Incremental value of bilateral ankle-brachial index for ten-year heart and cerebrovascular mortality prediction: an exploratory temporal benchmark in NHANES
- 1Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China
Abstract
Background: Ankle-brachial index (ABI) is associated with systemic vascular disease, but its incremental predictive value depends on the clinical comparator, endpoint and validation design. Objective: To test whether a bilateral ABI feature block improves a nonlaboratory clinical benchmark for ten-year death from diseases of the heart or cerebrovascular disease, and whether a limited nonlinear learner improves the same chronological evaluation. Methods: We rebuilt public NHANES 1999-2004 examination data linked to the 2019 public-use mortality file. Adults aged at least 40 years with bilateral ABI values in [0.20, 2.50] and ascertainable 120-month status formed a survey-weighted analytic subset. Models were trained on 1999-2002, tuned within development cycles, and evaluated on 2003-2004. Primary models were linear clinical logistic regression, flexible clinical logistic regression, flexible clinical plus ABI regression, and histogram gradient boosting plus ABI. Point estimates used full evaluation weights; conditional intervals used 32-replicate Fay balanced repeated replication with 15 design degrees of freedom. The study was not prospectively registered. Results: The corrected cohort contained 6,807 participants (4,617 development; 2,190 temporal evaluation) and 409 primary events, including 139 in evaluation. Evaluation AUROC was 0.834 for flexible clinical regression and 0.834 after ABI addition. The paired ABI increment was -0.0007 (95% CI -0.0047 to 0.0032); the paired Brier difference was 0.0008 (95% CI -0.0003 to 0.0018). Boosting plus ABI had AUROC 0.822; versus regression with the same predictor block, its AUROC difference was -0.0117 (95% CI -0.0379 to 0.0144). Its Brier difference was -0.000661 (95% CI -0.001322 to -7.53e-08); the upper limit was extremely close to zero. Neither primary hypothesis of improvement in both metrics was supported. Conclusions: In this corrective, exploratory chronological benchmark, bilateral ABI did not improve discrimination or Brier score beyond a matched flexible clinical model. The result does not negate ABI associations, establish equivalence, or support treatment decisions. It supports transparent evaluation of incremental information in a new cohort rather than claims of clinical utility.
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BibTeX
@misc{you2026incremental,
title = {{Incremental value of bilateral ankle-brachial index for ten-year heart and cerebrovascular mortality prediction: an exploratory temporal benchmark in NHANES}},
author = {L. You and Y. Guo and X. Zhong and Z. Peng and W. Wang and L. Shen and J. Ge},
howpublished = {medRxiv},
year = {2026},
month = oct,
doi = {10.64898/2026.10.30.26366960},
url = {https://www.medrxiv.org/content/10.64898/2026.10.30.26366960v1},
note = {CC BY},
}
RIS
TY - UNPB
TI - Incremental value of bilateral ankle-brachial index for ten-year heart and cerebrovascular mortality prediction: an exploratory temporal benchmark in NHANES
AU - L. You
AU - Y. Guo
AU - X. Zhong
AU - Z. Peng
AU - W. Wang
AU - L. Shen
AU - J. Ge
PY - 2026
DA - 2026/10/30
PB - medRxiv
DO - 10.64898/2026.10.30.26366960
UR - https://www.medrxiv.org/content/10.64898/2026.10.30.26366960v1
AB - Background: Ankle-brachial index (ABI) is associated with systemic vascular disease, but its incremental predictive value depends on the clinical comparator, endpoint and validation design. Objective: To test whether a bilateral ABI feature block improves a nonlaboratory clinical benchmark for ten-year death from diseases of the heart or cerebrovascular disease, and whether a limited nonlinear learner improves the same chronological evaluation. Methods: We rebuilt public NHANES 1999-2004 examination data linked to the 2019 public-use mortality file. Adults aged at least 40 years with bilateral ABI values in [0.20, 2.50] and ascertainable 120-month status formed a survey-weighted analytic subset. Models were trained on 1999-2002, tuned within development cycles, and evaluated on 2003-2004. Primary models were linear clinical logistic regression, flexible clinical logistic regression, flexible clinical plus ABI regression, and histogram gradient boosting plus ABI. Point estimates used full evaluation weights; conditional intervals used 32-replicate Fay balanced repeated replication with 15 design degrees of freedom. The study was not prospectively registered. Results: The corrected cohort contained 6,807 participants (4,617 development; 2,190 temporal evaluation) and 409 primary events, including 139 in evaluation. Evaluation AUROC was 0.834 for flexible clinical regression and 0.834 after ABI addition. The paired ABI increment was -0.0007 (95% CI -0.0047 to 0.0032); the paired Brier difference was 0.0008 (95% CI -0.0003 to 0.0018). Boosting plus ABI had AUROC 0.822; versus regression with the same predictor block, its AUROC difference was -0.0117 (95% CI -0.0379 to 0.0144). Its Brier difference was -0.000661 (95% CI -0.001322 to -7.53e-08); the upper limit was extremely close to zero. Neither primary hypothesis of improvement in both metrics was supported. Conclusions: In this corrective, exploratory chronological benchmark, bilateral ABI did not improve discrimination or Brier score beyond a matched flexible clinical model. The result does not negate ABI associations, establish equivalence, or support treatment decisions. It supports transparent evaluation of incremental information in a new cohort rather than claims of clinical utility.
ER -