Macrovascular Disease and Lower-Extremity Foot Care

Macrovascular Disease: CVD, Cerebrovascular Disease, and PAD

Cardiovascular disease is the leading cause of death in people with diabetes, and diabetes itself is a major independent risk factor for atherosclerotic cardiovascular disease, stroke, and peripheral artery disease (PAD). Risk-reduction therapy, not glucose control alone, drives macrovascular outcomes, and the CDCES must know which interventions matter most.

Statins are the foundation of lipid management: high-intensity statin therapy is recommended for most adults with diabetes who have additional atherosclerotic risk factors or established cardiovascular disease, reinforced with ezetimibe, a PCSK9 inhibitor, or bempedoic acid when LDL goals are not reached on maximally tolerated statin therapy alone. Blood pressure control to individualized targets reduces both cardiovascular and microvascular events; ACE inhibitors or ARBs are preferred first-line agents when albuminuria or chronic kidney disease coexists with hypertension. Antiplatelet therapy with low-dose aspirin is used for secondary prevention in people with established atherosclerotic disease; routine aspirin for primary prevention is individualized based on cardiovascular risk and bleeding risk rather than applied uniformly to everyone with diabetes.

PAD screening with the ankle-brachial index (ABI) is recommended for adults with diabetes who have PAD symptoms (claudication, rest pain, non-healing wounds), and for asymptomatic adults age 65 or older or those with any microvascular disease, foot complications, or other end-organ damage from diabetes. Systematic pulse and foot exams, paired with smoking cessation, physical activity, and nutrition counseling, remain the most direct levers for reducing amputation and cardiovascular risk when PAD is present. When PAD is confirmed, a structured exercise program and, for chronic symptomatic disease or after peripheral revascularization, combined low-dose rivaroxaban plus low-dose aspirin can further reduce major adverse cardiovascular and limb events; aspirin alone has not shown benefit in asymptomatic PAD with a borderline ABI.

Stroke risk parallels cardiovascular risk in people with diabetes and shares the same core risk-reduction levers: glycemic management, blood pressure control, statin therapy, and smoking cessation. The CDCES's role for macrovascular disease overall is less about diagnosing it and more about reinforcing adherence to the statin, antihypertensive, and antiplatelet regimens a person's clinician has already prescribed, since nonadherence quietly erodes the benefit of each of these therapies.

The Comprehensive Foot Exam

All people with diabetes need a comprehensive foot exam at least annually, and more often for higher-risk feet. The exam has five components: inspection (skin integrity, deformity, footwear fit), palpation of the dorsalis pedis and posterior tibial pulses, proprioception, vibration sense using a 128-Hz tuning fork, and the 10-gram monofilament test for loss of protective sensation, together with a symptom check for neuropathic pain.

Risk-based rescreening intervals stratify follow-up beyond the annual minimum:

Ulcers, Charcot Foot, and Amputation Prevention

Foot ulcers arise from the combination of loss of protective sensation, structural deformity, and unrecognized trauma or repetitive pressure, often worsened by PAD impairing wound healing. Management centers on offloading (total contact casting or removable offloading devices), debridement of nonviable tissue, infection control, and revascularization when PAD is present, coordinated through a multidisciplinary foot-care team that may include podiatry, vascular surgery, and infectious disease.

Charcot neuroarthropathy is an acute, non-infectious inflammatory process affecting bone, joint, and soft tissue in a neuropathic, usually well-perfused foot. It classically presents as a warm, red, swollen foot with a palpable pulse and disproportionately little pain, given the degree of underlying tissue involvement, a presentation frequently mistaken for cellulitis or gout. Missing the diagnosis allows progressive bone and joint destruction, leading to a collapsed midfoot, often called a "rocker-bottom" deformity, and dramatically higher subsequent ulcer and amputation risk. Suspected Charcot foot requires immediate immobilization and offloading, typically with total contact casting, and non-weight-bearing status until acute inflammation resolves; routine footwear is not an acceptable substitute during the acute phase.

Amputation prevention rests on early risk categorization using the table above, patient education on daily foot self-inspection, properly fitted or therapeutic footwear for higher-risk feet, and prompt referral to podiatry whenever deformity, a new ulcer, or Charcot changes appear.

Dermatologic Manifestations

Diabetes-associated skin findings are common and are often visible before other complications are formally diagnosed:

• Acanthosis nigricans — velvety, hyperpigmented, thickened skin in body folds such as the neck and axillae; a marker of underlying insulin resistance rather than of diabetes itself.
• Necrobiosis lipoidica diabeticorum — yellow-brown, atrophic plaques with visible telangiectasias, classically located on the pretibial shins; lesions can ulcerate.
• Diabetic dermopathy ("shin spots") — flat, brownish, atrophic macules on the shins caused by minor microvascular trauma; harmless in themselves but a marker of vascular disease elsewhere.
• Bullosis diabeticorum — spontaneous, painless blisters on the extremities that are essentially unique to diabetes.

The CDCES who recognizes these findings during a routine visit, whether it is a warm swollen foot with a palpable pulse, a velvety hyperpigmented neck, or a pretibial plaque, is positioned to trigger the referral that prevents an amputation or catches an underlying insulin-resistance problem early, well before it would otherwise be flagged.