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 ? King H, et al. Diabetes Care 1998 2025 2000 1995 Population (millions) developeddeveloping total 100 300 200 0 250 millions 120 millions

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 ± 9.2 YEARS

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

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

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

13. cardiac disease 9762.8% stroke2113.4% cancer1710.8% abdominal disease31.9% renal insufficiency42.5% cirrhosis21.3% pneumonia42.5% geromarasmus74.5% septic shock10.6% suicide10.6% CAUSES OF DEATH IN 564 DIABETICS WITH CLI Faglia E et al: Eur J Vasc Endovasc Surg. 2006; 32:484-90

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

15. 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 ?

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

17. IN HOSPITAL COMPLICATIONS

18. 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ORGAN FAILURE 1 STROKE IN HOSPITAL MORTALITY IN 1072 DIABETIC PATIENTS ADMITTED FOR FOOT ULCER IN THE 2009-2010 YEARS unpublished data

19. COMPLICATIONS IN 1072 DIABETIC PATIENTS ADMITTED FOR FOOT ULCER IN THE 2009-2010 YEARS unpublished data ICU ADMISSION: 29 ACUTE CORONARY SYNDROME 12 LEFT VENTRICULAR FAILURE 11 CARDIAC ARRHYTHMIA

20. SURGICAL RISK EVALUATION

21. ENDOLUMINAL 85.6%SURGICAL 11.1% 64% OF PATIENTS ADMITTED FOR FOOT ULCER UNDERWENT PERIPHERAL REVASCULARIZATION 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. 2007 GUIDELINES ACC/AHA, 2007 ABOUT the 90% of the diabetics with CLI have ≥ 3 clinical risk factors

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

28. IS THERE ANYTHING COMMON BETWEEN CARDIOLOGIST AND PODIATRY ?

29. PROLONGED STAY IN THE ICU 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 ?

35. 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..etc 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 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

36. 30-64 yy Nondiabetics NondiabeticsDiabetics AUTOPTIC PREVALENCE OF CAD IN PATIENTS WITHOUT CLINICAL CAD >65 yy 30-64 yy >65 yy % % WomenMen p<0.01 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. 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

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

45. 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

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. OUTCOMES.......... 0.00 0.25 0.50 0.75 1.00 020406080 months MR: myocardial revascularizazion no MR old MR new MR Kaplan-Meier survival estimates, by chd J Cardiovasc Med 9:1030-6, 2008

48. 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

49. THANKS FOR YOUR ATTENTION Ezio Faglia