Top Things to Know: Current Status and Principles for the Treatment and Prevention of Diabetic Foot Ulcers in the CV Patient Population

Published: December 14, 2023

  1. Diabetic foot ulcers, a complication of diabetes mellitus (DM), are the main cause of morbidity and mortality and the leading cause of lower extremity amputation in the United States. Foot ulcer in a patient with DM doubles the expected mortality and constitutes the most common factor contributing to hospital admission.
  2. Peripheral artery disease (PAD) associated with non-healing diabetic ulcers has become increasingly challenging to manage due to increasing patient complexity derived from multiple co-morbid conditions. In addition, there is currently little guidance on best preventive and management practices regarding this patient population.
  3. The current statement reviews the latest evidence on the complex etiology and management of diabetic wounds, therapeutic and preventive strategies, future research directions, health disparities, and other barriers to improving and advancing care.
  4. Diabetic foot wound resolution depends on underlying vascular issues. The macrovascular atherosclerotic occlusive disease can limit the available perfusion to the distal extremities, while the microvascular disease can also contribute to diabetic wounds and their failure to heal.
  5. In any cardiovascular patient with diabetic foot disease, assessment of peripheral perfusion via ABI (ankle-brachial index) and TBI (toe brachial index) is mandatory as it guides management strategies. In general, an ABI alone does not provide reliable results in patients with non-compressible vessels due to medial calcinosis; therefore, a TSP (toe systolic pressure) and TBI is needed to determine perfusion to the foot.
  6. Conventional radiography is the initial imaging study for any patient with DM and a foot ulcer greater than two weeks in duration or suspected of having a soft tissue or deep space infection. Magnetic resonance imaging (MRI) is practical in detecting osteomyelitis, especially if radiographs are negative or equivocal. A triple-phase bone scan with a tagged WBC scan is an acceptable alternative to evaluate for osteomyelitis in a patient who cannot undergo MRI.
  7. Restoration of in-line flow to the foot in a patient with DM is generally considered a requisite to heal a diabetic foot ulcer, a stark contrast to patients with intermittent claudication or rest pain successfully managed with a single-level reconstruction of proximal or inflow lesions alone.
  8. The majority of aortoiliac lesions are amendable to endovascular treatment. The primary endovascular strategy remains balloon angioplasty and stent placement; balloon-expandable (bare metal vs. covered) stents are preferred for the common iliac artery, while self-expanding stents are for external iliac artery lesions.
  9. Common femoral endarterectomy with patch angioplasty remains the gold standard approach for common femoral lesions, while femoropopliteal lesions may be treated with either endovascular or open approaches. The primary endovascular approach for a tibial disease is percutaneous angioplasty.
  10. Concomitant DM and PAD pose a grave threat to life and limb; hence early identification and staging of the limb for contributory factors and amputation risk must be expeditious. The involvement of multidisciplinary teams with a broad-based skill set has been demonstrated to improve limb salvage rates in multiple clinical settings.


Gallagher KA, Mills JL, Armstrong DG, Conte MS, Kirsner RS, Minc SD, Plutzky J, Southerland KW, Tomic-Canic M; on behalf of the American Heart Association Council on Peripheral Vascular Disease, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Lifestyle and Cardiometabolic Health. Current status and principles for the treatment and prevention of diabetic foot ulcers in the cardiovascular patient population: a scientific statement from the American Heart Association. Circulation. Published online December 14, 2023. doi: 10.1161/CIR.0000000000001192