Current Status and Principles for the Treatment and Prevention of Diabetic Foot Ulcers in the Cardiovascular Patient Population: A Scientific Statement From the American Heart Association

Abstract

Despite the known higher risk of cardiovascular disease in individuals with type 2 diabetes, the pathophysiology and optimal management of diabetic foot ulcers (DFUs), a leading complication associated with diabetes, is complex and continues to evolve. Complications of type 2 diabetes, such as DFUs, are a major cause of morbidity and mortality and the leading cause of major lower extremity amputation in the United States. There has recently been a strong focus on the prevention and early treatment of DFUs, leading to the development of multidisciplinary diabetic wound and amputation prevention clinics across the country. Mounting evidence has shown that, despite these efforts, amputations associated with DFUs continue to increase. Furthermore, due to increasing patient complexity of management secondary to comorbid conditions, such as cardiovascular disease, the management of peripheral artery disease associated with DFUs has become increasingly difficult, and care delivery is often episodic and fragmented. Although structured, process-specific approaches exist at individual institutions for the management of DFUs in the cardiovascular patient population, there is insufficient awareness of these principles in the general medicine communities. Furthermore, there is growing interest in better understanding the mechanistic underpinnings of DFUs to better define personalized medicine to improve outcomes. The goals of this scientific statement are to provide salient background information on the complex pathogenesis and current management of DFUs in cardiovascular patients, to guide therapeutic and preventive strategies and future research directions, and to inform public policy makers on health disparities and other barriers to improving and advancing care in this expanding patient population.

Keywords: AHA Scientific Statements; amputation, surgical; cardiovascular diseases; diabetes, type 2; diabetic foot; health care disparities; health inequities; peripheral arterial disease.

Figure 1.

WiFi staging criteria for DFUs. SIRS indicates Systemic Inflammatory Response Score.

Figure 2.

Mechanisms for nonhealing wounds in diabetes. HDL indicates high-density lipoprotein; IL, interleukin; INFγ, interferon γ; TGF, transforming growth factor; Th2, T helper 2 cell; Th16, T helper 16 cell; TNFα, tumor necrosis factor α; and VEGF, vascular endothelial growth factor.

Figure 3.

Cellular dysfunction in nonhealing diabetic wounds.

Figure 4.

Representative images of diabetic footwear.

Figure 5.

Algorithm for evaluation of new DFUs. CVD indicates cardiovascular disease; DFU, diabetic foot ulcer; and TCC, total contact cast.