Excess risk of cardiovascular disease and mortality after amputation in type 2 diabetes: a nationwide population study from the Swedish National Diabetes Register.
Lower-extremity amputation in individuals with type 2 diabetes is associated with a substantially increased risk of cardiovascular disease and mortality, independent of pre-existing cardiovascular disease and established risk factors.
Key Findings
Results
Lower-extremity amputation in type 2 diabetes was associated with a markedly increased risk of all-cause mortality compared to matched controls without amputation.
Adjusted hazard ratio (aHR) for all-cause mortality was 2.46 (95% CI 2.31–2.61)
The hazard of all-cause mortality was more than threefold higher in the first year after amputation compared with matched controls
All-cause mortality risk remained approximately 50% higher after five years post-amputation
3,485 individuals with amputation were compared to 13,940 matched controls
Results
Amputation in type 2 diabetes was associated with a markedly increased risk of cardiovascular mortality.
aHR for cardiovascular mortality was 2.43 (95% CI 2.18–2.71)
This risk was independent of pre-existing cardiovascular disease and established risk factors
Controls were matched on age, sex, and calendar time and had type 2 diabetes but no previous amputation
Results
Amputation in type 2 diabetes was associated with more than double the risk of heart failure compared to matched controls.
aHR for heart failure was 2.13 (95% CI 1.92–2.36)
Heart failure had the highest aHR among the specific cardiovascular outcomes examined
Risk was estimated using cause-specific Cox proportional hazards regression accounting for demographic and clinical risk factors
Results
Amputation in type 2 diabetes was associated with a significantly increased risk of myocardial infarction.
aHR for myocardial infarction was 1.79 (95% CI 1.55–2.08)
This finding was independent of pre-existing cardiovascular disease and established risk factors
The study included amputations occurring between 2006 and 2019 identified from the Swedish National Diabetes Register linked to the National Patient Register
Results
Amputation in type 2 diabetes was associated with a significantly increased risk of stroke compared to matched controls.
aHR for stroke was 1.52 (95% CI 1.31–1.76)
Stroke had the lowest aHR among the specific cardiovascular outcomes examined, but remained statistically significant
All cardiovascular outcomes were estimated using cause-specific Cox proportional hazards regression
Methods
The study population consisted of 3,485 individuals with type 2 diabetes who underwent major or minor lower-extremity amputation matched to 13,940 controls.
Controls had type 2 diabetes but no previous amputation and were matched on age, sex, and calendar time at a 1:4 ratio
Amputations occurred between 2006 and 2019
Data were drawn from the Swedish National Diabetes Register linked to the National Patient Register and the Cause of Death Register
This was an observational, population-based retrospective cohort study
Discussion
The excess cardiovascular and mortality risk associated with amputation in type 2 diabetes was independent of pre-existing cardiovascular disease and established risk factors.
Analyses were adjusted for demographic and clinical risk factors using cause-specific Cox proportional hazards regression
The authors concluded this finding underlines the need for intensive cardiovascular risk management both before and after amputation
The long-term cardiovascular impact of amputation in persons with type 2 diabetes had previously been insufficiently characterised
What This Means
This research suggests that people with type 2 diabetes who undergo a lower-leg amputation face dramatically higher risks of heart disease and death compared to people with type 2 diabetes who have not had an amputation. Using data from over 17,000 people in Sweden's national health registers, the study found that after accounting for age, sex, and other health risk factors, those who had an amputation were about 2.5 times more likely to die from any cause, 2.4 times more likely to die from heart disease, twice as likely to develop heart failure, and roughly 1.8 and 1.5 times more likely to suffer a heart attack or stroke, respectively. The elevated risk of death was more than three times higher in the first year after amputation and remained about 50% higher even five years later.
Importantly, these elevated risks persisted even after the researchers accounted for pre-existing heart disease and other known cardiovascular risk factors, meaning the amputation itself — or the underlying disease processes that lead to it — appears to be an independent warning sign of serious cardiovascular risk. This research suggests that amputation should be treated not only as a limb-related event but as a major signal that a patient's overall cardiovascular health needs urgent and sustained attention.
The practical implication is that healthcare providers may need to intensify cardiovascular monitoring and treatment both in the period leading up to amputation and in the years that follow. The findings highlight a gap in care for this high-risk group and suggest that more proactive management of heart disease risk factors in people with diabetes who face or have undergone amputation could potentially improve long-term survival and quality of life.
Bergqvist K, Imberg H, Hallström S, Michelsen J, Liljebäck H, Franzén S, et al.. (2026). 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. https://doi.org/10.1186/s12933-026-03319-5