After Amputation, the Heart Still Needs Our Attention

The incision is not the finish line

A well-healed surgical site can look like the end of a difficult story. For the person living with diabetes, it should be the beginning of a more connected chapter of care.

We need to ask two questions at the same time: How is the limb healing? And who is looking after the person attached to it?

Our thanks to the great and good Prof. David Klonoff of UCSF and the Diabetes Technology Society for sending this paper our way.

What the Swedish study adds

Karin Bergqvist and colleagues studied 3,485 adults with type 2 diabetes undergoing amputation and 13,940 matched controls in Sweden (2006–2019). Median follow-up was 3.5 years. Participants had no previous myocardial infarction, stroke, or hospitalization for heart failure.

Adjusted hazard ratios were 2.46 for all-cause mortality, 2.43 for cardiovascular mortality, and 2.13 for heart failure. Mortality hazards were greatest early; minor amputations also carried excess risk. The accompanying infographic provides confidence intervals. [1]

A hazard ratio compares event rates over time; it is not an individual’s probability of dying.

A signal—not a verdict on surgery

This observational study cannot establish causation. Residual confounding, incomplete registry data, and a treatment era predating widespread use of newer cardioprotective diabetes drugs limit interpretation. [1]

It would be a serious mistake to turn this into an argument against a necessary operation. An amputation can be essential for controlling life-threatening infection or addressing an unsalvageable limb. [4] The relevant question is not whether an indicated operation should be withheld. It is whether the operation becomes a reliable handoff to the next phase of care.

Nor should population statistics be handed to a patient as a personal countdown. We should use them to organize attention, not to take away hope.

The foot–heart connection is not a new idea

Independent evidence points in the same direction. A Korean national cohort reported associations between diabetes-related foot amputation and cardiovascular events (HR 1.9) and mortality (HR 2.1). Its cardiovascular endpoint combined myocardial infarction and stroke; its design and follow-up differed from the Swedish study. These are corroborating observations, not interchangeable estimates. [2]

Readers of DiabeticFootOnline will recognize the theme from our earlier coverage of severe diabetic foot outcomes. The useful next step is to make the connection operational: a foot problem should not disappear into one specialty’s inbox while the rest of the patient waits elsewhere.

Make the handoff as deliberate as the operation

Here is the practical response I would advocate—not a care pathway tested by this study, but a way to close the gap between recognizing risk and accepting responsibility for it.

• Name the next clinician. Before discharge, make clear who owns the cardiovascular and diabetes review, how the appointment will happen, and whom the patient should contact if the plan breaks down.
• Review protection, not just glucose. Current ADA guidance supports cardiovascular risk-factor treatment and, for appropriate people with type 2 diabetes and atherosclerotic cardiovascular disease or kidney disease, an SGLT2 inhibitor or GLP-1 receptor agonist with demonstrated cardiovascular benefit. Treatment choices still require individualized clinical assessment. [3]
• Use the right evaluation—not every test. ADA guidance does not recommend routine coronary screening in asymptomatic people simply because they have diabetes. Symptoms, vascular findings, and ECG abnormalities can warrant investigation. Heart-failure screening is a separate question: natriuretic-peptide assessment may be considered, with echocardiography after an abnormal result. [3]
• Build a plan the person can actually follow. Ask about transport, medication access, rehabilitation, caregiver support, and protection of the remaining foot. A referral written is not the same thing as care received.

Limb preservation needs a longer horizon

Our endpoint should be bigger than a closed incision or a completed procedure. We should care about the person’s ability to move, participate, get home, and remain there—with a care team that does not dissolve when the dressing comes off.

The wound-care plan and the cardiovascular plan should be two parts of the same conversation.

Limb care. Heart care. One person.

Related reading

• Earlier DFO coverage: communicating severe diabetic foot outcomes
• Prof. David Klonoff: UCSF profile
• Diabetes Technology Society

References

1. Bergqvist K, et al. Excess risk of cardiovascular disease and mortality after amputation in type 2 diabetes: a nationwide population study from the Swedish National Diabetes Register. Cardiovascular Diabetology. 2026;25:260.
2. Jang J, et al. Diabetic foot ulcer-related amputation is associated with twofold increased risk of cardiovascular disease: A Korean National Health Information Database Study. Journal of Diabetes Investigation. 2026;17:1024–1033.
3. American Diabetes Association Professional Practice Committee for Diabetes. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2026. Diabetes Care. 2026;49(Suppl 1):S216–S245.
4. IWGDF/IDSA Guidelines on the Diagnosis and Treatment of Diabetes-Related Foot Infections (2023).