Elsevier

Metabolism

Volume 57, Issue 5, May 2008, Pages 676-682
Metabolism

Cardiovascular risk profile and morbidity in subjects affected by type 2 diabetes mellitus with and without diabetic foot

https://doi.org/10.1016/j.metabol.2008.01.004Get rights and content

Abstract

Diabetic foot syndrome (DFS) is the most frequent cause of hospitalization of diabetic patients and one of the most economically demanding complications of diabetes. People with diabetes have been shown to have higher mortality than people without diabetes. On this basis, the aim of our study was to evaluate the possible role of diabetic foot as a cardiovascular risk marker in patients with type 2 diabetes mellitus. We enrolled 102 consecutive patients with type 2 diabetes mellitus with diabetic foot and 123 patients with type 2 diabetes mellitus without limb lesions to compare the prevalence of main cardiovascular risk factors, subclinical cardiovascular disease, previous cardiovascular morbidity, and incidence of new vascular events on a 5-year follow-up. Diabetic patients with diabetic foot were more likely to have a higher prevalence of cardiovascular risk factors such as hypercholesterolemia, hypertriglyceridemia, hyperuricemia, and microalbuminuria or proteinuria, a higher prevalence of a previous cardiovascular morbidity (coronary artery disease, transient ischemic attack/ischemic stroke, diabetic retinopathy), and a higher prevalence of subclinical cardiovascular disease. Furthermore, diabetic patients with foot ulceration showed, on a 5-year follow-up, a higher incidence of new-onset vascular events (coronary artery disease, transient ischemic attack/ischemic stroke, diabetic retinopathy). At multivariate analysis, duration of diabetes, age, hemoglobin A1c, and DFS maintained a significant association with cardiovascular morbidity; but DFS presence showed the highest hazard ratio.

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.

Section snippets

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

References (38)

  • I. Aoki et al.

    Platelet-dependent thrombin generation in patients with diabetes mellitus: effects of glycemic control on coagulability in diabetes

    J Am Coll Cardiol

    (1996)
  • W.J. Jeffcoate et al.

    The description and classification of diabetic foot lesions

    Diabet Med

    (1993)
  • G.E. Reiber et al.

    Risk factors for amputation in patients with diabetes mellitus. A case control study

    Arch Intern Med

    (1992)
  • G.E. Reiber et al.

    The burden of diabetic foot ulcers

    Am J Surg

    (1998)
  • W.B. Kannel et al.

    Diabetes and glucose tolerance as risk factors for cardiovascular disease: the Framingham study

    Diabetes Care

    (1979)
  • E.J. Boyko et al.

    Increased mortality associated with diabetic foot ulcer

    Diabet Med

    (1996)
  • J.M. Giurini et al.

    Diabetic foot complications: diagnosis and management.

    Int J Low Extrem Wounds.

    (2005)
  • W. Gatling et al.

    Mortality rates in diabetic patients from a community-based population compared to local age/sex matched controls

    Diabet Med

    (1997)
  • N.A. Roper et al.

    Excess mortality in a population with diabetes and the impact of material deprivation: longitudinal, population based study

    BMJ

    (2001)
  • E.J.G. Peters et al.

    Effectiveness of the diabetic foot risk classification system of the International Working Group on the Diabetic Foot

    Diabetes care

    (2001)
  • A. Zanchetti et al.

    The 1993 guidelines for the management of mild hypertension: memorandum from a WHO/ISH meeting

    Blood Press.

    (1993)
  • No authors listed, The 1993 guidelines for the management of mild hypertension: memorandum from a WHO/ISH meeting

    Bull World Health Organ.

    (1993)
  • D.J. Drown et al.

    New guidelines for blood cholesterol by the National Cholesterol Education Program (NCEP). National Cholesterol Education Program (NCEP)

    Prog Cardiovasc Nurs.

    (1994)
  • National Cholesterol Education Program Panel

    Second report of the expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel) II)

    Circulation

    (1994)
  • A. Jager et al.

    Microalbuminuria and peripheral arterial disease are independent predictors of cardiovascular and all-cause mortality, especially among hypertensive subjects: five-year follow-up of the Hoorn Study

    Arterioscler Thromb Vasc Biol.

    (1999)
  • H.P. Adams et al.

    Classification of subtype of acute ischemic stroke

    Stroke

    (1993)
  • L.B. Goldstein et al.

    Improving the reliability of stroke subgroup classification using the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) criteria

    Stroke

    (2001)
  • A.R. Folsom et al.

    Relation of carotid artery wall thickness to diabetes mellitus, fasting glucose and insulin, body size, and physical activity

    Stroke

    (1994)
  • L.H. Kuller et al.

    Subclinical disease as an independent risk factor for cardiovascular disease

    Circulation

    (1995)
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