Assessment of Toe Blood Pressure Is an Effective Screening Method to Identify Diabetes Patients with Lower Extremity Arterial Disease

Abstract

The authors evaluated a screening program for lower extremity arterial disease (LEAD) in diabetic patients and focused on the value of toe blood pressure assessment. They recruited 437 subjects, ages 30-70 years (134 healthy controls, 166 type 1 and 137 type 2 diabetic patients; control [Ctr], DM1, and DM2) with no previous history of LEAD. They were enrolled in a longitudinal study with a planned follow-up of 10 years. Patients were consecutively enrolled from outpatient diabetes units of 2 university hospitals. Subjects were screened with respect to peripheral circulation by use of established noninvasive techniques. These included arm, ankle (AP), and toe (TP) blood pressure measurements; evaluation of peripheral neuropathy; and a standardized physical examination. Results from the baseline examination are presented in this report. The number of patients who presented peripheral pressures or indices below normal (< mean -2 SD for controls) was higher among diabetic patients; 24% of DM1 and 31% of DM2, as compared to 6% of Ctr, had at least 1 lower limb with a low TP, AP, toe/arm index (TI), or ankle/arm index (AI), and these subjects were mainly identified by using the toe/arm index. TI was independently and negatively associated with fasting blood glucose in both patient groups, and with smoking, age, and diabetes duration in DM1. The mean AP was higher in the DM1 and DM2 groups compared to Ctr, whereas overall TP, TI, and AI were similar in the groups. It was also shown that abnormally low TI was significantly more common than low AI among diabetics (p<0.001), and this was true for TP vs AP as well (p<0.05). It is beneficial to include assessment of toe blood pressure and toe/arm blood pressure index to detect early LEAD in diabetic patients. Ankle blood pressure and indices alone are less efficient, owing probably to medial sclerosis in diabetic patients. Up to 30% of diabetic patients with no ischemic symptoms may have signs of impaired arterial circulation.

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References

Boulton AJM , Connor H , Cavanagh PR (eds): The Foot in Diabetes, ed. 2. Chichester, UK: John Wiley & Sons Ltd, 2001, pp 1-388.

Graves EJ : National Center for Health Statistics: National Hospital Discharge Survey: Annual Summary, 1990. Vital and Health Statistics, Series 13, 1992.

Apelqvist J , Ragnarson-Tennvall G , Persson U , et al : Diabetic foot ulcers in a multidisciplinary setting. An economic analysis of primary healing and healing with amputation. J Intern Med 235:463-471, 1994.

Larsson J , Apelqvist J , Agardh CD , et al : Decreasing incidence of major amputation in diabetic patients: A consequence of a multidisciplinary foot care team approach? Diabet Med 12:770-776, 1995.

Samuelsson P , Blohmé G , Fowelin J , et al : A new non-invasive method using pulse oximetry for the assessment of arterial toe pressure. Clin Physiol 16:463-467, 1996.

The DCCT Group : The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependant diabetes mellitus. N Engl J Med 329:977-986, 1993.

UK Prospective Diabetes Study (UKPDS) Group : Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 352:837-853, 1998.

Jorneskog G , Brismar K , Fagrell B: Skin capillary circulation severely impaired in toes of patients with IDDM, with and without late diabetic complications. Diabetologia 38:474-480, 1995.

Jorneskog G , Brismar K , Fagrell B: Skin capillary circulation is more impaired in the toes of diabetic than non-diabetic patients with peripheral vascular disease. Diabet Med 12:36-41, 1995.

10.

Kalani M , Brismar K , Fagrell B , et al : Transcutaneous oxygen tension and toe blood pressure as predictors for outcome of diabetic foot ulcers. Diabetes Care 22:147-151, 1999.

11.

Flynn MD , Tooke JE: Aetiology of diabetic foot ulceration: A role for the microcirculation? Diabet Med 9:320-329, 1992.

12.

Niskanen L , Siitonen O , Suhonen M , et al : Medial artery calcification predicts cardiovascular mortality in patients with NIDDM. Diabetes Care 17:1252-1256, 1994.

13.

Goebel FD , Fuessl HS: Monckeberg’s sclerosis after sympathetic denervation in diabetic and non-diabetic subjects, Diabetologia 24:347-350, 1983.

14.

Shanahan CM , Proudfoot D , Farzaneh-Far A , et al : The role of Gla proteins in vascular calcification. Crit Rev Eukaryot Gene Expr 8:357-375, 1998.

15.

Brooks B , Dean R , Patel S , et al : TBI or not TBI: That is the question. Is it better to measure toe pressure than ankle pressure in diabetic patients? Diabet Med 18:528-532, 2001.

16.

Johansson KE , Marklund BR , Fowelin JH: Evaluation of a new screening method for detecting peripheral arterial disease in a primary health care population of patients with diabetes mellitus. Diabet Med 19:307-310, 2002.

17.

Okumura KI , Yoshimasa A , Wakabayashi S , et al : Markers of vascular inflammation are more strongly associated with toe brachial index than with ankle brachial index in patients with type 2 diabetes (abstract). Diabetes 52(suppl 1):A163, 2003.

18.

Kalogeropoulou K , Mortzos G , Migdalis I , et al : Carotid atherosclerosis in type 2 diabetes mellitus: Potential of endothelin-1, lipoperoxides, and prostacyclin. Angiology 53:279-285, 2002.