THE DIABETIC FOOT: A MIRROR OF THE DIABETIC HEART

1. THE DIABETIC FOOT: A MIRROR OF THE DIABETIC HEART Ezio Faglia Chief of research on diabetic foot IRCCS MultiMedica

3. DIABETES : IS A PROBLEM ? 250 millions 2000 2025 1995 300 200 120 millions Population (millions) 100 0 developed developing total King H, et al. Diabetes Care 1998

4. Wild S et al : Diabetes Care 27,1047-1053,2004

5. DIABETIC FOOT 15-25% of the diabetics will be affected by a foot ulcer during your life

6. IT IS THE MOST FREQUENTLY CAUSE OF HOSPITALIZATION FOR DIABETICS

7. DIABETIC FOOT PATIENTS: HISTORY Brownrigg jr et al: Diabetologia 55:2906–2912, 2012

8. INCREASED MORTALITY ASSOCIATED WITH THE ULCERATED DIABETIC FOOT *p<0.01 * Boyko et al, Diabet Med 13: 1996

9. AGE AND DIABETIC FOOT NEUROPATHIC: 63.7 ± 9.4 YEARS NEURO-ISCHEMIC: 72.7 ± 9.2YEARS

10. NEUROPATHIC FOOT: SURVIVAL Van Baal J et al: Diabetes Care 33:186-1089, 2010

11. CLI 1 YEAR LATER DISEASE-FREE AMPUTATED DEAD NATURAL HISTORY OF PERIPHERAL ARTERIAL DISEASE Hirsch et al: Am J Coll Cardiol 47:1239-1312,2006

12. 564 CLI DIABETICS: AMPUTATION AND DEATH • Faglia E et al: Diabetes Care 32:822-827,2009

13. CAUSES OF DEATH IN 564 DIABETICS WITH CLI • Faglia E et al: Eur J Vasc Endovasc Surg. 2006; 32:484-90

14. Il piede diabetico IS THERE ANYTHING COMMONBETWEEN PODIATRY AND CARDIOLOGIST ?

15. WHEN AND WHERE ? CENTER LEVEL 1: screening, patients without foot ulcer CENTER LEVEL 2: patients with mild lesions CENTER LEVEL 3: TREATMENT OF SEVERE LESIONS REQUIRING ADMISSION

16. IS THERE ANYTHING COMMONBETWEEN CARDIOLOGIST AND PODIATRY ? • IN HOSPITAL COMPLICATIONS • SURGICAL RISK EVALUATION • RESEARCH ?

17. IN HOSPITAL COMPLICATIONS

18. 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(cardiopulmonary resuscitation) 1 SUDDEN DEATH AFTER PTA 2 REFRACTORY HEART FAILURE 1 MULTI ORGAN FAILURE 1 STROKE unpublished data

19. 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IN THE 2009-2010 YEARS ICU ADMISSION: 29 ACUTE CORONARY SYNDROME 12 LEFT VENTRICULAR FAILURE 11 CARDIAC ARRHYTHMIA unpublished data

20. SURGICAL RISK EVALUATION

21. 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.

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

23. SURGICAL RISK EVALUATION

24. J Vasc Surg 2005

25. GUIDELINES ACC/AHA, 2007 ABOUT the 90% of the diabetics with CLIhave ≥ 3 clinical risk factors

26. Patient admitted because of foot ulcer (low surgical risk) DIPARTIMENTO CARDIOVASCOLARE UO DI DIABETOLOGIA E TRATTAMENTO DEL PIEDE DIABETICO YES ACUTE INFECTED FOOT (abscess, fasciitis, gas gangrene) SI NO CHD unstable (ECG or symptoms) CHD stable (ECG or symptoms) CHD asymptomatic (ECG or symptoms) urgent cardiological examination CARDIOLOGY UNIT ADMISSION operating room appropriate therapy

28. IS THERE ANYTHING COMMONBETWEEN CARDIOLOGIST AND PODIATRY ?

29. PROLONGED STAY IN THE ICU AFTER CARDIAC SURGERY

30. PROLONGED STAY IN THEICU AFTER CARDIAC SURGERY

31. ANKLE-BRACHIAL INDEX AND OUTCOMES IN BARI 2 Abbot JD et al: Am Heart J 164,585-590,2012

32. ANKLE-BRACHIAL INDEX

33. RESEARCH ?

34. RESEARCH ?

35. 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

36. AUTOPTIC PREVALENCE OF CAD IN PATIENTS WITHOUT CLINICAL CAD Nondiabetics Diabetics Men Women p<0.01 p<0.01 p<0.01 % % >65 yy >65 yy 30-64 yy 30-64 yy Goraya. JACC 2002;40:946

37. DIABETOLOGICAL GUIDELINES American Diabetes Association Clinical Practice Recommendations 2013

38. 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

39. WHY THIS DIFFERENCE ?

40. CARDIOLOGICAL GUIDELINES ? €

42. OVERALL SENSITIVITY OF 94%, SPECIFICITY OF 34% €

43. HR 6.04,CI, 2.38-15.33 B-type natriuretic peptide as marker of mortality in diabetic patients with foot ulcer 45/71 (63.4%) died from cardiac cause. Of these, 24 patients had no history of CAD SUBMITTED PAPER

44. USING THE CLI TO CURE THE CAD? J Cardiovasc Med 9:1030-6, 2008

45. USING THE CLI TO CURE THE CAD ? PROTOCOL: Patients with a history of CADand ejection fraction <40%we proposeda subsequent hospitalizationfor coronary angiography J Cardiovasc Med 9:1030-6, 2008

46. Figure 3 Number of cardiac deaths on the basis of presence of CAD and myocardial revascularization J Cardiovasc Med 9:1030-6, 2008

47. Kaplan-Meier survival estimates, by chd 1.00 0.75 0.50 no MR old MR 0.25 new MR 0.00 0 20 40 60 80 months MR: myocardial revascularizazion OUTCOMES .......... J Cardiovasc Med 9:1030-6, 2008

48. WHAT TO DO ? in any diabetic CLIor neuropathic patient PROBABLY is a usefulfurther diagnostic ifknown for CADand also  NOT known for CAD

49. THANKS FOR YOUR ATTENTION Ezio Faglia