THE DIABETIC FOOT:

A MIRROR OF THE

DIABETIC HEART

Ezio Faglia

Chief of research on

diabetic foot

IRCCS MultiMedica

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

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

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

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

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

564 CLI DIABETICS: AMPUTATION AND DEATH

Faglia E et al: Diabetes Care 32:822-827, 2009

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

IS THERE ANYTHING COMMON BETWEEN PODIATRY AND CARDIOLOGIST ?

Il piede diabetico

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 ?

• IN HOSPITAL COMPLICATIONS

• SURGICAL RISK EVALUATION

• RESEARCH ?

IS THERE ANYTHING COMMON BETWEEN CARDIOLOGIST AND PODIATRY ?

IN HOSPITAL COMPLICATIONS

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unpublished data

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unpublished data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

SURGICAL RISK EVALUATION

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.

RISK STRATIFICATION

Faglia E et al. Diabetes Res Clin Pract. 2012;95:364-71.

SURGICAL RISK EVALUATION

J Vasc Surg 2005

GUIDELINES ACC/AHA, 20072007

ABOUT the 90% of the

diabetics with CLI have ≥ 3

clinical risk factors

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

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 INDEXANKLE-BRACHIAL INDEX

RESEARCH ?

RESEARCH ?

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

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

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

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

J Cardiovasc Med 9:1030-6, 2008

USING THE CLI TO CURE THE CAD?

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

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.

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

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