was conducted on individuals who had no previous history of coronary heart disease.

Results Sixteen population cohort studies fulfilling the inclusion criteria were included. During 480 325 person- years of follow- up of 24 955 men and 23 339 women, the risk of death by ABI had a reverse J- shaped distribution with a normal ( low risk) ABI of 1.11 to 1.40. The 10- year cardiovascular mortality in men with a low ABI ( <= 0.90) was 18.7% ( 95% confidence interval [ CI], 13.3%- 24.1%) and with normal ABI ( 1.11- 1.40) was 4.4% ( 95% CI, 3.2%- 5.7%) ( hazard ratio [ HR], 4.2; 95% CI, 3.3- 5.4). Corresponding mortalities in women were 12.6% ( 95% CI, 6.2%-19.0%) and 4.1% ( 95% CI, 2.2%- 6.1%) ( HR, 3.5; 95% CI, 2.4- 5.1). The HRs remained elevated after adjusting for FRS ( 2.9 [ 95% CI, 2.3- 3.7] for men vs 3.0 [ 95% CI, 2.0- 4.4] for women). A low ABI ( <= 0.90) was associated with approximately twice the 10- year total mortality, cardiovascular mortality, and major coronary event rate compared with the overall rate in each FRS category. Inclusion of the ABI in cardiovascular risk stratification using the FRS would result in reclassification of the risk category and modification of treatment recommendations in approximately 19% of men and 36% of women.

Conclusion Measurement of the ABI may improve the accuracy of cardiovascular risk prediction beyond the FRS.
Original languageEnglish
Pages (from-to)197-208
Number of pages12
JournalJAMA
Volume300
Issue number2
DOIs
Publication statusPublished - 9 Jul 2008

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Ankle Brachial Index
Meta-Analysis
Mortality
Confidence Intervals
Medical Subject Headings
Information Storage and Retrieval
MEDLINE
Population
Coronary Disease
Atherosclerosis

Keywords

  • ankle-brachial index
  • artherosclerosis
  • cardiovascular diseases
  • clinician's corner
  • coronary disease
  • framingham risk score
  • meta analysis
  • mortality
  • prognosis
  • risk factors

Cite this

Fowkes, F. G. R., Murray, G. D., Butcher, I., Heald, C. L., Lee, R. J., Chambless, L. E., ... Ankle Brachial Index Collaboration (2008). Ankle brachial index combined with Framingham risk score to predict cardiovascular events and mortality: A meta-analysis. JAMA, 300(2), 197-208. https://doi.org/10.1001/jama.300.2.197

Ankle brachial index combined with Framingham risk score to predict cardiovascular events and mortality : A meta-analysis. / Fowkes, F. G. R. ; Murray, G. D.; Butcher, I.; Heald, C. L.; Lee, R. J.; Chambless, L. E.; Folsom, A. R.; Hirsch, A. T.; Dramaix, M.; deBacker, G.; Wautrecht, J-C.; Kornitzer, M.; Newman, A. B.; Cushman, M.; Sutton-Tyrrell, K.; Lee, Amanda Jane; Price, J. F.; d'Agostino, R. B.; Murabito, J. M.; Norman, P. E.; Jamrozik, K.; Curb, J. D.; Masaki, K. H.; Rodriquez, B. L.; Dekker, J. M.; Bouter, L. M.; Heine, R. J.; Nijpels, G.; Stehouwer, C. D. A.; Ferrucci, L.; McDermott, M. M.; Stoffers, H. E.; Hooi, J. D.; Knottnerus, J. A.; Ogren, M.; Hedblad, B.; Witteman, J. C.; Breteler, M. M. B.; Hunink, M. G. M.; Hofman, A.; Criqui, M. H.; Langer, R. D.; Fronek, A.; Hiatt, W. R.; Hamman, R.; Resnick, H. E.; Guralnik, J.; Ankle Brachial Index Collaboration.

In: JAMA, Vol. 300, No. 2, 09.07.2008, p. 197-208.

Research output: Contribution to journalLiterature review

Fowkes, FGR, Murray, GD, Butcher, I, Heald, CL, Lee, RJ, Chambless, LE, Folsom, AR, Hirsch, AT, Dramaix, M, deBacker, G, Wautrecht, J-C, Kornitzer, M, Newman, AB, Cushman, M, Sutton-Tyrrell, K, Lee, AJ, Price, JF, d'Agostino, RB, Murabito, JM, Norman, PE, Jamrozik, K, Curb, JD, Masaki, KH, Rodriquez, BL, Dekker, JM, Bouter, LM, Heine, RJ, Nijpels, G, Stehouwer, CDA, Ferrucci, L, McDermott, MM, Stoffers, HE, Hooi, JD, Knottnerus, JA, Ogren, M, Hedblad, B, Witteman, JC, Breteler, MMB, Hunink, MGM, Hofman, A, Criqui, MH, Langer, RD, Fronek, A, Hiatt, WR, Hamman, R, Resnick, HE, Guralnik, J & Ankle Brachial Index Collaboration 2008, 'Ankle brachial index combined with Framingham risk score to predict cardiovascular events and mortality: A meta-analysis', JAMA, vol. 300, no. 2, pp. 197-208. https://doi.org/10.1001/jama.300.2.197
Fowkes, F. G. R. ; Murray, G. D. ; Butcher, I. ; Heald, C. L. ; Lee, R. J. ; Chambless, L. E. ; Folsom, A. R. ; Hirsch, A. T. ; Dramaix, M. ; deBacker, G. ; Wautrecht, J-C. ; Kornitzer, M. ; Newman, A. B. ; Cushman, M. ; Sutton-Tyrrell, K. ; Lee, Amanda Jane ; Price, J. F. ; d'Agostino, R. B. ; Murabito, J. M. ; Norman, P. E. ; Jamrozik, K. ; Curb, J. D. ; Masaki, K. H. ; Rodriquez, B. L. ; Dekker, J. M. ; Bouter, L. M. ; Heine, R. J. ; Nijpels, G. ; Stehouwer, C. D. A. ; Ferrucci, L. ; McDermott, M. M. ; Stoffers, H. E. ; Hooi, J. D. ; Knottnerus, J. A. ; Ogren, M. ; Hedblad, B. ; Witteman, J. C. ; Breteler, M. M. B. ; Hunink, M. G. M. ; Hofman, A. ; Criqui, M. H. ; Langer, R. D. ; Fronek, A. ; Hiatt, W. R. ; Hamman, R. ; Resnick, H. E. ; Guralnik, J. ; Ankle Brachial Index Collaboration. / Ankle brachial index combined with Framingham risk score to predict cardiovascular events and mortality : A meta-analysis. In: JAMA. 2008 ; Vol. 300, No. 2. pp. 197-208.
@article{391dc25ddd5141d68bde91ad93bc3884,
title = "Ankle brachial index combined with Framingham risk score to predict cardiovascular events and mortality: A meta-analysis",
abstract = "Context Prediction models to identify healthy individuals at high risk of cardiovascular disease have limited accuracy. A low ankle brachial index ( ABI) is an indicator of atherosclerosis and has the potential to improve prediction. Objective To determine if the ABI provides information on the risk of cardiovascular events and mortality independently of the Framingham risk score ( FRS) and can improve risk prediction. Data Sources Relevant studies were identified. A search of MEDLINE ( 1950 to February 2008) and EMBASE ( 1980 to February 2008) was conducted using common text words for the term ankle brachial index combined with text words and Medical Subject Headings to capture prospective cohort designs. Review of reference lists and conference proceedings, and correspondence with experts was conducted to identify additional published and unpublished studies. Study Selection Studies were included if participants were derived from a general population, ABI was measured at baseline, and individuals were followed up to detect total and cardiovascular mortality. Data Extraction Prespecified data on individuals in each selected study were extracted into a combined data set and an individual participant data meta- analysis was conducted on individuals who had no previous history of coronary heart disease. Results Sixteen population cohort studies fulfilling the inclusion criteria were included. During 480 325 person- years of follow- up of 24 955 men and 23 339 women, the risk of death by ABI had a reverse J- shaped distribution with a normal ( low risk) ABI of 1.11 to 1.40. The 10- year cardiovascular mortality in men with a low ABI ( <= 0.90) was 18.7{\%} ( 95{\%} confidence interval [ CI], 13.3{\%}- 24.1{\%}) and with normal ABI ( 1.11- 1.40) was 4.4{\%} ( 95{\%} CI, 3.2{\%}- 5.7{\%}) ( hazard ratio [ HR], 4.2; 95{\%} CI, 3.3- 5.4). Corresponding mortalities in women were 12.6{\%} ( 95{\%} CI, 6.2{\%}-19.0{\%}) and 4.1{\%} ( 95{\%} CI, 2.2{\%}- 6.1{\%}) ( HR, 3.5; 95{\%} CI, 2.4- 5.1). The HRs remained elevated after adjusting for FRS ( 2.9 [ 95{\%} CI, 2.3- 3.7] for men vs 3.0 [ 95{\%} CI, 2.0- 4.4] for women). A low ABI ( <= 0.90) was associated with approximately twice the 10- year total mortality, cardiovascular mortality, and major coronary event rate compared with the overall rate in each FRS category. Inclusion of the ABI in cardiovascular risk stratification using the FRS would result in reclassification of the risk category and modification of treatment recommendations in approximately 19{\%} of men and 36{\%} of women. Conclusion Measurement of the ABI may improve the accuracy of cardiovascular risk prediction beyond the FRS.",
keywords = "ankle-brachial index, artherosclerosis, cardiovascular diseases, clinician's corner, coronary disease, framingham risk score, meta analysis, mortality, prognosis, risk factors",
author = "Fowkes, {F. G. R.} and Murray, {G. D.} and I. Butcher and Heald, {C. L.} and Lee, {R. J.} and Chambless, {L. E.} and Folsom, {A. R.} and Hirsch, {A. T.} and M. Dramaix and G. deBacker and J-C. Wautrecht and M. Kornitzer and Newman, {A. B.} and M. Cushman and K. Sutton-Tyrrell and Lee, {Amanda Jane} and Price, {J. F.} and d'Agostino, {R. B.} and Murabito, {J. M.} and Norman, {P. E.} and K. Jamrozik and Curb, {J. D.} and Masaki, {K. H.} and Rodriquez, {B. L.} and Dekker, {J. M.} and Bouter, {L. M.} and Heine, {R. J.} and G. Nijpels and Stehouwer, {C. D. A.} and L. Ferrucci and McDermott, {M. M.} and Stoffers, {H. E.} and Hooi, {J. D.} and Knottnerus, {J. A.} and M. Ogren and B. Hedblad and Witteman, {J. C.} and Breteler, {M. M. B.} and Hunink, {M. G. M.} and A. Hofman and Criqui, {M. H.} and Langer, {R. D.} and A. Fronek and Hiatt, {W. R.} and R. Hamman and Resnick, {H. E.} and J. Guralnik and {Ankle Brachial Index Collaboration}",
year = "2008",
month = "7",
day = "9",
doi = "10.1001/jama.300.2.197",
language = "English",
volume = "300",
pages = "197--208",
journal = "JAMA",
issn = "0098-7484",
publisher = "American Medical Association",
number = "2",

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TY - JOUR

T1 - Ankle brachial index combined with Framingham risk score to predict cardiovascular events and mortality

T2 - A meta-analysis

AU - Fowkes, F. G. R.

AU - Murray, G. D.

AU - Butcher, I.

AU - Heald, C. L.

AU - Lee, R. J.

AU - Chambless, L. E.

AU - Folsom, A. R.

AU - Hirsch, A. T.

AU - Dramaix, M.

AU - deBacker, G.

AU - Wautrecht, J-C.

AU - Kornitzer, M.

AU - Newman, A. B.

AU - Cushman, M.

AU - Sutton-Tyrrell, K.

AU - Lee, Amanda Jane

AU - Price, J. F.

AU - d'Agostino, R. B.

AU - Murabito, J. M.

AU - Norman, P. E.

AU - Jamrozik, K.

AU - Curb, J. D.

AU - Masaki, K. H.

AU - Rodriquez, B. L.

AU - Dekker, J. M.

AU - Bouter, L. M.

AU - Heine, R. J.

AU - Nijpels, G.

AU - Stehouwer, C. D. A.

AU - Ferrucci, L.

AU - McDermott, M. M.

AU - Stoffers, H. E.

AU - Hooi, J. D.

AU - Knottnerus, J. A.

AU - Ogren, M.

AU - Hedblad, B.

AU - Witteman, J. C.

AU - Breteler, M. M. B.

AU - Hunink, M. G. M.

AU - Hofman, A.

AU - Criqui, M. H.

AU - Langer, R. D.

AU - Fronek, A.

AU - Hiatt, W. R.

AU - Hamman, R.

AU - Resnick, H. E.

AU - Guralnik, J.

AU - Ankle Brachial Index Collaboration

PY - 2008/7/9

Y1 - 2008/7/9

N2 - Context Prediction models to identify healthy individuals at high risk of cardiovascular disease have limited accuracy. A low ankle brachial index ( ABI) is an indicator of atherosclerosis and has the potential to improve prediction. Objective To determine if the ABI provides information on the risk of cardiovascular events and mortality independently of the Framingham risk score ( FRS) and can improve risk prediction. Data Sources Relevant studies were identified. A search of MEDLINE ( 1950 to February 2008) and EMBASE ( 1980 to February 2008) was conducted using common text words for the term ankle brachial index combined with text words and Medical Subject Headings to capture prospective cohort designs. Review of reference lists and conference proceedings, and correspondence with experts was conducted to identify additional published and unpublished studies. Study Selection Studies were included if participants were derived from a general population, ABI was measured at baseline, and individuals were followed up to detect total and cardiovascular mortality. Data Extraction Prespecified data on individuals in each selected study were extracted into a combined data set and an individual participant data meta- analysis was conducted on individuals who had no previous history of coronary heart disease. Results Sixteen population cohort studies fulfilling the inclusion criteria were included. During 480 325 person- years of follow- up of 24 955 men and 23 339 women, the risk of death by ABI had a reverse J- shaped distribution with a normal ( low risk) ABI of 1.11 to 1.40. The 10- year cardiovascular mortality in men with a low ABI ( <= 0.90) was 18.7% ( 95% confidence interval [ CI], 13.3%- 24.1%) and with normal ABI ( 1.11- 1.40) was 4.4% ( 95% CI, 3.2%- 5.7%) ( hazard ratio [ HR], 4.2; 95% CI, 3.3- 5.4). Corresponding mortalities in women were 12.6% ( 95% CI, 6.2%-19.0%) and 4.1% ( 95% CI, 2.2%- 6.1%) ( HR, 3.5; 95% CI, 2.4- 5.1). The HRs remained elevated after adjusting for FRS ( 2.9 [ 95% CI, 2.3- 3.7] for men vs 3.0 [ 95% CI, 2.0- 4.4] for women). A low ABI ( <= 0.90) was associated with approximately twice the 10- year total mortality, cardiovascular mortality, and major coronary event rate compared with the overall rate in each FRS category. Inclusion of the ABI in cardiovascular risk stratification using the FRS would result in reclassification of the risk category and modification of treatment recommendations in approximately 19% of men and 36% of women. Conclusion Measurement of the ABI may improve the accuracy of cardiovascular risk prediction beyond the FRS.

AB - Context Prediction models to identify healthy individuals at high risk of cardiovascular disease have limited accuracy. A low ankle brachial index ( ABI) is an indicator of atherosclerosis and has the potential to improve prediction. Objective To determine if the ABI provides information on the risk of cardiovascular events and mortality independently of the Framingham risk score ( FRS) and can improve risk prediction. Data Sources Relevant studies were identified. A search of MEDLINE ( 1950 to February 2008) and EMBASE ( 1980 to February 2008) was conducted using common text words for the term ankle brachial index combined with text words and Medical Subject Headings to capture prospective cohort designs. Review of reference lists and conference proceedings, and correspondence with experts was conducted to identify additional published and unpublished studies. Study Selection Studies were included if participants were derived from a general population, ABI was measured at baseline, and individuals were followed up to detect total and cardiovascular mortality. Data Extraction Prespecified data on individuals in each selected study were extracted into a combined data set and an individual participant data meta- analysis was conducted on individuals who had no previous history of coronary heart disease. Results Sixteen population cohort studies fulfilling the inclusion criteria were included. During 480 325 person- years of follow- up of 24 955 men and 23 339 women, the risk of death by ABI had a reverse J- shaped distribution with a normal ( low risk) ABI of 1.11 to 1.40. The 10- year cardiovascular mortality in men with a low ABI ( <= 0.90) was 18.7% ( 95% confidence interval [ CI], 13.3%- 24.1%) and with normal ABI ( 1.11- 1.40) was 4.4% ( 95% CI, 3.2%- 5.7%) ( hazard ratio [ HR], 4.2; 95% CI, 3.3- 5.4). Corresponding mortalities in women were 12.6% ( 95% CI, 6.2%-19.0%) and 4.1% ( 95% CI, 2.2%- 6.1%) ( HR, 3.5; 95% CI, 2.4- 5.1). The HRs remained elevated after adjusting for FRS ( 2.9 [ 95% CI, 2.3- 3.7] for men vs 3.0 [ 95% CI, 2.0- 4.4] for women). A low ABI ( <= 0.90) was associated with approximately twice the 10- year total mortality, cardiovascular mortality, and major coronary event rate compared with the overall rate in each FRS category. Inclusion of the ABI in cardiovascular risk stratification using the FRS would result in reclassification of the risk category and modification of treatment recommendations in approximately 19% of men and 36% of women. Conclusion Measurement of the ABI may improve the accuracy of cardiovascular risk prediction beyond the FRS.

KW - ankle-brachial index

KW - artherosclerosis

KW - cardiovascular diseases

KW - clinician's corner

KW - coronary disease

KW - framingham risk score

KW - meta analysis

KW - mortality

KW - prognosis

KW - risk factors

U2 - 10.1001/jama.300.2.197

DO - 10.1001/jama.300.2.197

M3 - Literature review

VL - 300

SP - 197

EP - 208

JO - JAMA

JF - JAMA

SN - 0098-7484

IS - 2

ER -