Ankle-Brachial Index as a Predictor of Cardiovascular and Cerebrovascular Events in Hypertension: A Systematic Review

Hoda  Borooghani; Kiana  Orangi; Parmida Bagher  Zadi; Hoda  Asefi; Mohsen  Arabi

doi:10.18502/jthc.v21i1.21284

Hoda Borooghani School of Medicine, Iran University of Medical Sciences, Tehran, Iran.
Kiana Orangi School of Medicine, Iran University of Medical Sciences, Tehran, Iran.
Parmida Bagher Zadi School of Medicine, Iran University of Medical Sciences, Tehran, Iran.
Hoda Asefi Assistant Professor of Radiology, Department of Radiology, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran.
Mohsen Arabi Preventive Medicine and Public Health Research Center, Psychosocial Health Research Institute, Department of Community and Family Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran.

DOI: https://doi.org/10.18502/jthc.v21i1.21284

Keywords: Hypertension; Ankle–Brachial Index (ABI); Cardiovascular Risk; Cerebrovascular Events; Peripheral Artery Disease (PAD); Stroke; Myocardial Infarction

Abstract

Objectives: Hypertension is a major cause of cardiovascular and cerebrovascular morbidity and mortality worldwide. The ankle-brachial index (ABI) is a simple, noninvasive test usually used for peripheral artery disease detection, but its prognostic value in hypertensive patients is still poorly defined. In this study, we sought to systematically review the relationship between abnormal ABI values and cardiovascular and cerebrovascular events in adults with hypertension.

Methods: A systematic literature search was conducted in PubMed, Scopus, and Web of Science up to March 2025 for observational studies evaluating ABI in hypertensive populations. Studies were included if they stratified outcomes by ABI categories and reported at least one cardiovascular or cerebrovascular outcome. Data on study design, population characteristics, measurement and cutoff values of ABI, outcomes, duration of follow-up, and adjustment for confounding variables were extracted. Study quality was assessed according to the Newcastle-Ottawa Scale.

Results: Twenty-two studies from varied geographic and clinical populations were eligible. Both low ABI (≤0.9) and high ABI (>1.4) were consistently associated with elevated risks of myocardial infarction, heart failure, stroke, and all-cause or cardiovascular mortality, independent of conventional risk factors. Low ABI was also associated with subclinical target organ damage, such as left ventricular hypertrophy and silent brain infarct. Some studies have indicated that modified cutoffs (<1.05 or ≤1.10) help to detect risk in some populations, such as older and Asian cohorts. Measurement techniques and ABI cutoffs differed, reducing comparability.

Conclusion: Abnormal ABI is independently associated with increased risks of adverse cardiovascular and cerebrovascular outcomes in patients with hypertension. Standardized protocols for ABI measurement and cutoff points are required to maximize its utility in risk stratification. Prospective studies are needed to determine whether ABI-guided interventions can improve outcomes.