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THE DIABETIC FOOT:
A MIRROR OF THE
DIABETIC HEART
Ezio Faglia
Chief of research on
diabetic foot
IRCCS MultiMedica
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DIABETES : IS A PROBLEM ?DIABETES : IS A PROBLEM ?
King H, et al. Diabetes Care 1998
2025 20001995
Po
pu
lati
on
(m
illi
on
s)
developed developing total
100
300
200
0
250 millions
120 millions
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Wild S et al : Diabetes Care 27,1047-1053,2004
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DIABETIC FOOT
15-25% of the diabetics
will be affected by
a foot ulcer
during your life
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IT IS THE MOST FREQUENTLY CAUSE OF HOSPITALIZATION FOR DIABETICS
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DIABETIC FOOT PATIENTS: HISTORY
Brownrigg jr et al: Diabetologia 55:2906–2912, 2012
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INCREASED MORTALITY ASSOCIATED WITH THE ULCERATED DIABETIC FOOT
0
5
10
15
Deaths/100 persons/year
no DFU
DFU
***p<0.01*p<0.01
Boyko et al, Diabet Med 13: 1996Boyko et al, Diabet Med 13: 1996
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AGE AND DIABETIC FOOT
NEUROPATHIC:63.7 ± 9.4 YEARS
NEURO-ISCHEMIC:72.7 ± 9.2 YEARS
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NEUROPATHIC FOOT: SURVIVAL
Van Baal J et al: Diabetes Care 33:186-1089, 2010
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Hirsch et al: Am J Coll Cardiol 47:1239-1312,2006
NATURAL HISTORY OF PERIPHERAL ARTERIAL DISEASE
CLI
DISEASE-FREE AMPUTATED DEAD
1 YEAR LATER
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564 CLI DIABETICS: AMPUTATION AND DEATH
Faglia E et al: Diabetes Care 32:822-827, 2009
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cardiac disease 97 62.8%
stroke 21 13.4%
cancer 17 10.8%
abdominal disease 3 1.9%
renal insufficiency 4 2.5%
cirrhosis 2 1.3%
pneumonia 4 2.5%
geromarasmus 7 4.5%
septic shock 1 0.6%
suicide 1 0.6%
CAUSES OF DEATH IN 564 DIABETICS WITH CLI
Faglia E et al: Eur J Vasc Endovasc Surg. 2006; 32:484-90
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IS THERE ANYTHING COMMON BETWEEN PODIATRY AND CARDIOLOGIST ?
Il piede diabetico
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CENTER LEVEL 1: screening,
patients without foot ulcer
CENTER LEVEL 2 : patients with
mild lesions
CENTER LEVEL 3:
TREATMENT OF SEVERE LESIONS
REQUIRING ADMISSION
WHEN AND WHERE ?
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• IN HOSPITAL COMPLICATIONS
• SURGICAL RISK EVALUATION
• RESEARCH ?
IS THERE ANYTHING COMMON BETWEEN CARDIOLOGIST AND PODIATRY ?
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IN HOSPITAL COMPLICATIONS
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DEATH: 11, OF THESE 9 CARDIAC
6 CARDIAC ARREST (cardiopulmonary resuscitation)
1 SUDDEN DEATH AFTER PTA
2 REFRACTORY HEART FAILURE
1 MULTI ORGAN FAILURE
1 STROKE
IN HOSPITAL MORTALITY IN 1072 DIABETIC PATIENTS
ADMITTED FOR FOOT ULCER IN THE 2009-2010 YEARS
unpublished data
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COMPLICATIONS IN 1072 DIABETIC PATIENTS ADMITTED
FOR FOOT ULCER IN THE 2009-2010 YEARS
unpublished data
ICU ADMISSION:
29 ACUTE CORONARY SYNDROME
12 LEFT VENTRICULAR FAILURE
11 CARDIAC ARRHYTHMIA
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SURGICAL RISK EVALUATION
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ENDOLUMINAL 85.6% SURGICAL 11.1%
64% OF PATIENTS ADMITTED FOR FOOT ULCERUNDERWENT PERIPHERAL REVASCULARIZATION
Faglia E et al. Diabetes Res Clin Pract. 2012;95:364-71.
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RISK STRATIFICATION
Faglia E et al. Diabetes Res Clin Pract. 2012;95:364-71.
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SURGICAL RISK EVALUATION
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J Vasc Surg 2005
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GUIDELINES ACC/AHA, 20072007
ABOUT the 90% of the
diabetics with CLI have ≥ 3
clinical risk factors
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CHD unstable(ECG or symptoms)
ACUTE INFECTED FOOT(abscess, fasciitis, gas gangrene)
operating room
CHD stable(ECG or symptoms)
CHD asymptomatic(ECG or symptoms)
urgentcardiological examination
CARDIOLOGY UNIT ADMISSION
Patient admitted because of foot ulcer
(low surgical risk)
SI
NO
appropriate therapy
DIPARTIMENTO CARDIOVASCOLAREUO DI DIABETOLOGIA E
TRATTAMENTO DEL PIEDE DIABETICO
YES
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IS THERE ANYTHING COMMON BETWEEN CARDIOLOGIST AND PODIATRY ?
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PROLONGED STAY IN THE ICU AFTER CARDIAC SURGERY
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PROLONGED STAY IN THE ICU AFTER CARDIAC SURGERY
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ANKLE-BRACHIAL INDEX AND OUTCOMES IN BARI 2
Abbot JD et al: Am Heart J 164,585-590,2012
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ANKLE-BRACHIAL INDEXANKLE-BRACHIAL INDEX
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RESEARCH ?
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RESEARCH ?
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Wingard DL: Diabetes Care 1993. Balkau B: Lancet 1997. Most RS: Diabetes Care 1983. Faglia E :AHJ Wingard DL: Diabetes Care 1993. Balkau B: Lancet 1997. Most RS: Diabetes Care 1983. Faglia E :AHJ 2004. Diad study: Diabetes Care 2004. Sconamiglio R: 2004. Diad study: Diabetes Care 2004. Sconamiglio R: JACC 2006JACC 2006.. Kamalesh M: Clin. Cardiol
2009. Boyd CM: J Am Geriatr Soc 2011. Boonman-de Winter LJM: Diabetologia 2012.etc.etc
CAD E PAD IN DIABETES
2–4 x increased risk of heart disease
4-6 x increased risk of peripheral arteriopathy
compared with general population
20% silent
20% silent
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58
44
80
39
0
20
40
60
80
100
30-64 yy
NondiabeticsNondiabetics DiabeticsDiabetics
AUTOPTIC PREVALENCE OF CAD IN AUTOPTIC PREVALENCE OF CAD IN PATIENTS WITHOUT CLINICAL CADPATIENTS WITHOUT CLINICAL CAD
>65 yy
4950
69
19
0
20
40
60
80
100
30-64 yy >65 yy
% %
WomenWomenMenMen
p<0.01 p<0.01 p<0.01
Goraya. JACC 2002;40:946
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DIABETOLOGICAL GUIDELINES
American Diabetes Association Clinical Practice Recommendations 2013
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AMERICAN DIABETES ASSOCIATION: PAD in People With Diabetes
A screening ABI should be considered in
diabetic patients 50 years of age who have
other PAD risk factors (e.g., smoking,
hypertension, hyperlipidemia, or duration
of diabetes 10 years).
POSITION STATEMENTS Diabetes Care 2003
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WHY THIS DIFFERENCE ?
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CARDIOLOGICAL GUIDELINES
?€
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€
OVERALL SENSITIVITY OF 94%, SPECIFICITY OF 34%
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B-type natriuretic peptide as marker of mortality in diabetic patients with foot ulcer
SUBMITTED PAPER
HR 6.04,CI, 2.38-15.33
45/71 (63.4%)
died from cardiac cause .
Of these, 24 patients had
no history of CAD
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J Cardiovasc Med 9:1030-6, 2008
USING THE CLI TO CURE THE CAD?
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Patients with a history of CAD
and ejection fraction <40%
we proposed
a subsequent hospitalization
for coronary angiography
PROTOCOL:
USING THE CLI TO CURE THE CAD ?
J Cardiovasc Med 9:1030-6, 2008
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Figure 3 Number of cardiac deaths on the basis of presence of CAD and myocardial revascularization
J Cardiovasc Med 9:1030-6, 2008
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OUTCOMES ..........0.
000.
250.
500.
751.
00
0 20 40 60 80months
MR: myocardial revascularizazion
no MR
old MR
new MR
Kaplan-Meier survival estimates, by chd
J Cardiovasc Med 9:1030-6, 2008
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WHAT TO DO ?
in any diabetic CLI
or neuropathic patient
PROBABLY is a useful
further diagnostic if
known for CAD
and also NOT known for CAD
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THANKS FOR YOUR ATTENTION
Ezio Faglia