Exercise ABI, post-exercise testing, and handling noncompressible arteries
Applied
Type
AdditionConfidence
90%
Created
Mar 19, 2026
Evidence
1 source
Rationale
The 2025 ACC Scientific Statement provides updated guidance specifically for patients with diabetes, who are at high risk for medial arterial calcification and noncompressible arteries. Integrating this evidence reinforces the importance of TBI and exercise testing in this population and provides specific diagnostic thresholds (TBI <0.70) that were missing from the original text.
Evidence
Content Changes
removedadded
**Exercise ankle-brachial index (ABI) and Noncompressible Arteries** When clinical symptoms suggest peripheral arterial disease (PAD) but the resting ABIankle-brachial index (ABI) is normal, post-exercise testing should be performed using treadmill or heel-raise protocols. A decrease in ABI ≥20% or an ankle pressure drop ≥30 mmHg after exercise supports the diagnosis of peripheralPAD arterial[@aboyans2012] disease[@aha2016]. (PAD).In [@aboyans2012]patients [@aha2016]with diabetes, exercise testing is particularly valuable as resting hemodynamics may be masked by arterial stiffness [@acc2025-c]. An ABI >1.40 indicates noncompressible arteries due to medial arterial calcification.calcification (MAC), a condition highly prevalent in patients with diabetes and chronic kidney disease (CKD) [@acc2025-c]. In such cases, toe systolic pressure and toe-brachial index (TBI) should be measured, as these metrics are less affected by calcification. A TBI <0.70 is generally considered diagnostic for PAD, while a toe pressure <30 mmHg suggests severe ischemia in chronic limb-threatening ischemia (CLTI).(CLTI) [@potier2011] [@mills2014] [@conte2019-gvg] [@acc2025-c].