Abstract Body: Resting ankle-brachial-index (ABI) is used to diagnose peripheral artery disease (PAD). Provocative maneuvers can increase the sensitivity of ABIs. Traditionally, treadmill exercises served as provocative maneuvers, but heel-toe exercises may offer a simpler alternative. Hyperlipidemia (HLD) is a well-established risk factor for vascular disease, yet its relationship with PAD severity remains inconsistent. We evaluated the relationship between lipid profile and PAD severity using heel-toe provocative ABI testing with duplex ultrasound correlation.

Retrospective analysis was performed on 1014 patients with resting and heel-toe provocative ABI testing. PAD severity was defined as moderate (50-74% stenosis) or severe (≥75% stenosis) based on lower extremity arterial duplex ultrasound. Provocative ABI criteria included post-exercise ABI<0.90. Diagnostic performance was assessed with sensitivity, specificity, positive and negatives predictive values (PPV and NPV), and area under the receiver operating characteristic curve (AUC). HLD was defined as those on antilipidemic therapy or with LDL >130. Lipid levels (LDL, Tchol) were compared across PAD severity (moderate, severe) categories.

LDL and Tchol levels were not consistently elevated in patients with moderate or severe PAD compared to those without PAD. LDL and Tchol levels were significantly lower in patients with moderate and severe PAD compared to those without PAD (p<0.02). Statin usage was significantly higher in patients with moderate and severe PAD (p<0.01) than those without PAD. Interestingly, a right–left limb asymmetry was observed in the association between categorical HLD and moderate PAD; HLD as a categorical variable was associated with moderate PAD in the right limb (p=<0.03) alone.

In this large cohort evaluated with heel-toe provocative ABI testing, lower LDL and total cholesterol levels were observed in patients with moderate and severe PAD, largely reflecting the significantly higher rates of statin therapy in this group. These findings underscore the confounding impact of lipid-lowering therapy when interpreting lipid values in PAD populations. Continuous lipid measures may more accurately reflect residual vascular risk than binary hyperlipidemia categorization, particularly when used alongside functional testing such as heel-toe ABI provocations.