A multicenter study on the diagnostic value of ankle brachial index combined with pulse volume wave parameters for peripheral arterial disease

Abstract

Objective: To evaluate the significance of incorporating all pulse volume wave parameters, such as the inter-arm systolic blood pressure disparity, inter-leg systolic blood pressure difference, proportion of mean arterial pressure, and upstroke time, into the ankle-brachial index for the detection of peripheral arterial disease.

Methods: This multicenter cross-sectional investigation, conducted across five tertiary medical institutions, enrolled 1,156 participants. Hemodynamic parameters including blood pressure and pulse volume were systematically assessed utilizing an OMRON BP-203RPEIII arterial stiffness analyzer. All four extremities were evaluated in a simultaneous manner under strictly standardized conditions. PAD diagnosis was established by fulfilling one of the predefined criteria: ankle-brachial index (ABI) ≤ 0.9, inter-arm systolic blood pressure disparity (IASBPD) ≥ 10 mmHg, or inter-leg systolic blood pressure divergence (ILSBPD) ≥ 15 mmHg. Diagnostic efficacy was evaluated via receiver operating characteristic curve analysis. Multivariate logistic regression was employed to determine the independent predictive utility of individual or composite parameters.

Results: Integrated diagnostic model demonstrated superior discrimination performance in differentiating PAD patients from non-PAD individuals (AUC = 0.924, 95% CI: 0.908-0.940) compared with individual parameters analysis: ABI (AUC = 0.892, 95% CI: 0.872-0.912), ILSBPD (AUC = 0.846, 95% CI: 0.824-0.868), and %MAP (AUC = 0.834, 95% CI: 0.812-0.856). Multivariate logistic regression analysis of all parameters revealed significant independent association with PAD diagnosis. Specifically, ILSBPD exhibited the strongest positive correlation (OR = 1.82, 95% CI: 1.56-2.12, p < 0.001), followed by %MAP (OR = 1.76, 95% CI: 1.48-2.08, p < 0.001). Subgroup analyses identified augmented diagnostic value in patients over 75 years and with diffuse arterial disease. Composite model achieved optimal diagnostic metrics of 88.6% sensitivity and 85.4% specificity.

Conclusions: Integration of ABI with pulse volume wave parameter improved PAD diagnostic accuracy significantly. Quantitative PVR metrics provides objective assessment of peripheral arteries, effectively mitigating limitations of conventional modalities. Automated measurements with predefined thresholds ensure clinical applicability. This approach enhances the clinical utility of a multi-parameter diagnostic strategy applicable across both specialized vascular laboratories and primary care settings, thereby enhancing the precision of PAD detection.

Keywords: ankle-brachial index; arterial stiffness; blood pressure measurement; cardiovascular risk assessment; inter-leg systolic blood pressure difference; peripheral arterial disease; pulse volume recording; vascular diagnosis.

Figure 1

Research workflow diagram.

Figure 2

ROC curves for individual and combined parameters in PAD diagnosis. (A) ROC curves for individual parameters: ABI (red), IASBPD (blue), ILSBPD (green), %MAP (purple), and UT (orange). (B) ROC curve for the combined diagnostic model incorporating all parameters. The diagonal dashed line represents the line of no discrimination.

Figure 3

Regression analysis results for PAD diagnosis. (A) Forest plot showing odds ratios with 95% confidence intervals for each parameter in the multivariate model. (B) Predicted probability curve showing the relationship between ABI values and PAD probability based on the logistic regression model”.

Figure 4

Stratified analysis of diagnostic parameters. (A) Gender-specific analysis showing diagnostic performance in males and females. (B) Age-stratified analysis comparing diagnostic accuracy across age groups. (C) Analysis by stenosis pattern demonstrating parameter performance in different disease presentations. Error bars represent 95% confidence intervals”.

Figure 5

ROC curves for stratified analysis of cardiovascular disease-related parameters in PAD diagnosis. (A) ROC curves for individual parameters: ABI (green), IASBPD (blue), ILSBPD (orange), %MAP (red), and UT (purple) stratified by Anamnestic myocardial infarction (MI). (B) ROC curve for the individual parameters stratified by Atrial fibrillation (AF). (C) ROC curve for the individual parameters stratified by Ischemic stroke. The dashed line represents not having the cardiovascular disease while the solid line represents having the disease.