We appreciate the comments of Gutierrez et al. on our paper [1]. In response, we agree on the diagnostic and prognostic value of ABI<0.9. The limits of ABI<0.9 or >1.3 are still valid for the American Heart Association [2]. A recent meta-analysis [3] associates an ABI>1.4 to a hazard ratio (HR) of overall mortality in men of 1.38 [95% confidence interval (CI) 1.17–1.62], with increased cardiovascular mortality having no statistical significance (HR 1.14, 95% CI 0.8–1.63). Meanwhile, ABI in women >1.4 is associated with increased cardiovascular and overall mortality, although this is not statistically significant (HR 1.23, 95% CI 1.00–1.52 and HR 1.48, 95% CI 1.00–2.21, respectively). This meta-analysis also associated ABI <1.1 to a higher overall and coronary mortality in men and a higher incidence of serious coronary events, whereas in women it was associated only with a statistically significant increase in overall mortality. Therefore, rather than ask whether an ABI>1.3 is indeed a change in the population without HIV infection, the debate should be about the true values of the pathological ABI.

In people with HIV infection it is true that the prevalence of ABI is unusually high, pointing to the arterial elasticity of these patients. This may lead to concern about people who are not infected, or that part of antiretroviral treatment can affect this elasticity. It remains to be demonstrated whether such high ABI is associated with a higher overall mortality, cardiovascular or sub-clinical atherosclerotic disease.

Our purpose is not to diagnose PAD but to have a cheap and feasible non-invasive tool to identify patients with a risk of mortality – especially cardiovascular disease – at the consultation, leading to the immediate implementation of preventive measures.


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  2. References
  • 1
    Olalla J, Salas D, Del Arco A et al. Ankle-branch index and HIV: the role of antiretrovirals. HIV Med 2009; 10: 15.
  • 2
    Hirsch AT, Haskal ZJ, Hertzer NR et al. ACC/AHA 2005 practice guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic). Circulation 2006; 113: e463e654.
  • 3
    Fowkes FG, Murray GD, Butcher I et al. Ankle brachial index combined with Framingham Risk Score to predict cardiovascular events and mortality: a meta-analysis. JAMA 2008; 300: 197208.