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General ReviewMeasurement, Calculation, and NormalRange of the Ankle-Arm Index: ABibliometric Analysis and Recommendationfor StandardizationSteven Hein, M D , a n d J . Joris Haye, MD, PhD, Amster dam, The Netherlands

Since its introduction in 1950, a variety of methods of measurement and calculation have beenused to establish the ankle-arm index (AAI). This has resulted in variations of its normal rangeand difficulty in comparing study results. Hence, the objective of our study was to analyze thedisparate methods used to assess AAI and its normal range and to recommend a standardizedmethod to assess AAI based on that analysis. We made an inventory of the disparate AAImethods and its normal range reported in 100 randomly selected publications and recommendthe means of such standardization. We recommend that an experienced observer assess AAIwith the patient at rest in the supine position. The width of the sphygmometer cuffs should be 1.5times that of the extremity to be measured, and brachial and crural pulses should be detectedusing a Doppler device. Systolic pressures should be measured at both arms and over theanterior and posterior arteries of both legs, with the cuff placed just proximally to the malleoli.The left arm pressure ought to be used as denominator and the mean of pressuresof both cruralarteries of each leg ought to be used for the numerator of the AAI for that leg. We advocate 0.90as the cut-off value to distinguish patients who need further arterial assessment.

INTRODUCTIONThe an kle -am index (AAI ) is the ratio of systolicblood pressure at the level of the ankle to that atthe level of the arm. Because this noninvasivemethod is simple, reproducible,- and accurate atdetecting the decreased blood pressure distal to anarterial s ten~sis ,~.~t is often used to assessperipheral arterial occlusive disease ( PAOD) . Sincethe introduction of the concept of the AAI byWinsor, in 195O1 and its popularization by Yao

Section of Surgical Disciplines, A n tm i van Leeuwenhoek H ospiral,Amsterdam, The Netherlands.Correspondence to: J . Joris Hage, M D , PhD, Section of SurgicalDisciplines, Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, N L -1066 CX, Amsterdam, Th e Netherlands, E -ma il: [email protected]

An n Vasc Surg 2006; 20: 282-292DOI: 10.1OO 7 l s i0016-006-9019 -x0 nnals of Vascular Surgery Inc.Published online : March 23. 2006

et al. in 1969, a wide variety of methods of AAImeasurement and calculation have been used instudies on its diagnostic and epidemiological value.Use of these nonuniform and nonstandardizedmethods has resulted in variations of reportedlynormal versus abnormal distribution of AAI.This results in confusion and hampers adequatecomparison of results from one study to another.Moreover, i t prohibits the development of an evi-dence-based diagnostic approach. Therefore, theobjective of our study was to make an analysis ofthe disparate methods used to assess AAI and itsnormal range and LO recommend a standardizedmethod to assess AAI based on that analysis.MATERIALS A ND METHODSSelection of 100 Publications on AAIOur method of bibliornetric analysis has been pre-viously tried and described.12 Briefly, it seeks to

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reproducibly trace and analyze publications on acertain topic, in this case the methodology of AAIassessment. To do so, we considered all originalstudies and reviews indexed in Pubmed or themedical library of the University of Amsterdam,The Netherlands, that featured the term ankle-armindex or ankle-brachial index in the abstract forinclusion in our analysis. Using the Pubmed searchengine (http: /www.ncbi.nlm.nih.gov/ accessedNovember 18, 2004) and the search engine of themedical library, 812 medical journal articles and 32book chapters were traced. As our purpose was toreview the variation of techniques of AAI assess-ment rather than to calculate quantitative esti-

Whenever th e methodology of any of the 11scored items was not indicated in the text of thepublication, the references provided by the au-thor(s) were searched for such an indication. Still,when authors described the methods they had usedand referred to other studies to motivate theirchoice of method, we did not check whether thedescribed method corresponded with the reportedsource method.

RESULTSInformation on Patient Position duringAssessment of AAI

mates of the outcome of these assessments, weused simple random sampling to select 100 publi-cations that mentioned use of AAI as the method todistinguish PAOD.13 Doing so , we came across 13publications that neither mentioned what methodshad been used to assess and calculate the AAI norreferred to any other report to provide any indi-cation as to what method was used. Hence, these13 publications were excluded, and instead, 13other publications were randomly selected.

In 60 of the 100 analyzed reports, the supine po-sition was mentioned as the position used to rnea-sure the brachial and crural blood pressures. Only areference to other studies indicated the position innine of the other 40 reports. Still, two of these ninereferences failed to mention this position. Theremaining 31 reports offered neither informationon the position of the patient nor a reference toindicate this position.

Assessment of Data from the PublicationsThe 100 publications were systematically analyzedfor indications as to what method of AAI assessmenthad been used by the author(s) .As such, we scoredon 11 key points of measurement and calculation.Apart from data provided in each publication on (1)the position of the patient during measurement, wenoted information on (2 ) he width of the cuff of thesphygmometer used for the arm, (3 ) the width ofthe cuff of the sphygmometer used for the lower leg,(4) the level of placement of this cuff on the lowerleg, ( 5 ) the method of detection of the pulse in thearm, (6) the method of detection of crural pulses,(7) whether or not the brachial pressure was mea-sured bilaterally, (8) whether or not crural pres-sures were measured bilaterally, (9) which of thecrural pulses were assessed to calculate the AAI(anterior tibial, posterior tibial, or peroneal), (10)which of the brachial and crural pressures wereused for the AAI denominator and numerator, and(11) the cut-off value for the normal AAI. To notfurther complicate the grouping of various ranges ofdistribution of normal AAI, o difference was madebetween lower than ( ) and equal to or lowerthan ( 5 ) or between higher than (>) andequal to or higher than (2). ikewise, no atten-tion was paid to the mean and range indicated forthe different stages of PAOD because we did notintend to describe these stages.

Information on Sphygmometer Cuff WidthUsed to Assess Brachial Blood PressureWhile describing the method of AAI measurement,a single largest group of 56 (groups of) authors didnot provide any information as to the size of the cuffthat was used to assess the brachial blood pressure.

Twenty-one (groups of) authors stipulated whatsize of cuff was used, and of these, nine used a cuffof 12 cm,3,4,14-20 two a cuff of 13 cm,21,22wo a cuffof 14 cm,23r24 nd three a cuff of 15 cm.25-27Oneauthor measured the circumference of the arm todetermine the proper cuff width,28 and a cuff of 1.5times the diameter of the arm was used in two

One group of authors used either a 14or a 17 cm cuff, depending on the size of the pa-tients arm. The one remaining of these 21 (groupsof) authors reported using a pediatric cuff (8cm) toassess AAI in ~hildren.~

In 10 studies, the cuff size was reported to havebeen appropriate or carefully ~ e l e c t e d , ~ ~ - ~ whereas a standard cuff was reportedly used infive.41-45 ight (groups of) a ~ t h o r s ~ , ~ ~ , ~ ~ - ~ ~eferredto other studies for their method of AAI assess-ment, but in seven of these references, no infor-mation on cuff size was provided either.Information on Sphygmometer Cuff WidthUsed to Assess Crural Blood PressureA majority of 5 2 (groups of) authors did not pro-vide any information as to the size of the cuff used


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V o l . 20, No. 2, 2006 Ank le-arm index revisited 28 5

Table I. The 100 publications that were studied divided according to the information provided on thecrural pulses used to assess AAI numeratorDescription Number of reportsPT and DPIAT = ~~2,4,14,16,17,20,28,31,33-35,37,39,4O,46,53-55,62,65,74-76,78,82,93-lOOPT, DP/AT, and PAEYT or DPlATPT only"Ankle"N o informationReferences for method

= 327.101.102= 2 ~3,7,19,24.29.30,36.41,43.56,66,67,69.73,77,79,8 .90.103- 107= 13 1,6,22,23,32,38,58-60.71.72.85.108= 1 5.10.1 1,18,21,25,26,42,44,45,57,61,63,64,68,70,80,109= 315.84.110= 79.47-52

of the bilateral blood pressures to determine thepresence of PAOD in their patients. Shinozaki etal.23and Zheng et al.32reported diagnosing PAODby measuring the AAI of just one leg. Two authorsdid not provide any information about whetherone or two legs were measured.75r76Information on Which Crural Pulses Wer eAssessed for AAIIn 33 studies, both the pressures over the posteriortibial artery (PT) and the dorsal pedal or anteriortibial artery (DP/AT) were measured before calcu-lating AA I (Table I) . The peroneal artery (PA) pulsewas assessed in addition to that of the PT and DP/AT in three studies. Twenty-three studies recom-mended using the pressures over the PT or DP/ATfor the numerator of t he AM. Three of these 2 3advocated use of the best audible flowIn 13 studies, the crural pulse was detected only atthe PT.

No specification of the crural artery other than"ankle" was provided to indicate which of thecrural or pedal pulses were detected in 18 reports.In 10 of these 18 reports, this remained unclearbecause of the method used for crural pulsedetection (strain-gauge, plethysmography, capaci-tance pulse pick-up, spectroscopy, visual flush

Three reports did not clarify which pedal arterywas used to detect the crural pressure, whereasseven (groups of) authors referred to other studiesfor their method of AAI assessment. Two of theseseven references merely mentioned "ankle" as thelocation of pulse detection.

technique, or D ~ ~ ~ ~ ~ ~ )10,18.21.25,26,56.57.61.63,6,64

Information on Which of the Brachial andCrural Pressures (Highest, Mean, Median, orLowest) Were Used for Denominator andNumerator of AAIN o fewer than 39 different ways to calculate AAIwere reported in 77 of the 100 studies. Amongthese, the formulas provided most often were as

follows: AAI = highest of PT and DPlAT pressures/highest arm pressure (n= IS), AAI = ankle pres-surelarm pressure (n= 9) , and AAI = PT or DPIATpressure/arm pressure ( n = 8). Seven times wefound the same (group of) author(s) to have usedtwo different formulas in two different stud-ies~19,25,26,28,37,55,56,60,72,77-81 Confusing matterseven further, some authors used more than oneformula in a single s t ~ d y . ~ ~ , ~ ~ ~ ~ ~

The remaining 23 (groups of) authors did notreport the formula they had used to calculate theAAI. Eight of these 2 3 provided a reference for theformula, whereas 15 did not.Of the 47 (groups of) authors who measuredsystolic pressure at both arms, the highest pressurefound was used for the denominator of the AAI in38 studies, whereas the mean of both arm pressureswas used in 11 studies. This totals 49 rarher than 47studies because Hiatt et al. twice compared twodifferent ways of calculating the denominator.28r78The lowest pressure of both arms was never re-ported to have been used as denominator.

Seven (groups of) authors used both the PT andthe DPlAT for the numerator of separate

Twenty-nine more (groups of) authors usedmore than one detected pressure for the definitecalculation of the numerator. In 2 3 of these 29studies, the highest of the two or three crural bloodpressures was used for the numerator, whereas thelower was used in the five and the mean of thosepressures in four. Again, this totals 32 rather than29 studies because Hiatt et a1.28 compared twomethods (average and lower) while McGraeMcDermott et aL31 compared three methods(average, higher, and lower) to calculate thenumerator of the AAI.

*,qs.2, 14,20,33,34,78,82

Cut-off Value of the Normal AAISome (groups of) authors defined a lower limit ofAAI for the absence of PAOD, whereas othersprovided an upper limit felt to be indicative of the


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Table 11. Reports categorized according to information provided on the lower limits of the range of AAI insubjects without PAODCut-off value Number of reportsAAI = 0.85 n = 174

n = 1"'= 1720,31,32,34,36,40.45,46.53.60.67-9.71.77.97.98AAI = 0.90AAI = 0.92

AAI = 0.95AAI = 0.97AAI = 1.10 = 259.80

II = 61,81,82,84,103.104= 34.9 .55

7,10,11,16.18,19.21-23,29.38,39,41,42,54.56,66.70.72,7~,75,80,99-101.1O5.1O6.108AAI = 1.00 n = 28

presence of PAOD. Still others considered these twocut-off values to be the same, thus defining oneAAI below which PAOD was accepted to be presentand above which it was not.

The lower cut-off value of a normal AAI as of-fered in 58 of the 100 studies varied from 0.85 to1.10, but most often, 1.00 was cited for this (Ta-ble 11).

Eight different upper AAI limits indicative ofPAOD were cited in 60 of the 100 studies. Althoughthese varied from 0.80 to 1.00 (Table HI), 0.90 wasmost often used as this cut-off value.

Rather than one cut-off value, Lennihan andMacKereth& cited median AAI values for subjectswith and without claudication. Eighteen reportsmentioned the method of assessment but lackedany information on its normal or abnormal limits.Three additional (groups of) authors provided ref-erences for information on theseNeither a description nor a reference was found inone s t~ d y . ' ~

COMMENTS AND RECOMMENDATIONSAlthough AAI assessment currently is the mostcommon diagnostic instrument for the detectionand quantification of PAOD,33,7734 the repeatabil-ity of assessment continues to be subject to con-trovers y.2,33377,83~'5,86 The variability of AAIassessment attributable to observers, timing ofmeasurement, and repeated measures is consider-ably less than that attributable to biological factors.Estimates of intraobserver variability range from7.3% for experienced observers to 12% for less-experienced observer^,^,^, 19r'7 and repeatedmeasurements may decrease this ~ariability.~,'~Standardized, repeated measurement of AAI byexperienced observers is sufficiently accurate toguide clinical decision m a k i r ~ g . ~ ~ , ~ ~hen the artand science of AA I measurement and calculationare being taught or discussed, moreover, it isimportant that all involved are speaking of the

same standard. Even when limited to 100 publi-cations, however, our bibliometric analysis yieldeda great variety of methodology. This indicates thatthere is still need for a consensus on the method ofAAI measurement.

Before we present our recommendations tocome to such consensus, some potential limitationsof our study need to be addressed. As such, westress that ours are not evidence-based suggestions.Because of the variety of methodology, any and allof such suggestions would lack an adequate level ofevidence. Furthermore, we did not score for po-tential key points such as minimum resting timeprior to measurement, room temperature, or fre-quency of Doppler probe since these were rarelymentioned in the 100 reviewed publications.Hence, ours are merely recommendations providedin an attempt at the standardization that is urgentlyneeded to allow comparison and meta-analysis offuture study results.Position of the Patient during MeasurementThe supine position seems to be the position ofchoice to assess AAI because the influence of heightof the subject and his or her blood column pressureon AAI may be prevented only in this position. Lessagreement exists on the routine use of premea-surement exercise. Such exercise may be neededsince the ankle pressure may be normal at rest inpatients with mild PAOD and there may be ade-quate collateral flow around the arterial occlu-sions.' Even though such PAOD may only bedetectable after exercise, exercise influences theheart rate during measurement, which in turninfluences AAI.25 Hence, in studies where AAI ismeasured during exercise, this should be men-tioned in the Melhods section.Width and Level of the SphygmometerIf the width of the sphygmometer cuff is too nar-row in comparison to the extremity ("undercuff-

Cuff@)


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Table In. Reports categorized according to information provided on the upper limits of the range of AAI insubjects with PAODDescription Number of reportsAAI = 0.80AAI = 0.85AAI = 0.90AAI = 0.92AAI = 0.94AAI = 0.95AAI = 0.97AAI = 1.00

ing), the blood pressure reading will be errone-ously high, whereas the reading may be too low ifthe cuff is too wide (overcuffing).88 deally, thecuff width should be at least 1.5 times the diameterof that part of the extremity where the pressure isbeing rn ea s~ re d, ~nd the size of the cuff should beadjusted in obese patients or in patients with odd-shaped arms or ankles.88 Still, calcification in thearterial wall can result in spuriously high readingsof the systolic pressure,7t29 nd this may not becorrected by the use of a wider cuff.

As to the position of the cuffs at the extremities,general agreement exists on placement just proxi-mal to the elbow on the upper arm and just prox-imal to the malleoli at the lower leg.

Method of Detection of the Pulse in the Armand LegFrom their comparison of three methods of mea-surement of brachial systolic blood pressure, Jee-lani et aL15 concluded that the technique ofmeasurement significantly affects the calculation ofAAI. As they found a 20% margin of error, theseauthors advocated the use of just one technique tolimit inter- and intraobserver errors. For this, use ofa pencil-Doppler should be considered the methodof choice to detect the brachial pulse as this wasalready done in half of the reviewed studies.Measurements by Doppler device were proven athigh, medium, and low blood pressures to correlatewith systolic pressure measurement obtained byconventional methods. o,

observed good agreement between thevalues of systolic blood pressure obtained by fourdifferent methods of monitoring the crural pulses(pulse pick-ups, pencil-Doppler flow detection,spectroscopy, and visual flush), and capacitancepulse pick-up even allows for detection of nonpal-pable pulse^.^ Still, allegedly normal crural bloodpressures can be recorded with pulse pick-up, spec-troscopic, and visual flush methods as long as only

one crural artery is patent, whereas the pencil-Doppler may provide information on individualtibia1 Pencil-Doppler readings are highlycorrelated to intra-arterial pressure reading^.^,'^Moreover, ultrasonography is less cumbersome thanplethysmography and more reliable than the aus-cultation method, which has a 10% failure rate inobtaining ankle pressures in normal individ~als.~Although the accuracy of measurement with theDynamap may be higher than that with pencil-Doppler, the Dynamap is not available everywhere.For this reason, we recommend the pencil-Dopplerdevice as the standard instrument to measure boththe brachial and crural blood pressures.Whether or Not to Bilaterally Measure theBrachial Pressure and Which One to Use forDenominatorA majority of authors measured the systolic pres-sures of both arms to assess the denominator of theAAI.A minority measured only one arm, and ofthese, only one indicated using the left arm. Thisis remarkable as the blood pressure used for thedenominator of the AAI should be measured at theleft arm in cases where aortic coarctation results ina difference of blood pressure in the right and left

In these cases, a difference of 5-10 mmHg warrants further examination, while a differ-ence of 20 mm Hg between the arms indicates se-vere stenosis. In general, AAI calculated on thebasis of systolic pressure at the left arm was 0.02lower than that at the right arm.78 For these rea-sons, we advise taking the blood pressure at botharms to rule out serious differences and using thatof the left arm to calculate the AAI denominator.

arms.28.3 .36

Whether or not to Bilaterally Measure CruralPressures and Which of These to Use asNumeratorIn the healthy population, the differences betweenthe systolic pressures of the DP/AT and PT do not


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288 Klein and Hage Annals of Vascular Surgery

exceed 10 mm Hg.55 n general, the AAI at the DPIAT was found to be 0.04 lower than that at thePT.7s PAOD may, however, separately affect eachof the main arteries, and a difference of over 15mm Hg between the DPfAT and the PT may pro-vide a useful clue about the involvement of theindividual crural arteries by the occlusive pro-c e s ~ . ~ ~

Difference in pressure readings between the DP/AT and PT in the same limb, as well as an abnormalAAI of both the DP/AT and PT in the same leg,should be considered indicative of PAOD.8*55 e-cause PAOD may also affect both legs separately,moreover, we advise bilaterally measuring theblood pressure of both the DPIAT and the PT.How to Calculate the AAI Numerator andDenominatorNumerator. McGrae McDermott et a1.3 per-formed a multiple linear analysis to identify whichone out of three commonly used formulas to cal-culate the AAI was most closely associated withobjective measures of leg functioning in PAOD:AAI = highest of DPIAT and PT/mean of both arms,AAI = mean of DP/AT and PT/mean of both arms,and AAI = lowest of DP/ AT and PT/mean of botharms.

The prevalence of PAOD, defined as an AAI 0.9,ranged from a minimum of 47% when the firstformula was used to a maximum of 59% when thethird was used.3 In cases where the right and leftlegs showed a difference of AAI, the lowest of thesecorrelated best with leg functioning. Moreover, thelower AAI determined by mean of DP/AT and FT/mean both radial artery was most predictive ofwalking endurance and walking velocity in cases ofPAOD. The authors offered two potential explana-tions for the finding that using the mean of the DP/AT and PT systolic pressures is the optimal way tocalculate AAI when assessing lower extremityfunctioning.

First, the mean of DP/AT and PT may best reflecttotal perfusion of the more diseased lowerextremity and, second, when the two pressures areaveraged, the random variation and measurementerror intrinsic to measures of arterial pressure areminimized, the result being a closer association ofthe mean AAI with f ~ n c t i o n i n g . ~ ~iatt etused two ways to calculate the numerator of theM I . Since the difference in systolic blood pressurebetween the DP/AT and PT was found to have a95% range of -21 to + I 0 mm Hg, the mean of PTand DP/AT was used if PT and DPIAT differed nomore than -21 to +10 mm Hg. Alternatively, the

lower of PT and DPIAT was used if PT and DP/ATdiffered more than -21 to +10 mm Hg.

Since AAI may indicate the presence and, morevaguely, the severity of PAOD without a highsensitivity or specificity, only one standardizedformula should be used to calculate it. This maykeep its use simple and reproducible in varyinghospital and general practice settings. We stronglyadvise against calculating AAI separately for eachlower leg artery since the sensitivity and specificityof the AAI for detecting PAOD per artery is evenlower.92 Still, a large difference in pressure readingsbetween the DPIAT and PT in the same limb shouldbe considered indicative of PAOD.s,55Hence, weadvise calculating AAI for each leg by measuringthe systolic pressures over both DP/AT and PT andusing their mean for the numerator as this reducesthe measurement bias and gives a good impressionof the total lower leg perfusion. Bias can further bereduced by measuring the AAl twice per leg andusing the mean of both measurements for thenumerator.Denominator. Furthermore, Hiatt et al.28878advised using the mean of both arms for thedenominator in cases where the difference in sys-tolic blood pressure between the right and left armsdid not exceed the 95% range of -9 to +8 mm Hg.Alternatively, they advised using the higher ofboth arms for this if the brachial pressure of botharms differed more than -9 to +8 mm Hg becausethey assumed that there might be an arterialocclusion on one side causing the

For reasons of simplicity, we advise measuringthe systolic pressures of both arms to detect possiblepressure differences indicating aortic coarctation orbrachial arterial stenosis. Because the systolicpressure perfusing the body distal of the run-off ofthe left subclavian artery is equal to that in the leftarm, the left brachial systolic pressure should beused for the denominator, provided no brachialarterial stenosis is found. Isolated stenosis of the leftsubclavian artery, however, is very rare; and thechance of having a left subclavian stenosis withoutlower extremity involvement can be considerednaught.

In short, we advice calculating AAI separatelyfor each leg and using the formula AAI = mean ofDPIAT and PT/left brachial artery.Cut-off Value of the Normal AAIThe lower cut-off point of the normal AAI indica-tive of the absence of PAOD may importantly differfrom the upper cut-off point of an aberrant AAIindicating the presence of PAOD (Tables T and 111).


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Typically, the AAI cut-off value for presence ofdisease has been defined between 0.90 and0.80,60,74but it is obvious that there is - not in theleast due to differences in methods of AAI mea-surement - no one fixed cut-off point indicatingthe absence or presence of PAOD.

Varying the cut-off AAI may triple the sensitivityof the test4,25and double the estimates of PAODp r e v a ~ e n c e . ~ ~ , ~ ' , ~ ~iatt et aL7' included an exten-sive table of lower limits of the normal range sub-divided for the left and right legs, the PT and DP,and the two sexes; and some (groups of) authorseven included estimations on the probability ofPAOD for a given AAI.54r63 till, such differentia-tion is hardly applicable in daily clinical practice.

The sensitivity and specificity of AAI cut-offvalues to detect PAOD are 96% or higher whenusing arteriography as the gold standard,24 andsubjects with a resting M I of 0.94 or higher haveno arteriographic evidence of PAOD.4r24r55found 95% of patients without PAOD to have AAIof 0.97 or higher, whereas all of his patients witharteriographically proven PAOD had AAI lowerthan that.

We recommend that 0.9 be accepted as the up-per limit of an aberrant AAI and 1.0 as the lowerlimit of a normal AAI. An AAI between 0.9 and 1.0seems to be not conclusive and should lead tofurther assessment. Future investigators shouldstate what AAI value was used as a cut-off pointsince the sensitivity of the AAI for the presence ofPAOD depends on this.

To summarize, we feel that AAI reported in sci-entific work should be assessed by experiencedobservers. Assessment of AAI at rest in the supineposition is acceptable as the standard procedure.Different sphygmometer cuffs ought to be used forthe arms and legs, both of which should have awidth of 1.5 that of the extremity at the level ofmeasurement. The cuff should be placed justproximal to the malleoli to assess crural bloodpressures. A handheld pencil-Doppler device oughtto be used for measurement of both the brachialand crural blood pressures. Measurements shouldbe performed at both arms and over the DPlAT andPT of both legs, but the left arm pressure is pre-ferred for use as the denominator. The mean of thesystolic pressures of the DP/AT and the PT ought tobe used for the numerator of the AAI for that leg.However, difference in pressure readings betweenthe DP/AT and PT in the same limb should beconsidered indicative of PAOD. Measurement biasis further reduced by measuring AAI twice per legand using the mean of the two measurements. Werecommend accepting 0.9 as the upper limit of an

aberrant AAI and further assessing the arterialstatus of all patients with an AAI between 0.9 and1 o.

To allow for comparison of results from oneinvestigator to another without tremendous varia-tions due to the different methods of assessment,we urge future investigators to adhere to theserecommendations or to mention the circumstancesor methods of assessment and calculation of AAI inthe Method section of their report in cases wherethese differ from those recommended. In thesecases, information on why the authors felt it betterto use an alternative method may further enhancethe possibilities of comparison with reports fromother research groups.

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