“Diabetic foot”

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““Diabetic foot”Diabetic foot”

INFECTIONINFECTION

NEUROPATHYNEUROPATHY

TRAUMATRAUMA

PADPAD

ULCERULCER

SensoryAutonomicMotor

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Neuropathic: 45-60%

Purely ischaemic: 10%

Mixed neuroischaemic: 25-40%

Diabetic foot ulceration

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Diabetes and PADDiabetes and PAD Spectrum of diseaseSpectrum of disease

Intermittent claudicationIntermittent claudication Rest painRest pain Ulceration/gangreneUlceration/gangrene

Incidental/ScreeningIncidental/Screening

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Intermittent claudicationIntermittent claudication

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Intermittent ClaudicationIntermittent Claudication

Prevalence: 5.3% in patients aged Prevalence: 5.3% in patients aged 45-74yrs45-74yrs

Quality of life: Significantly impairedQuality of life: Significantly impaired Limb Outlook: Relatively benignLimb Outlook: Relatively benign

10% require intervention to prevent 10% require intervention to prevent limb losslimb loss

1% per year require amputation1% per year require amputation Life expectancy: 2-4 X ↑ mortalityLife expectancy: 2-4 X ↑ mortality

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Peripheral Arterial Peripheral Arterial Disease and All-Cause Disease and All-Cause

MortalityMortalityNormal subjects

Asymptomatic PAD†

Symptomatic PAD†

Severe symptomatic PAD†

1.00

0.75

0.50

0.25

0.00

0 2 4 6 8 10 12

Su

rviv

al

Year

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

3–7.3–7.

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Odds ratio for risk factors forOdds ratio for risk factors forintermittent claudicationintermittent claudication

Male gender (cf female)

Age (per 10 years)

Diabetes

Smoking

Hypertension

Hypercholesterolemia

Fibrinogen

Alcohol

-2 -1 0 1 2 3 4Protective Harmful

Odds Ratio

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

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Intermittent ClaudicationIntermittent Claudicationand diabetesand diabetes

Prevalence: 2 x ↑Prevalence: 2 x ↑ Diabetics – 20% of PAD Diabetics – 20% of PAD

population population Limb Outlook: WorseLimb Outlook: Worse

2x ↑ rest pain, 6x ↑gangrene2x ↑ rest pain, 6x ↑gangrene 80% of amputations occur in 80% of amputations occur in

diabeticsdiabetics Life expectancy: 8 x ↑ mortalityLife expectancy: 8 x ↑ mortality

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Diagnosis: HistoryDiagnosis: History

Intermittent claudication Intermittent claudication

cramp like pain in muscles cramp like pain in muscles

Location: buttock, thigh, calf ,footLocation: buttock, thigh, calf ,foot

occurs on exercising occurs on exercising

relieved by restrelieved by rest

Atypical symptoms Atypical symptoms

are commonare common

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Diagnosis – clinical Diagnosis – clinical examinationexamination

Examination of pulsesExamination of pulses

Peripheral pulses- HIGHLY Peripheral pulses- HIGHLY SUBJECTIVESUBJECTIVE

Rotterdam study Rotterdam study

60% inaccurate60% inaccurate

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Pulses & PADPulses & PAD

Collins 206, 403 pts screenedCollins 206, 403 pts screened PAD prevalence :16.6%PAD prevalence :16.6% Sensitivity of a non detectable pedal pulse -Sensitivity of a non detectable pedal pulse -

18%18% Specificity: 98%Specificity: 98%

Post tibial pulse: sensitivity 33%, Post tibial pulse: sensitivity 33%, specificity 66% specificity 66% ( Brealey S et al)( Brealey S et al)

Probability of agreement of an absent Probability of agreement of an absent pedal pulse between experienced pedal pulse between experienced examiners : 0.49-0.59 examiners : 0.49-0.59 (Marinelli et al)(Marinelli et al)

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Ankle Brachial Pressure Index Ankle Brachial Pressure Index (ABPI)(ABPI)

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Ankle Brachial Pressure Index Ankle Brachial Pressure Index (ABPI)(ABPI)

Ankle pressure (mm Hg)

Brachial pressure (mm Hg)

ABPI =

Value <0.9 indicates PAD

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ABPI – DIAGNOSIS & PROGNOSIS

McKenna et al, atherosclerosis, 1991

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ABPIABPI

Reliable Reliable Positive predictive value -95%Positive predictive value -95% Negative predictive value-99%Negative predictive value-99% But a normal ABPI at rest and classical But a normal ABPI at rest and classical

symptoms may indicate need for symptoms may indicate need for exercise ABPIexercise ABPI

ESSENTIAL FOR DIAGNOSIS ESSENTIAL FOR DIAGNOSIS Do we have expertise in the Do we have expertise in the

community? community?

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Diabetes and ABPIDiabetes and ABPI

Medial calcification: non Medial calcification: non compressible (nc) arteriescompressible (nc) arteries

ABPI in diabetics : 5-10% too ABPI in diabetics : 5-10% too highhigh

Alternatives: Elevate footAlternatives: Elevate foot

Toe pressuresToe pressures

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Toe pressuresToe pressures

Cuff placed around proximal phalanxCuff placed around proximal phalanx Normal pressures are less than Normal pressures are less than

ankle pressuresankle pressures average 24average 24±± 7 – 41 7 – 41±± 17mmHg 17mmHg

Normal ratios compared to brachial Normal ratios compared to brachial 0.72-0.910.72-0.91

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First line : Prolong First line : Prolong lifelife

Risk factor Risk factor managementmanagement

Improve symptomsImprove symptoms

ExerciseExercise

Medical therapyMedical therapy

RevascularisationRevascularisation

CLAUDICATION: CLAUDICATION: SURGICAL TREATMENTSURGICAL TREATMENT

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Treatment Treatment

*Statin for all*Statin for all *Screen for diabetes/ Glycaemic *Screen for diabetes/ Glycaemic

controlcontrol *BP control *BP control Smoking cessation: NRT Smoking cessation: NRT Anti-platelet therapy Anti-platelet therapy Increase exerciseIncrease exercise ACE inhibitor (HOPE study)ACE inhibitor (HOPE study) ReviewReview: ? For revascularisation: ? For revascularisation

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VASCULAR EVENT by PRIOR DISEASEMRC/BHF Heart Protection Study

Risk ratio and 95% CISTATIN PLACEBOBaselinefeature (10269) (10267) STATIN better STATIN worse

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(19.9%) (25.4%)

24%SE 2.6reduction(2P<0.00001)

0.4 0.6 0.8 1.0 1.2 1.4

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Diabetes and PADDiabetes and PAD No clinical trials have been set up No clinical trials have been set up

specifically to investigate glycaemic control. specifically to investigate glycaemic control. Type 2 diabetes,Type 2 diabetes, glycaemia (HbA1C) glycaemia (HbA1C) risk risk

of cardiovascular morbidity and mortality of cardiovascular morbidity and mortality (1) (1)

Each 1% difference in HbA1C Each 1% difference in HbA1C 21% (95% 21% (95% CI 15-27%) change in the risk of diabetes-CI 15-27%) change in the risk of diabetes-related death and a 14% reduction in fatal related death and a 14% reduction in fatal and nonfatal myocardial infarction over 10 and nonfatal myocardial infarction over 10 years (2)years (2)

Turner RC, et al.. BMJ 1998; 316: 823-8.Turner RC, et al.. BMJ 1998; 316: 823-8.Stratton IM et al,. BMJ. 2000;321(7258):405-12.Stratton IM et al,. BMJ. 2000;321(7258):405-12.

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HOPE studyHOPE study Effects of ramipril on patients with Effects of ramipril on patients with 1. symptomatic PAD 1. symptomatic PAD 2. Asymptomatic PAD (ABPI2. Asymptomatic PAD (ABPI ≤ 0.9) plus an ≤ 0.9) plus an

additional coronary risk factor were analysed. additional coronary risk factor were analysed. Only 50% of the patients were defined as Only 50% of the patients were defined as

hypertensive.hypertensive. In both groups- In both groups- ~ 25% reduction in the ~ 25% reduction in the

primary combined outcome of cardiovascular primary combined outcome of cardiovascular mortality, myocardial infarction or stroke with mortality, myocardial infarction or stroke with ramipril. ramipril.

(ABPI) was measured unconventionally(ABPI) was measured unconventionallyOstergren J, et al. Eur Heart J 2004; 25: 17-24.Ostergren J, et al. Eur Heart J 2004; 25: 17-24.

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Diabetes and PADDiabetes and PAD Spectrum of diseaseSpectrum of disease

Intermittent claudicationIntermittent claudication

Rest painRest pain Ulceration/gangreneUlceration/gangrene

Incidental/ScreeningIncidental/Screening

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Severe limb ischaemiaRest pain>2/52, Tissue lossABPI <0.5

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Severe limb ischaemiaRest pain>2/52, Tissue lossABPI <0.5

Critical limb ischaemiaAbsolute ankle pressure<50mmHg

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Neuropathic: 45-60% Purely ischaemic: 10% Mixed neuroischaemic:

25-40%

Diabetic foot ulceration

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Diabetes & foot ulcersDiabetes & foot ulcers

15% develop a foot ulcer15% develop a foot ulcer 12-24% require amputation12-24% require amputation Leading cause of lower limb Leading cause of lower limb

amputationamputation

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Will the ulcer heal?Will the ulcer heal?

Study of patients with foot ulcers and toe Study of patients with foot ulcers and toe amputations amputations

Non-heeling occurred inNon-heeling occurred in(Ramsey et al)(Ramsey et al)

92% of limbs with ankle pressure <80mmHg92% of limbs with ankle pressure <80mmHg But also in 45% of limbs with higher ankle But also in 45% of limbs with higher ankle

pressurespressures

95% of limbs with toe pressures <30mmHg95% of limbs with toe pressures <30mmHg But only in 14% of limbs with higher toe pressures But only in 14% of limbs with higher toe pressures

Toe pressures – greater prognostic valueToe pressures – greater prognostic value PPV 67%, NPV 77% PPV 67%, NPV 77% (Kaloni et al, 1999;Diabetes Care)(Kaloni et al, 1999;Diabetes Care)

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Investigation of PAD in Investigation of PAD in patients with diabetespatients with diabetes

Duplex scanDuplex scan AngiographyAngiography CT CT

angiographyangiography MRA/MRIMRA/MRI

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Figure 1.2Figure 1.2

A

B

C

D

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Diabetes: distribution of Diabetes: distribution of PADPAD

Atherosclerosis in :Atherosclerosis in : Classical sites: Classical sites:

aorto-iliac, Fem aorto-iliac, Fem arteryartery

Medium-sized Medium-sized vessels-vessels- peroneal/tibial peroneal/tibial vesselsvessels

Foot vessels Foot vessels sparedspared

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RevascularisationRevascularisation

AngioplastyAngioplasty By-passBy-pass

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Figure 3.8Figure 3.8

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AmputationAmputation

Minor- infection, osteomyelitisMinor- infection, osteomyelitis

Possible if good blood supplyPossible if good blood supply

Major – extensive soft tissue Major – extensive soft tissue infection or infection or

Insufficient blood supplyInsufficient blood supply 80% of amputees have diabetes80% of amputees have diabetes

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When to refer ?When to refer ? Symptoms:Symptoms: Intermittent claudicationIntermittent claudication Rest pain ( nb neuropathy)Rest pain ( nb neuropathy)

Signs: Signs: low/nc ABPIslow/nc ABPIs Ulceration Ulceration GangreneGangrene

? ? Screening – value for risk factor Mx? ? Screening – value for risk factor Mx

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Asymptomatic PADAsymptomatic PAD

Relatively commonRelatively common Associated with increased mortalityAssociated with increased mortality Can early treatment prevent events ?Can early treatment prevent events ?

2 Major trials will report ‘06/’072 Major trials will report ‘06/’07 Potential to save lives using ABPI:Potential to save lives using ABPI:

a simple a simple non-invasive screening testnon-invasive screening test

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Aspirin for Asymptomatic

Atherosclerosis (AAA) Trial

ABPI<0.95

N=3334

Study Population:Study Population:

men and women men and women

>50 years of age>50 years of age

Study Population:Study Population:

men and women men and women

>50 years of age>50 years of age

££British British Heart Heart

FoundationFoundation

££British British Heart Heart

FoundationFoundation

3- 4 Year3- 4 YearFollow-upFollow-up3- 4 Year3- 4 Year

Follow-upFollow-up

Aspirin Aspirin vs vs

placeboplacebo

EndpointsEndpointsCardiovascularCardiovascular

• Events• Events• Deaths• Deaths



Fowkes & Douglas, personal communication 2002

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POPADAD

ABPI <0.99Diabetes

Men & women

aged>40 yearsN=8000

Low ABPI in Low ABPI in 20.1%20.1%

Low ABPI in Low ABPI in 20.1%20.1%

Royal CollegeRoyal Collegeof Physiciansof Physicians

Diabetic Diabetic Registry Registry GroupGroup

Royal CollegeRoyal Collegeof Physiciansof Physicians

Diabetic Diabetic Registry Registry GroupGroup

NO clinical evidence of

vascular disease

NO clinical evidence of

vascular disease

££

Medical Medical Research Research Council Council

££

Medical Medical Research Research Council Council





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“Diabetic foot”

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