2023+AHA科学声明：心血管患者群体中糖尿病足溃疡的现状及防治原则（英文版）.pdf

《2023+AHA科学声明：心血管患者群体中糖尿病足溃疡的现状及防治原则（英文版）.pdf》由会员分享，可在线阅读，更多相关《2023+AHA科学声明：心血管患者群体中糖尿病足溃疡的现状及防治原则（英文版）.pdf（22页珍藏版）》请在周易易学书店|道易五术书社上搜索。

1、CirculationCirculation.2023;148:e00e00.DOI:10.1161/CIR.0000000000001192 TBD TBD,2023 e1Circulation is available at www.ahajournals.org/journal/circ Supplemental Material is available at https:/www.ahajournals.org/doi/suppl/10.1161/CIR.0000000000001192.2023 American Heart Association,Inc.AHA SCIENTIF

2、IC STATEMENTCurrent Status and Principles for the Treatment and Prevention of Diabetic Foot Ulcers in the Cardiovascular Patient Population:A Scientific Statement From the American Heart AssociationKatherine A.Gallagher,MD,FACS,FAHA,Chair;Joseph L.Mills,FACS,MD,Vice Chair;David G.Armstrong,DPM,MD,Ph

3、D;Michael S.Conte,MD,FACS,FAHA;Robert S.Kirsner,MD,PhD;Samantha D.Minc,MD,MPH,FACS;Jorge Plutzky,MD,FAHA;Kevin W.Southerland,MD;Marjana Tomic-Canic,PhD;on behalf of the American Heart Association Council on Peripheral Vascular Disease;Council on Cardiovascular and Stroke Nursing;Council on Clinical

4、Cardiology;and Council on Lifestyle and Cardiometabolic HealthABSTRACT:Despite the known higher risk of cardiovascular disease in individuals with type 2 diabetes,the pathophysiology and optimal management of diabetic foot ulcers(DFUs),a leading complication associated with diabetes,is complex and c

5、ontinues to evolve.Complications of type 2 diabetes,such as DFUs,are a major cause of morbidity and mortality and the leading cause of major lower extremity amputation in the United States.There has recently been a strong focus on the prevention and early treatment of DFUs,leading to the development

6、 of multidisciplinary diabetic wound and amputation prevention clinics across the country.Mounting evidence has shown that,despite these efforts,amputations associated with DFUs continue to increase.Furthermore,due to increasing patient complexity of management secondary to comorbid conditions,such

7、as cardiovascular disease,the management of peripheral artery disease associated with DFUs has become increasingly difficult,and care delivery is often episodic and fragmented.Although structured,process-specific approaches exist at individual institutions for the management of DFUs in the cardiovas

8、cular patient population,there is insufficient awareness of these principles in the general medicine communities.Furthermore,there is growing interest in better understanding the mechanistic underpinnings of DFUs to better define personalized medicine to improve outcomes.The goals of this scientific

9、 statement are to provide salient background information on the complex pathogenesis and current management of DFUs in cardiovascular patients,to guide therapeutic and preventive strategies and future research directions,and to inform public policy makers on health disparities and other barriers to

10、improving and advancing care in this expanding patient population.Key Words:AHA Scientific Statements amputation,surgical cardiovascular diseases diabetes,type 2 diabetic foot health care disparities health inequities peripheral arterial diseaseThe number of cardiovascular patients with diabetes and

11、 associated diabetic foot disease has dramati-cally increased during the past decade.Although both type 1 and type 2 diabetes are strongly associated with cardiovascular disease,type 2 diabetes accounts for 95%of patients with diabetes,and,as such,type 2 diabe-tes is commonly linked to a large propo

12、rtion of nonheal-ing diabetic foot ulcers(DFUs).The prevalence of people with diabetes-related lower extremity complications was a staggering 131 million people,or 1.8%of the global popu-lation.1 This dramatic increase,combined with the inherent complexities related to the management of this populat

13、ion,and other factors related to health care delivery and social inequities,as well,all contribute to the unacceptably high amputation rates in the United States.Moreover,because current treatments and algorithms of care are presently suboptimal and not always followed,we will address research progr

14、ess in this arena while highlighting health CLINICAL STATEMENTS AND GUIDELINESTBD TBD,2023 Circulation.2023;148:e00e00.DOI:10.1161/CIR.0000000000001192Gallagher et al Treatment and Prevention of Diabetic Foot Ulcerse2disparities and translational work that may improve both access to care and treatme

15、nt options in these patients.Therefore,understanding the prevention and current best management practices for this complex population is vital to reducing the public health burden of this devastat-ing disease.The focus of this scientific statement is to review the latest evidence supporting the prev

16、ention and management of diabetic foot disease in the cardiovascu-lar population and advances made in the outcomes,dis-parities,and translational research space that can improve outcomes for these patients in the near future.EPIDEMIOLOGY AND STAGINGEpidemiologyNonhealing wounds in patients with conc

17、omitant cardiovas-cular disease and diabetes constitute a significant public health burden.DFUs constitute wounds below the malleoli in patients with diabetes and are typically caused by a com-bination of factors,including nerve damage,immune sys-tem dysfunction,and peripheral artery disease(PAD)and

18、 are frequently associated with trauma to the foot.This is in accordance with the International Working Group on the diabetic foot2 where DFUs are defined as occurring in pa-tients with current or previously diagnosed diabetes,usually accompanied by neuropathy or PAD in the lower extrem-ity.The life

19、time risk of developing a DFU2 in patients with diabetes is at least 25%and may exceed 34%.3 Perhaps equally alarming,DFUs constitute one of the most com-mon factors contributing to hospital admission in patients with diabetes,placing a direct burden on an already over-whelmed health care system.4 L

20、ikewise,the direct costs associated with treating DFUs exceed treatment costs for many common forms of cancer.5 The personal cost for in-dividuals with DFUs is also significant and can be greater than a years worth of salary,depending on health system and severity of disease,6 and may also lead to j

21、ob loss for individuals who cannot work while nonweight bearing.Over the past decade,the epidemiology of lower extremity ampu-tation has been relatively dynamic,particularly in the United States compared with other areas of the world.Although some studies suggest that the overall prevalence of lower

22、 extremity amputation appears to have peaked from 2010 to 2015,trends over the past decade clearly suggest that there has been a dramatic increase in amputations among people with diabetes.6,7 As mentioned,DFUs are primary drivers of hospitalization in the ever-growing diabetes popu-lation;hence,the

23、se studies suggest a disturbing trend that has the potential to overwhelm our health care system.The natural history of DFUs is highly morbid,particu-larly in the cardiovascular population.For example,the presence of a DFU in a patient with diabetes more than doubles expected mortality compared with

24、 patients with diabetes without a DFU.7,8 More than half of DFUs,unfor-tunately,will become infected,9 and once infected,at least 20%will require some form of amputation.In addition,mortality rate after diabetes-related amputation is worse than amputations performed for other reasons,where the morta

25、lity rate in patients with diabetes exceeds 70%at 5 years and increases to 74%at 2 years for those patients with diabetes who are also on renal replacement therapy,a common comorbidity in the cardiovascular/diabetic population.9 This mortality rate exceeds all but the most aggressive forms of cancer

26、,yet the manage-ment and treatment algorithms for these patients remain less well defined and often unclear to the primary physi-cians treating these patients on a regular basis.5StagingAlthough it is well established that 85%of diabetes-related amputations are preceded by a DFU,with early,high-qual

27、ity care,a higher percentage of DFUs can heal.The current standard of care includes surgical debridement,pressure offloading,attention to infec-tion,assessment of circulation,and,when needed,re-vascularization;these interventions are the mainstays of current treatment and will be discussed in detail

28、 later in this document.However,the first step in ensur-ing high-quality care begins with appropriate taxonomy and risk assessment of each patient presenting with a DFU.Several validated classification systems exist to assess wounds,10 ischemia,11 and foot infection,and these are reviewed in Supplem

29、ental Table 1.12,13 Many of the previously used classification systems,however,generally focused primarily on one wound or limb fac-tor(eg,wound depth,severity of ischemia,severity of infection)without allowing for description and interac-tion of the presence or severity of additional contrib-uting

30、factors to exist simultaneously.To combat this issue,the Society for Vascular Surgery Wound,Ischemia and Foot Infection(WIfI)threatened limb classification system14 brought these critical elements together,has been widely validated,and is summarized in Figure 1.The WIfI system is based on wound seve

31、rity,extent of infection,and perfusion status,and it provides a reliable model for determining amputation risk while aiding in the clinical decision-making process.15 It is important that WIfI mandates not only pulse palpation but also objective measurements of foot perfusion(ankle bra-chial index a

32、nd toe systolic pressure or transcutaneous oxygen measurement TcPo2)to avoid failure to identify ischemia as a potentially correctable,contributory factor for nonhealing DFU.Although not specific to DFUs,the WIfI classification is extremely useful in the risk assess-ment of patients with DFU because

33、 it consists of ordinal severity grading of tissue loss,ischemia,and infection on a 4-point scale and is dedicated to staging overall limb threat,analogous to the tumor,node,metastasis(TNM)classification for cancers.The 64 total WIfI combinations have been grouped into 4 clinical stages that correla

34、te CLINICAL STATEMENTS AND GUIDELINESCirculation.2023;148:e00e00.DOI:10.1161/CIR.0000000000001192 TBD TBD,2023Gallagher et al Treatment and Prevention of Diabetic Foot Ulcerse3with the expected risk of major amputation at 1 year.WIfI staging allows the clinician to triage urgency,iden-tify the curre

35、nt dominant condition or conditions,and sequence treatment accordingly.16 For example,patients presenting with WIfI clinical stage 4 limb severity are at extremely high risk of major limb amputation,mandating an expedited treatment approach to preserve functional limb salvage.WIfI staging also allow

36、s for the serial as-sessment of treatment response over time,an important factor for patients with DFUs.11,17 For these reasons,the WIfI is the preferred classification system for patients presenting with a DFU and should be used widely in the initial assessment of any patient presenting with a DFU.

37、DISPARITIES IN DFUsHealth Disparities Associated With DFU Related AmputationsDisparities in amputation rates for patients with diabe-tes have been identified as an area of national concern since 2003.18 Since that time,multiple studies have identified variation in amputation risk on the basis of so-

38、cioeconomic,racial,ethnic,and geographic(rural-and urban-dwelling)status,1925 and there has been an expo-nential growth in publications on the subject.Although the risk for amputation is highest in communities with higher levels of traditional risk factors,such as diabe-tes,cardiovascular disease,an

39、d tobacco use,it is also disproportionately higher in disenfranchised populations affected by high economic hardship and chronic exter-nal stressors.20,26 Disparities in amputation rates,thus,serve as a marker for structural inequities in health care access,quality of health care,and nonmedical fact

40、ors,such as food security,transportation,and housing stabil-ity(ie,the Social Determinants of Health).In addition,diabetes-related amputation in some cases may be pre-ventable with access to higher quality medical,podiatric,and vascular care,2731 and as such,reducing dispari-ties in amputation rates

41、 has been adopted as a lead-ing health indicator and national objective for achieving equity in the treatment of diabetes across the country.32Disparities Related to Ethnicity and RaceThere is a significant body of literature describing racial and ethnic disparities in amputation rates for both chro

42、n-ic limb-threatening ischemia(CL TI)and diabetes,19,30,3344 and although it is often argued that the increased risk of race and ethnicity cannot be separated from confound-ers,such as socioeconomic status,numerous studies have identified that,even after controlling for risk fac-tors,such as socioec

43、onomic status,comorbidities,and advanced disease,Black and African American and Hispanic and Latino patients are more likely to undergo major amputation for CLTI and diabetes than White patients.19,25,33,36,3941,44 Similar findings have been reported in Native American populations.45,46 It is even m

44、ore trou-bling that there is ample evidence to support that race and ethnicity is also an independent predictor for primary Figure 1.WiFi staging criteria for DFUs.SIRS indicates Systemic Inflammatory Response Score.CLINICAL STATEMENTS AND GUIDELINESTBD TBD,2023 Circulation.2023;148:e00e00.DOI:10.11

45、61/CIR.0000000000001192Gallagher et al Treatment and Prevention of Diabetic Foot Ulcerse4amputation(ie,amputation without attempt at revascu-larization),33,36,38,39,41,44,47,48 suggesting that there are other factors at play that have yet to be identified or measured in a meaningful way.These factor

46、s may include structural inequities49,50 and implicit bias,51 among other factors.Geographic DisparitiesRural-dwelling populations have been repeatedly identi-fied as a major at-risk group for health disparities,in-cluding DFU-associated amputation.Studies suggest that rural-dwelling patients underg

47、o amputation at rates 51.3%higher than non-rural-dwelling patients,52 and there are data to support that heavily rural-dwelling ar-eas have higher amputation rates compared with the rest of the country.23,24,53 One potential explanation for these findings is that rural-dwelling patients tend to be m

48、edi-cally underresourced and deal with significant physical and cultural barriers to accessing quality care.In addition,rural-dwelling populations tend to be older,more eco-nomically depressed,and have higher levels of chronic disease,such as diabetes,and riskier health behaviors than their urban-dw

49、elling counterparts.54 It is interesting to note,however,that even when controlling for comor-bidities and other risk factors,studies have demonstrated that geographic variation in amputation risk continues to exist,23 further reinforcing the hypothesis that there are other variables involved that r

50、emain unknown.IntersectionalityIntersectionality is the theory that individuals multiple identities within social systems compound and exacerbate experiences of ill health.55,56 The effect of intersectional-ity in amplifying risk for amputation also finds support in the literature.Examples of the ef