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Open Access Highly Accessed Research article

Ankle-brachial index and the incidence of cardiovascular events in the Mediterranean low cardiovascular risk population ARTPER cohort

Maria Teresa Alzamora12*, Rosa Forés12, Guillem Pera2, Pere Torán2, Antonio Heras12, Marta Sorribes3, Jose Miguel Baena-Diez45, Magalí Urrea2, Judit Alegre1, María Viozquez6 and Carme Vela1

Author Affiliations

1 Primary Healthcare Centre Riu Nord-Riu Sud, Institut Català de la Salut, Santa Coloma de Gramenet, Spain

2 Unitat de Suport a la Recerca Metropolitana Nord, Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Santa Coloma de Gramenet, Spain

3 Primary Healthcare Centre Numància, Institut Català de la Salut, Barcelona, Spain

4 Primary Healthcare Centre La Marina, Institut Català de la Salut, Barcelona, Spain

5 Unitat de Suport a la Recerca de l’Àmbit de l’Atenció Primària de Barcelona Ciutat, Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain

6 Primary Healthcare Centre Singuerlín, Institut Català de la Salut, Santa Coloma de Gramenet, Spain

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BMC Cardiovascular Disorders 2013, 13:119  doi:10.1186/1471-2261-13-119

Published: 17 December 2013



Peripheral arterial disease (PAD) of the lower limbs is a cardiovascular disease highly prevalent particularly in the asymptomatic form. Its prevalence starts to be a concern in low coronary risk countries like Spain. Few studies have analyzed the relationship between ankle-brachial index (ABI) and cardiovascular morbi-mortality in low cardiovascular risk countries like Spain where we observe significant low incidence of ischemic heart diseases together with high prevalence of cardiovascular risk factors. The objective of this study is to determine the relationship between pathological ABI and incidence of cardiovascular events (coronary disease, cerebrovascular disease, symptomatic aneurism of abdominal aorta, vascular surgery) and death in the >49 year population-based cohort in Spain (ARTPER).


Baseline ABI was measured in 3,786 randomly selected patients from 28 Primary Health Centers in Barcelona, distributed as: ABI<0.9 peripheral arterial disease (PAD), ABI ≥1.4 arterial calcification (AC), ABI 0.9-1.4 healthy; and followed during 4 years.


3,307 subjects were included after excluding those with previous vascular events. Subjects with abnormal ABI were older with higher proportion of men, smokers and diabetics. 260 people presented cardiovascular events (incidence 2,117/100,000 person-years) and 124 died from any cause (incidence 978/100,000 person-years). PAD had two-fold greater risk of coronary disease (adjusted hazard ratio (HR) = 2.0, 95% confidence interval (CI) 1.3-3.2) and increased risk of vascular surgery (HR = 5.6, 95%CI 2.8-11.5) and mortality (HR = 1.8, 95%CI 1.4-2.5). AC increased twice risk of cerebrovascular events (HR = 1.9, 95%CI 1.0-3.5) with no relationship with ischemic heart disease.


PAD increases coronary disease risk and AC cerebrovascular disease risk in low cardiovascular risk Mediterranean population. ABI could be a useful tool to detect patients at risk in Primary Health Care.

Peripheral arterial disease; Ankle-brachial index; Cardiovascular diseases; Incidence; Primary health care; Cohort studies