Graz Critical Limb Ischemia Score

Abstract

Critical limb ischemia (CLI), a frequently encountered disorder, is associated with a high rate of limb amputation and mortality. To identify patients at high risk for CLI, we developed a simple risk score for peripheral arterial occlusive disease (PAOD).In our cross-sectional study, we first evaluated 1000 consecutive PAOD patients treated at our institution from 2005 to 2007, documenting clinical symptoms, comorbidities, and concomitant medication. We calculated odds ratios (OR) in a binary logistic regression model to find possible risk factors for CLI. We then verified the score in a second step that included the 1124 PAOD patients we treated between 2007 and 2011.In the first patient group, the greatest risk factors for CLI were age ≥75 years (OR 2.0), type 2 diabetes (OR 3.1), prior myocardial infarction (OR 2.5), and therapy with low molecular weight heparins (2.8). We scored 1 point for each of those conditions. One point was given for age between 65 and 75 years (OR 1.6) as well as for therapy with cardiac glycosides (OR 1.9) or loop diuretic therapy (OR 1.5). As statin therapy was protective for CLI with an OR of 0.5, we subtracted 1 point for those patients.In the second group, we could prove that frequency of CLI was significantly higher in patients with a high CLI score. The score correlated well with inflammatory parameters (c-reactive protein and fibrinogen). We were also able to define 3 different risk groups for low (score −1 to 1), intermediate (score 2–4), and high CLI risk (score >4).We developed a simple risk stratification scheme that is based on conditions that can be easily assessed from the medical history, without any laboratory parameters. This score should help to identify PAOD patients at high risk for CLI.

Lower limb events in individuals with type 2 diabetes: evidence for an increased risk associated with diuretic use

“…We observed consistent findings after using multiple adjustment methods for confounding covariates. Previous epidemiological data have already suggested a similar association in individuals with and without diabetes [7,8]. The absolute risk of LLE is much higher in longstanding diabetes but, to our knowledge, this is the first longitudinal study supporting an association between diuretic use and LLE in type 2 diabetes.…”

“…However, the design was cross-sectional and other classes of diuretic (loop and potassium-sparing diuretics) were not included in the analyses. In another crosssectional study of 1000 participants with known PAD, a 1.5fold increased risk of critical limb ischaemia with the use of loop diuretics was reported but no information was available regarding other types of diuretic [8]. Randomised controlled trials testing diuretics would have been the best design to assess causality, but relevant reports did not include precise data on LLE, probably because these events are expected to occur infrequently in this setting.…”

“…With this hypothesis, diuretics should also show a similar safety profile. A number of studies have analysed the association between diuretic use and LLA but were limited regarding type of diuretic or number of participants with diabetes [7,8].…”

Hydration must be maintained in patients taking sodium glucose cotransporter 2 inhibitors

“…Ueda and colleagues briefly discuss the putative mechanism of the increased risk of amputation with the use of sodium glucose cotransporter 2 inhibitors—namely, volume depletion due to the diuretic effect of this drug class 1. This is in keeping with other studies indicating that standard diuretics are a risk factor for amputation 23…”

Canagliflozin and Amputation Risk: Evidence So Far

“…35 Previous studies have shown an association between diuretics, both thiazide diuretics and loop diuretics, and lower limb amputation. [36][37][38] If this theory is correct and the association between SGLT2i and amputation is true, then we would expect to be a class effect for all SGLT2i and not limited to canagliflozin.…”