Pulse Oximetry as a Screening Test for Hemodynamically Significant Lower Extremity Peripheral Artery Disease in Adults with Type 2 Diabetes Mellitus



diabetes mellitus, type 2, peripheral artery disease, oximetry


Objective. The main objective is to determine if digital pulse oximetry is an acceptable screening tool to detect hemodynamically significant lower extremity peripheral artery disease (PAD) in patients 50 years old and above with type 2 diabetes mellitus (T2DM) seen at the University of Santo Tomas Hospital (USTH).

Methodology. 78 subjects (155 limbs) were included. Using duplex ultrasonography as the reference standard for the presence of hemodynamically significant lower extremity PAD, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were obtained for abnormal percent oxygen saturation (SpO2) gradients and for ankle-brachial index (ABI).

Results. Of the 155 limbs, 38.7% had hemodynamically significant stenosis. Pulse oximetry had 76.7% (95% CI, 64.0% - 86.6%) sensitivity, 85.3% (95% CI, 76.5%-91.7%) specificity, 76.7% (95% CI, 66.5%- 84.4%) PPV, and 85.3% (95% CI, 78.4%-90.2%) NPV. ABI had 40.7% (95% CI, 28.1%-54.3%) sensitivity, 88.2% (95% CI, 79.8%-94.0%) specificity, 68.6% (95% CI, 53.6%-80.4%) PPV, and 70.1% (95% CI, 65.1%-74.5%) NPV. Combining both produces 88.1% (95% CI, 77.1%- 95.1%) sensitivity, 74.2% (95% CI, 64.1- 82.7%) specificity, 68.4 (95% CI, 60.3%-75.6%) PPV, and 90.8% (95% CI, 83.0% -95.2%) NPV.

Conclusion. The results of this study suggest that pulse oximetry has a higher sensitivity than ABI as a screening tool for hemodynamically significant lower extremity PAD in T2DM patients 50 years old and above. Combining these two tests may be done to achieve a higher sensitivity.



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Da Silva JA Jr, Souza DUF, Ferreira DR, et al. Tissue oxygen saturation assessment during claudication symptoms in patients with peripheral arterial disease. J Vasc Bras. 2015;14(4):311-8. https://doi.org/10.1590/1677-5449.002115.

Sen S, Lynch DR Jr, Kaltsas E, et al. Association of asymptomatic peripheral arterial disease with vascular events in patients with stroke or transient ischemic attack. Stroke. 2009;40(11):3472-7. PMID: 19713540. https://doi.org/10.1161/STROKEAHA.109.559278.

Guo X, Li J, Pang W, et al. Sensitivity and specificity of ankle-brachial index for detecting angiographic stenosis of peripheral arteries. Circ J. 2008;72:605–10. PMID: 18362433.

Sy RG, Morales DD, Dans AL, et al. Prevalence of atherosclerosis-related risk factors and diseases in the Philippines. J Epidemiol. 2012;22(5):440-7. PMID: 22813647. PMCID: PMC3798639.

American Diabetes Association. Peripheral arterial disease in people with diabetes. Diabetes Care. 2003;26(12):3333-41. PMID: 14633825.

Bendermacher BL, Teijink JA, Willigendael EM, et al. A clinical prediction model for the presence of peripheral arterial disease – the benefit of screening individuals before initiation of measurement of the ankle-brachial index: An observational study. Vasc Med. 2007;12(1):5-11. PMID: 17451087. https://doi.org/10.1177/1358863X07076827.

Mourad JJ, Cacoub P, Collet JP, et al. Screening of unrecognized peripheral arterial disease (PAD) using ankle-brachial index in high cardiovascular risk patients free from symptomatic PAD. J Vasc Surg. 2009;50(3):572-80. PMID: 19560312. https://doi.org/10.1016/j.jvs.2009.04.055.

Kallio M, Forsblom C, Groop PH, Groop L, Lepäntalo M. Development of new peripheral arterial occlusive disease in patients with type 2 diabetes during a mean follow-up of 11 years. Diabetes Care. 2003;26(4):1241-5. PMID: 12663604/

McDermott MM, Guralnik JM, Ferrucci L, et al. asymptomatic peripheral arterial disease is associated with more adverse lower extremity characteristics than intermittent claudication. Circulation. 2008;117(19):2484-91. PMID: 18458172. PMCID: PMC5077147. https://doi.org/10.1161/CIRCULATIONAHA.107.736108.

Hooi JD, Stoffers HE, Kester AD, et al. Risk factors and cardiovascular diseases associated with asymptomatic peripheral arterial occlusive disease. The Limburg PAOD Study. Peripheral arterial occlusive disease. Scand J Prim Health Care. 1998 Sep;16(3):177-82. PMID: 9800232.

Khan TH, Farooqui FA, Niazi K. Critical review of the ankle brachial index. Curr Cardiol Rev. 2008;4(2):101-6. PMID: 19936284. PMCID: PMC2779349. https://doi.org/10.2174/157340308784245810.

Stein R, Hriljac I, Halperin JL, Gustavson SM, Teodorescu V, Olin JW. Limitation of the resting ankle-brachial index in symptomatic patients with peripheral arterial disease. Vasc Med. 2006;11(1):29-33. PMID: 16669410. https://doi.org/10.1191/1358863x06vm663oa.

Al-Qaisi M, Nott DM, King DH, Kaddoura S. Ankle brachial pressure index (ABPI): An update for practitioners. Vasc Health Risk Manag. 2009:5 833–41. PMID: 19851521. PMCID: PMC2762432.

Khammash MR, Obeidat KA, El-Qarqas EA. Screening of hospitalised diabetic patients for lower limb ischaemia: is it necessary? Singapore Med J. 2008;49(2):110-3. PMID: 18301836.

Jörneskog G. Why critical limb ischemia criteria are not applicable to diabetic foot and what the consequences are. Scand J Surg. 2012;101(2):114-8. PMID: 22623444. https://doi.org/10.1177/145749691210100207.

Williams DT, Pugh ND, Coleman DP, Harding KG, Price P. Review: The laboratory evaluation of lower limb perfusion in diabetes mellitus. A clinical review. Br J Diabetes Vasc Dis. 2005;5:64–70. https://doi.org/10.1177/14746514050050020301.

Andersen CA. Noninvasive assessment of lower extremity hemodynamics in individuals with diabetes Mellitus. J Vasc Surg. 2010;52(3 Suppl):76S-80S. PMID: 20804937. https://doi.org/10.1016/j.jvs.2010.06.012.

Resnick H, Lindsay RS, McDermott MM, et al. Relationship of high and low ankle brachial index to all-cause and cardiovascular disease mortality the strong heart study. Circulation. 2004;109(6):733-9. PMID: 14970108. https://doi.org/ 10.1161/01.CIR.0000112642.63927.54.

Parameswaran G, Brand K, Dolan J. Pulse oximetry as a potential screening tool for lower extremity arterial disease in asymptomatic patients with diabetes mellitus. Arch Intern Med.2005;165(4):442-6. PMID: 15738375. https://doi.org/10.1001/archinte.165.4.442.

Kyriacou P. Pulse oximetry in the esophagus. Physiol Meas. 2006;27(1):R1-35. PMID: 16365505. https://doi.org/10.1088/0967-3334/27/1/R01.

Kumar MS, Lohiya A, Ramesh V, Behera P, Palepu S, Rizwan SA. Sensitivity and specificity of pulse oximetry and ankle-brachial index for screening asymptomatic peripheral vascular diseases in type 2 diabetes mellitus. J Assoc Physicians India. 2016;64(8):38-43. PMID: 27762107.

Wise DL. Bioinstrumentation and biosensors. Florida: CRC Press, 1991, p. 270.

Merrick EB, Hayes TJ. Continuous, non-invasive measurements of arterial blood oxygen levels. Hewlett-Packard Journal. 1976;28(2):2-9. http://www.hpl.hp.com/hpjournal/pdfs/IssuePDFs/1976-10.pdf.

Mendelson Y. Pulse oximetry: Theories and applications for non-invasive monitoring. Clin Chem. 1992;38(9):1601-7. PMID: 1525987.

Razi E,Akbari H. A Comparison of arterial oxygen saturation measured both by pulse oximeter and arterial blood gas analyzer in hypoxemic and non-hypoxemic pulmonary diseases. TRJ. 2006;7(2):43-7.

Jensen LA, Onyskiw JE, Prasad NG. Meta-analysis of arterial oxygen saturation monitoring by pulse oximetry in adults. Heart Lung.1998;27(6):387-408. PMID: 9835670.

Webster JG. Design of pulse oximeters. Florida: CRC Press, 1997, p.182.

Ignjatović N, Vasiljević M, Milić D, et al. Diagnostic importance of pulse oximetry in the determination of the stage of chronic arterial insufficiency of lower extremities. Srp Arh Celok Lek. 2010;138(5-6):300-4. PMID: 20607972.

Kwon JN, Lee WB. Utility of digital pulse oximetry in the screening of lower extremity arterial disease. J Korean Surg Soc. 2012;82(2):94-100. PMID: 22347711. PMCID: PMC3278641. https://doi.org/ 10.4174/jkss.2012.82.2.94.

Ena J, Argente C, Gonzáles-Sánchez V, et al. Use of pocket pulse oximeters for detecting peripheral arterial disease in patients with diabetes mellitus. Journal of Diabetes Mellitus. 2013;3(2):Article ID 31380. https://doi.org/10.4236/jdm.2013.32012.

Arellano R, Abella M. Diagnosis of arterial disease of the lower extremities with duplex scanning: A validation study. Phil Heart Center J. 2007; 13(2):96-100.

Eiberg JP, Grønvall Rasmussen JB, Hansen MA, Schroeder TV. Duplex ultrasound scanning of peripheral arterial disease of the lower limb. Eur J Vasc Endovasc Surg. 2010;40(4):507-12. PMID: 20609601. https://doi.org/10.1016/j.ejvs.2010.06.002.

Hingorani A, Ascher E, Markevich N, et al. A comparison of magnetic resonance angiography, contrast arteriography, and duplex arteriography for patients undergoing lower extremity revascularization. Ann Vasc Surg. 2004; 18(3):294-301. PMID: 15354630. https://doi.org/10.1007/s10016-004-0039-0.

2011 Writing Group Members; 2005 Writing Committee Members, ACCF/AHA Task Force Members. 2011 ACCF/AHA focused update of the guideline for the management of patients with peripheral artery disease (Updating the 2005 Guideline) A report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2011;124(18):2020-45. PMID: 21959305. https://doi.org/10.1161/CIR.0b013e31822e80c3.

McCarthy WF, Guo N. The estimation of sensitivity and specificity of clustered binary data. Paper 206-31. SAS Institute Inc. Proceedings of the Thirty-first Annual SAS® Users Group International Conference. Cary, NC: SAS Institute Inc. 2006. http://www2.sas.com/proceedings/sugi31/206-31.pdf.

Genç Y, Gökmen D, Tüccar E, YagMurlu B. Estimation of sensitivity and specificity for clustered data. Turk J Med Sci. 2004;35:21-4.

Pollak AW, Norton PT, Kramer CM. Multimodality imaging of lower extremity peripheral arterial disease: Current role and future directions. Circ Cardiovasc Imaging. 2012;5(6):797–807. PMID: 23169982. PMCID: PMC3504350. https://doi.org/10.1161/CIRCIMAGING.111.970814.

Gerhard-Herman MD, Gornick 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. J Am Coll Cardiol. 2017;135(12):e686-e725. PMID: 27840332. PMCID: PMC5479414. https://doi.org/10.1161/CIR.0000000000000470.

Kasper DL, Fauci AS, Hauser SL, eds. Harrison's Principles of Internal Medicine, 19th ed. New York: McGraw Hill Education, 2015.

Criqui MH, Aboyans V. Epidemiology of peripheral artery disease. Circ Res. 2015;116(9):1509-26. PMID: 25908725. https://doi.org/ 10.1161/CIRCRESAHA.116.303849.



How to Cite

Siao, R. M., So, M. J., & Gomez, M. H. (2018). Pulse Oximetry as a Screening Test for Hemodynamically Significant Lower Extremity Peripheral Artery Disease in Adults with Type 2 Diabetes Mellitus. Journal of the ASEAN Federation of Endocrine Societies, 33(2), 130. Retrieved from https://asean-endocrinejournal.org/index.php/JAFES/article/view/457



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