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“Diabetic foot”. Sensory Autonomic Motor. Diabetic foot ulceration. Neuropathic: 45-60% Purely ischaemic: 10% Mixed neuroischaemic: 25-40%. Diabetes and PAD Spectrum of disease. Intermittent claudication Rest pain Ulceration/gangrene Incidental/Screening. Intermittent claudication.

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diabetic foot
“Diabetic foot”

Sensory

Autonomic

Motor

diabetic foot ulceration
Diabetic foot ulceration
  • Neuropathic: 45-60%
  • Purely ischaemic: 10%
  • Mixed neuroischaemic: 25-40%
diabetes and pad spectrum of disease
Diabetes and PADSpectrum of disease
  • Intermittent claudication
  • Rest pain
  • Ulceration/gangrene
  • Incidental/Screening
intermittent claudication1
Intermittent Claudication
  • Prevalence: 5.3% in patients aged 45-74yrs
  • Quality of life: Significantly impaired
  • Limb Outlook: Relatively benign

10% require intervention to prevent limb loss

1% per year require amputation

  • Life expectancy: 2-4 X ↑ mortality
slide6

Peripheral Arterial Disease and All-Cause Mortality

1.00

Normal subjects

0.75

Asymptomatic PAD†

0.50

Survival

Symptomatic PAD†

0.25

Severe symptomatic PAD†

0.00

0

2

4

6

8

10

12

Year

  • *Kaplan-Meier survival curves based on mortality from all causes
  • †Large-vessel PAD
  • 1. Criqui MH. Vasc Med 2001; 6(suppl 1): 3–7.
slide7

Odds ratio for risk factors for

intermittent claudication

Odds Ratio

Protective

Harmful

-2

-1

0

1

2

3

4

Male gender (cf female)

Age (per 10 years)

Diabetes

Smoking

Hypertension

Hypercholesterolemia

Fibrinogen

Alcohol

Dormandy JA et al. J Vasc Surgery. 2000;31(1 Part 2):S1-S296.

intermittent claudication and diabetes
Intermittent Claudicationand diabetes
  • Prevalence: 2 x ↑
  • Diabetics – 20% of PAD population
  • Limb Outlook: Worse
    • 2x ↑ rest pain, 6x ↑gangrene
    • 80% of amputations occur in diabetics
  • Life expectancy: 8 x ↑ mortality
diagnosis history
Diagnosis: History
  • Intermittent claudication

cramp like pain in muscles

Location: buttock, thigh, calf ,foot

occurs on exercising

relieved by rest

  • Atypical symptoms

are common

diagnosis clinical examination
Diagnosis – clinical examination
  • Examination of pulses

Peripheral pulses- HIGHLY SUBJECTIVE

  • Rotterdam study

60% inaccurate

pulses pad
Pulses & PAD
  • Collins 206, 403 pts screened
    • PAD prevalence :16.6%
    • Sensitivity of a non detectable pedal pulse -18%
    • Specificity: 98%
  • Post tibial pulse: sensitivity 33%, specificity 66% ( Brealey S et al)
  • Probability of agreement of an absent pedal pulse between experienced examiners : 0.49-0.59 (Marinelli et al)
slide13

Ankle pressure (mm Hg)

Brachial pressure (mm Hg)

ABPI =

Ankle Brachial Pressure Index (ABPI)

Value <0.9 indicates PAD

figure 1 5
Figure 1.5

ABPI – DIAGNOSIS & PROGNOSIS

McKenna et al, atherosclerosis, 1991

slide15
ABPI
  • Reliable
    • Positive predictive value -95%
    • Negative predictive value-99%
    • But a normal ABPI at rest and classical symptoms may indicate need for exercise ABPI
  • ESSENTIAL FOR DIAGNOSIS
  • Do we have expertise in the community?
diabetes and abpi
Diabetes and ABPI
  • Medial calcification: non compressible (nc) arteries
  • ABPI in diabetics : 5-10% too high
  • Alternatives: Elevate foot

Toe pressures

toe pressures
Toe pressures
  • Cuff placed around proximal phalanx
  • Normal pressures are less than ankle pressures
    • average 24± 7 – 41± 17mmHg
  • Normal ratios compared to brachial 0.72-0.91
claudication surgical treatment
CLAUDICATION: SURGICAL TREATMENT
  • First line : Prolong life

Risk factor management

  • Improve symptoms

Exercise

Medical therapy

Revascularisation

treatment
Treatment
  • *Statin for all
  • *Screen for diabetes/ Glycaemic control
  • *BP control
  • Smoking cessation: NRT
  • Anti-platelet therapy
  • Increase exercise
  • ACE inhibitor (HOPE study)
  • Review: ? For revascularisation
slide20

VASCULAR EVENT by PRIOR DISEASE

MRC/BHF Heart Protection Study

STATIN worse

Baseline

STATIN

PLACEBO

Risk ratio and 95% CI

feature

(10269)

(10267)

STATIN better

STATIN worse

Previous MI

1007

1255

Other CHD (not MI)

452

597

No prior CHD

CVD

182

215

PVD

332

427

Diabetes

279

369

ALL PATIENTS

2042

2606

24%

SE 2.6

reduction

(19.9%)

(25.4%)

(2P<0.00001)

0.4

0.6

0.8

1.0

1.2

1.4

diabetes and pad
Diabetes and PAD
  • No clinical trials have been set up specifically to investigate glycaemic control.
  • Type 2 diabetes, glycaemia (HbA1C)  risk of cardiovascular morbidity and mortality (1)
  • Each 1% difference in HbA1C  21% (95% CI 15-27%) change in the risk of diabetes-related death and a 14% reduction in fatal and nonfatal myocardial infarction over 10 years (2)

Turner RC, et al.. BMJ 1998; 316: 823-8.

Stratton IM et al,. BMJ. 2000;321(7258):405-12.

hope study
HOPE study
  • Effects of ramipril on patients with

1. symptomatic PAD

2. Asymptomatic PAD (ABPI≤ 0.9) plus an additional coronary risk factor were analysed.

  • Only 50% of the patients were defined as hypertensive.
  • In both groups-  ~ 25% reduction in the primary combined outcome of cardiovascular mortality, myocardial infarction or stroke with ramipril.
  • (ABPI) was measured unconventionally

Ostergren J, et al. Eur Heart J 2004; 25: 17-24.

diabetes and pad spectrum of disease1
Diabetes and PADSpectrum of disease
  • Intermittent claudication
  • Rest pain
  • Ulceration/gangrene
  • Incidental/Screening
slide24

Severe limb ischaemia

Rest pain>2/52,

Tissue loss

ABPI <0.5

slide25

Severe limb ischaemia

Rest pain>2/52,

Tissue loss

ABPI <0.5

Critical limb ischaemia

Absolute ankle pressure

<50mmHg

diabetic foot ulceration1
Diabetic foot ulceration
  • Neuropathic: 45-60%
  • Purely ischaemic: 10%
  • Mixed neuroischaemic: 25-40%
diabetes foot ulcers
Diabetes & foot ulcers
  • 15% develop a foot ulcer
  • 12-24% require amputation
  • Leading cause of lower limb amputation
will the ulcer heal
Will the ulcer heal?

Study of patients with foot ulcers and toe amputations

Non-heeling occurred in(Ramsey et al)

    • 92% of limbs with ankle pressure <80mmHg
    • But also in 45% of limbs with higher ankle pressures
    • 95% of limbs with toe pressures <30mmHg
    • But only in 14% of limbs with higher toe pressures
  • Toe pressures – greater prognostic value
  • PPV 67%, NPV 77% (Kaloni et al, 1999;Diabetes Care)
investigation of pad in patients with diabetes
Investigation of PAD in patients with diabetes
  • Duplex scan
  • Angiography
  • CT angiography
  • MRA/MRI
diabetes distribution of pad
Diabetes: distribution of PAD
  • Atherosclerosis in :
    • Classical sites: aorto-iliac, Fem artery
    • Medium-sized vessels- peroneal/tibial vessels

Foot vessels spared

revascularisation
Revascularisation
  • Angioplasty
  • By-pass
figure 3 8
Figure 3.8

Figure 3.8

amputation
Amputation
  • Minor- infection, osteomyelitis

Possible if good blood supply

  • Major – extensive soft tissue infection or

Insufficient blood supply

  • 80% of amputees have diabetes
when to refer
When to refer ?
  • Symptoms:

Intermittent claudication

Rest pain ( nb neuropathy)

  • Signs:

low/nc ABPIs

Ulceration

Gangrene

  • ? ? Screening – value for risk factor Mx
asymptomatic pad
Asymptomatic PAD
  • Relatively common
  • Associated with increased mortality
  • Can early treatment prevent events ?

2 Major trials will report ‘06/’07

  • Potential to save lives using ABPI: a simplenon-invasive screening test
slide39

£

British Heart Foundation

Study Population:

men and women

>50 years of age

Endpoints

Cardiovascular• Events• Deaths

Aspirin vs placebo

Aspirin for Asymptomatic Atherosclerosis (AAA) Trial

ABPI<0.95

N=3334

3- 4 YearFollow-up

Fowkes & Douglas, personal communication 2002

slide40

Royal Collegeof Physicians

Diabetic Registry Group

Low ABPI in 20.1%

Endpoints

Cardiovascular• Events• Deaths

£

Medical Research Council

POPADAD

ABPI <0.99Diabetes

Men & women

aged>40 yearsN=8000

NO clinical evidence of vascular disease