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THE DIABETIC FOOT:
A MIRROR OF THE
DIABETIC HEART
Ezio Faglia
Chief of research on
diabetic foot
IRCCS MultiMedica
DIABETES : IS A PROBLEM ?
250 millions
1995
2000
2025
Population (millions)
300
200
120 millions
100
0
developed
developing
total
King H, et al. Diabetes Care 1998
Wild S et al : Diabetes Care 27,1047-1053,2004
DIABETIC FOOT
15-25% of the diabetics
will be affected by
a foot ulcer
during your life
IT IS THE MOST FREQUENTLY CAUSE OF
HOSPITALIZATION FOR DIABETICS
DIABETIC FOOT PATIENTS: HISTORY
Brownrigg jr et al: Diabetologia 55:2906–2912, 2012
INCREASED MORTALITY ASSOCIATED
WITH THE ULCERATED DIABETIC FOOT
15
no DFU
DFU
10
*p<0.01
*
5
0
Deaths/100 persons/year
Boyko et al, Diabet Med 13: 1996
AGE AND DIABETIC FOOT
NEUROPATHIC:
63.7 ± 9.4 YEARS
NEURO-ISCHEMIC:
72.7 ± 9.2 YEARS
NEUROPATHIC FOOT: SURVIVAL
Van Baal J et al: Diabetes Care 33:186-1089, 2010
NATURAL HISTORY OF
PERIPHERAL ARTERIAL DISEASE
CLI
1 YEAR LATER
DISEASE-FREE
AMPUTATED
DEAD
Hirsch et al: Am J Coll Cardiol 47:1239-1312,2006
564 CLI DIABETICS: AMPUTATION AND DEATH
Faglia E et al: Diabetes Care 32:822-827, 2009
CAUSES OF DEATH IN 564 DIABETICS WITH CLI
cardiac disease
97
62.8%
stroke
cancer
abdominal disease
renal insufficiency
cirrhosis
pneumonia
geromarasmus
septic shock
suicide
21
17
3
4
2
4
7
1
1
13.4%
10.8%
1.9%
2.5%
1.3%
2.5%
4.5%
0.6%
0.6%
Faglia E et al: Eur J Vasc Endovasc Surg. 2006; 32:484-90
IS THERE ANYTHING COMMON BETWEEN
PODIATRY AND CARDIOLOGIST ?
Il piede diabetico
WHEN AND WHERE ?
CENTER
LEVEL
3:
CENTER
LEVEL
1: screening,
patients without foot ulcer
TREATMENT OF SEVERE LESIONS
CENTER
LEVEL ADMISSION
2 : patients with
REQUIRING
mild lesions
IS THERE ANYTHING COMMON BETWEEN
CARDIOLOGIST AND PODIATRY ?
• IN HOSPITAL COMPLICATIONS
• SURGICAL RISK EVALUATION
• RESEARCH ?
IN HOSPITAL COMPLICATIONS
IN HOSPITAL MORTALITY IN 1072 DIABETIC PATIENTS
ADMITTED FOR FOOT ULCER IN THE 2009-2010 YEARS
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
unpublished data
COMPLICATIONS IN 1072 DIABETIC PATIENTS ADMITTED
FOR FOOT ULCER IN THE 2009-2010 YEARS
ICU ADMISSION:
29 ACUTE CORONARY SYNDROME
12 LEFT VENTRICULAR FAILURE
11 CARDIAC ARRHYTHMIA
unpublished data
SURGICAL RISK EVALUATION
64% OF PATIENTS ADMITTED FOR FOOT ULCER
UNDERWENT PERIPHERAL REVASCULARIZATION
ENDOLUMINAL 85.6%
SURGICAL 11.1%
Faglia E et al. Diabetes Res Clin Pract. 2012;95:364-71.
RISK STRATIFICATION
Faglia E et al. Diabetes Res Clin Pract. 2012;95:364-71.
SURGICAL RISK EVALUATION
J Vasc Surg 2005
GUIDELINES ACC/AHA, 2007
ABOUT the 90% of the
diabetics with CLI have ≥ 3
clinical risk factors
Patient admitted because of foot ulcer
DIPARTIMENTO CARDIOVASCOLARE
UO DI DIABETOLOGIA E
TRATTAMENTO DEL PIEDE DIABETICO
(low surgical risk)
ACUTE INFECTED FOOT
SI
YES
(abscess, fasciitis, gas gangrene)
NO
CHD unstable
(ECG or symptoms)
CHD stable
(ECG or symptoms)
CHD asymptomatic
(ECG or symptoms)
urgent
cardiological
examination
CARDIOLOGY
UNIT ADMISSION
appropriate therapy
operating room
IS THERE ANYTHING COMMON BETWEEN
CARDIOLOGIST AND PODIATRY ?
PROLONGED STAY IN THE ICU
AFTER CARDIAC SURGERY
PROLONGED STAY IN THE ICU
AFTER CARDIAC SURGERY
ANKLE-BRACHIAL INDEX AND
OUTCOMES IN BARI 2
Abbot JD et al: Am Heart J 164,585-590,2012
ANKLE-BRACHIAL INDEX
RESEARCH ?
RESEARCH ?
CAD E PAD IN DIABETES
compared with general population
2–4 x increased risk
of heart disease
20% silent
4-6 x increased risk of
peripheral arteriopathy
20% silent
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: JACC 2006. Kamalesh M: Clin. Cardiol
2009. Boyd CM: J Am Geriatr Soc 2011. Boonman-de Winter LJM: Diabetologia 2012.etc
AUTOPTIC PREVALENCE OF CAD IN
PATIENTS WITHOUT CLINICAL CAD
Nondiabetics
Diabetics
Men
Women
100
100
p<0.01
p<0.01
p<0.01
80
80
80
58
60
%
40
39
60
50
%
44
49
40
20
20
0
0
30-64 yy
69
>65 yy
19
30-64 yy
>65 yy
Goraya. JACC 2002;40:946
DIABETOLOGICAL GUIDELINES
American Diabetes Association
Clinical Practice Recommendations 2013
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
WHY THIS DIFFERENCE ?
CARDIOLOGICAL GUIDELINES
?
€
OVERALL SENSITIVITY OF 94%,
SPECIFICITY OF 34%
€
B-type natriuretic peptide as marker of
mortality in diabetic patients with foot ulcer
45/71 (63.4%)
HR 6.04,CI, 2.38-15.33
died from cardiac cause .
Of these, 24 patients had
no history of CAD
SUBMITTED PAPER
USING THE CLI TO CURE THE CAD?
J Cardiovasc Med 9:1030-6, 2008
USING THE CLI TO CURE THE CAD ?
PROTOCOL:
Patients with a history of CAD
and ejection fraction <40%
we proposed
a subsequent hospitalization
for coronary angiography
J Cardiovasc Med 9:1030-6, 2008
Figure 3 Number of cardiac deaths on the basis of
presence of CAD and myocardial revascularization
J Cardiovasc Med 9:1030-6, 2008
OUTCOMES ..........
0.50
0.75
1.00
Kaplan-Meier survival estimates, by chd
no MR
0.25
old MR
0.00
new MR
0
20
40
months
60
80
MR: myocardial revascularizazion
J Cardiovasc Med 9:1030-6, 2008
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
THANKS FOR YOUR ATTENTION
Ezio Faglia