Revista da Sociedade Portuguesa de Endocrinologia Diabetes e Metabolismo

Online first

Revista Portuguesa de Endocrinologia, Diabetes e Metabolismo - Online first: 2018-12-04
Original article

Current status of cardiovascular disease prevention in diabetic foot patients

Ferreira L, Pereira T, Fonseca L, Amado A, Carvalho R

Abstract

Introduction: Cardiovascular disease (CVD) is the leading cause of morbidity and mortality among diabetic patients. Antiplatelet and statin therapy are effective and recommended in secondary prevention in diabetic patients with overt CVD. Statin therapy is also recommended in primary prevention in diabetic patients with at least one cardiovascular risk factor and/or target organ damage. The purpose of this study was to evaluate the intervention level to reduce cardiovascular risk in patients with Diabetic Foot. Methods: A retrospective observational study was performed. Patients observed in a multidisciplinary outpatient diabetic foot clinic between 2012 and 2014 were reviewed (n=829). Demographic and clinical data namely micro and macrovascular complications, additional cardiovascular risk factors and statin or antiplatelet therapy were collected. Results: Patients were mainly men (56.5%), with a median age of 68 years old, median duration of diabetes of 15 years and median HBA1c of 7.4%. The majority had microvascular disease (47.2% - retinopathy, 29.1% - nephropathy and 73.6% peripheral neuropathy) or established macrovascular disease [22.4% - coronary artery disease (CAD), 22.7% cerebrovascular disease (CeVD) and 59.4% had peripheral arterial disease (PAD)]; 82.2% had hypertension, 66.1% dyslipidemia and 15.9% were smokers. Statin therapy was documented in 54% of patients and was more frequent in patients with hypertension (58.1% vs 35.9%;p<0.001), dyslipidemia (77.7% vs 10.0%;p<0.001) and CAD (66.5% vs 50.1%;p<0.001). No association was found between statin therapy and patients with PAD, CeVD, microvascular disease or smoking. Antiplatelet therapy was documented in 47.9% of patients, but only in 53.1% of those with evidence of macrovascular disease. This therapy was more frequent in patients with hypertension (50.2% vs 37.2%;p=0.005), dyslipidemia (52.8% vs 36.1%;p<0.001), retinopathy (51.9% vs 44.2%;p=0.032), nephropathy (57.2% vs 44.6%;p=0.002), CAD (66.5% vs 43.0%;p<0.001) and CeVD (63.2% vs 43.1%;p<0.001). No association was found between antiplatelet therapy and patients with PAD. Conclusion: The level of intervention for reducing cardiovascular risk in this group of diabetic patients was insufficient. This may reflect an undervaluation of PAD in assessing cardiovascular risk. It is important to reinforce the need to adopt prevention strategies in these patients, which can reduce their high morbidity and mortality.

Portuguese abstract

Introdução: A doença cardiovascular é a principal causa de morbilidade e mortalidade associada à diabetes. A terapêutica com estatinas e antiagregantes plaquetares demonstrou ser eficaz na prevenção secundária de eventos cardiovasculares ateroscleróticos. As estatinas demonstraram ser igualmente benéficas na prevenção primária de indivíduos com diabetes, outros fatores de risco cardiovascular e/ou doença de órgão-alvo. Com este trabalho pretende-se descrever a prevalência de fatores de risco cardiovascular e de estratégias de prevenção cardiovascular em doentes com Pé Diabético. Métodos: Estudo retrospetivo de 829 doentes observados na Unidade Multidisciplinar de Pé Diabético, entre 2012 e 2014 e com dados relativos à terapêutica com estatinas ou antiagregante plaquetar. Avaliaram-se dados demográficos e clínicos, complicações micro e macrovasculares e a terapêutica com estatinas e antiagregantes plaquetares. Resultados: Os doentes eram maioritariamente do sexo masculino (56.5%) e apresentavam idade mediana de 68 anos, tempo mediano desde o diagnóstico da diabetes de 15 anos e HbA1c mediana de 7.4%. A maioria apresentava doença microvascular – 73.6% neuropatia periférica sensitivomotora, 47.2% retinopatia diabética, 29.1% nefropatia diabética, e/ou macrovascular – 59.4% arteriopatia periférica (DAP), 22.7% doença cerebrovascular (DCV) e 22.4% doença cardíaca isquémica (DCI). Documentou-se hipertensão arterial em 82.2%, dislipidemia em 66.1% e tabagismo ativo em 15.9% dos doentes. Verificou-se prescrição de uma estatina em apenas 54% dos doentes. Esta terapêutica foi mais frequente na presença de hipertensão (58.1% vs 35.9%;p<0.001), dislipidemia (77.7% vs 10.0%;p<0.001) e DCI (66.5% vs 50.1%;p<0.001). Não foi encontrada associação com a presença de DAP, DCV, doença microvascular ou tabagismo. A antiagregação plaquetar foi documentada em 47.9% dos doentes e em apenas 53.1% dos doentes com doença macrovascular. Esta terapêutica foi mais frequente em doentes hipertensos (50.2% vs 37.2%;p=0.005), com dislipidemia (52.8% vs 36.1%;p<0.001), retinopatia (51.9% vs 44.2%;p=0.032), nefropatia diabética (57.2% vs 44.6%;p=0.002), DCI (66.5% vs 43.0%;p<0.001) e DCV (63.2% vs 43.1%;p<0.001). Não foi encontrada relação entre a antiagregação plaquetar e a presença de DAP. Conclusão: O nível de intervenção para redução do risco cardiovascular nos diabéticos é insuficiente, o que poderá refletir a subvalorização da DAP na avaliação do risco cardiovascular. O reforço destas estratégias de prevenção poderá reduzir a morbilidade e mortalidade