Could a routine heart test save lives for those with diabetic foot ulcers?

The risk of dying within two years of presenting with diabetic foot ulceration is over six times the risk of amputation.

In an attempt to enhance diabetic foot care and save lives, researchers, led by Professor Jonathan Valabhji from Imperial’s Department of Metabolism Digestion and Reproduction, have been evaluating whether introducing a 12-lead ECG into routine care for patients presenting with foot ulceration in diabetic foot clinics could potentially reduce mortality rates.

"Although only one third of attendees at the pilot units received an ECG, in those that did, mortality at 5 years was lower." Professor Jonathan Valabhji Clinical Chair in Medicine

The real-world implementation pilot in England, conducted between July 2014 and December 2017, involved ten multidisciplinary diabetic foot services across England. The study analysed data on new attendees with foot ulceration, comparing subsequent 2- and 5-year mortality rates between the 3,110 individuals receiving care in participating pilot units and the 25,195 individuals attending other units across England. 

Despite efforts to integrate the 12-lead ECG into routine care pathways, the study found that overall mortality rates at participating units were not significantly reduced at 2 or 5 years following attendance, with confidence intervals just crossing parity. Challenges in the implementation process were noted, with only a third of attendees receiving an ECG across the ten units, indicating potential issues with operationalising the intervention. 

However, the study identified signals suggesting mortality benefits among those who did receive an ECG at the 5-year mark. This suggests that units able to effectively implement the 12-lead ECG may consider its incorporation into routine care pathways to potentially improve patient outcomes.

Speaking about the importance of the study, Professor Valabhji said: “Over recent years, we have got much better at saving the limbs of people with diabetes presenting with foot ulcers in England, with multidisciplinary foot care much more accessible, and major amputation rates now lower than in most other countries internationally. However, we are at risk of saving limbs but not saving lives. Mortality rates following presentation with diabetes-related foot ulcers are very high - 20% at 2 years and 40% at 5-years in England. We therefore undertook this real-world implementation study to assess whether the introduction of a routine heart test, the 12-lead ECG, into the diabetes footcare pathway could improve the high mortality rates.

"Operational delivery proved challenging in this population, many of whom rely on hospital transport and struggle to walk between hospital departments. Nevertheless, although only one third of attendees at the pilot units received an ECG, in those that did, mortality at 5 years was lower. NHS England will support the communication of these messages to foot units across the country, as units that can operationalise this approach may wish to take this on.”

Read the full study in Diabetologia