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Levels of ankle–brachial index and the risk of diabetes mellitus complications
  1. Lia Alves-Cabratosa1,
  2. Marc Comas-Cufí1,
  3. Anna Ponjoan1,2,
  4. Maria Garcia-Gil1,
  5. Ruth Martí-Lluch1,2,
  6. Jordi Blanch1,
  7. Marc Elosua-Bayes1,
  8. Dídac Parramon1,3,
  9. Lourdes Camós1,3,
  10. Lidia Guzmán1,
  11. Rafel Ramos1,3
  1. 1ISV Girona, IDIAP Jordi Gol, Girona, Catalunya, Spain
  2. 2IDIBGI, Girona, Catalunya, Spain
  3. 3Primary Care Services, Catalan Institute of Health, Girona, Catalunya, Spain
  1. Correspondence to Dr Rafel Ramos; rramos.girona.ics{at}


Objective We sought to compare the association of categorized ankle–brachial index (ABI) with mortality and complications of diabetes in persons with no symptoms of peripheral arterial disease (PAD) and in primary cardiovascular disease prevention.

Research design and methods This is a retrospective cohort study of persons with type 2 diabetes aged 35–85 years, from 2006 to 2011. Data were obtained from the Sistema d'Informació per al Desenvolupament de la Investigació en Atenció Primària (SIDIAPQ). Participants had an ABI measurement that was classified into six categories. For each category of ABI, we assessed the incidence of mortality; macrovascular complications of diabetes: acute myocardial infarction (AMI), ischemic stroke, and a composite of these two; and microvascular complications of this metabolic condition: nephropathy, retinopathy, and neuropathy. We also estimated the HRs for these outcomes by ABI category using Cox proportional hazards models.

Results Data from 34 689 persons with type 2 diabetes were included. The mean age was 66.2; 51.5% were men; and the median follow-up was 6.0 years. The outcome with the highest incidence was nephropathy, with 24.4 cases per 1000 person-years in the reference category of 1.1≤ABI≤1.3. The incidences in this category for mortality and AMI were 15.4 and 4.1, respectively. In the Cox models, low ABI was associated with increased risk and was significant from ABI lower than 0.9; below this level, the risk kept increasing steeply. High ABI (over 1.3) was also associated with significant increased risk for most outcomes.

Conclusions The studied categories of ABI were associated with different risks of type 2 diabetes complications in persons asymptomatic for PAD, who were in primary cardiovascular prevention. These findings could be useful to optimize preventive interventions according to the ABI category in this population.

  • peripheral arterial disease
  • vascular complications
  • electronic patient records
  • primary care

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  • Contributors LA-C designed the research, researched data, interpreted the results, and wrote the manuscript. MC-C researched data, performed statistical analysis, interpreted the results, and reviewed/edited the manuscript. AP researched data, interpreted the results, and wrote the manuscript. MG-G designed the research, interpreted the results, and contributed to the discussion. RM-L researched data, and interpreted the results. JB researched data and performed statistical analysis. ME-B researched data and interpreted the results. DP interpreted the results and contributed to the discussion. LC contributed to the discussion. LG reviewed/edited the manuscript. RR designed the research, researched data, interpreted the results, and reviewed/edited the manuscript. RR and MG-G are the guarantors of this work and, as such, had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

  • Funding This project was supported by clinical research grants from Spain’s Health Ministry (ED10-83, EC10-84) and Science and Innovation Ministry (Carlos III Health Institute), cofinanced with European Union ERDF funds (Network for Prevention and Health Promotion in Primary Care, RedIAPP RD16/0007), and the Agency for Management of University and Research Grants (2014 SGR 902). The funding sources were not involved in study design; collection, analysis, and interpretation of data; report writing; or the decision to submit the article for publication. The authors take sole responsibility for the integrity of the data and the accuracy of the analysis.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Ethics approval to use SIDIAPQ data for observational research was obtained from the Ethics Committee for Clinical Research IDIAP Jordi Gol (P14/052).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No data are available. Data may be obtained from a third party and are not publicly available.