Improved survival of diabetic foot ulcer patients 1995-2008, possible impact of aggressive cardiovascular risk management

Abstract

Objectives: To determine if a strategy of aggressive cardiovascular risk management reduced the mortality associated with diabetic foot ulceration.

Research design and methods: Following an initial audit of outcomes demonstrating a high mortality rate in 404 diabetic foot ulceration patients with first ulceration developing between 1995 and 1999, a new aggressive cardiovascular risk policy was introduced as standard practice at the Diabetic Foot Clinic, Royal Infirmary of Edinburgh in 2001. 251 patients were screened and identified in the first three years of this policy. The audit cycle was then closed by re-auditing the five year mortality for a second group of foot ulcer patients in 2008.

Results: Overall five-year mortality reduced from 48.0% in cohort 1 to 26.8% in cohort 2 (p<0.001). Improvement in survival was seen for both neuroischaemic patients (five year mortality 58% to 36% relative reduction 38%) and neuropathic patients (36% to 19%, relative reduction 47%), both p<0.001. Patients were more likely to die if they were older at time of ulceration or had type 2 diabetes, renal impairment, pre-existing cardiovascular disease or were already on aspirin. Prior statin use, current or ex smoking, blood pressure, HbA1c or total cholesterol were not significantly different between survivors and those who died in the follow up periods.

Conclusions: Diabetic foot ulcer patients are at high risk of death. Survival has improved over the past 13 years. The adoption of an aggressive cardiovascular risk management policy in diabetic foot ulcer clinics is recommended for these patients.