Medical literature is replete with mnemonics and literary devices to make management of our patients easier to remember and implement. One mnemonic has been used to propose a variety of easy to remember guidelines is the ABC’s of diabetes. Reputable institutions such as the American College of Cardiology have utilized this mnemonic to advocate for a healthier lifestyle and for more heavily regulated glycemic management. As podiatrists, we propose that these guidelines can be made even more comprehensive by including an important letter, “F”, for foot-care. With up to 60% of all amputations being preventable1, routine foot care and prophylactic intervention is often limb and life saving. With the aging population, there is an associated high risk and incidence for diabetes and vascular disease. A multidisciplinary approach emphasizing early active intervention combined with podiatric education, will help combat the alarming complications linked to these diseases.
In 2015 the American College of Cardiology developed a guideline to address the rise in cardiovascular related deaths for the first time since 1999. The ABCDE structured checklist was devised in 2019, it was created as a device or tool to minimize a patient’s risk for atherosclerotic cardiovascular disease. This approach emphasizes addressing shared decision making, a team-based care approach, and socioeconomic factors. What this scheme seems to be missing is “F” for podiatric foot care.
The ABCDE of primary prevention and lifestyle changes is a more global approach to patient care minimizing the risk of a significant cardiovascular event. The A stands for assessment of cardiovascular risk and antiplatelet therapy, particularly with the use of low dose aspirin in the select group of high risk patients. The B is for maintenance of blood pressure as close to <130/80 mmHg as possible. The C is for smoking cessation and cholesterol management. Cholesterol personalization with risk enhancers is used to assess atherosclerotic cardiovascular disease, furthermore, this scheme advocates for the use of the coronary artery calcium (CAC) test as needed. The CAC test is a computed tomography scan to assess for calcium build up in the coronary arteries, reserved for those who are at risk, especially those with diabetes, very high cholesterol, or who are heavy smokers. Diabetes, diet, and weight management with an emphasis on consumption of vegetables, fruits, nuts and legumes falls under the letter D. With regard to diabetes, the ACC recommends control through diet and lifestyle modification with specific pharmacological management. The pharmacological diabetes management advocated by the ACC begins with metformin as a first line agent with the addition of a sodium-glucose co-transporter-2 (SGLT2) or a glucagon-like-peptide-1 (GLP-1) receptor as a secondary agent. Of note, since the publication of these guidelines, three randomized controlled trials have surfaced and have shown a reduction in cardiovascular events and heart failure admissions or exacerbations as well as improvement in hemoglobin A1c, body weight, and blood pressure control with SGLT-2 inhibitors. Finally, the E is for exercise. This guideline maintains that one should perform more than 150 minutes a week of moderate physical activity or greater than 75 minutes a week of vigorous activity2. This guideline can be enhanced by including F for feet in the ABC’s for management of disease.
The diabetic and dysvascular foot are significant contributors to the modern epidemic of cardiovascular related deaths. Amputation places substantial strain on the cardiovascular system with a predicted 5-year mortality rate of 50%3. Therefore, it is imperative that education initiatives are implemented and that routine foot surveillance and care be part of the podiatric physician’s armamentarium. As podiatric professionals, the F for foot care would seemingly play an integral role in the holistic approach of patients with diabetes and cardiovascular risks.
Diabetes is a complex disease and it is important to involve ancillary services and take a multidisciplinary approach in treating patients. The guideline touches on the micro and macrovascular complications. This is where foot care and awareness fits into cardiovascular health. Acute and chronic diabetic foot infections are known to cause fluctuations in a patient’s glycemic profile. It is therefore critical to communicate and consider how the foot may be affecting this critically important glycemic profile.
According to the CDC there are 100 million people in the US living with either diabetes or pre-diabetes, a condition that if not treated, often leads to diabetes within the next 5 years. Diabetes is still the 7th leading cause of death in the US4. Furthermore, the complications of diabetes, such as a diabetic foot ulceration, carries a relatively high morbidity and mortality rate. Jupiter et al. reported in their systematic review that there is a staggering five-year mortality rate of 40%-50% in patients with a new diagnosis of a diabetic foot ulceration5. Even a simple toe amputation carries the risks and complications associated with any surgery, including death. With this information in mind, a multidisciplinary approach with an emphasis on early intervention and amputation prevention is paramount in keeping our patients alive and on their feet. A strong referral network including vascular surgeons, endocrinologists, internists, and ancillary services are important in the coordination of care for our patients.
The American Diabetes Association recommends that every diabetic patient have a comprehensive foot exam at least once a year; including an examination of skin, muscles and bones, blood flow, and sensation using a monofilament6. Routine foot screenings have been shown to prevent hospitalizations and delay or prevent amputations. Both macro and micro vascular disease are known culprits in diabetic foot complications. Macrovascular disease is often the product of atherosclerotic occlusive disease leading to reduced nutrient capillary blood flow and the loss of protective sensation. Additionally, this high risk patient population often presents with both sensory and autonomic neuropathies. The sensory neuropathy predisposes patients to loss of protective sensation, whereas the autonomic neuropathy affects the micro-neurovasculature. Sensory neuropathy manifests with wound and skin complications. In the absence of sensation patients are more predisposed to developing blisters, wounds, and foreign body contacts from stepping on items with out feeling or noticing them. The autonomic neuropathy affects the capillary basement membrane and will manifest as dystrophic skin changes and with neuropathic edema. Furthermore, patients with peripheral neuropathy and loss of protective sensation, altered biomechanics in the presence of neuropathy, evidence of increased pressure or callus formation, bony deformity, absent pulses or peripheral vascular disease, a history of ulcers or amputations, and those with severe nail pathology should be monitored more frequently for signs of infection and for at risk foot care. Loss of limb secondary to foot infection places significant strain on the cardiovascular system. One must maintain that the foot is literally, and intrinsically connected to the body and recognize that amputation carries a high 5-year mortality rate.
With diabetic foot care, there is a strong emphasis on patient engagement and action. Emphasis is frequently made to have patients check their feet, remain shod, and avoid barefoot walking. More often than not, a recommendation is made for patients to wear their shoes. It is imperative that the discussion should include that shoes be worn not only outside the house but also inside the house. All scenarios should be discussed to ensure proper patient compliance.
The NIH has recommended that patients know their ABCs of diabetes and discuss these numbers should be routinely reviewed by physicians. A for A1c. The aim is for this value to be below 7 mg/dl. B for blood pressure control which should be checked at each physician visit and hypertensive patients should be recording their own blood pressures at home. C for cholesterol, specifically low density below 100 mg/dl. The NIH encourages patients to know these numbers and discuss management methods with their physicians.
Diabetic foot related hospitalizations are among the leading causes for diabetes-related hospitalizations and can often be avoided. In a nationwide study between the years 2005-2010 it was determined that diabetic foot ulcer care costs the Medicare system approximately $1.5 billion per year7. The rise in cost of treatment of these ulcerations has been attributed to the push for limb salvage and the expenses associated with these efforts. Furthermore, the majority of these costs are associated with the treatment of infected diabetic foot ulcerations. Unfortunately, many of these wound infections are preventable. Education initiatives and compliance on an outpatient basis with a multidisciplinary approach targeted at these high-risk populations is important in preventing what is already a disproportionate economic burden. Identifying diabetics at risk is vital, the ratio of hospital admissions in for the purpose of ulceration is 11 times higher in the diabetic population.
The following is a case presentation that features cardiovascular complications that lead to the eventual death of a patient who had poorly managed ABC’s. A 74-year-old female with a past medical history of peripheral arterial disease with 3 vessel disease and 2 vessel runoff to the level of the ankle after right leg selective angioplasty, hyperlipidemia, hypertension, diabetes mellitus type II with a HbA1c of 9.8, atrial fibrillation on anticoagulants, and end stage renal disease on hemodialysis presented to the hospital with immense pain right foot pain in the setting of a gangrenous hallux after routine foot care by her local podiatrist (Figure 1). The patient diligently followed up as an outpatient for about 1 year. Her Right hallux got infected, became wet and warranted a partial 1st ray amputation with vacuum assisted closure (Figure 2). She returned with a post-operative infection 1 month later (figure 3) and underwent an urgent guillotine trans-metatarsal amputation and an additional angioplasty shortly thereafter. The patient was taken off of her anticoagulation for a proximal amputation and primary closure (figure 4). She subsequently underwent a large right sided cerebrovascular event and was transferred to the intensive care unit for persistent hypotension and for stroke management. Shortly afterwards the patient went into cardiogenic shock, coded, and passed several days later. This patient, unfortunately died in less than 2 years after developing a lesion to her right hallux. Her cardiovascular disease ultimately led to complex and difficult to treat foot manifestations and to her eventual death. This case study highlights how important the ABC’s truly are. This patient’s cardiovascular status was a product of years of neglect of her ABC’s with manifested with a poor prognostic simple gangrenous skin lesion. Foot health is a good predictor of overall health, both literature and this case support that once the disease appears on the foot one’s condition is in jeopardy. One must therefore coordinate a multidisciplinary care base approach to identify, educate, and treat at risk patients before ulceration or skin lesions appear, as they carry a relatively high 5-year mortality rate.
The ABCDE and F’s of care are applied to either of the aforementioned mnemonics is a helpful tool and if adhered to and followed diligently, can lead to better results, treatment, and management of a difficult diseases that involve the entire body. It is imperative that the feet are included in diabetic care to prolong life, quality of it, and to address the extraordinary economic burden. The message to patients is “know your numbers, and your letters!”.
Works Cited
1) Oregon, Monica Maria, et al. “Cost-Effectiveness of Prevention and Treatment of the Diabetic Foot, A Markov Analysis.” Diabetes Care, vol. 27, 2004, pp. 901–907.
2) Alfaddagh, Abdulhameid, et al. “The ABCs of Primary Cardiovascular Prevention: 2019 Update.” American College of Cardiology, 21 Mar. 2019, www.acc.org/latest-in-cardiology/articles/2019/03/21/14/39/abcs-of-primary-cv-prevention-2019-update-gl-prevention.
3) Morten Tange Kristensen, Gitte Holm, Klaus Kirketerp-Møller, Michael Krasheninnikoff, Peter Gebuhr, Very low survival rates after non-traumatic lower limb amputation in a consecutive series: what to do?, Interactive CardioVascular and Thoracic Surgery, Volume 14, Issue 5, May 2012, Pages 543–547, https://doi.org/10.1093/icvts/ivr075
4) “New CDC Report: More than 100 Million Americans Have Diabetes or Prediabetes | CDC Online Newsroom | CDC.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, July 2017, www.cdc.gov/media/releases/2017/p0718-diabetes-report.html.
5) Jupiter, Daniel C, et al. “The Impact of Foot Ulceration and Amputation on Mortality in Diabetic Patients. I: From Ulceration to Death, a Systematic Review.” Wiley Online Library, John Wiley & Sons, Ltd (10.1111), 20 Jan. 2015, onlinelibrary.wiley.com/doi/full/10.1111/iwj.12404.
6) “Preventive Foot Care in Diabetes.” Diabetes Care, American Diabetes Association, 1 Jan. 2004, care.diabetesjournals.org/content/27/suppl_1/s63. Diabetes Care 2004 Jan; 27(suppl 1): s63-s64.
7) Hicks CW, Selvarajah S, Mathioudakis N, et al. Burden of Infected Diabetic Foot Ulcers on Hospital Admissions and Costs. Ann Vasc Surg. 2016;33:149–158. doi:10.1016/j.avsg.2015.11.025
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