India is known as capital for diabetes mellitus in world. It is a metabolic degenerative disease. It has became a challenging health problem to deal with diabetes and its complications [1].

Microvascular and macrovascular complications are the main long-term effects of untreated diabetes. One of it’s major macrovascular consequences is peripheral vascular Disease (PVD), frequently manifests as intermittent claudication. It is the main risk factor for limb gangrene and amputation in people living with diabetes [2].

Without thorough screening, it can be challenging to identify peripheral vascular disease in diabetes patients because sensory neuropathy delays the onset of symptoms. Ankle Brachial Index (ABI) assessment offers a straightforward, reproducible, non-invasive and efficient method to assess vascular status even in asymtomatic individuals with excellent sensitivity and specificity. ABI measures the ratio between the ankle and arm's systolic blood pressure [3].

The current study is undertaken to screen diabetes mellitus patients for peripheral vascular disease using ankle brachial index and correlate ankle brachial index with duration of diabetes and other risk factors such as hypertension, smoking and age.

Subjects and Methods

In this cross-sectional observational study, patient with known history of type 2 diabetes who came to the outpatient or inpatient department of tertiary care hospital and fulfilled the inclusion criteria were enrolled in the study from November 2021 to April 2022. Detailed history and thorough general examination and systemic examination of the individual was done with special reference to blood pressure, palpation of peripheral pulse and anthropometric measurements. All patients are subjected to HbA1C, lipid profile and ankle brachial index.

Inclusion Criteria

•  Diabetes Mellitus type 2 diagnose patient, on insulin or oral hypoglycaemic drug or both 

• Patient giving consent for study

Exclusion Criteria

• Patient <18 years of age 

• Patients with newly diagnosed diabetes mellitus on admission

• Type 2 diabetics with overt foot ulceration/gangrene

• Type 2 diabetic patients with foot lesions secondary to recent trauma (e.g: burns, road traffic accidents etc.) 

• Type 2 diabetics with spinal cord injuries

• Diabetic patients with infectious diseases that can involve peripheral nerves (e.g.: Leprosy)

• Type 2 diabetics with Thrombo Angiitis Obliterans. 

• Type 2 diabetics with acute illnesses like myocardial infarction, cerebrovascular accidents, diabetic ketoacidosis, hypoglycaemias etc.

Ankle brachia index is calculated using hand held Doppler and sphygmomanometer. Prior to the measurement of the ABI, patients are kept in supine position for at least 5 minutes. Sphygmomanometer cuff is tied around the calf muscles of lower limb and blood pressure is measured at the dorsalis pedis or posterior tibial arteries using a Hand-Held Doppler probe. The same technique is used for the other lower limb and for both arms to measure the brachial artery pressure. The ABI is calculated by dividing the highest pressure of the lower limb by the highest pressure of the arm of each side separately. The lowest ratio of either side is taken as final ABI.

ABI Interpretation [4]

• >1.30 – non compressible 

• 0.91-1.30- normal 

• 0.8 -0.9 – mild 

• 0.5 – 0.8 moderate 

• <0.50 –severe peripheral arterial disease

Study Type

Cross sectional study.

Statistical Analysis

Statistical Package for Social Sciences [SPSS] for Windows Version 22.0 Released 2013. Armonk, NY: IBM Corp., is used to perform statistical analyses. Descriptive Statistics: Descriptive analysis of all the explanatory and outcome parameters is done using frequency and proportions for categorical variables, whereas in Mean and SD for continuous variables.

Inferential Statistics

Chi Square Test is used to compare the age, gender, BMI status, smoking habit, comorbidities and diabetic profile as risk factors of Peripheral Vascular Disease among study patients. 95% Confidence Interval for significant Predictors of Risk for Peripheral Vascular Disease. The level of significance is set at (p<0.05).

Total 74 diagnosed diabetic patients were included in study. Out of them 38 were male and 36 were female. Mean age of study subjects was 66.65±10.61 years. In study, patients with <5years duration of diabetes were 38 (51.35%), with duration of 6-10 years were 22 (29.73%) and with duration of >10 years were 14 (18.92%).

In present study, we found that 31(41.89%) diabetic patients were having HbA1C value of less than 6.5% and 43 (58.11%) were having HbA1C value more than 6.5%. 49(66.22%) subjects were compliant to diabetic medications and 25(33.78%) not compliant. History of smoking were seen in 26 patients and 48 gave no history of smoking. Out of 74, 34 patients were also having history of hypertension. 

Total 18 patients were having ankle brachial index of less than 0.9 and 56 were having normal (0.9-1.3) index. 

Association of different Variables to Ankle-Brachial Index 

According to Ankle-Brachial index value, study population was divided into ABI <0.9, ABI >0.9 categories depending on age, duration of diabetes hypertension history and smoking history. 

The results of present study found a significant association of age, duration of diabetes, hypertension, smoking and HbA1C level with ABI <0.9. 

Out of total 74 study population, 18 were having ABI<0.9 and 56 were having ABI>0.9. Among age group of 35-50 years from 29 diabetic patients, 3 were having ABI <0.9, in 51-60 years age group 5 from 23 diabetic patients, in 61-70 age group 6 from 15 diabetic patients and in age group of >70 years 4 from 7 diabetic patients were having ABI <0.9.

In duration of diabetes with less than 5 years 3 from total 38 had ABI <0.9, in 5-10 years group 5 from 22 had ABI <0.9 and 10 from 14 diabetic patients with more than 10 years have ABI <0.9 (Figure 1).

Figure 1: Distribution of ABI <0.9 in Relation to Age and Duration of Diabetes among the Study Population

Out of total 34 hypertensive patients with diabetes, 15 had ABI <0.9 and 19 had normal ABI. This was found significant statistically with p value <0.001.

From 26 diabetic patients with history of smoking, 11 had ABI <0.9 an 15 had normal ABI. This was statistically significant with p value of 0.007 (Figure 2).

Figure 2: Distribution of Abnormal ABI (<0.9) in Diabetic Patients according to Presence of Hypertension and Smoking History, Demonstrating Statistically Significant Associations with both Risk Factors

Total 43 patients had uncontrolled diabetes (HbA1C >6.5%), 17 had ABI <0.9. Only 1 patient had ABI <0.9 with HbA1C <6.5%. This is statistical significant with p value <0.001 (Table 1).

Table 1: Association of ABI Values with Age, Duration of Diabetes, Hypertension, Smoking Status and HbA1C Levels in Diabetic Patients

One of the common macrovascular complication of diabetes mellitus which remains underdiagnosed and under treated is peripheral vascular disease, due to its long duration of asymptomatic period in its natural course [5]. Even in the absence of symptoms, there remains a significant risk for cardiovascular and cerebrovascular morbidity and mortality [6]. Hence the importance lies in identifying the PVD at the earliest.

In this study, 74 asymptomatic type 2 Diabetes Mellitus patients are screened for peripheral vascular disease using ankle brachial index and assessed for risk factors.

In the present study, 18 (24.3%) patients are having ankle brachial index of less than 0.9. In a cross-sectional study done by Khan et al. [7] in Abbottabad, Pakistan to know the risk factor for Peripheral Vascular Disease in diabetes mellitus, 53(19.9%) patients out of 266 have ABI value of less than 0.9. A Multi-country study on the prevalence and clinical features of peripheral arterial disease in Asian type 2 diabetes patients conducted by S.Y. Rhee et al. [8] shows 1172 (17.7%) patients from 6625 of 7 Asian countries have ABI less than 0.9. The results of these studies are comparable with our study. Narayanan et al. [9] have done a community-based study on type 2 diabetes mellitus patients for peripheral vascular disease in Singapore. In that study 79(15.2%) patients from 521 have lower ABI value than 0.9.

In this study 11 patients from low ABI group (18 patients) have history of smoking. There is a significant association (p value 0.007) of smoking with low ABI. In study done by Tummala et al. [10]  out of 69 patients with history of smoking 48 are having low ABI with significant p value of <0.001, in Khan et al. [7] studies 24 patients with history of smoking have ABI <0.9 with p value of less than 0.001. In multi country study done by Rhee et al. [8] has 860 patients with history of smoking. All these patients have ABI <0.9 with p value of 0.001.

There are 34 hypertensive patients in present study, of which 15 are having low ABI. Hypertension is significantly associated with low ABI (p value <0.001). Khan et al. [7] study out of 95 hypertensive patients 33 have low ABI (p value 0.001), Narayanan et al. [9] study there are 79 patients with low ABI. Among them 57 are hypertensive. In their history of hypertension in patients shows positive correlation with low ABI. Rhee et al. [8] study 6625 type 2 diabetes mellitus patients are screened for peripheral vascular disease in 7 Asian countries. Among them 5007 patients have hypertension.920 patients are having low ABI with a significant association with hypertension (p value <0.001).

In this study, duration of diabetes has been significant with increasing risk of peripheral vascular disease (p<0.001). Similar results are also seen in Rhee et al. [8] study and Narayanan et al. [9] studies with p value <0.001. We can infer from these findings that the likelihood of complications rises as diabetes duration increases.

In the present study 18 [24.3%] patients have low Ankle Brachial Index and is significantly associated with risk factors such as increasing age of the patient, duration of diabetes, smoking, hypertension and uncontrolled blood glucose level. From our study we conclude that, Ankle Brachial Index is a simple screening tool to detect asymptomatic peripheral vascular disease in diabetic patients. Identification and management of modifiable risk factors has benefit in delaying progression of peripheral vascular disease.

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8. Rhee, S.Y. et al. “Multicountry Study on the Prevalence and Clinical Features of Peripheral Arterial Disease in Asian Type 2 Diabetes Patients at High Risk of Atherosclerosis.” Diabetes Research and Clinical Practice, vol. 76, no. 1, April 2007, pp. 82–92.

9. Narayanan, R.M.L. et al. “Peripheral arterial disease in community-based patients with diabetes in Singapore: Results from a primary healthcare study.” Annals of the Academy of Medicine, Singapore, vol. 39, no. 7, July 2010, pp. 525–527.

10. Tummala, R. et al. “Utility of ankle–brachial index in screening for peripheral arterial disease in Rural India: A Cross-sectional study and review of literature.” Indian Heart Journal, vol. 70, no. 2, March 2018, pp. 323–325.