How to calculate and interpret ankle-brachial index (ABI) numbers

26th Feb 2021

An ankle-brachial index (ABI) report consists of two parts—the qualitative and quantitative data. The quantitative portion includes the ABI ratios and the patient’s blood pressure measurements from both arms and both ankles. Let’s go over which pressures are measured, how they are used to calculate the ABI ratios, and how to interpret these numbers.

 

Which blood pressures are measured to calculate the ABI?

To calculate the ABI ratios, the patient’s blood pressure must be measured in both arms and both ankles. But, the only numbers recorded are for systolic blood pressure. Six values are typically recorded:

  1. Right brachial systolic pressure
  2. Left brachial systolic pressure
  3. Right posterior tibial artery (PTA) systolic pressure
  4. Left posterior tibial artery (PTA) systolic pressure
  5. Right dorsalis pedis artery (DPA) systolic pressure
  6. Left dorsalis pedis artery (DPA) systolic pressure

Brachial artery pressures are chosen because they are the closest to the heart. As well, two ankle systolic pressures are recorded on each side of the body (PTA and DPA). 

Body indicating the locations of systolic pressure measurements including the brachial pressures and ankle pressures. Illustration.

Figure 1. To calculate ankle-brachial index ratios, record the patient’s brachial systolic pressure, posterior tibial artery systolic pressure, and dorsalis pedis artery systolic pressure on each side of the body. 

An automated ABI machine will automatically save the blood pressure values and calculate the patient’s ratios. It will also print analog waveforms. If you are performing a manual ABI, you will need to write all six systolic pressure values down one at a time.

Both the left and right brachial pressures are measured because sometimes there is a contralateral pressure gradient that may indicate subclavian steal syndrome. This is a unilateral occlusion in the subclavian artery that blocks blood flow to the brachial artery and causes lower blood pressure in the affected arm. Usually, this is not considered significant unless there is a 10–20 mmHg difference. 

There are circumstances where only a unilateral brachial pressure can be taken, such as the presence of a dialysis shunt, a mastectomy, a lumpectomy, or lymphadenopathy. Always ask the patient if it’s okay to take their blood pressure in both arms. Although unilateral pressure values are not as ideal as bilateral values, it still provides valuable information.

Blood pressure cuff pointing to the patient’s right side and ‘X’ over the left side with list of reasons for taking only a unilateral brachial pressure. Illustration.

Figure 2. A patient’s brachial blood pressure may only be obtained on one side of the body because of a dialysis shunt, a mastectomy, a lumpectomy, or lymphadenopathy. 

 

How to calculate ABI ratios

Ankle-brachial index ratios are always performed bilaterally but calculated one leg at a time. There are three steps to calculating the ABI ratio for each leg:

  1. Determine the highest brachial pressure (left or right).
  2. Determine the highest ankle pressure for each leg (PTA or DPA). 
  3. Divide the highest ankle pressure on each side by the highest overall brachial pressure.

Torso and blood pressure cuff pointing to both arms, legs with posterior tibial artery (PTA) and dorsalis pedis artery (DPA) labeled beside a blood pressure cuff, and formula for the ankle-brachial index (ABI) ratio. Illustration.

Figure 3. Steps for calculating ankle-brachial indices include, 1) determine the highest brachial pressure, 2) determine the highest ankle pressure for each leg, and 3) divide the highest ankle pressure on each side by the highest overall brachial pressure.  

Step 1: Determine the highest brachial pressure

Choose the highest brachial pressure (regardless of which side it is from) and use that value for both the left and right ABI calculations.

Step 2: Determine the highest ankle pressure for each leg

Two measurements are required for each ankle—the PTA and DPA systolic pressure values. From the ankle pressures recorded, select whichever pressure is higher between the PTA and DPA on each side. These are the values that will be used for the ABI calculations.

Step 3: Divide the highest ankle pressure on each side by the highest brachial pressure 

To calculate the left ABI ratio, divide the highest ankle systolic pressure from the left leg by the highest overall brachial systolic pressure. Repeat this process with the highest ankle pressure recorded from the right side to calculate the ABI ratio for the right leg. 

If there is a large pressure difference between the brachial and ankle pressures, we can assume there is an obstruction occurring between the two locations. 

 

How to interpret ABI ratios

Once the ABI ratios have been calculated, you can compare these findings with the obtained audible waveforms (e.g., qualitative portion of the ABI report). The sound of the flow you hear from the Doppler probe can help characterize the degree of proximal obstruction.

An ABI ratio between 0.9–1.4 that is correlated with a multiphasic waveform (e.g., triphasic or mild biphasic) is consistent with a patient who does not have arterial occlusion.

An ABI between 0.7–0.9 should correlate with biphasic waveforms (e.g., mild or weak biphasic). These waveforms have a sharp upstroke to the peak and one pit. The findings represent mild to moderate arterial insufficiency. These patients typically present with claudication. 

An ABI between 0.3–0.5 represents severe peripheral arterial disease (PAD) and usually correlates with a monophasic waveform (e.g., high or dampened monophasic). These patients typically present with pain and ulcers. 

A critical ABI range is less than 0.3 to absent, which correlates with an absent waveform and represents critical PAD. In this case, there is no flow in the DPA or PTA; patients with no flow to the feet typically present with advanced ulcers and gangrene. 

Table summarizing the degrees of peripheral arterial disease and their associated ankle-brachial index (ABI) ranges, signs and symptoms, and waveforms.

Table 1. Degrees of arterial perfusion and associated ankle-brachial index (ABI) ranges, signs and symptoms, and waveforms. Lower arterial perfusion is associated with more severe peripheral arterial disease.

 

Example demonstrating how to calculate and interpret ABI ratios

Let’s say that you have a patient whose highest right ankle pressure is 139 mmHg and their highest overall brachial pressure is 126 mmHg. The right ABI ratio is calculated by dividing 139 mmHg by 126 mmHg, which equals 1.10 (a normal ABI). 

Formula for the right ankle-brachial index (ABI) ratio. The highest right ankle pressure of 139 divided by the highest overall brachial pressure of 126 beside calculator showing 1.10. Illustration.

Figure 4. To calculate the right ankle’s ankle-brachial index (ABI), divide the highest ankle pressure on the right by the highest overall brachial pressure. 

Next, you listen to the patient’s audible waveforms and find them to be triphasic, which correlates with the finding of a normal right ABI and represents normal flow. 

Keep in mind that if the patient’s ABI ratio is in the normal range, but the corresponding waveform is found to be monophasic, a further investigation would be needed. 

Continuing with our example, let’s say that you had access to the patient’s report from an ABI machine. Automated ABI reports calculate the ratios for you. 

In this case, let’s say that the patient’s ABI report shows that the highest ankle pressure on the right is the DPA at 134 mmHg. The ABI machine automatically chooses the patient’s highest ankle pressure and highest overall brachial pressure, which is 126 mmHg, to calculate the ABI ratio. So, the right ABI is calculated by dividing 134 mmHg by 126 mmHg, which equals 1.06 (a normal ABI). 

This finding should be correlated with the analog waveforms shown on the patient’s ABI report. If the analog waveforms are triphasic (which is normal), then the patient has normal flow.

Report showing a higher left brachial pressure of 126 mmHg and higher dorsalis pedis artery (DPA) pressures of 139 mmHg and 134 mmHg, resulting in a left ankle-brachial index (ABI) of 1.10 and a right ABI of 1.06. Illustration.

Figure 5. An automated ankle-brachial index (ABI) report showing the ABI ratios for each side of the body. 

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Recommended reading

  • Aboyans, V, Criqui, MH, Abraham, P, et al. 2012. Measurement and interpretation of the ankle-brachial index: a scientific statement from the American Heart Association. Circulation126: 2890–2909. PMID: 23159553
  • Cervin, A, Wanhainen, A, and Björck, M. 2020. Popliteal aneurysms are common among men with screening detected abdominal aortic aneurysms, and prevalence correlates with the diameters of the common iliac arteries. Eur J Vasc Endovasc Surg59: 67–72. PMID: 31757587
  • Cleveland Clinic. 2021. Leg and foot ulcers. Cleveland Clinichttps://my.clevelandclinic.org
  • Cleveland Clinic. 2021. Marfan syndrome. Cleveland Clinichttps://my.clevelandclinic.org
  • Cleveland Clinic. 2021. Popliteal artery entrapment syndrome (PAES). Cleveland Clinichttps://my.clevelandclinic.org
  • Cleveland Clinic. 2021. Statin medications & heart disease. Cleveland Clinichttps://my.clevelandclinic.org
  • Collins, L and Seraj, S. 2010. Diagnosis and treatment of venous ulcers. Am Fam Physician81: 989–996. PMID: 20387775
  • Høyer, C, Sandermann, J, and Peterson, LJ. 2013. The toe-brachial index in the diagnosis of peripheral arterial disease. J Vasc Surg58: 231–238. PMID: 23688630
  • Jaoude, WA. 2010. Management of popliteal artery aneurysms. SUNY Downstate Department of Surgeryhttp://www.downstatesurgery.org
  • Johns Hopkins Medicine. 2021. Aneurysm. Johns Hopkins Medicinehttps://www.hopkinsmedicine.org
  • Kassem, MM and Gonzalez, L. 2020. “Popliteal artery aneurysm”. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov
  • Moxon, JV, Parr, A, Emeto, TI, et al. 2010. Diagnosis and monitoring of abdominal aortic aneurysm: current status and future prospects. Curr Probl Cardiol35: 512–548. PMID: 20932435
  • Richert, DL. 2016. Gundersen/Lutheran Ultrasound Department Policy and Procedure Manual. Gundersen Health Systemhttps://www.gundersenhealth.org
  • Rivera, PA and Dattilo, JB. 2020. “Pseudoaneurysm”. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov
  • Stanford Medicine 25. 2021. Measuring and understanding the ankle brachial index (ABI). Stanford Medicine 25https://stanfordmedicine25.stanford.edu/
  • Teo, KK. 2019. Acute peripheral arterial occlusion. Merck Manuals Professional Editionhttps://www.merckmanuals.com
  • The Regents of the University of California. 2020. Diabetic foot ulcers. UCSF Department of Surgeryhttps://surgery.ucsf.edu
  • Zwiebel, WJ and Pellerito, JS. 2005. Introduction to Vascular Ultrasonography. 5th edition. Philadelphia: Elsevier Saunders. (Zwiebel and Pellerito 2005, 254–259)