AHA releases scientific statement on diabetic foot ulcers in cardiovascular patients
Qualitative and quantitative research is needed to resolve the reasons behind amputations for diabetic foot ulcers, the American Heart Association (AHA) said.
A multidisciplinary approach can help abate increases in amputations stemming from diabetic foot ulcers, according to a new scientific statement from the American Heart Association.
The scientific statement is intended to guide therapeutic and preventive strategies, as well as future research, in cardiovascular patients and to inform public policymakers on health disparities and other barriers to improving and advancing care. The statement was published Dec. 14, 2023, by Circulation.
The first step in ensuring high-quality care begins with appropriate taxonomy and risk assessment of each patient presenting, the statement said. To triage urgency, identify the condition, and start treatment, the statement points clinicians to the Society for Vascular Surgery's Wound, Ischemia and Foot Infection (WIfI) threatened limb classification system. The WIfI system is based on wound severity, extent of infection, and perfusion status, and it provides a reliable model for determining amputation risk while aiding in the clinical decision-making process, the statement said. WIfI mandates not only pulse palpation but also objective measurements of foot perfusion, defined by the ankle brachial index and toe systolic pressure or transcutaneous oxygen measurement. The goal is to identify ischemia as a potentially correctable, contributory factor for nonhealing foot ulcers.
The statement also provides guidance on special considerations related to diabetic foot ulcers in patients with diabetes and cardiovascular disease. Guidance on diagnosing and treating diabetic foot ulcers addresses the use of imaging, debridement, dressings, offloading, and biologics. The statement recognizes peripheral neuropathy as a major risk factor for development of diabetic foot ulcers, noting it to be beyond the scope of this document. It refers clinicians to guidance from the American Diabetes Association.
The statement also discussed a variety of disparities in treatment. While race and ethnicity cannot be separated from confounders such as socioeconomic status, numerous studies have identified that Black and Latino patients are more likely to undergo major amputation than White patients, even after controlling for risk factors, such as socioeconomic status, comorbidities, and advanced disease, the statement said. Rural patients also have amputation rates 51.3% higher than non-rural patients.
Mixed-methods research approaches are needed to better understand these issues, the statement concludes. The overwhelming majority of research has been quantitative, which was useful in identifying the existence and magnitude of amputation disparities. “Qualitative methods are ideal for answering the ‘why,’ because they provide essential information about the actual experiences of patients and health care professional dealing with amputation,” the statement said.