Cardiovascular risk profile and morbidity in subjects affected by type 2 diabetes mellitus with and without diabetic foot
Introduction
Diabetic foot syndrome (DFS) is defined, according to the World health Organization, as “ulceration of the foot (distally from the ankle and including the ankle) associated with neuropathy and different grades of ischemia and infection” [1]. Diabetic foot syndrome is a major complication of diabetes and consumes most of the resources allocated for the treatment of diabetes [2]. It is estimated that foot ulceration may occur in up to 15% of diabetic patients during their lifetime [3].
Several studies have indicated that mortality and morbidity rates of cardiovascular diseases (CVDs) are 2 to 4 times higher among patients with type 2 diabetes mellitus than in nondiabetic subjects [4]. Boyko et al [5] affirmed that foot ulcer and lower extremity vascular disease are related to a higher risk of death in diabetic subjects, but the reasons for this higher mortality require further investigation.
Diabetic foot represents an important cause of morbidity in diabetic patients [6], and the mortality rate is approximately twice that of patients without foot ulcerations [7], [8], [9].
Despite the magnitude of the problem of diabetic foot ulcer and its consequences, little research has been performed to investigate the epidemiologic and the prognostic pattern of the subjects with type 2 diabetes mellitus complicated with diabetic foot compared with diabetic patients without foot ulcerations. We hypothesize that patients with type 2 diabetes mellitus with diabetic foot could have a worse prognosis in terms of faster progression of cardiovascular damage and higher cardiovascular morbidity. On this basis, our study was designed with the aim of assessing the following in subjects with type 2 diabetes mellitus with and without diabetic foot: (1) cardiovascular risk factor distribution, (2) prevalence of cardiovascular morbidity on a retrospective evaluation, (3) prevalence of markers of subclinical cardiovascular damage at the time of recruitment, and (4) incidence of new-onset cardiovascular events on a prospective evaluation.
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Subjects, materials, and methods
Between 1995 and 2002, subjects with type 2 diabetes mellitus and foot ulceration hospitalized for every condition related to diabetic disease (decompensated diabetes, hypoglycemia, clinical revaluation for foot ulceration), but not for new vascular events, at the Internal and Specialist Medicine Department of the Policlinico P. Giaccone Hospital of Palermo were recruited. All the patients enrolled underwent a 5-year follow-up and were monitored after discharge until April 2006. We also
Statistical analysis
Continuous variables were represented as mean ± standard deviation (SD). The Student t test for nonpaired data was used to compare the means. F test was used to control the variances, and Beherens-Welch test with Satterwaite approximation was applied in case of unequality. The χ2 test was used to analyze the frequencies by contingence 2 by 2 tables. Yates correction was used if necessary. A P value less than .05 was considered statistically significant.
Hazard ratios for the composite end point
Results
We recruited 102 patients with type 2 diabetes mellitus with diabetic foot (male, 57; female, 43; mean age, 66.7 ± 9.8 years) (group I) and 123 subjects with type 2 diabetes mellitus without diabetic foot (male, 67; female, 56; mean age, 66.9 ± 13 years) (group II) matched for age and sex, body mass index, and mean duration of diabetes (Table 1).
Prevalence of cardiovascular risk factors (Table 1) in the 2 groups was as follows: 61 (60.3%) patients with diabetic foot and 75 (60.9%) without foot
Discussion
Our study was designed to evaluate in subjects with type 2 diabetes mellitus with and without diabetic foot differences in the following: (1) cardiovascular risk factor profile, (2) cardiovascular morbidity prevalence by a retrospective evaluation, (3) prevalence of markers of subclinical cardiovascular damage at the time of recruitment, and (4) incidence of new-onset vascular events on a prospective analysis.
Our findings show a higher prevalence of major cardiovascular risk factors, of
Conclusions
Multiple mechanisms contribute to the development of diabetic foot ulcer, which represents a diabetic complication in addition to neuropathy, atherosclerotic macroangiopathy, and diabetic microangiopathy. Because of the interrelatedness of many diabetic complications and associated factors, it may be misleading to consider individual potential risk factors for foot ulcer because many predictors in univariate analysis will not be shown to have independent effects on ulcer risk. Our findings show
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