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Ankle–Brachial Index Remains the Most Powerful Tool for Peripheral Arterial Disease Detection in Epidemiological Studies

We thank Balta S et al for their letter regarding our study. In fact, the ankle–brachial index (ABI) is the most recognizable powerful diagnostic tool for peripheral arterial disease (PAD). The ABI has been used in several epidemiological studies such as The Edinburgh Artery Study, The Rotterdam Study, and the European Stroke Organization, for the identification of PAD in symptomatic and asymptomatic patients. Therefore, we chose to use it in our study as it is easy to perform and gives a clear interpretation; and for this reason, it is the most commonly acceptable diagnostic examination for epidemiological purposes. The use of other investigations such as photoplethysmography and continuous wave Doppler ultrasound may be useful as complementary to ABI investigations, but using all of them may result in a significant loss of time and funds. Other markers such as C-reactive protein can be used for specific aims but not necessarily within the context of all general epidemiological studies. We accept that using only ABI may not help in recognizing PAD in some asymptomatic individuals; but this does not undermine the strong message of our work that PAD is prevalent but underdiagnosed and undertreated. As it has been reported, a resting ABI < 0.9 is used for the PAD diagnosis, and it is a strong predictor of future cardiovascular events. What in fact matters in epidemiological perspectives is to have a simple and strong factor to screen for PAD at a population scale, and ABI has been used in this way in most algorithms proposed for such purpose. With respect to the risk factors present in our population, table 2 displays the data not only for the total population but also for some groups of them. The relationship of ABI < 0.9 and > 1.4 with the health individuals can be seen in the last two columns of the table 2 of our article. Compared to larger epidemiological studies, the relatively small number of individuals and patients included in our study did not allow detailed statistical analysis in order to obtain any powerful relationship between the risk factors and the ABI. We expect to provide such analysis when we accomplish another epidemiological study on PAD, which is run in parallel to our abdominal aortic aneurysm screening program.