Role of the toe-brachial index in assessing the patient’s clinical status
https://doi.org/10.15829/1560-4071-2025-6398
EDN: EIOXYH
Abstract
Although the term "target organ damage" is used primarily in relation to the diagnosis of hypertension, the fact that vessels are involved in a wider range of diseases is beyond doubt. Over the past 30 years, arterial stiffness has moved from the area of scientific interest to clinical guidelines. The ankle-brachial index is widely used to assess target organ damage. In a number of conditions (diabetes, chronic kidney disease, especially in the end-stage renal failure and hemodialysis), severe medial calcification of the arterial walls develops. As a result, the arteries become non-compressible, which leads to falsely elevated ankle-brachial index (>1,4). Toe vessels are less susceptible to vascular stiffness, which makes the toe-brachial index an accessible alternative in such a situation. The literature review highlights the history of toe-brachial index development as a research method, as well as the predictive value and prospects for further application. Its use offers opportunities for deepening and expanding understanding of the pathogenesis of a wide range of diseases, searching for and testing correction methods and developing effective prevention methods.
Supporting agencies: Grant of the Russian Science Foundation 25-25-00352 "Study of non-lipid-mediated endothelial dysfunction with an assessment of statin effect".
About the Authors
V. E. Oleynikov
Penza State University
Russian Federation
Russian Federation
Penza
D. Mindzhi
The Second Affiliated Hospital of Xi’an Jiaotong University
China
China
Xi’an
I. V. Avdeeva
Penza State University
Russian Federation
Russian Federation
Penza
E. V. Kulakova
Penza State University
Russian Federation
Russian Federation
Penza
K. I. Pavlenko
Penza State University
Russian Federation
Russian Federation
Penza
References
1. Kobalava ZhD, Konradi AO, Nedogoda SV, et al. 2024 Clinical practice guidelines for Hypertension in adults. Russian Journal of Cardiology. 2024;29(9):6117. (In Russ.)doi:10.15829/1560-4071-2024-6117.
2. Vasyuk YuA, Ivanova SV, Shkolnik EL, et al. Consensus of Russian experts on the evaluation of arterial stiffness in clinical practice. Cardiovascular Therapy and Prevention. 2016;15(2):4-19. (In Russ.) doi:10.15829/1728-8800-2016-2-4-19.
3. Prenner SB, Chirinos JA. Arterial stiffness in diabetes mellitus. Atherosclerosis. 2015;238(2):370-9. doi:10.1016/j.atherosclerosis.2014.12.023.
4. Mazzolai L, Teixido-Tura G, Lanzi S, et al. 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases. Eur Heart J. 2024;45(36):3538-700. doi:10.1093/eurheartj/ehae179.
5. Harrison ML, Hsin-Fu L, Blakely DW, et al.Preliminary assessment of an automatic screening device for peripheral arterial disease using ankle–brachial and toe–brachial indices. Blood Pressure Monitoring. 2011;16(3):138-41. doi:10.1097/MBP.0b013e328346a839.
6. Nirala N, Periyasamy R, Kumar A. Non invasive diagnostic methods for better screening of peripheral arterial disease. Ann Vasc Surg. 2018;52:263-72. doi:10.1016/j.avsg.2018.03.018.
7. Gavrilova NE, Zhatkina MV. Ankle-brachial index: extension of diagnostic area. CARDIOLOGY: news, opinions, training. 2017;3:47-50. (In Russ.)
8. Boytsov SA, Pogosova NV, Ansheles AA, et al. Cardiovascular prevention 2022. Russian national guidelines. Russian Journal of Cardiology. 2023;28(5):5452. (In Russ.) doi:10.15829/1560-4071-2023-5452.
9. Arora E, Korada H, Devasia T, et al. Profile of Peripheral Arterial Disease in Type 2 Diabetes Mellitus — A Hospital-based observational study in Coastal Karnataka. Diabetes mellitus. 2020;23(4):324-8. doi:10.14341/DM12260.
10. Davidson BP, Hodovan J, Mason O’NR, et al. Limb Perfusion During Exercise Assessed by Contrast Ultrasound Varies According to Symptom Severity in Patients with Peripheral Artery Disease. J Am Soc Echocardiogr. 2019;32(9):1086-94.e3. doi:10.1016/j.echo.2019.05.001.
11. Chen J, He H, Starcke CC, et al. Accuracy of Ankle-Brachial Index, Toe-Brachial Index, and Risk Classification Score in Discriminating Peripheral Artery Disease in Patients With Chronic Kidney Disease. Am J Cardiol. 2021:160:117-23. doi:10.1016/j.amjcard.2021.08.046.
12. Arora E, Yadav H, Maiya GA, et al. Correlation between toe brachial index and walking ability in peripheral arterial disease with type 2 diabetes mellitus. Bull Fac Phys Ther. 2023;28:44. doi:10.1186/s43161-023-00155-6.
13. Høyer C, Sandermann J, Petersen LJ. The toe-brachial index in the diagnosis of peripheral arterial disease. J Vasc Surg. 2013;58(1):231-8. doi:10.1016/j.jvs.2013.03.044.
14. Quong WL, Ting-Hei Fung A, Yu RY, et al. Reassessing the normal toe-brachial index in young healthy adults. Journal of Vascular Surgery. 2016;63(3):652-6. doi:10.1016/j.jvs.2015.09.019.
15. Watanabe Y, Masaki H, Yunoki Y, et al. Ankle-Brachial Index, Toe-Brachial Index, and Pulse Volume Recording in Healthy Young Adults. Ann Vasc Dis. 2015;8(3):227-35. doi:10.3400/avd.oa.15-00056.
16. Herraiz-Adillo Á, Cavero-Redondo I, Álvarez-Bueno C, et al. The accuracy of toe brachial index and ankle brachial index in the diagnosis of lower limb peripheral arterial di-sease: A systematic review and meta-analysis. Atherosclerosis. 2020;315:81-92. doi:j.atherosclerosis.2020.09.026.
17. Singhania P, Das TC, Bose C, et al. Toe brachial index and not ankle brachial index is appropriate in initial evaluation of peripheral arterial disease in type 2 diabetes. Diabetol Metab Syndr. 2024;16(1):52. doi:10.1186/s13098-024-01291-2.
18. Maichuk EYu, Voevodina IV, Vyzhigin DA. Arterial stiffness and comorbid pathology. Therapy. 2020;2:123-30. (In Russ.) doi:10.18565/therapy.2020.2.123-130.
19. Gapon LI. Hypertension and arterial wall stiffness in clinical practice: literature review. Russian Journal of Cardiology. 2024;29(5):5924. (In Russ.) doi:10.15829/1560-4071-2024-5924.
20. Chisalita SI, Wijkman M, Davidson LT, et al. Toe brachial index predicts major acute cardiovascular events in patients with type 2 diabetes independently of arterial stiffness. Diabetes Res Clin Pract. 2020;161:108040. doi:10.1016/j.diabres.2020.108040.
21. Hyun S, Forbang NI, Allison MA, et al. Ankle-brachial index, toe-brachial index, and cardiovascular mortality in persons with and without diabetes mellitus. J Vasc Surg. 2014;60(2):390-5. doi:10.1016/j.jvs.2014.02.008.
22. Han M, Kim YD, Lee I, et al. Low Toe-Brachial Index Is Associated With Stroke Outcome Despite Normal Ankle-Brachial Index. Front Neurol. 2021;12:754258. doi:10.3389/fneur.2021.754258.
23. Koivunen V, Juonala M, Venermo M, et al. Toe pressure and toe brachial index are predictive of cardiovascular mortality regardless of the most diseased arterial segment in symptomatic lower-extremity artery disease-A retrospective cohort study. PLoS One. 2021;16(11):e0259122. doi:10.1371/journal.pone.0259122.
24. Zobel EH, von Scholten BJ, Reinhard H, et al. Toe-brachial index as a predictor of cardiovascular disease and all-cause mortality in people with type 2 diabetes and microalbuminuria. Diabetologia. 2017;60(10):1883-91. doi:10.1007/s00125-017-4344-x.
25. Kamath TP, Prasad R, Allison MA, et al. Association of Ankle-Brachial and Toe-Brachial Indexes With Mortality in Patients With CKD. Kidney Med. 2020;2(1):68-75. doi:10.1016/j.xkme.2019.11.001.
26. Fukui M, Tanaka M, Hamaguchi M, et al. Toe-brachial index is associated more strongly with albuminuria or glomerular filtration rate than ankle-brachial index in patients with type 2 diabetes. Hypertens Res. 2012;35(7):745-9. doi:10.1038/hr.2012.16.
27. Prasad R, Kamath T, Ginsberg C, et al. The association of the ankle-brachial index, the toe-brachial index, and their difference, with mortality and limb outcomes in dialysis patients. Hemodial Int. 2019;23(2):214-22. doi:10.1111/hdi.12734.
28. Moayerifar M, Moayerifar M, Mirdamadi A, et al. Integrating Toe Brachial Index and longitudinal strain echocardiography for detecting coronary artery disease in patients with diabetic foot syndrome. Int Wound J. 2024;21(8):e70026. doi:10.1111/iwj.70026.
29. Alaika O, Jamai S, Doghmi N, et al. Diagnostic Accuracy of Global Longitudinal Strain for Detecting Significant Coronary Artery Disease in Diabetic Patients without Regional Wall Motion Abnormality. J Saudi Heart Assoc. 2020;32(3):425-33. doi:10.37616/2212-5043.1096.
30. Jakubiak GK, Pawlas N, Morawiecka-Pietrzak M, et al. Relationship of Thyroid Volume and Function with Ankle-Brachial Index, Toe-Brachial Index, and Toe Pressure in Euthyroid People Aged 18-65. Medicina (Kaunas). 2024;60(9):1445. doi:10.3390/medicina60091445.
31. Sigl M, Hsu E, Scheffel H, et al. Lower extremity vasculitis in giant cell arteritis: important differential diagnosis in patients with lower limb claudication. Vasa. 2014;43(5):326-36. doi:10.1024/0301-1526/a000370.
32. Bryce Y, Santos-Martin E, Ziv E, et al. Abnormal photoplethysmography waveforms are associated with chemotherapy induced neuropathy. Vasa. 2022;51(2):85-92. doi:10.1024/0301-1526/a000987.
33. Budoff MJ, Alpert B, Chirinos JA, et al. Clinical Applications Measuring Arterial Stiffness: An Expert Consensus for the Application of Cardio-Ankle Vascular Index. Am J Hypertens. 2022;35(5):441-53. doi:10.1093/ajh/hpab178.
34. Asmar R, Stergiou G, de la Sierra A. Blood pressure measurement and assessment of arterial structure and function: an expert group position paper. J Hypertens. 2024;42(9):1465-81. doi:10.1097/HJH.0000000000003787.
35. Chang CW, Sung YW, Huang YT, et al. Better Detection of Peripheral Arterial Disease with Toe-Brachial Index Compared to Ankle-Brachial Index among Taiwanese Patients with Diabetic Kidney Disease. J Clin Med. 2023;12(23):7393. doi:10.3390/jcm12237393.
36. Tehan PE, Mills J, Leask S, et al. Toe‐brachial index and toe systolic blood pressure for the diagnosis of peripheral arterial disease. Cochrane Database of Systematic Reviews. 2024;10(10):CD013783. doi:10.1002/14651858.CD013783.pub2.
37. Zhan LX, Branco BC, Armstrong DG, et al. The Society for Vascular Surgery lower extremity threatened limb classification system based on Wound, Ischemia, and foot Infection (WIfI) correlates with risk of major amputation and time to wound healing. J Vasc Surg. 2015;61(4):939-44. doi:10.1016/j.jvs.2014.11.045.
38. Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017;135(12):e686-e725. doi:10.1161/CIR.0000000000000470.
39. Aboyans V, Ricco JB, Bartelink MEL, et al. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteriesEndorsed by: the European Stroke Organization (ESO) The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur Heart J. 2018;39(9):763-816. doi:10.1093/eurheartj/ehx095.
40. Functional diagnostics: national guidelines. Еdited by Beresten NF, Sandrikov VA, Fedorova SI. Moscow: GEOTAR-Media, 2019. 784 p. (In Russ.)ISBN: 978-5-9704-4242-5.
41. Vasyuk YuA, Gendlin GE, Emelina EI, et al. Сonsensus statement of Russian experts on the prevention, diagnosis and treatment of cardiotoxicity of anticancer therapy. Russian Journal of Cardiology. 2021;26(9):4703. (In Russ.) doi:10.15829/1560-4071-2021-4703.
42. Satalkina TS, Brodskaya TA, Geltser BI, et al. Arterial stiffness and 24-hour blood pressure profile in women with breast cancer before and after chemotherapy with doxorubicin and cyclophosphamide. Russian Journal of Cardiology. 2025;30(2):5920. (In Russ.) doi:10.15829/1560-4071-2025-5920.
43. Brodskaya TA, Geltser BI, Satalkina TS, et al. Arterial hypertension and breast cancer in women: mechanisms of comorbidity and iatrogenic disease. "Arterial’naya Gipertenziya" ("Arterial Hypertension"). 2022;28(2):147-56. (In Russ.) doi:10.18705/1607-419X-2022-28-2-147-156.
44. Kursov SV, Mikhnevich KG. Capillary leak syndrome. Emergency Medicine. 2011;7-8(38-39):24-32. (In Russ.)
45. Siddall E, Khatri M, Radhakrishnan J. Capillary leak syndrome: etiologies, pathophysiology, and management. Kidney International. 2017;92(1):37-46. doi:10.1016/j.kint.2016.11.029.
Supplementary files
Review
For citations:
Oleynikov V.E., Mindzhi D., Avdeeva I.V., Kulakova E.V., Pavlenko K.I. Role of the toe-brachial index in assessing the patient’s clinical status. Russian Journal of Cardiology. 2025;30(9S):6398. (In Russ.) https://doi.org/10.15829/1560-4071-2025-6398. EDN: EIOXYH
Views:
202
Email this article 