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Assessment of Toe Blood Pressure Is an Effective Screening Method to Identify Diabetes Patients with Lower Extremity Arterial Disease.
Sahli D, Eliasson B, Svensson M, Blohme G, Eliasson M, Samuelsson P, Ojbrandt K, Eriksson JW.
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
As a podiatrist in Australia the non-invasive objective measurement of arterial supply both interests and frustrates me!
I've recently been using PPG to look at toe pressures. Although the interpretation of the digital artery waveform (there are no audible sounds) seems a little subjective I am now often finding low pressures in toes where an ABI/ankle systolic pressure may indicate a reasonable arterial supply. This appears to confirm my own (short) experience of doing ABI's on people with diabetes.
The concept of artery calcification in people with diabetes in not new but the general literature still seems to talk about the ABI as a reliable, easy to use tool. Toe pressures require more expensive equipment but is encouraging people to do ABI's on people with diabetes the right way to go? It seems to me that ABI's may be misleading when giving a prognosis on a wound, or trying to determine the risk a person is of having future problems.
Toe Blood Pressure To Identify Arterial Disease
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