Management of Lower Arterial Disease in Diabetic Foot Patients

Cardiovascular Risk Reduction

The American College of Cardiology recommends aspirin 75-325 mg daily as the first-line antiplatelet therapy to reduce the risk of myocardial infarction, stroke, and vascular death in all patients with atherosclerotic lower extremity PAD 1, 2
The American College of Cardiology suggests clopidogrel 75 mg daily as an effective alternative to aspirin for cardiovascular risk reduction 1, 2
The American College of Cardiology recommends ACE inhibitors for symptomatic PAD patients to reduce myocardial infarction, stroke, and vascular death by approximately 25% 1, 2
The American College of Cardiology states that beta-blockers are safe and effective antihypertensive agents in PAD patients and do not adversely affect walking capacity 1, 2

The American College of Cardiology recommends that all patients be advised to stop smoking at every clinical encounter and offered comprehensive cessation interventions including behavioral therapy, nicotine replacement, bupropion, or varenicline 1, 2, 3
Coordinated programs combining counseling and pharmacotherapy increase cessation rates to 21.3% versus 6.8% with standard advice alone 3

The American College of Cardiology recommends targeting HbA1c <7% to reduce microvascular complications and potentially improve cardiovascular outcomes 1, 2
The American College of Cardiology states that glycemic control is particularly critical in patients with critical limb ischemia, as optimized glucose control improves limb-related outcomes including lower amputation rates and better patency after infrapopliteal intervention 3

The American Diabetes Association recommends that patients perform daily foot inspection using visual examination or an unbreakable mirror if loss of protective sensation is present 4, 5, 6
The American College of Cardiology suggests applying topical moisturizing creams daily after gentle cleansing to maintain skin integrity and prevent ulceration 1, 2, 7
The American Diabetes Association recommends performing comprehensive foot evaluation at least annually, with more frequent assessments for high-risk patients 4, 5, 6
The American Diabetes Association states that the examination must include inspection of skin integrity and musculoskeletal deformities, neurological assessment, vascular assessment, and history of decreased walking speed, leg fatigue, and claudication 4, 5, 6
The American Diabetes Association recommends performing ankle-brachial index testing in patients with symptoms or signs of PAD 4, 5
The American Diabetes Association suggests that patients with neuropathy or increased plantar pressures require well-fitted walking shoes or athletic shoes that cushion feet and redistribute pressure 4, 5
The American Diabetes Association recommends that patients with bony deformities need extra wide or deep shoes 4, 5
The American Diabetes Association states that patients with severe deformities including Charcot foot require custom-molded shoes if commercial therapeutic footwear cannot accommodate them 4, 5

The American College of Cardiology states that beta-blockers do not worsen claudication and are safe and effective in PAD patients 1, 2
The American Diabetes Association recommends obtaining ankle-brachial index testing when clinical suspicion of PAD exists, rather than relying solely on pedal pulse palpation 4, 5
The American Diabetes Association suggests that patients with visual difficulties, physical constraints, or cognitive problems need family members to assist with foot care 4, 5