Exercise ABI, post-exercise testing, and handling noncompressible arteries

in Vascular Diagnostics and Imaging

Applied

Type

Modification

Confidence

90%

Created

Mar 20, 2026

Evidence

1 source

Rationale

The 2025 ACC Scientific Statement provides updated, high-level evidence specifically regarding PAD management in diabetic patients, who represent the majority of cases involving noncompressible arteries. Integrating this evidence strengthens the section by identifying specific risk factors (DM, CKD) and providing the diagnostic TBI threshold (<0.70) which was missing from the original text.

Evidence

Das SR et al. Management of Peripheral Artery Disease in Adults With Diabetes: 2025 ACC Scientific Statement: A Report of the American College of Cardiology. J Am Coll Cardiol. 2025. PMID: 41405527.
Verified source
PubMedDOI

Content Changes

**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 peripheral arterial disease (PAD).PAD [@aboyans2012] [@aha2016] [@acc2025-j].

An ABI >1.40 indicates noncompressible arteries due to medial arterial calcification.calcification (MAC), a condition highly prevalent in patients with diabetes mellitus (DM) and chronic kidney disease (CKD) [@acc2025-j]. In such cases, toe systolic pressure and toe-brachial index (TBI) should be measured, as thesedigital metricsarteries are lessoften affectedspared byfrom calcification.MAC [@potier2011] [@mills2014] [@conte2019-gvg]. A TBI <0.70 is diagnostic of PAD, while a toe pressure <30 mmHg suggests severe ischemia in chronic limb-threatening ischemia (CLTI). [@potier2011](CLTI) [@mills2014] [@conte2019-gvg][@acc2025-j].
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