Does a patient with heart failure with reduced ejection fraction (HFrEF) and diabetic foot gangrene require cardiac clearance before undergoing an angiogram or amputation?

Cardiac Clearance for Angiogram or Amputation in a Patient with HFrEF and Diabetic Foot Gangrene

Patients with heart failure with reduced ejection fraction (HFrEF) and diabetic foot gangrene do not require additional cardiac clearance before undergoing an angiogram or amputation, as revascularization should not be delayed in favor of prolonged cardiac evaluation. 1

Rationale for Proceeding Without Additional Cardiac Clearance

Urgency of Revascularization

• For patients with diabetic foot gangrene, early revascularization is critical for limb salvage
• The ESC guidelines specifically state: "For a patient with a severely infected ischemic foot, it is usually preferable to perform any needed revascularization early rather than to delay this procedure in favor of prolonged antibiotic therapy" 1
• Delaying revascularization to obtain cardiac clearance may lead to progression of infection and tissue loss

Existing Cardiac Management

• The patient already has a known diagnosis of HFrEF
• Current guideline-directed medical therapy (GDMT) for HFrEF should be continued during hospitalization except in cases of hemodynamic instability 1
• Patients with diabetes and LEAD (Lower Extremity Artery Disease) are already classified as very high cardiovascular risk 1

Management Approach

Pre-Procedural Considerations

• Check renal function before angiography if the patient is taking metformin, and withhold metformin if renal function deteriorates 1
• Continue heart failure medications through the perioperative period unless hemodynamically unstable 1
• For patients with chronic symptomatic LEAD without high bleeding risk, consider combination of low-dose rivaroxaban (2.5 mg BID) and aspirin (100 mg daily) 1

Vascular Assessment and Intervention

1. Perform duplex ultrasound as first-line imaging to assess lower extremity arterial anatomy and hemodynamics 1
2. Proceed with CT angiography or magnetic resonance angiography when revascularization is considered 1
3. For below-the-knee lesions, angiography including foot run-off should be performed before revascularization 1
4. Assess the risk of amputation using validated tools such as the WIfI (Wound, Ischemia, and foot Infection) score 1

Heart Failure Management During Procedure

• Continue guideline-directed medical therapy for HFrEF including:
  • ACE inhibitors/ARBs or ARNI
  • Beta-blockers
  • Mineralocorticoid receptor antagonists
  • SGLT2 inhibitors 2
• Monitor fluid status carefully during perioperative period to avoid decompensation
• Consider diuretics for signs of fluid congestion 1

Important Considerations and Potential Pitfalls

Cardiac Risk Assessment

• While formal "cardiac clearance" is not needed to delay the procedure, basic cardiac assessment should be performed:
  • Review current cardiac medications and ensure optimal therapy
  • Assess volume status and optimize before procedure
  • Obtain baseline ECG to identify any new changes

Procedural Risk Mitigation

• Patients with diabetes and chronic foot ulcers have a high prevalence of cardiac dysfunction (78%), even in those without known cardiac disease 3
• Heart failure is an independent predictor of mortality in diabetic patients with ischemic foot ulcers 4
• The presence of both heart failure and dialysis is associated with particularly poor outcomes (55% mortality at one year) 4

Post-Procedure Monitoring

• Monitor for signs of heart failure decompensation
• Resume all guideline-directed medical therapy as soon as hemodynamically stable
• Ensure appropriate wound care and infection control

Conclusion

The evidence strongly supports proceeding with necessary angiography or amputation without additional cardiac clearance in patients with known HFrEF and diabetic foot gangrene. Delaying these procedures for cardiac evaluation may lead to worse outcomes due to progression of infection and tissue loss. Instead, focus on optimizing the patient's current heart failure therapy, monitoring fluid status, and ensuring appropriate perioperative management.