Have Clinicians Been Wrong About How They Diagnose PAD?

Why It Matters

Treating borderline ABI as high‑risk could reshape screening and early‑intervention guidelines, potentially reducing limb loss and associated health‑care costs. Early action may improve outcomes for millions at risk of peripheral artery disease.

Key Takeaways

• Borderline ABI (0.91‑1.00) linked to higher MALE risk.
• Risk increase observed across women, White and Black veterans.
• Men show slightly higher amputation rates in all ABI groups.
• Study suggests ABI should be treated as a risk continuum.
• Early prevention may lower limb‑related morbidity and costs.

Pulse Analysis

The ankle‑brachial index has long been the bedside tool for detecting peripheral artery disease, with clinicians traditionally drawing a hard line at 0.90 to flag disease and labeling 0.91‑1.00 as merely “borderline.” This binary view simplifies decision‑making but may mask early atherosclerotic changes that threaten limb viability. As the U.S. population ages and diabetes prevalence rises, the pool of patients hovering just above the diagnostic threshold is expanding, prompting renewed scrutiny of how the test is interpreted.

The recent JACC analysis leveraged electronic health records from nearly 225,000 veterans, providing a uniquely diverse and sizable sample. Researchers found that individuals with borderline ABI values experienced a statistically significant rise in major adverse limb events, including both major and total amputations as well as revascularization procedures. The risk signal persisted after stratifying by sex and race, and men exhibited marginally higher amputation rates across all ABI categories. These data suggest that the physiological continuum captured by the ABI begins to influence outcomes well before the conventional 0.90 cutoff.

If clinicians adopt a continuum‑based approach, patients with ABI 0.91‑1.00 could become candidates for intensified risk factor modification, supervised exercise programs, or earlier pharmacologic therapy. Such proactive measures have the potential to curb downstream costs associated with hospitalizations, prosthetic care, and loss of productivity. Moreover, the findings may spur guideline committees to revise PAD screening recommendations, aligning them with emerging evidence that borderline values are not benign. Future research will need to define optimal intervention thresholds and test whether early treatment truly translates into fewer limb‑loss events.