Brachial-Ankle Pulse Wave Velocity, Mortality, and Cardiovascular Events

Review Article

J Cardiovasc Disord. 2015;2(1): 1009.

Brachial-Ankle Pulse Wave Velocity, Mortality, and Cardiovascular Events

Dai Ato¹* and Takeshi Takami²*

¹Science Representative, Sales Strategy Department,Japan

²Department of Internal Medicine, Clinic Jingumae,Japan

*Corresponding author: Ato D, Sales Strategy Department, OMRON COLIN Co., Ltd., 1-12-14 Koishikawa, Bunkyo-ku, Tokyo, 112-0002, Japan,

Takami T, Department of Internal Medicine, Clinic Jingumae, ConfortYagi 1F 5-4-41 Naizencho, Kashihara, Nara 634-0804, Japan

Received: December 18, 2014; Accepted: March 03, 2015; Published: March 06, 2015


Pulse Wave Velocity (PWV) is used as an index of arterial stiffness worldwide. One standard PWV is the carotid-femoral PWV (cfPWV). Articles reporting the usefulness of brachial-ankle PWV (baPWV), which is measured at the brachium and ankle, are rapidly increasing.And the number of prognosis follow-up studies is approaching 40. Observing these reports, baPWV shows a prognostic predictability independent from classic atherosclerotic risk factors that are considered to improve upon the exclusion of patients with Peripheral Arterial Disease (PAD). On the other hand, it is difficult to exclude PAD only by the ordinal cut-off of ABI 0.9, especially in populations of patients with diabetes or those on hemodialysis. In this review, we summarize previously reported articles, identify the efficacy of baPWV in the various reports, consider why the predictability of baPWV is decreased in those populations, suggest possible solutions to avoid the use of inaccurate baPWV measurements, and present future perspectives.

Keywords: Brachial-Ankle Pulse Wave Velocity; Ankle-Brachial Index; Prognostic Predictability; Arterial Stiffness; Peripheral Arterial Disease; Cardiovascular Disease


The prevention of atherosclerotic disease is an important issue in developed and developing countries. The prevention of this disease is based on controlling classical risk factors such as hypertension and Diabetes Mellitus (DM), but since it is impossible to perfectly predict future events by combining these factors, confirming arterial damage is important. CfPWV is an index vascular test with proven prognostic predictability, and many related studies have been performed in Europe [1,2].

An apparatus that simultaneously measures Ankle-Brachial Index (ABI) and PWV became available in December 1999 in Japan. This machine continuously measures PWV between the brachium and the ankle (baPWV) after the ABI. With its procedural convenience, this machine first became rapidly popular in Japan and East Asian countries. The clinical use of baPWV was first started in Japan, so Japan is virtually the origin of this biomarker. The product name of this machine is “form” and it means “let us watch the ‘form” of the pulse wave.” Abroad, the name of “VP-1000” or “VP-2000” (Vascular Profiler) has essentially the same intent. Fifteen years have passed since its debut, and to date, more than 1000 English-language articles have reported the use of this device, not only the ABI tested by this device indicated prognostic predictability like as many preceding studies worldwide, the number of the studies of the prognostic significance of baPWV has reached nearly 40. Moreover, in early 2014, the cut-off value of 18 m/s was announced in the Japanese Circulation Society (JCS) and Japanese Society of Hypertension (JSH) guidelines [3,4]. In this review, we summarize articles focusing on the current prognostic value of baPWV and suggest possible solutions to avoid the use of inaccurate baPWV measurements as well as future perspectives.

Researched Articles

Until the end of November 2014, 38 articles that mainly or additively researched the prognostic predictability of baPWV measured almost by VP in terms of all-cause mortality, cardiovascular mortality, and cardiovascular events were included. Cardiovascular events that were variously defined in different articles focusing on the events in these organs were considered in this review. The follow-up studies focusing on the progression to chronic kidney disease (>CKD3) or PAD were excluded. We summarized these articles by study population and checked the baPWV cut-off value and PAD exclusion criteria in each document because baPWV is underestimated in the limbs of patients with PAD [5]. We also included articles which provide the product name when the baPWV was measured by other apparatuses. The additive value to classical atherosclerotic risk factors is a crucial point in the consideration of the prognostic predictability of vascular function tests [6], so we classified the articles in which baPWV showed effectiveness as an independent prognostic biomarker after adjustment on Cox Multiple Regression Analysis (CMRA).

Measurement of baPWV and ABI

The method of measuring these indices by this apparatus was previously reported [7]. Briefly, after at least a 5-minute rest, four oscillometric cuffs are placed in both brachia and ankles, Electrocardiography (ECG) sensors are placed on both wrists, and a Phonocardiography (PCG) sensoris placed on the spine position. In the Hemodialysis (HD) population, the arm cuff is placed on the arm opposite the arteriovenous fistula. The original structure of the ankle cuff is composed of two parts, one that senses the pulse and another that occludes the artery. After automatically measuring the Blood Pressures (BP) of the four limbs, a plethysmogram is simultaneously measured for about 10 seconds. The pulse volume recording is performed on four limbs and the cuff pressure is kept at 55 mmHg. The Pulse-Transit Time (PTT) is calculated by the time difference between the up-stroke of the right brachium and both ankles as pulse transit Time brachial-ankle (Tba). The travel path of the pulse is defined as follows: Lba (cm) = 0.59 × height (cm) + 14.4 [8]. As such, baPWV is Lba/Tba. The baPWV value is reportedly significantly correlated with aortic PWV and the Pearson correlation coefficient is approximately 0.8 [7,9,10]. Its reproducibility is also reportedly good. The inter-observer coefficient is 0.98 [7] and the intra-observer coefficient is 0.89 [11].

In the evaluation of baPWV, the first step is to confirm whether there is decline of ABI to exclude baPWV underestimation [5] because PTT decreases when there is any significant stenosis in the pulse pathway. The ankle BP and ABI accuracy measured by this machine is also valid compared to the Doppler method [12-15], for example, the Pearson correlation coefficient of the ankle systolic BP is 0.95 [14]. Moreover, in this machine, Upstroke Time (UT), and percent mean arterial pressure (%MAP) are provided as quantitative indices of the pulse wave form. These parameters are supportively used to judge the existence of PAD in the clinical setting. Nevertheless, the studies included in this review did not add these supportive parameters to define PAD, so we only focused on whether they describe ABI/PAD exclusion criteria for baPWV analysis in this review. To easily image this point, we provided two examples of the printed results of this apparatus to demonstrate the change of the ankle pulse wave form from normal to PAD (Figures 1,2).