Diabetics with foot ulcers have higher risk of heart attack, stroke
16 October 2012
People with diabetes who develop foot ulcers are at more risk
of dying prematurely than those without the complication, finds a new
large-scale study. The researchers say the findings highlight the
potential need for improved detection and management of those with
diabetes and foot ulcers.
The study, which is the largest analysis of diabetes into the
link between foot ulcers and the condition, is published in this
month’s (November) edition of the journal Diabetologia.
About 3.7 million people in the UK have diabetes, including an
estimated 850,000 people who have the condition but do not know it.
Diabetes can damage a person’s blood vessels and nerves, especially
if their blood sugar is poorly controlled. Poor circulation and
nerve damage in the feet makes people vulnerable to unnoticed cuts
or other injuries and progress into poorly healing ulcers, or sores.
In severe cases, this can lead to foot or leg amputation.
Researchers from St George’s, University of London analysed
patient records from eight studies, conducted in Europe, America,
Australasia and South-East Asia, published between 2006 and 2011.
The length of time the health of participants was followed for
varied between an average of two and 10 years for each of the
The study included 17,830 patients with diabetes — 3,095
diagnosed with foot ulceration and 14,735 without — and investigated
how diabetic foot ulcers affected a person’s risk of dying earlier.
They found that there were an extra 58 deaths per 1,000 people each
year among people with diabetic foot ulcers.
People with foot ulcers and diabetes showed more cardiovascular
risk factors, such as high blood pressure, and were more likely to
die from cardiovascular causes. Approximately half of the additional
mortalities were due to cardiovascular disease, such as heart attack
The cause of non-cardiovascular deaths was not studied as part of
this investigation but the researchers say this is potentially
linked to infections and complications of foot ulceration, such as
Robert Hinchliffe from St George’s, University of London, who
co-led the study, said: “Our research, which is the largest and
therefore most reliable study to date, shows that people with
diabetes who have foot ulcers are at considerably higher risk of an
earlier death compared to those patients without. We suspect that
this may be due in part to the effect of infections among those with
foot ulcers and the greater co-existence of cardiovascular disease
and foot ulcers with diabetes although the reasons are not entirely
The researchers say these results underline the importance of a
two-pronged approach for people with diabetes: enhanced foot
ulceration screening as early detection and treatment may help
reduce some of the complications; and more intensive control of
blood pressure and cholesterol among those diagnosed with foot
ulcers as they are at higher cardiovascular risk.
Currently, experts already recommend that people with diabetes
undertake a number of precautions to prevent foot ulcers including
blood sugar control, wearing socks to prevent cuts, self-checking
for abrasions and getting a complete foot examination at least once
Existing guidelines to prevent cardiovascular disease include
healthy diet choices, regular exercise, a medical check-up at least
once a year and, often, medically prescribed drug treatment.
Professor Kausik Ray, who also co-led the study, said: “Our
results warrant further investigation as to whether even greater
control of risk factors such as blood pressure, blood glucose and
early preventative screening can further reduce mortality among
those with foot ulcers. There is likely an unmet potential to reduce
deaths in this group.”
Brownrigg J, et al. The association of ulceration of the
foot with cardiovascular and all-cause mortality in patients with
diabetes: a meta-analysis. Diabetologia, Volume 55, Number 11
(2012), 2906-2912, DOI: 10.1007/s00125-012-2673-3.