1. HIV infection and the risk of peripheral artery disease
Matthew S. Freiberg, Meredith S. Duncan, Amy Justice, and Joshua Beckman
IAS 2017
Potpourri of Comorbidities
Paris, France
July 26th, 2017

2. Disclosures
None

3. Background: Peripheral Artery Disease (PAD)
202 million people worldwide and ~8 million people in the US suffer from PAD1
PAD is second largest clinical manifestation of atherosclerosis2
Individuals with PAD have increased risk of Major Adverse Cardiovascular Events (MACE) events3
You will need to tell people what MACE and MALE are…. Not what this rate is…..5% of what…..
1Fowkes, FG. Lancet 2013; 2Criqui, M. Circ Res 2015; 3Fowkes, FG JAMA 2008

4. Background: HIV and the risk of cardiovascular diseases
HIV is associated with an increased risk of
Acute myocardial infarction1
Ischemic Stroke2
Both reduced and preserved systolic ejection fraction heart failure3
Whether HIV infected people have an increased risk of PAD as compared to uninfected people is not clear
1 Freiberg et al. JAMA IM 2013; 2 Chow JAIDS 2012; 3Freiberg et al. JAMA cardiology 2017

5. Methods
We analyzed data on 92,287 VACS participants (32% HIV+) without prevalent CVD.
Follow up from 4/1/2003 until a PAD event, death, their last follow-up date, or 12/31/2011.
We used ICD-9 and CPT codes to identify participants with incident PAD.1
1 Bali et al. Vascular Medicine 2016

6. Methods continued Cumulative incidence of PAD (plots) by HIV status
Cox proportional hazard models to assess
HIV and PAD
time updated CD4 and HIV VL and PAD
Mortality risk after development of PAD by HIV status using KM curves

7. Demographic Characteristics of VACS participants stratified by HIV Status
Baseline Characteristic
HIV Infected
(n = 29,291)
HIV Uninfected (n = 62,996)
Mean Age years (SD)
47.6 (9.7)
48.1 (9.5)
Male sex, %
97.1
96.8
Race/ethnicity, %
African American
48.5
48.3
White
38.8
38.1
Hispanic
7.2
8.0
Other
5.5
5.6

8. Baseline comorbidities of VACS participants stratified by HIV Status
Characteristics (%)
HIV Infected
(n = 29,291)
HIV Uninfected (n = 62,996)
Hypertension
 50.4
62.7 
Diabetes mellitus
 8.9
13.0 
LDL cholesterol >160 mg/dL
7.6
12.1
HDL cholesterol <40 mg/dL
50.9
37.2
Triglycerides >150 mg/dL
45.8
37.4
Current Smoking
56.2
50.6
HCV infection
29.3
12.5
eGFR >60 mL/min/1.73m2
94.8
96.2
Obesity (BMI > 30 kg/m2)
15.1
39.1
Hemoglobin >14
56.8
74.2
History of Alcohol Abuse
24.8
26.7
History of Cocaine Abuse
18.9
15.5
COPD
8.0
8.2

9. Baseline comorbidities of VACS participants stratified by HIV Status
Characteristics (%)
HIV Infected
(n = 29,291)
HIV Uninfected (n = 62,996)
Hypertension
 50.4
62.7 
Diabetes mellitus
 8.9
13.0 
LDL cholesterol >160 mg/dL
7.6
12.1
HDL cholesterol <40 mg/dL
50.9
37.2
Triglycerides >150 mg/dL
45.8
37.4
Current Smoking
56.2
50.6
HCV infection
29.3
12.5
eGFR >60 mL/min/1.73m2
94.8
96.2
Obesity (BMI > 30 kg/m2)
15.1
39.1
Hemoglobin >14
56.8
74.2
History of Alcohol Abuse
24.8
26.7
History of Cocaine Abuse
18.9
15.5
COPD
8.0
8.2

10. Baseline comorbidities of VACS participants stratified by HIV Status
Characteristics (%)
HIV Infected
(n = 29,291)
HIV Uninfected (n = 62,996)
Hypertension
 50.4
62.7 
Diabetes mellitus
 8.9
13.0 
LDL cholesterol >160 mg/dL
7.6
12.1
HDL cholesterol <40 mg/dL
50.9
37.2
Triglycerides >150 mg/dL
45.8
37.4
Current Smoking
56.2
50.6
HCV infection
29.3
12.5
eGFR >60 mL/min/1.73m2
94.8
96.2
Obesity (BMI > 30 kg/m2)
15.1
39.1
Hemoglobin >14
56.8
74.2
History of Alcohol Abuse
24.8
26.7
History of Cocaine Abuse
18.9
15.5
COPD
8.0
8.2

11. Baseline HIV specific biomarkers of VACS participants stratified by HIV Status
HIV Infected
(n = 29,291)
Median CD4 Cell count, mm
383 
Median HIV-1 RNA, copies/mL
1320 
ART regimen, %
NRTI + PI
23.5
NRTI + NNRTI
15.1
Other
4.9
No ART
56.5

12. Unadjusted Cumulative Incidence of PAD by HIV Status

13. Adjusted Risk of PAD among HIV+ and uninfected veterans

14. Hazard Ratio [95% CI]* P value
Adjusted Risk of PAD among HIV+ and uninfected veterans stratified by time updated CD4 cell count
HIV and CD4 cell count status
Hazard Ratio [95% CI]*
P value
Uninfected
1.0
CD4 count >500
1.08 [ ]
0.08
CD4 count
1.24 [ ]
<0.001
CD4 count<200
1.73 [ ]
*adjusted for age, sex, race/ethnicity, hypertension, diabetes, LDL and HDL cholesterol, triglycerides, HCV infection, smoking status, renal disease, obesity, anemia, cocaine dependence or abuse, alcohol dependence or abuse, and COPD

15. HIV specific biomarkers and the risk of incident PAD among HIV+ Infected Veterans
Characteristic
Hazard Ratio [95% CI]
Using Baseline
Covariates*
Time-Updated
CD4 and VL*
CD4 Cell count, mm
vs. >500
1.03 [0.92, 1.15]
1.13 [1.02, 1.25]
<200 vs. >500
1.13 [0.99, 1.30]
1.50 [1.30, 1.74]
HIV-1 RNA, copies/mL
>500 vs. <500
1.04 [0.91, 1.18]
1.19 [1.05, 1.34]
*adjusted for age, sex, race/ethnicity, hypertension, diabetes, LDL and HDL cholesterol, triglycerides, HCV infection, smoking status, renal disease, obesity, anemia, cocaine dependence or abuse, alcohol dependence or abuse, and COPD and ART regimen (NTRI+PI vs. No ART, NRTI+NNRTI vs. No ART, other vs. No ART).

16. Mortality risk following PAD Diagnosis stratified by HIV status and HIV biomarkers
The 690 HIV infected individuals with missing CD4+ T cell count at the time of PAD were excluded from Panel A. The 688 HIV infected individuals with missing viral load at the time of PAD were excluded from panel B

17. Limitations
There is no agreement in the literature for the exact ICD-9 and CPT codes to use to define PAD
Stratified Analyses of mortality risk by HIV viral load and CD4 cell count are at time of PAD diagnosis and not time updated
Our sample is overwhelming male

18. Summary
HIV is infection is associated with an increased risk of incident PAD even after adjustment for traditional CVD risk factors
Among HIV infected veterans, those with higher HIV viral loads and lower CD4 cell counts have the highest risk of PAD
PAD has impact on mortality risk and is greatest among those with immunodeficiency or unsuppressed virus

19. Acknowledgements Consortium PI : AC Justice*
Scientific Collaborator (NIAAA): K Bryant
Affiliated PIs: S Braithwaite, K Crothers*, R Dubrow, DA Fiellin*, M Freiberg*, V LoRe*, K Kraemer
Participating VA Medical Centers: Atlanta (V Marconi*), Baltimore (M Sajadi, R Titanji), Bronx (S Brown, Y Ponomarenko), Dallas (R Bedimo*), Houston (M Rodriguez-Barradas, N Masozera), Los Angeles (M Goetz, D Leaf), Manhattan-Brooklyn (M Simberkoff, D Blumenthal, H Leaf, J Leung), Pittsburgh (A Butt, K Kraemer, E Hoffman), and Washington DC (C Gibert, R Peck)
Core and Workgroup Chairs: B Agan, W Becker, C Brandt, J Edelman, J Goulet, B Gulanski, K McGinnis, KA Oursler, L Park, C Rinaldo, K Sigel, J Tate, E Wang, F P Wilson, J Womack
Staff: H Bathulapalli, T Bohan, J Ciarleglio, A Consorte, L Erickson, S Felter, C Frank, K Gordon, J Huston, F Kidwai-Khan, G Koerbel, F Levin, S Shahrir, M Skanderson
Major Collaborators: VA Public Health Strategic Healthcare Group, VA Pharmacy Benefits Management, Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), Yale Center for Interdisciplinary Research on AIDS (CIRA), Center for Health Equity Research and Promotion (CHERP), ART-CC, NA-ACCORD, HIV-Causal
Cross Cohort Collaborators: Richard Moore (NA-ACCORD), Jonathan Sterne (ART-CC), Brian Agan (DoD), Miguel Hernan (HIV-Causal)
Major Funding by: National Institutes of Health: AHRQ (R01-HS018372), NIAAA (U24-AA020794, U01-AA020790, U01-AA020795, U01-AA020799, U24- AA022001, U24 AA022007, R01-AA023733, R01AA022886, U10 AA completed), NHLBI (R01-HL125032, R01-HL126555, R01-HL126557, R01- HL129856, R56-DK108352, R01-HL completed, R01-HL completed) , NIAID (U01-A ), NIDA (R01DA035616, R03DA completed) , NCI (R01 CA173754, R01 CA206465) and the Veterans Health Administration Office of Research and Development (i01 BX003341, 1 I50 HX001234, VA IRR Merit Award), Office of Rural Health, and Office of Academic Affiliations (Medical Informatics Fellowship)
*Indicates individual is also the Chair of a Core or Workgroup

20. Questions

21. Extra Slides

22. Stratified by HIV Status
Rates and Risk of PAD among HIV+ and uninfected veterans (Surgical Indications only)
Stratified by HIV Status
Group N
PAD Events
Rate/1000PY
[95% CI]
Unadjusted PAD Risk [95% CI]
Adjusted PAD Risk
HIV-
62,996
306
0.81 [0.72, 0.91]
1.00
HIV+
29,291
203
1.22 [1.06, 1.40]
1.52 [1.27, 1.82]
1.29[1.06, 1.58]

23. More detailed Table 1

24. Table 3. Associations between Clinical Characteristics and Incident PAD among HIV-Infected Veterans
Hazard Ratio [95% CI]
Using Baseline
Covariates
Time-Updated
CD4 and VL
Age, 10 years
1.49 [1.41, 1.58]
1.50 [1.42, 1.59]
Male sex
1.09 [0.80, 1.48]
1.07 [0.79, 1.46]
Race/ethnicity
African American vs. White
0.95 [0.85, 1.06]
0.94 [0.84, 1.05]
Hispanic vs. White
0.93 [0.78, 1.11]
Other vs. White
0.82 [0.62, 1.08]
0.82 [0.62, 1.07]
Hypertension
Controlled vs. None
1.29 [1.15, 1.45]
1.31 [1.16, 1.47]
Uncontrolled vs. None
1.55 [1.38, 1.73]
1.55 [1.39, 1.74]
Diabetes mellitus
Diabetes without Insulin vs. None
1.62 [1.40, 1.87]
1.64 [1.40, 1.91]
Diabetes with Insulin vs. None
1.98 [1.64, 2.38]
2.00 [1.66, 2.41]

25. Table 3. Associations between Clinical Characteristics and Incident PAD among HIV-Infected Veterans p.2
Characteristic
Hazard Ratio [95% CI]
Using Baseline
Covariates
Time-Updated
CD4 and VL
Lipids, mg/dL
LDL cholesterol: vs. <100
1.01 [0.90, 1.14]
1.02 [0.90, 1.15]
LDL cholesterol: vs. <100
1.16 [1.02, 1.33]
1.18 [1.03, 1.35]
LDL cholesterol: >160 vs. <100
1.09 [0.91, 1.30]
1.11 [0.92, 1.33]
HDL cholesterol: vs. >60
0.92 [0.79, 1.08]
0.92 [0.78, 1.08]
HDL cholesterol: <40 vs. >60
1.00 [0.81, 1.23]
0.99 [0.81, 1.22]
Triglycerides: >150 vs. <150
1.12 [0.99, 1.26]
1.13 [1.00, 1.27]
Smoking
Current vs. Never
1.47 [1.30, 1.66]
1.46 [1.29, 1.66]
Former vs. Never
1.12 [0.95, 1.32]
1.12 [0.95, 1.33]
HCV infection
1.45 [1.31, 1.61]
1.43 [1.30, 1.59]

26. Table 3. Associations between Clinical Characteristics and Incident PAD among HIV-Infected Veterans p.3
Characteristic
Hazard Ratio [95% CI]
Using Baseline
Covariates
Time-Updated
CD4 and VL
Renal disease, mL/min/1.73m2
eGFR vs. >60
1.65 [1.38, 1.98]
1.64 [1.36, 1.98]
eGFR <30 vs. >60
4.12 [3.13, 5.43]
4.07 [2.94, 5.65] 
Obesity, BMI > 30 kg/m2
0.96 [0847, 1.10]
0.98 [0.85, 1.12]
Anemia, g/dL b
Hemoglobin vs. >14
1.20 [1.08, 1.33]
1.18 [1.07, 1.31]
Hemoglobin vs. >14
1.53 [1.29, 1.81]
1.49 [1.26, 1.76]
Hemoglobin <10 vs. >14
1.83 [1.36, 2.47]
1.77 [1.30, 2.41]
Bilirubin, mg/dL
0.98 [0.89, 1.08]
0.98 [0.90, 1.08]
History of Alcohol Abuse
1.03 [0.90, 1.18]
1.03 [0.90, 1.17]
History of Cocaine Abuse
1.15 [1.00, 1.32]
1.13 [0.98, 1.30]
COPD
1.46 [1.28, 1.66]
1.44 [1.26, 1.66]

27. Baseline HIV specific biomarkers of VACS participants stratified by HIV Status
HIV Infected
(n = 29,291)
CD4 Cell count, mm b
Mean (SD)
425.3 (297.7)
Median
383.0
HIV-1 RNA, copies/mL b
( )
1320.0
ART regimen, %
NRTI + PI
23.5
NRTI + NNRTI
15.1
Other
4.9
No ART
56.5

28. HIV and the risk of PAD additional data

29. Stratified by HIV Status
Rates and Risk of Peripheral Arterial Disease among HIV+ and uninfected veterans
Stratified by HIV Status
Group N
PAD Events
Rate/1000PY
[95% CI]
Unadjusted PAD Risk [95% CI]
Adjusted PAD Risk
[95% CI]b
HIV-
62,996
3412
9.3 [9.0, 9.6]
1.00
HIV+
29,291
1950
12.0 [11.5, 12.6]
1.31 [1.24, 1.38]
1.23 [1.16, 1.31]
Stratified by HIV Status and CD4 Cell Count
HIV+, CD4>500
8381
547
10.8 [9.9, 11.7]
1.19 [1.09, 1.30]
1.18 [1.08, 1.29]
HIV+, 200<CD4<500
10,198
704
11.8 [10.9, 12.7]
1.29 [1.19, 1.39]
1.22 [1.12, 1.33]
HIV+, CD4<200
5743
402
14.0 [12.7, 15.5]
1.57 [1.42, 1.74]
1.36 [1.21, 1.52]
HIV+, Missing CD4c
4969
197
12.9 [11.5, 14.4]
---
Stratified by HIV Status and Viral Load
HIV+, VL<500
11,056
828
12.4 [11.5, 13.2]
1.31 [1.21, 1.42]
1.17 [1.08, 1.28]
HIV+, VL >500
13,835
852
11.6 [10.9, 12.5]
1.30 [1.21, 1.41]
1.30 [1.20, 1.41]
HIV+, Missing VLc
4,400
270
12.2 [10.8, 13.8]
a CI = confidence interval; HIV = human immunodeficiency virus; PAD = peripheral arterial disease; PY = person years
b adjusted for age, sex, race/ethnicity, hypertension, diabetes, LDL and HDL cholesterol, triglycerides, HCV infection, smoking status, renal disease, obesity, anemia, cocaine dependence or abuse, alcohol dependence or abuse, and COPD.
c missing category used only for calculation of incidence rates. For models, missing CD4 cell counts and viral load were imputed

30. Data for those who developed PAD

31. Table S1. Baseline Characteristics of Veterans who developed PAD stratified by HIV Status
Baseline Characteristic a
Developed PAD (n = 5362)
HIV Infected
(n = 1950)
HIV Uninfected
(n = 3412)
Age, y
Mean (SD)
51.5 (8.9)
53.1 (8.5)
Median
51.0
53.0
Male sex, %
97.7
98.1
Race/ethnicity, %
African American
51.1
49.8
White
38.3
40.5
Hispanic
7.7
7.2
Other
2.9
2.6

32. Framingham Risk Factors, %
Table S1. Baseline Characteristics of Veterans who developed PAD stratified by HIV Status p.2
Framingham Risk Factors, %
Hypertension
None
34.0
21.1
Controlled
32.7
37.9
Uncontrolled
33.3
41.1
Diabetes mellitus
81.6
69.9
Diabetes without Insulin
11.6
17.6
Diabetes with Insulin
6.7
12.6
Lipids, mg/dL b
LDL cholesterol <100
45.3
34.6
LDL cholesterol
28.4
33.4
LDL cholesterol
17.8
20.8
LDL cholesterol >160
8.5
11.3
HDL cholesterol >60
12.2
14.1
HDL cholesterol 40-59
36.1
45.7
HDL cholesterol <40
51.7
40.3
Triglycerides >150
52.8
42.8
Smoking, % b
Current
64.1
62.7
Former
15.6
16.0
Never
20.3
21.3

33. Table S1. Baseline Characteristics of Veterans who developed PAD stratified by HIV Status p.3
Other risk factors, %
HCV infection, %
43.2
19.4
Renal disease, mL/min/1.73m2 b
eGFR >60
88.4
91.1
eGFR 30-59
8.3
7.1
eGFR <30
3.3
1.8
Obesity (BMI > 30 kg/m2) b, %
39.7
14.4
Anemia, g/dL b
Hemoglobin >14
50.6
65.9
Hemoglobin
35.2
27.8
Hemoglobin
11.3
5.3
Hemoglobin <10
3.0
1.0
Bilirubin, mg/dL
Mean (SD)
0.7 (0.5)
0.6 (0.4)
Median
0.6
History of Alcohol Abuse, %
31.2
33.7
History of Cocaine Abuse, %
25.7
18.8
COPD, %
13.9
13.7

34. HIV-specific variables c
Table S1. Baseline Characteristics of Veterans who developed PAD stratified by HIV Status p.4
HIV-specific variables c
CD4 Cell count, mm b
Mean (SD)
419.4 (310.4)
---
Median
364.0
HIV-1 RNA, copies/mL b
48,103.2 (131,572.7)
583.5
ART regimen, %
NRTI + PI
29.6
NRTI + NNRTI
18.8
Other
6.4
No ART
45.3
Atazanavir Usage
0.7
Abbreviations; ART, antiretroviral therapy; BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); COPD, chronic obstructive pulmonary disease; eGFR, estimated glomerular filtration rate; HCV, hepatitis C virus; HDL, high-density lipoprotein; HIV, human immunodeficiency virus; LDL, low-density lipoprotein; NNRTI, nonnucleoside reverse-transcriptase inhibitor; NRTI, nucleoside reverse-transcriptase inhibitor; PI, protease inhibitor
SI conversion factors: To convert HDL and LDL to millimoles per liter, multiply by ; hemoglobin to grams per liter, multiply by 10; and triglycerides to millimoles per liter, multiply by
a All characteristics were statistically different among HIV-infected and uninfected Veterans who developed PAD (P<.05) using χ2 test or Wilcoxon rank sum test except sex (P=0.3170), race/ethnicity (P=0.4063), smoking status (P=0.6918), COPD (P=0.8062), bilirubin (P=0.9948), and alcohol abuse (P=0.0666).
b All variables had complete data except the following: Hypertension data were available on 1929 (HIV-infected) and 3302 (uninfected); LDL cholesterol data were available on 1558 (HIV-infected) and 2699 (uninfected); HDL cholesterol data were available on 1603 (HIV-infected) and 2742 (uninfected); triglyceride data were available on 1649 (HIV-infected) and 2742 (uninfected); smoking data were available on 1276 (HIV-infected) and 2316 (uninfected); eGFR data were available on 1867 (HIV-infected) and 3135 (uninfected); BMI data were available on 1910 (HIV-infected) and 3240 (uninfected); anemia data were available on 1884 (HIV-infected) and 3087 (uninfected); bilirubin data were available on 1855 (HIV-infected) and 2988 (uninfected); CD4 cell count data were available on 1653 (HIV-infected); and HIV-1 RNA data were available on 1680 (HIV-infected).
c Because uninfected Veterans do not have HIV-specific biomarkers or ART regimens, these cells contain only dashes.

35. PAD mortality slide with missing data

36. Table S1. Mortality risk following PAD Diagnosis stratified by HIV status and HIV Biomarkers

37. PAD ICD-9 codes

38. ICD-9 Diagnosis and ICD-9 Procedure codes used in ascertaining PAD cases
Description
ICD-9 Diagnosis Codes
Atherosclerosis of Native Arteries of the Lower Extremities
440.20, , , , , , , , , 440.8, 440.9, 443.9
ICD-9 Procedure Codes
CPT Codes
Lower Extremity Amputation
84.10, 84.11, 84.12, 84.13, 84.14, 84.15, 84.16, 84.17, 84.18, 84.19, 84.91
27295, 27590, 27591, 27592, 27598, 27880, 27881, 27882, 27888, 27889, 28800, 28805
Lower Extremity Peripheral Angioplasty, Atherectomy, or Endarterectomy
38.81, 39.50
35302, 35303, 35304, 35305, 35306, 35331, 35351, 35355, 35361, 35363, 35371, 35372, 35381, 35452, 35454, 35456, 35459, 35470, 35472, 35473, 35474, 35481, 35482, 35483, 35485, 35491, 35492, 35493, 35495
Lower Bypass Peripheral Bypass
39.25, 39.29
35521, 35533, 35537, 35538, 35539, 35540, 35541, 35546, 35548, 35549, 35551, 35556, 35558, 35563, 35565, 35566, 35571, 35582, 35583, 35585, 35587, 35621, 35623, 35637, 35638, 35641, 35646, 35647, 35651, 35654, 35656, 35661, 35663, 35665, 35666, 35671
Repair, Exploration, Revision, Resection of Lower Extremity Arteries, or Thrombectomy of Graft
38.08, 38.38, 38.48, 39.49, 39.56, 39.57, 39.58
35226, 35286, 35700, 35721, 35741, 35876, 35879, 35881, 35883, 35884
Non-Coronary Vessel Percutaneous Transluminal Mechanical Thrombectomy, or Stents
39.90
37184, 37185, 37186, 37205, 37206, 37207, 37208
Diagnostic Procedures
38.29, 88.42, 88.48, 88.77
75630, 75631, 75710, 75711, 75712, 75716, 75717, 75718, 93925, 93926, 93978, 74175, 72191, 73706, 75635, 74185, 72198, 73725, 93922, 93924

39. ICD-9-CM Diagnosis Codes Used to Exclude Non-Atherosclerotic Causes of PAD and Procedures with NON-PAD Indications
Description
ICD-9 Diagnosis Codes
Non-Atherosclerotic Causes of PAD
237.70, , , , , 443.1, 446.0, 446.4, 446.5, 446.6, 446.7, 447.6, 710.1, 747.1, ,
Lower Extremity Trauma/Injury and Others
736.30, , , , 736.4, , , 736.5, 736.6, , , , , , , , , , , 736.9, 735.0, 735.1, 735.2, 735.3, 735.4, 735.5, 735.8, 735.9, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 755.4, , , , , , , , , , 755.8, 759.7, , 890.0, 890.1, 890.2, 891.0, 891.1, 891.2, 895.0, 895.1, 896.0, 896.1, 896.2, 896.3, 897.0, 897.1, 897.2, 897.3, 897.4, 897.5, 897.6, 897.7, , , , , , , , , , , , , , , , , 820.8, 820.9, , , , , , , , , , , , , , , 822.0, 822.1, , , , , , , , , , , , , , , , , , , , , , 824.0, 824.1, 824.2, 824.3, 824.4, 824.5, 824.6, 824.7, 824.8, 824.9, 825.0, 825.1, , , , , , , , , , , , , , , 826.0, 826.1, 827.0, 827.1, 828.0, 828.1, 829.0, 829.1, , , , , , , , , 836.0, 836.1, 836.2, 836.3, 836.4, , , , , , , , , , , , , 837.0, 837.1, , , , , , , , , , , , , , , , , 904.0, 904.1, 904.2, 904.3, , , , , , , , , 904.6, 904.7, 904.8, 904.9, , , , , , , 928.3, 928.8, 928.9, 929.0, 929.9, 959.6, 959.7, , , , , , , , , , , ,
Amputations with Not-PAD Indications
170.6, 170.7, 170.8, 170.9, 171.3, 172.7, , , , , 198.5, 344.1, , , , , , , , , , , 728.6, , , , , , , , , , , 736.5, 736.6, , , , , , , , , , , 736.9, 735.0, 735.1, 735.2, 735.3, 735.4, 735.5, 735.8, 735.9, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 755.4, , , , , , , , , , 755.8, 759.7, , 890.0, 890.1, 890.2, 891.0, 891.1, 891.2, 895.0, 895.1, 896.0, 896.1, 896.2, 896.3, 897.0, 897.1, 897.2, 897.3, 897.4, 897.5, 897.6, 897.7, , , , , , , , , , , , , , , , , 820.8, 820.9, , , , , , , , , , , , , , , 822.0, 822.1, , , , , , , , , , , , , , , , , , , , , , 824.0, 824.1, 824.2, 824.3, 824.4, 824.5, 824.6, 824.7, 824.8, 824.9, 825.0, 825.1, , , , , , , , , , , , , , , 826.0, 826.1, 827.0, 827.1, 828.0, 828.1, 829.0, 829.1, , , , , , , , , 836.0, 836.1, 836.2, 836.3, 836.4, , , , , , , , , , , , , 837.0, 837.1, , , , , , , , , , , , , , , , , 904.0, 904.1, 904.2, 904.3, , , , , , , , , 904.6, 904.7, 904.8, 904.9, 905.4, , , , , , , 928.3, 928.8, 928.9, 929.0, 929.9, 959.6, 959.7, , , , , , , , , , , ,

40. ABI procedure

41. Ankle Brachial Index values
ABPI value
Interpretation
Action
Nature of ulcers, if present
above 1.2
Abnormal Vessel hardening from PVD
Refer routinely
Venous ulcer use full compression bandaging
Normal range
None
Acceptable
Some arterial disease
Manage risk factors
Moderate arterial disease
Routine specialist referral
Mixed ulcers use reduced compression bandaging
under 0.50
Severe arterial disease
Urgent specialist referral
Arterial ulcer no compression bandaging used