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Open Access Highly Accessed Research article

Ankle blood pressure as a predictor of total and cardiovascular mortality

Heikki Hietanen1, Rauni Pääkkönen2 and Veikko Salomaa2*

Author Affiliations

1 Helsinki Deaconess Institute, Alppikatu 2, Helsinki, Finland

2 KTL-National Public Health Institute, Mannerheimintie 166, FI-00300 Helsinki, Finland

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BMC Cardiovascular Disorders 2008, 8:3  doi:10.1186/1471-2261-8-3

Published: 12 February 2008



The ankle blood pressure is commonly used as a ratio to the brachial blood pressure, called ankle-brachial index (ABI). Very few studies have considered the independent value of the ankle blood pressure without indexing it to the brachial blood pressure. We examined the value of ankle blood pressure, together with the exercise blood pressure, as a predictor of cardiovascular (CVD) and total mortality.


A prospective follow-up study of 3,858 consecutive ambulatory patients (mean age 51 years, 65,9% male) referred to a symptom-limited exercise test between August 1989 and December 1995. The cohort was followed up for all-cause and CVD mortality until December 31, 2004, by record linkage with the National Causes-of-Death Register. The independent value of ankle blood pressure as a predictor of cardiovascular and total mortality was assessed using Cox proportional hazards modelling.


The average follow-up time was 14 years, during which 346 persons died, 108 of them due to CVD. Persons with normal (<140 mmHg) resting brachial blood pressure, ankle blood pressure < 175 mmHg and exercise blood pressure at moderate exercise level ≤215 mmHg at baseline investigation, had the best prognosis and were taken as the reference category. Among persons with elevated ankle blood pressure (≥175 mmHg) but normal or borderline resting brachial pressure and normal exercise blood pressure (≤215 mmHg) at moderate exercise level the multivariate-adjusted hazard ratios (HR, 95% confidence interval) for CVD and total mortality were 2.70 (1.52 – 4.80) and 2.13 (1.58 – 2.85), respectively. Similar and equally significant HRs were observed in persons with both elevated ankle blood pressure and elevated exercise blood pressure, as well as in those persons with elevated exercise blood pressure but ankle blood pressure < 175 mmHg.


These results suggest that the ankle blood pressure has an independent value as a marker of arterial stiffness or subclinical atherosclerosis and a risk of future mortality in middle-aged, asymptomatic persons.