1 / 42

“Diabetic foot”

“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.

kamana
Download Presentation

“Diabetic foot”

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. “Diabetic foot” Sensory Autonomic Motor

  2. Diabetic foot ulceration • Neuropathic: 45-60% • Purely ischaemic: 10% • Mixed neuroischaemic: 25-40%

  3. Diabetes and PADSpectrum of disease • Intermittent claudication • Rest pain • Ulceration/gangrene • Incidental/Screening

  4. Intermittent claudication

  5. 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

  6. 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.

  7. 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.

  8. 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

  9. Diagnosis: History • Intermittent claudication cramp like pain in muscles Location: buttock, thigh, calf ,foot occurs on exercising relieved by rest • Atypical symptoms are common

  10. Diagnosis – clinical examination • Examination of pulses Peripheral pulses- HIGHLY SUBJECTIVE • Rotterdam study 60% inaccurate

  11. 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)

  12. Ankle Brachial Pressure Index (ABPI)

  13. Ankle pressure (mm Hg) Brachial pressure (mm Hg) ABPI = Ankle Brachial Pressure Index (ABPI) Value <0.9 indicates PAD

  14. Figure 1.5 ABPI – DIAGNOSIS & PROGNOSIS McKenna et al, atherosclerosis, 1991

  15. 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?

  16. Diabetes and ABPI • Medial calcification: non compressible (nc) arteries • ABPI in diabetics : 5-10% too high • Alternatives: Elevate foot Toe pressures

  17. 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

  18. CLAUDICATION: SURGICAL TREATMENT • First line : Prolong life Risk factor management • Improve symptoms Exercise Medical therapy Revascularisation

  19. 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

  20. 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

  21. 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.

  22. 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.

  23. Diabetes and PADSpectrum of disease • Intermittent claudication • Rest pain • Ulceration/gangrene • Incidental/Screening

  24. Severe limb ischaemia Rest pain>2/52, Tissue loss ABPI <0.5

  25. Severe limb ischaemia Rest pain>2/52, Tissue loss ABPI <0.5 Critical limb ischaemia Absolute ankle pressure <50mmHg

  26. Diabetic foot ulceration • Neuropathic: 45-60% • Purely ischaemic: 10% • Mixed neuroischaemic: 25-40%

  27. Figure 14.2

  28. Diabetes & foot ulcers • 15% develop a foot ulcer • 12-24% require amputation • Leading cause of lower limb amputation

  29. 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)

  30. Investigation of PAD in patients with diabetes • Duplex scan • Angiography • CT angiography • MRA/MRI

  31. Figure 1.2 Figure 1.2 A B C D

  32. Diabetes: distribution of PAD • Atherosclerosis in : • Classical sites: aorto-iliac, Fem artery • Medium-sized vessels- peroneal/tibial vessels Foot vessels spared

  33. Revascularisation • Angioplasty • By-pass

  34. Figure 3.8 Figure 3.8

  35. Amputation • Minor- infection, osteomyelitis Possible if good blood supply • Major – extensive soft tissue infection or Insufficient blood supply • 80% of amputees have diabetes

  36. When to refer ? • Symptoms: Intermittent claudication Rest pain ( nb neuropathy) • Signs: low/nc ABPIs Ulceration Gangrene • ? ? Screening – value for risk factor Mx

  37. 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

  38. £ 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

  39. 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

More Related