The index of ankle pressures is a non-invasive diagnostic method, thanks to which the doctor obtains information about the ratio of arterial pressures on the upper and lower extremities. This is the most reliable way to detect ICHDK. At the conference Primary Care Congress si MUDr. Ondřej Sobotka spoke with the managing director of Compek Medical Services, s. r.o., which offers practitioners an effective tool for this examination.

Today I would like to welcome our next guest in front of the camera, which is Petr Čermák from Compek.

Thanks, hi.

I have a weakness for devices, and I already use a few things in the office, but I don't have a “baby” there yet. I wanted to ask you if you could tell us what the hell it is. Ankle Brachial Index is what the device can do and why should I buy it as a practitioner?

It is a simple screening for ischemic disease of the lower extremities. The “treatment” does not hurt, and if it is late, the patient usually has a very short claudication distance and then it is about some necessary interventions. When it comes to it on time, it's generally better for everyone, and our device can help a lot.

Do you have any numbers or studies to prove that it is medically worthwhile?

The study was one, conducted in collaboration with the Czech Society of Angiology and the Society of General Medicine. It took off around 2008, ran until 2012, and was the basis for later establishing the 12024 power code. In this study, 13.5% of ICHDK was estimated in a cross-sectional population over 50 years of age. It was originally called Moje ICHDK, but Associate Professor Karetová got it into an impacted magazine and with that they renamed it to The Czech ABI Project. The numbers are certainly traceable, and I think it worked out very nicely. To this day, I remember Mrs. Dr. Karetová running from one lecture to another around our booth during the cardio congress and saying, guys, it worked out well, I'm going to stop. These are the things that flourish to man.

I love how technology helps us detect various diseases more and more quickly.

At the time when the MOET ICHDK project (monitoring effective therapy of ischemic disease of the lower extremities) began, pocket dopplers were used for diagnosis. But it turned out to be absolutely useless for a practitioner, because it takes time. I remember a workshop with angiologist Dr. Muchová. Someone from the local doctors invited a patient there, which completely smashed the workshop. He was a gentleman with an AB index, I think, somewhere around 0.3-0.4, which is a heavy ICHDK, and before the doctor measured him with doppler, it was after the workshop, because the examination took about half an hour.

This is not really applicable to the practitioner.

In Germany, the Get ABI study was running and it turned out that dopplers aren't a pathway there either. Professor Diehm established a collaboration with Boso and together they developed the first device called Boso AbiStop. We're talking about 2007, 2008 roughly like that. Well, there was still a long way to go, about seven years before the code, which has existed since January 1, 2014, was even created.

You mentioned Germany. What is the experience of this examination abroad? Is it carried out, is it part of some standard examination?

We were the first country to have a performance code. This is due thanks to the Czech Angiological Society and the Association of General Practitioners of the Czech Republic, where Dr. Šonka was already behind this. In Germany, this is the standard for general practitioners. I know that Boso sells a lot of its instruments in the Nordic countries as well, so I think it is a widely used examination in Europe over the last decade. It used to be done as well, but probably only in professional workplaces.

Is it an examination that can be done by a general practitioner?

I would correct you, of course a doctor can do it too, but it is an examination that a trained nurse can handle without any problems.

And how long does it take?

The examination takes one, maximum two minutes. It's simple, quick, four cuffs are put on four limbs and the nurse presses a button that measures all four pressures. And the device, or rather the utility software, calculates everything.

So you get some protocol out of this?

The log comes out of it, AB index on the right, AB index on the left. And there are clearly defined limits. What is above 0.9 is physiological, what is below 0.9 is pathological, and the device will determine any ICHDK levels — light, moderate, severe. According to this, the doctor already arranges further and sends the patient to a specialized workplace.

Your company sells an instrument for measuring AB index. Is there still competition?

Of course, during the time Boso developed and manufactured this device, several competing devices appeared, which are already sold on the Czech market today.

I wonder frame-wise, how do the acquisition costs for such a device move?

We offer the device in two variants. One is the basic ABI, the other variant is with pulse wave velocity measurement, which is not yet addressed much in the Czech Republic. But I think it's a shame, because that's another cardiovascular risk factor that would fit very well into the whole screening process. The basic device costs about 60 thousand, the more expensive one about 90 thousand.

This is realizable. You mentioned that the insurance company is already paying for the performance at the moment. What do I need as a practitioner to contract that performance?

In order to get the 12024 power code, you need proof of charge of the device, a declaration of conformity and an application that you send to the health insurance company.

You give me the first two things. I have to write a request. Don't you want to send it right away with the request?

We will provide it to you with the training protocol. They might want you that one, too.

What is the current rate roughly?

We are talking about March 2024, the reimbursement is 159 points. Times the value of the points you have as practitioners. And with this reimbursement, the payback is roughly that after 380 examinations.

Can you tell by eye how long it will take for my investment in the device to return?

If you have a plus-minus 2,000 patients on your ward, that's probably a year.

Are there any additional costs associated with the operation?

It's an electrical device, so of course energy. In addition, the ABI measures pressure, so it is a set gauge. Once every two years, you need to do a safety and technical inspection and metrological verification of the accuracy of the pressure measurement. This operation costs zhruba2500, -. And so that you do not have to send the devices outside the office, we have technicians who drive around the offices and do BTK and metrology on site. You just need to always get to the doctor's office.

Well, that can be a problem.

Time management is sometimes quite complicated.

You need to try to book into that office through the Emmys.

Well, that's what I did. It would be a solution. But it would have to have the Emmys 100 percent coverage in the marketplace. Then it would be good.

You can make a fuss about it. You mentioned two types of devices, the basic one and the one with the pulsed wave. What type of examination is this? What will it bring us and what is the output from it?

The output is two numbers. One is on the right limb, the other on the left. They show the speed of blood flow in the vascular system. This has its given limits. When the aortic wall is rigid, then the blood flows faster here. The faster it is, the stiffer the wall and thus represents a more risky condition for the patient.

Is this taken as the first symptom of atherosclerosis?

The patient can have a beautiful ABI because he will have the pressures on the lower upper limbs a lot similar. But it is precisely from the speed of blood flow that we can tell that the wall is rigid and thus catch another marker of risk.

Are there any values already set?

When it comes to carotid femoral pulse velocity, there is a limit of 10 meters per second. And when it's brachial ankle, so there is 14.5 meters per second. When it is over the limit, it needs to be taken into account in relation to the general condition of the patient.

And so, the output is some index, a number that expresses a certain increased risk of atherosclerosis. For me as a practitioner, this should mean being more rigorous in the treatment of hypertension, diabetes, hyperlipidemia. Are there any “guidelines” for this, or have they not been set yet in the Czech Republic?

In Slovakia, the code of performance already has concern for hypertensive patients. And there is automatically ABI plus pulse wave speed. In the Czech Republic there is the code 11112, which is the internist performance code. But it is not yet shared with the expertise of general medicine, only with the angiological codes, or with the angiological or cardiological expertise.

My question was more about whether the guidelines are already set. That is, if the value of this index were somehow increased, the speed of the pulse wave would be higher, does this mean that I need to be more strict with the administration of a statin in such a patient, or with the treatment of pressure to reach even lower values, because there are already early signs of atherosclerosis?

Personally, I think it's completely unrelated to the pressure, because the ABI can be really beautiful, there can be the same pressures on the lower and upper limbs, but by making that wall stiffer, there's probably going to be a greater susceptibility to mediocalcinosis. Or it will be a patient who may already be approaching some type of diabetes and so on. You have to treat yourself as a doctor, I'm a technician. Here in the Czech Republic, pulse velocity is still a cinder. So far I know that the code exists, it is made a little bit on another device, but in Slovakia, let's say 95% of devices with a pulse wave. Here in the Czech Republic, about 40-50 doctors have a pulse wave, here it is really not enough yet. But people are asking about it. In addition, during the installation of the device, we had the experience that we tested a volunteer as part of the personnel we trained, the ABI came out beautiful, but the pulse wave was out of tolerance.

Well, yeah, a healthy patient is just a poorly examined patient. So if we try something on ourselves, of course we will come up with anything. I have to say that you have confused me quite a bit, and I think that if I were considering “Abička”, I would have thought directly about the pulsed wave variant.

It's probably a similar situationas today with ultrasounds. Anyone who wants to increase the credit of the ambulance will get an ultrasound, even if the insurance company will not pay him, but he will do something extra for his patient. And for this you will not need so much requested care.

Of course, the sooner I catch the patient, the sooner I start treatment and I'm more likely not to end up with the intervention. That sounds good. Peter, I thank you. It was interesting. One does not have to follow all the trends. And especially with the technology, we don't see everything. Therefore, I am glad that we also meet with people from companies at conferences, and that you can tell us anything about it from the point of view of engineers. Perhaps some colleagues will also be inspired by this and wonder if ABI in the office makes sense for them.

I thank you for inviting me. It was my first interview and it was enjoyable. Thanks.

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