How to manage high arch foot in patients with cardiovascular disease?

Management of High Arch Foot (Pes Cavus) in Patients with Cardiovascular Disease

Patients with cardiovascular disease and high arch foot deformity should be referred to a podiatrist for therapeutic footwear that redistributes plantar pressure and prevents ulceration, while simultaneously implementing comprehensive cardiovascular risk factor management and structured exercise therapy. 1

Immediate Foot Care Priorities

High arch foot (pes cavus) is specifically identified as a foot deformity that places patients at moderate to high risk for foot ulcer development, particularly when combined with cardiovascular disease and peripheral artery disease (PAD). 1

Therapeutic Footwear Prescription

• Refer immediately to a podiatrist or therapeutic footwear specialist for patients with severe high-arch foot deformity, as this structural abnormality creates abnormal pressure distribution that can lead to ulceration. 1
• Therapeutic footwear should have sufficient depth to accommodate the high arch, adequate length (1-2 cm longer than the foot), adjustable features, firm support with comfortable fit, and cushioning to redistribute plantar pressure away from high-pressure areas. 2
• Custom or prefabricated orthoses can help redistribute pressure and reduce pain in patients with foot deformities. 2

Patient Self-Care Education

Educate patients on the following daily practices: 1

• Daily foot inspection, especially examining pressure points under the metatarsal heads and heel where high arches concentrate force
• Washing feet daily with soap and water, drying thoroughly between toes
• Wearing appropriately fitting shoes at all times—never walking barefoot indoors or outdoors
• Changing socks at least once daily, preferably seamless options
• Applying moisturizing creams to dry skin but NOT between toes
• Cutting toenails straight across
• Seeking immediate medical attention for any new foot lesions, redness, or signs of infection

Cardiovascular Risk Management

Patients with foot deformities and cardiovascular disease require aggressive management to prevent both major adverse cardiovascular events (MACE) and major adverse limb events (MALE). 1

Medical Therapy

• Statin therapy is essential—statins not only reduce cardiovascular events but also improve claudication symptoms and walking distance in PAD patients. 1, 3
• Antihypertensive therapy should target <140/90 mmHg (or <130/80 mmHg if diabetic), with beta-blockers being safe and effective despite historical concerns. 1
• ACE inhibitors are reasonable for symptomatic PAD patients to reduce cardiovascular events. 1
• Antiplatelet therapy should be part of the comprehensive cardiovascular risk reduction strategy. 1

Glycemic Control (if diabetic)

• Target HbA1c <7% to reduce microvascular complications and potentially improve cardiovascular outcomes. 1
• Meticulous glycemic control is particularly important in patients with foot deformities, as they are at higher risk for ulceration. 1

Structured Exercise Therapy

Supervised exercise programs are Class I, Level A recommendations for patients with PAD and should be discussed before considering revascularization. 1

Exercise Prescription

• Supervised exercise programs improve functional status, quality of life, and reduce leg symptoms with excellent safety profiles. 1
• Alternative exercise strategies including upper-body ergometry, cycling, and pain-free walking can be beneficial for improving walking ability without exacerbating foot pressure issues from high arches. 1
• Structured community- or home-based programs with behavioral change techniques can be beneficial if supervised programs are not accessible. 1

Critical caveat: Screen for absolute contraindications including exercise-limiting cardiovascular disease, amputation, wheelchair confinement, and major comorbidities before initiating exercise. 1

Surveillance and Monitoring

Foot Examination Frequency

• Biannual foot examination by a clinician is reasonable for PAD patients, with more frequent assessment (every 1-3 months) for those at high risk due to foot deformities. 1
• Annual comprehensive foot evaluation including assessment for peripheral neuropathy, vascular status (pedal pulses), and skin integrity. 1
• Regular podiatric assessment every 3-6 months for elderly patients with foot deformities. 2

Signs Requiring Urgent Evaluation

Maintain high index of suspicion for foot infection, which may present subtly in cardiovascular disease patients: 1

• Local pain or tenderness
• Periwound erythema, edema, induration, or fluctuance
• Any discharge, especially purulent
• Foul odor
• Visible bone or wound that probes to bone
• Systemic inflammatory signs (fever, tachycardia, leukocytosis)

Prompt diagnosis and treatment of foot infection are Class I recommendations to avoid amputation. 1

Multidisciplinary Care Coordination

• Coordinate care between cardiology, vascular medicine, podiatry, and primary care to optimize both cardiovascular and limb outcomes. 1
• Prompt referral to an interdisciplinary care team is reasonable for patients with signs of foot infection or complications. 1
• Optimal management of cardiovascular risk factors (LDL-C, blood pressure, smoking cessation, antiplatelet therapy) could lead to an average of 6.3 MACE-free years gained. 1

Common Pitfalls to Avoid

• Do not delay podiatric referral for patients with high arch deformity—early intervention with therapeutic footwear prevents ulceration. 1
• Do not recommend unstructured walking programs that simply tell patients to "walk more"—these are not efficacious and may worsen foot problems. 1
• Do not withhold beta-blockers due to concerns about worsening claudication—they are safe and effective antihypertensives in PAD. 1
• Do not apply moisturizing creams between toes—this increases maceration risk and fungal infection. 4, 2
• Do not use heating devices to warm feet, as this can cause burns in patients with neuropathy. 4