Diabetes mellitus and outcome after primary coronary angioplasty for acute myocardial infarction: lessons from the GUSTO-IIb Angioplasty Substudy. Global Use of Strategies to Open Occluded Arteries in Acute Coronary Syndromes

Clinical characteristics and outcomes of Australian and Indian ST-segment elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (PCI)

INTRODUCTION

The incidence of STEMI and subsequent mortality has been reported to be higher in Indian populations compared to developed countries. However, there is limited data directly comparing contemporary primary percutaneous coronary intervention (pPCI) treatment strategies and clinical outcomes for STEMI patients between developed and developing countries.

MATERIALS AND METHODS

We compared population demographics, procedural characteristics, times to reperfusion and mortality in STEMI patients treated with pPCI between two tertiary referral centers in India and Australia respectively over a 3-year period (1st Jan 2017-31st Dec 2019).

RESULTS

A total of 1293 STEMI presentations (896 Indian vs 397 Australian) were included. On average, Indian patients had lower median BMI than Australian patients (BMI 25.4 vs 27.8; p < 0.001), were significantly younger (mean age 56.0 vs 63.2 years; p < 0.001), more likely male (84 % vs 80 %; p = 0.046) and diabetic (48 % vs 18 %); p < 0.001). Radial access (50 % vs 88 %; p < 0.001) and TIMI III flow post PCI was also significantly lower (85 % vs 96 %; p < 0.001) with median door-to-balloon time significantly shorter in the Indian cohort (20mins vs 43mins; p < 0.001); however, median symptom to balloon time was significantly longer (245mins vs 160mins; p < 0.001). No significant differences in 30-day mortality (4.0 % vs 2.8 % Australian; p = 0.209) or 1-year mortality (6.5 % vs 4.3 %; p = 0.120) were observed.

CONCLUSION

Significant differences in demographics and presentation characteristics exist between Indian and Australian STEMI patients treated with pPCI. Indian patients had significantly longer pre-hospital delays and lower achievement of TIMI III flow post PCI, yet shorter in-hospital time to treatment.

Clinical implications of diabetes mellitus in patients with acute coronary syndrome: Prognostic role and use of new P2Y12 receptor inhibitors

AIMS

We investigated the impact of diabetes mellitus (DM) in acute coronary syndrome (ACS) patients, and the 2-year prognosis based on antiplatelet therapy.

METHODS

This is a prospective and multicenter registry including hospitalized ACS patients. Clinical management and antiplatelet therapy at discharge were recorded. Bleeding events, all-cause mortality and major adverse cardiovascular events (MACEs) were recorded during 2-years and compared according to DM and the P2Y₁₂ receptor inhibitor.

RESULTS

From 1717 ACS patients, 653 (38%) had DM. Diabetic patients were older, more commonly females, with higher prevalence of comorbidities and more conservative management. After excluding antiplatelet monotherapy or oral anticoagulation, clopidogrel was prescribed in 59.6% of DM patients. Cox regression analysis showed that DM was an independent risk factor for MACE (aHR 1.39, 95% CI 1.05-1.83). The use of clopidogrel instead of ticagrelor/prasugrel was also independently associated with MACE (aHR 1.71, 95% CI 1.11-2.63), and all-cause mortality (aHR 2.47, 95% CI 1.23-4.96) in diabetic patients (log-rank p-values < 0.001).

CONCLUSIONS

In ACS patients, DM was associated with higher risk of MACE. In such patients, the use of ticagrelor/prasugrel reduced MACE and mortality compared to clopidogrel. Novel P2Y₁₂ receptor inhibitors might be used as the first therapeutic choice in these high-risk patients.

Myocardial injury in diabetic patients with multivessel coronary artery disease after revascularization interventions

BACKGROUND

Diabetic patients may be more susceptible to myocardial injury after coronary interventions. Thus, the aim of this study was to assess the release of cardiac biomarkers, CK-MB and troponin, and the findings of new late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) in patients with type 2 diabetes mellitus after elective revascularization procedures for multivessel coronary artery disease (CAD).

METHODS

Patients with multivessel CAD and preserved systolic ventricular function underwent either elective percutaneous coronary intervention (PCI), off-pump or on-pump bypass surgery (CABG). Troponin and CK-MB were systematically collected at baseline, 6, 12, 24, 36, 48 and 72 h after the procedures. CMR with LGE was performed before and after the interventions. Patients were stratified according to diabetes status at study entry. Biomarkers and CMR results were compared between diabetic and nondiabetics patients. Analyses of correlation were also performed among glycemic and glycated hemoglobin (A1c) levels and troponin and CK-MB peak levels. Patients were also stratified into tertiles of fasting glycemia and A1c levels and were compared in terms of periprocedural myocardial infarction (PMI) on CMR.

RESULTS

Ninety (44.5%) of the 202 patients had diabetes mellitus at study entry. After interventions, median peak troponin was 2.18 (0.47, 5.14) and 2.24 (0.69, 5.42) ng/mL (P = 0.81), and median peak CK-MB was 14.1 (6.8, 31.7) and 14.0 (4.2, 29.8) ng/mL (P = 0.43), in diabetic and nondiabetic patients, respectively. The release of troponin and CK-MB over time was statistically similar in both groups and in the three treatments, besides PCI. New LGE on CMR indicated that new myocardial fibrosis was present in 18.9 and 17.3% (P = 0.91), and myocardial edema in 15.5 and 22.9% (P = 0.39) in diabetic and nondiabetic patients, respectively. The incidence of PMI in the glycemia tertiles was 17.9% versus 19.3% versus 18.7% (P = 0.98), and in the A1c tertiles was 19.1% versus 13.3% versus 22.2% (P = 0.88).

CONCLUSIONS

In this study, diabetes mellitus did not add risk of myocardial injury after revascularization interventions in patients with multivessel coronary artery disease. Trial Registration Name of Registry: Evaluation of cardiac biomarker elevation after percutaneous coronary intervention or coronary artery bypass graft; URL: http://www.controlled-trials.com.ISRCTN09454308.

Comparing mortality between fibrinolysis and primary percutaneous coronary intervention in patients with acute myocardial infarction: a systematic review and meta-analysis of 27 randomized-controlled trials including 11 429 patients

OBJECTIVES

We aimed to improve the limitations encountered in previously published studies and then compare mortality in patients with acute myocardial infarction (AMI) who were treated with either fibrinolysis or a primary percutaneous coronary intervention (PPCI).

METHODS

EMBASE, MEDLINE, and the Cochrane databases were searched for trials comparing fibrinolysis with PPCI in patients with AMI. The only endpoint that was assessed in this analysis was all-cause mortality. Therefore, in-hospital, short-term, mid-term, and long-term mortality were analyzed, whereby odds ratios (OR) with 95% confidence intervals (CIs) were calculated using the RevMan 5.3.

RESULTS

A total of 11 429 patients obtained from 37 studies (involving 27 trials) were included. The results of this analysis showed that fibrinolytic therapy was associated with significantly higher in-hospital and mid-term mortality (OR: 0.61; 95% CI: 0.46-0.82, P=0.001 and OR: 0.73; 95% CI: 0.54-0.99, P=0.04, respectively). Short-term and long-term mortality were also significantly higher in the fibrinolytic group (OR: 0.76; 95% CI: 0.65-0.90, P=0.001, and OR: 0.82; 95% CI: 0.71-0.96, P=0.01, respectively) compared with PPCI.

CONCLUSION

This analysis of 11 429 patients showed a significantly higher mortality rate to be associated with fibrinolysis compared with PPCI in these patients with AMI. Hence, compared with fibrinolysis, PPCI is expected to be the preferred method of revascularization in patients with AMI, especially in PCI-capable centers.

Long-term mortality after acute myocardial infarction among individuals with and without diabetes: A systematic review and meta-analysis of studies in the post-reperfusion era

AIMS

To conduct a systematic review and meta-analysis with the aim of providing robust estimates of the association between diabetes and long-term (≥1 year) mortality after acute myocardial infarction (AMI).

MATERIAL AND METHODS

Medline, Embase and Web of Science databases were searched (January 1985 to July 2016) for terms related to long-term mortality, diabetes and AMI. Two authors independently abstracted the data. Hazard ratios (HRs) comparing mortality in people with and without diabetes were pooled across studies using Bayesian random-effects meta-analysis.

RESULTS

A total of 10 randomized controlled trials and 56 cohort studies, including 714 780 patients, reported an estimated total of 202 411 deaths over the median (range) follow-up of 2.0 (1-20) years. The risk of death over time was significantly higher among those with diabetes compared with those without (unadjusted HR 1.82, 95% credible interval [CrI] 1.73-1.91). Mortality remained higher in the analysis restricted to 23/64 cohorts reporting data adjusted for confounders (adjusted HR 1.48, 95% CrI 1.43-1.53). The excess long-term mortality in diabetes was evident irrespective of the phenotype and modern treatment of AMI, and persisted in early survivors (unadjusted HR 1.82, 95% CrI 1.70-1.95).

CONCLUSIONS

Despite medical advances, individuals with diabetes have a 50% greater long-term mortality compared with those without. Further research to understand the determinants of this excess risk are important for public health, given the predicted rise in global diabetes prevalence.

Recognising and Treating the Diabetic Patient in Cardiovascular Care

The global prevalence of diabetes mellitus has continuously and rapidly increased, and the number of diabetic people in the adult population is predicted to double within 30 years. The prevalence of and mortality from all forms of cardiovascular diseases is two- to eight-fold higher in diabetic individuals as compared with their non-diabetic counterparts. The excess of risk attributable to diabetes related heart disease accounts for 2.9% of the all cause annual mortality. Moreover, the cardiovascular risk increases continuously throughout a wide spectrum of glycaemia starting already at what, according to present definitions, is considered as normal blood glucose levels. Therefore, screening for diabetes and hyperglycaemia is recommended in various clinical settings. Criteria for classification of hyperglycaemic states are provided together with their relation to risk for cardiovascular events. The evidence-based treatment of cardiovascular disease in patients with concomitant diabetes is summarised. Degree of under-treatment of patients with diabetes and cardiovascular diseases is discussed. Finally, the potential impact that nurses may have on the quality and efficacy of care in the vulnerable patient with combined chronic diseases such as diabetes and cardiovascular disease and the improvement of the outcomes are discussed.

Impact of Modifiable Cardiovascular Risk Factors on Mortality After Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis of 100 Studies

Modifiable cardiovascular risk factors such as obesity, hypertension, dyslipidemia, smoking, diabetes mellitus, and metabolic syndrome can easily give rise to coronary heart disease (CHD). However, due to the existence of the so-called "obesity paradox" and "smoking paradox," the impact of these modifiable cardiovascular risk factors on mortality after percutaneous coronary intervention (PCI) is still not clear. Therefore, in order to solve this issue, we aim to compare mortality between patients with low and high modifiable cardiovascular risk factors after PCI. Medline and EMBASE were searched for studies related to these modifiable cardiovascular risk factors. Reported outcome was all-cause mortality after PCI. Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated, and the pooled analyses were performed with RevMan 5.3 software. A total of 100 studies consisting of 884,190 patients (330,068 and 514,122 with high and low cardiovascular risk factors respectively) have been included in this meta-analysis. Diabetes mellitus was associated with a significantly higher short and long-term mortality with RR 2.11; 95% CI: (1.91-2.33) and 1.85; 95% CI: (1.66-2.06), respectively, after PCI. A significantly higher long-term mortality in the hypertensive and metabolic syndrome patients with RR 1.45; 95% CI: (1.24-1.69) and RR 1.29; 95% CI: (1.11-1.51), respectively, has also been observed. However, an unexpectedly, significantly lower mortality risk was observed among the smokers and obese patients. Certain modifiable cardiovascular risk subgroups had a significantly higher impact on mortality after PCI. However, mortality among the obese patients and the smokers showed an unexpected paradox after coronary intervention.

Influence of cardiovascular risk factors on infarct size and interaction with mechanical ischaemic postconditioning in ST-elevation myocardial infarction

Objective

Previous studies have shown that mechanical postconditioning (PostC) significantly reduces infarct size (IS) in patients with acute myocardial infarction. Our objective was to assess the influence of traditional cardiovascular (CV) risk factors on IS and their interaction with ischaemic PostC in patients with acute ST-elevation myocardial infarction (STEMI).

Methods

The study population was constituted from the clinical database pooling of four previously published PostC prospective, multicentre, randomised, open-label controlled trials with identical inclusion criteria. Patients with STEMI, presenting within 12 h of symptoms onset referred for percutaneous coronary intervention, were included. Mechanical ischaemic PostC was performed by four repeated cycles of inflation–deflation of the angioplasty balloon within 1 min of reflow, while the control group underwent no intervention. IS was assessed by measuring total creatine kinase release over 72 h.

Results

173 patients, aged 58±12 years, 76% males, 48% anterior infarct were included (82 in the PostC group, 91 in the control group). IS was significantly reduced in the PostC compared to the control group (71.7±41.6 vs 88.2±54.5×10³ arbitrary units; p=0.027). After adjustment for abnormally contracting segments, older patients had smaller IS and smokers had larger IS. Gender, diabetes, hypertension, dyslipidemia and obesity did not have any significant effect on IS. Multivariate regression analysis showed that none of the traditional risk factors had a significant impact on the cardioprotective effect of mechanical ischaemic PostC.

Conclusions

The present analysis suggests that the cardioprotective effect of mechanical PostC is not influenced by traditional CV risk factors that are prevalent in patients with STEMI.

Heart failure in patients with diabetes undergoing primary percutaneous coronary intervention

INTRODUCTION

Diabetes mellitus is associated with increased risk after acute coronary syndromes. Primary percutaneous coronary intervention is the most effective method of reperfusion for acute ST-elevation myocardial infarction and can limit the ischaemic damage to the left ventricle. However, there are few data on the impact of diabetes mellitus on the risk of heart failure following primary percutaneous coronary intervention.

METHODS

We studied 958 ST-elevation myocardial infarction patients treated with primary percutaneous coronary intervention, of whom 263 (27.5%) had diabetes mellitus, with 67 (7.0%) treated with insulin. The primary end points of the study were re-admission for heart failure. Secondary end points were all-cause mortality and recurrent infarctions. The follow-up period was 5 years after hospital discharge.

RESULTS

The cumulative incidence of re-admission for heart failure was 8.4%, 15.2% and 26.7% in patients without diabetes mellitus, non-insulin-treated and insulin-treated diabetes mellitus, respectively. Compared with patients without diabetes mellitus, the adjusted hazard ratio for heart failure was 1.95 (95% confidence intervals 1.30-2.93) and 3.09 (95% confidence intervals 1.71-5.60) in non-insulin-treated and insulin-treated diabetes mellitus, respectively. The corresponding hazard ratios for mortality were 1.03 (95% confidence intervals 0.68-1.55) and 2.04 (95% confidence intervals 1.22-3.42), respectively. There was a J-shaped association between fasting glucose levels in the acute phase and risk of mortality (P=0.0001) and a direct association with heart failure (P=0.03).

CONCLUSION

Despite modern treatment of ST-elevation myocardial infarction and high levels of guideline-based medical care, diabetes mellitus had an independent adverse effect on the risk of re-admissions for heart failure, which was particularly high among insulin-treated patients.

Underuse of an invasive strategy for patients with diabetes with acute coronary syndrome: a nationwide study

Background

Guidelines recommend an early invasive strategy for patients with diabetes with acute coronary syndromes (ACS). We investigated if patients with diabetes with ACS are offered coronary angiography (CAG) and revascularisation to the same extent as patients without diabetes.

Methods and results

The study is a nationwide cohort study linking Danish national registries containing information on healthcare. The study population comprises all patients hospitalised with first-time ACS in Denmark during 2005–2007 (N=24 952). Diabetes was defined as claiming of a prescription for insulin and/or oral hypoglycaemic agents within 6 months prior to the ACS event. Diabetes was present in 2813 (11%) patients. Compared with patients without diabetes, patients with diabetes were older (mean 69 vs 67 years, p<0.0001), less often males (60% vs 64%, p=0.0001) and had more comorbidity. Fewer patients with diabetes underwent CAG: cumulative incidence 64% vs 74% for patients without diabetes, HR=0.72 (95% CI 0.69 to 0.76, p<0.0001); adjusted for age, sex, previous revascularisation and comorbidity HR=0.78 (95% CI 0.74 to 0.82, p<0.0001). More patients with diabetes had CAG showing two-vessel or three-vessel disease (53% vs 38%, p<0.0001). However, revascularisation after CAG revealing multivessel disease was less likely in patients with diabetes (multivariable adjusted HR=0.76, 95% CI 0.68 to 0.85, p<0.0001).

Conclusions

In this nationwide cohort of patients with incident ACS, patients with diabetes were found to be less aggressively managed by an invasive treatment strategy. The factors underlying the decision to defer an invasive strategy in patients with diabetes are unclear and merit further investigation.

Impact of nonculprit vessel myocardial perfusion on outcomes of patients undergoing percutaneous coronary intervention for acute coronary syndromes: analysis from the ACUITY trial (Acute Catheterization and Urgent Intervention Triage Strategy)

OBJECTIVES

This study evaluated the impact of nonculprit vessel myocardial perfusion on outcomes of non-ST-segment elevation acute coronary syndromes (NSTE-ACS) patients.

BACKGROUND

ST-segment elevation myocardial infarction patients have decreased perfusion in areas remote from the infarct-related vessel. The impact of myocardial hypoperfusion of regions supplied by nonculprit vessels in NSTE-ACS patients treated with percutaneous coronary intervention (PCI) is unknown.

METHODS

The angiographic substudy of the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial included 6,921 NSTE-ACS patients. Complete 3-vessel assessments of baseline coronary TIMI (Thrombolysis In Myocardial Infarction) flow grade and myocardial blush grade (MBG) were performed. We examined the outcomes of PCI-treated patients according to the worst nonculprit vessel MBG identified per patient.

RESULTS

Among the 3,826 patients treated with PCI, the worst nonculprit MBG was determined in 3,426 (89.5%) patients, including 375 (10.9%) MBG 0/1 patients, 475 (13.9%) MBG 2 patients, and 2,576 (75.2%) MBG 3 patients. Nonculprit MBG 0/1 was associated with worse baseline clinical characteristics. Patients with nonculprit MBG 0/1 versus MBG 3 had increased rates of 30-day (3.0% vs. 0.7%, p < 0.0001) and 1-year (4.4% vs. 1.0%, p < 0.0001) death. Similar results were found among patients with pre-procedural TIMI flow grade 3 in the culprit vessel, where nonculprit vessel MBG 0/1 (hazard ratio: 2.81 [95% confidence interval: 1.63 to 4.84], p = 0.0002) was the strongest predictor of 1-year mortality.

CONCLUSIONS

Reduced myocardial perfusion in an area supplied by a nonculprit vessel is associated with increased short- and long-term mortality rates in NSTE-ACS patients undergoing PCI. Furthermore, worst nonculprit MBG is able to risk-stratify patients with normal baseline flow of the culprit vessel.

Prognostic impact of hyperglycemia in nondiabetic and diabetic patients with ST-elevation myocardial infarction: insights from contrast-enhanced magnetic resonance imaging

BACKGROUND

Hyperglycemia on admission is associated with increased mortality rates in patients with ST-elevation myocardial infarction (STEMI). However, data regarding the relationship between hyperglycemia and myocardial damage in STEMI are scarce. The aim of this study was to determine the relationship of diabetes mellitus status and hyperglycemia on myocardial damage assessed by cardiovascular magnetic resonance imaging and to evaluate the long-term prognostic significance of hyperglycemia in a high-risk STEMI population.

METHODS AND RESULTS

Glucose levels were determined on admission in 411 consecutive STEMI patients reperfused by primary angioplasty. Patients were categorized on the basis of diabetes mellitus status and admission glucose level. Magnetic resonance imaging was performed for assessment of infarct size and microvascular obstruction. The primary clinical end point was the occurrence of major adverse cardiovascular events at long-term follow-up. STEMI patients with pre-existing diabetes mellitus were at greater risk for major adverse cardiovascular events (32% versus 11%; P<0.001) despite having similar infarct sizes and extent of reperfusion injury than nondiabetic patients. Glycemic status on admission was associated with greater myocardial damage and an increased risk for major adverse cardiovascular events (P<0.001). In nondiabetic patients, the risk of severe myocardial injury started to rise once admission glucose exceeded 7.8 mmol/L, whereas the threshold was higher among patients with diabetes mellitus (≥11.1 mmol/L).

CONCLUSIONS

The higher mortality rate in diabetic versus nondiabetic STEMI patients is not explained by more pronounced myocardial damage. Hyperglycemia on admission is associated with greater myocardial injury and an increased risk of major adverse cardiovascular events at long-term follow-up. However, hyperglycemia has a stronger relationship to myocardial injury in nondiabetic compared with diabetic patients.

Different impact of diabetes mellitus on in-hospital and 1-year mortality in patients with acute myocardial infarction who underwent successful percutaneous coronary intervention: results from the Korean Acute Myocardial Infarction Registry

BACKGROUND/AIMS

The aim of this study was to evaluate the impact of diabetes mellitus (DM) on in-hospital and 1-year mortality in patients who suffered acute myocardial infarction (AMI) and underwent successful percutaneous coronary intervention (PCI).

METHODS

Among 5,074 consecutive patients from the Korea AMI Registry with successful revascularization between November 2005 and June 2007, 1,412 patients had a history of DM.

RESULTS

The DM group had a higher mean age prevalence of history of hypertension, dyslipidemia, ischemic heart disease, high Killip class, and diagnoses as non-ST elevation MI than the non-DM group. Left ventricular ejection fraction (LVEF) and creatinine clearance were lower in the DM group, which also had a significantly higher incidence of in-hospital and 1-year mortality of hospital survivors (4.6% vs. 2.8%, p = 0.002; 5.0% vs. 2.5%, p < 0.001). A multivariate analysis revealed that independent predictors of in-hospital mortality were Killip class IV or III at admission, use of angiotensin converting enzyme inhibitors or angiotensin-II receptor blockers, LVEF, creatinine clearance, and a diagnosis of ST-elevated MI but not DM. However, a multivariate Cox regression analysis showed that DM was an independent predictor of 1-year mortality (hazard ratio, 1.504; 95% confidence interval, 1.032 to 2.191).

CONCLUSIONS

DM has a higher association with 1-year mortality than in-hospital mortality in patients with AMI who underwent successful PCI. Therefore, even when patients with AMI and DM undergo successful PCI, they may require further intensive treatment and continuous attention.

Prognostic significance of hemoglobin A1c level in patients hospitalized with coronary artery disease. A systematic review and meta-analysis

BACKGROUND

The prognostic value of hemoglobin A1c (HbA1c) in coronary artery disease (CAD) remains controversial. Herein, we conducted a systematic review to quantify the association between elevated HbA1c levels and all-cause mortality among patients hospitalized with CAD.

METHODS

A systematic search of electronic databases (PubMed, EMBASE, OVID, Web of Science, The Cochrane Library) for studies published from 1970 to May 2011 was performed. Cohort, case-control studies, and randomized controlled trials that examined the effect of HbA1c on all-cause mortality were included.

RESULTS

Twenty studies met final inclusion criteria (total n = 13, 224). From the pooled analyses, elevated HbA1c level was significantly associated with increased short-term (OR 2.32, 95% CI, 1.61 to 3.35) and long-term (OR 1.54, 95% CI, 1.23 to 1.94) mortality risk. Subgroup analyses suggested elevated HbA1c level predicted higher mortality risk in patients without diabetes (OR 1.84, 95% CI, 1.51 to 2.24). In contrast, in patients with diabetes, elevated HbA1c level was not associated with increased risk of mortality (OR 0.95, 95% CI, 0.70 to 1.28). In a risk-adjusted sensitivity analyses, elevated HbA1c was also associated with a significantly high risk of adjusted mortality in patients without diabetes (adjusted OR 1.49, 95% CI, 1.24 to 1.79), but had a borderline effect in patients with diabetes (adjusted OR 1.05, 95% CI, 1.00 to 1.11).

CONCLUSIONS

Our findings demonstrate that elevated HbA1c level is an independent risk factor for mortality in CAD patients without diabetes, but not in patients with established diabetes. Prospective studies should further investigate whether glycemic control might improve outcomes in CAD patients without previously diagnosed diabetes.

Revascularization for coronary artery disease in diabetes mellitus: angioplasty, stents and coronary artery bypass grafting

Patients with diabetes mellitus (DM) are prone to a diffuse and rapidly progressive form of atherosclerosis, which increases their likelihood of requiring revascularization. However, the unique pathophysiology of atherosclerosis in patients with DM modifies the response to arterial injury, with profound clinical consequences for patients undergoing percutaneous coronary intervention (PCI). Multiple studies have shown that DM is a strong risk factor for restenosis following successful balloon angioplasty or coronary stenting, with greater need for repeat revascularization and inferior clinical outcomes. Early data suggest that drug eluting stents reduce restenosis rates and the need for repeat revascularization irrespective of the diabetic state and with no significant reduction in hard clinical endpoints such as myocardial infarction and mortality. For many patients with 1- or 2-vessel coronary artery disease, there is little prognostic benefit from any intervention over optimal medical therapy. PCI with drug-eluting or bare metal stents is appropriate for patients who remain symptomatic with medical therapy. However, selection of the optimal myocardial revascularization strategy for patients with DM and multivessel coronary artery disease is crucial. Randomized trials comparing multivessel PCI with balloon angioplasty or bare metal stents to coronary artery bypass grafting (CABG) consistently demonstrated the superiority of CABG in patients with treated DM. In the setting of diabetes CABG had greater survival, fewer recurrent infarctions or need for re-intervention. Limited data suggests that CABG is superior to multivessel PCI even when drug-eluting stents are used. Several ongoing randomized trials are evaluating the long-term comparative efficacy of PCI with drug-eluting stents and CABG in patients with DM. Only further study will continue to unravel the mechanisms at play and optimal therapy in the face of the profoundly virulent atherosclerotic potential that accompanies diabetes mellitus.

Does reperfusion in the treatment of acute myocardial infarction improve the prognosis of acute myocardial infarction in diabetic patients?

BACKGROUND

Diabetic patients have a 6-fold increased mortality in acute coronary syndromes.

HYPOTHESIS

Different therapeutic strategies in diabetics with acute coronary syndromes have an impact on in-hospital and long-term prognosis.

METHODS

A total of 889 consecutive patients with ST-segment elevation myocardial infarction were included and followed-up for at least 6 months. The study population consisted of 168 (18.9%) diabetic patients and 721 nondiabetics.

RESULTS

Invasive therapy and fibrinolysis were less frequently used in diabetic patients (38.7% versus 50.2%; p = 0.0071 and 8.3% versus 15%; p = 0.024, respectively). In-hospital mortality in diabetic individuals was almost twice as high as in nondiabetic subjects (20.2% versus 11.1%; p < 0.0014). In-hospital mortality was slightly higher in diabetic patients undergoing primary percutaneous transluminal coronary angioplasty (PTCA; 8.3% versus 4.8%; p = 0.35), but lower in those treated with fibrinolysis (7.7% versus 16%; p = 0.7) compared with the rest of the patients. At 6-mo follow-up mortality was significantly higher in diabetic subjects as compared with nondiabetic subjects (28.0% versus 15.1%; p < 0.0001). The highest number of deaths was found in individuals receiving conservative treatment with diabetic subjects significantly outnumbering nondiabetic individuals (40.1% versus 27.9%; p = 0.028 at 6 mo). Both in-hospital and 6-mo mortality were similar in diabetics and nondiabetics receiving reperfusion therapy (7.1% versus 8.2%; p < 0.68 and 9.3% versus 15.3%; p < 0.098, respectively).

CONCLUSION

Reperfusion therapy, both fibrinolysis and the invasive approach, reduced in-hospital mortality from that observed in nondiabetic individuals.

History of diabetes mellitus as a neurologic predictor in comatose survivors of cardiac arrest of cardiac origin treated with mild hypothermia

AIM

To investigate the impact of a history of diabetes mellitus on the neurologic outcome in comatose survivors of cardiac arrest of cardiac origin treated with mild hypothermia.

METHODS

A prospective observational study was performed between September 2003 and July 2008. Eighty comatose survivors of cardiac arrest of cardiac origin were treated with mild hypothermia. Neurologic outcome at the time of hospital discharge, 30-day survival, and complications were assessed.

RESULTS

Twenty-four of the 80 patients (30%) had a history of diabetes. The rate of favorable neurologic outcome was significantly lower in diabetic (17%) than in nondiabetic patients (46%) (p=0.01). The rate of 30-day survival was lower in diabetic (33%) than in nondiabetic patients (54%), but the difference was not significant (p=0.10). Multivariate analysis suggested that a history of diabetes was an independent predictor of unfavorable neurologic outcome (odds ratio 7.00, 95% confidence interval 1.42-46.19, p=0.03), but not for 30-day survival. There was no significant difference in the prevalence of complications.

CONCLUSION

A history of diabetes is associated with poor neurologic outcome in comatose survivors of cardiac arrest treated with mild hypothermia.

Infarct size, ejection fraction, and mortality in diabetic patients with acute myocardial infarction treated with thrombolytic therapy

BACKGROUND

Diabetic patients with acute myocardial infarction (MI) have higher mortality than nondiabetic patients. The purpose of this study was to examine if larger infarct size explains the higher mortality in diabetic patients with acute ST-segment-elevation MI.

METHODS

In the CORE trial (n = 2948), subsets of patients underwent quantitative radionuclide measurement of technetium Tc 99m sestamibi infarct size (n = 1164) or gated equilibrium left ventricular ejection fraction (LVEF) (n = 1137) at days 6 to 16 after thrombolytic therapy. Clinical follow-up was 96.7% complete at 6 months.

RESULTS

The prevalence of diabetes in these patient imaging subsets was 16% to 17%. Higher risk clinical characteristics including older age and a greater prevalence of prior MI were more common in diabetic patients. Median infarct size was larger in diabetic patients (22% vs 17% of the left ventricle, P = .04), a difference that remained significant after adjustment for clinical variables (P = .048). Patients with diabetes also had lower median LVEF (48% vs 51%, unadjusted P = .002, adjusted P = .007). Six-month mortality was higher in diabetic patients: infarct size subset, 5.9% vs 1.6% (P = .0016); LVEF subset, 6.1% vs 1.0% (P < .0001). Multivariable models demonstrated that diabetes and each imaging variable were independent predictors of mortality.

CONCLUSIONS

Infarct size is modestly larger and LVEF modestly lower in diabetic patients with ST-segment-elevation MI. The substantially higher (4- to 6-fold) mortality rate in diabetic vs nondiabetic patients is only partially explained by relatively small differences in infarct size and LVEF.

Unrecognized glycometabolic disturbance as measured by hemoglobin A1c is associated with a poor outcome after acute myocardial infarction

BACKGROUND

Glycated hemoglobin A1c (HbA1c) is a measure of the average blood glucose levels over 2 months and is minimally affected by acute hyperglycemia often observed in myocardial infarction (MI). In a large population of high-risk patients with MI, we examined the prognostic impact of HbA1c in patients with and without a history of diabetes.

METHODS

In the OPTIMAAL trial, patients with MI complicated with heart failure were randomized to losartan or captopril. Of the 2841 patients who had HbA1c measured at randomization, 495 (17%) reported a history of diabetes. The remaining patients without diabetes history were stratified into 3 categories according to HbA1c level: HbA1c, <4.9% (n = 1642); HbA1c, 4.9% to 5.1% (n = 432); and HbA1c, >5.1% (n = 272). Mean follow-up time was 2.5 years.

RESULTS

Mortality rate during follow-up was 18% in patients with a history of diabetes. Increasing HbA1c levels were associated with higher mortality rate among patients without diabetes history (13% in patients with HbA1c <4.9%, 17% in patients with HbA1c 4.9%-5.1%, 22% in patients with HbA1c >5.1%). Among patients with no prior history of diabetes, a 1% absolute increase in HbA1c level at baseline resulted in a 24% increase in mortality, whereas the level of HbA1c had no impact on mortality among the patients with well-known diabetes (multivariate analyses).

CONCLUSIONS

In this high-risk MI population, HbA1c level was a potent predictor of mortality in patients without previously known diabetes.

Impact of admission hyperglycemia and diabetes mellitus on short- and long-term mortality after acute myocardial infarction in the coronary intervention era

The influence of admission hyperglycemia and diabetes on short- and long-term mortality of patients with acute myocardial infarction (AMI) in the percutaneous coronary intervention (PCI) era was investigated. From 1996 to 2003, a total of 802 consecutive patients with AMI underwent coronary angiography. Primary PCI was performed in 724 patients (90%). Three-year mortality curves were constructed using the Kaplan-Meier method. Cox proportional hazard regression was used to identify independent predictors of 30-day mortality and mortality from 30 days to 3 years. There were 261 patients with admission hyperglycemia (admission glucose>or=11.1 mmol/L) and 212 patients with diabetes. Admission hyperglycemia was associated with a significantly higher 30-day mortality rate (8.4% vs 2.4%, p<0.001). However, there was no significant difference in 30-day mortality rates between diabetic and nondiabetic patients (5.7% vs 3.9%, p=0.29). Conversely, diabetes significantly increased mortality from 30 days to 3 years (10.0% vs 5.5%, p=0.03), but admission hyperglycemia did not (8.4% vs 5.9%, p=0.19). Multivariate analysis showed that hyperglycemia was an independent predictor of 30-day mortality (odds ratio [OR] 1.71, 95% confidence interval [CI] 1.13 to 2.61, p=0.01), but diabetes was not (OR 0.84, 95% CI 0.55 to 1.27, p=0.42). Diabetes was independently associated with mortality from 30 days to 3 years (OR 1.43, 95% CI 1.02 to 1.97, p=0.04), but hyperglycemia had a neutral effect (OR 0.98, 95% CI 0.70 to 1.36, p=0.92). In conclusion, in the PCI era, admission hyperglycemia was associated with short-term mortality, whereas diabetes increased long-term mortality after convalescence in patients with AMI. Admission hyperglycemia and diabetes should be treated as 2 distinct disease states.

Influence of diabetes mellitus on in-hospital mortality in patients with acute myocardial infarction in Japan: a report from TAMIS-II

BACKGROUND

The relation between diabetes mellitus (DM) and mortality among patients with acute myocardial infarction is still controversial. We evaluated the influence of DM on the in-hospital mortality of acute myocardial infarction (AMI) patients using data from the Tokai Acute Myocardial Infarction Study-II, a multi-hospital prospective study performed in Japan.

METHODS

All of the study subjects were patients hospitalized for newly diagnosed AMI at 1 of 13 acute care hospitals between January of 2001 and December of 2003. We abstracted the baseline and procedural characteristics from detailed chart reviews. Multivariate analysis was performed, controlling for the variables found to be significantly different between AMI patients with and without DM by chi-square test or unpaired t-test. We evaluated a total of 940 DM and 2284 non-DM patients.

RESULTS

DM patients had roughly twice the in-hospital mortality rate of non-DM patients, with an unadjusted odds ratio of 1.77 (95% CI, 1.37-2.30). However, according to the multivariate analysis, DM was not identified as an independent predictor of in-hospital death, with an adjusted odds ratio of 5.73 (95% CI, 0.97-33.88).

CONCLUSIONS

DM is not an independent predictor of in-hospital mortality, and that there is a need for additional studies to confirm our conclusion.

Comparative early and late outcomes after primary percutaneous coronary intervention in ST-segment elevation and non-ST-segment elevation acute myocardial infarction (from the CADILLAC trial)

We determined the outcomes of patients with acute ST-segment elevation (STE) myocardial infarction (STEMI) and non-STEMI (NSTEMI) after primary percutaneous coronary intervention (PCI). The prognosis after primary PCI in STEMI has been extensively studied and defined. Outcomes of patients who undergo primary PCI for NSTEMI are less well established. In total, 2,082 patients with ongoing chest pain for > 30 minutes consistent with acute MI were randomized to balloon angioplasty versus stenting, each with/without abciximab. Of 1,964 patients, STEMI was present in 1,725 (87.8%) and NSTEMI in 239 (12.2%). Compared with STEMI, those with NSTEMI were more likely to have delayed time-to-hospital arrival (2.4 vs 1.8 hours, p = 0.0002) and increased door-to-balloon time (3.2 vs 1.9 hours, p < 0.0001). Patients with NSTEMI were more likely to have Thrombolysis In Myocardial Infarction grade 3 flow at baseline (37.3% vs 19.4%, p < 0.0001) and higher ejection fraction (58.7% vs 55.8%, p = 0.001), but similar rates of postprocedural Thrombolysis In Myocardial Infarction grade 3 flow. At 1 year, patients with NTEMI had similar mortality (3.4% vs 4.4%, p = 0.40) but higher rates of major adverse cardiac events (24.0% vs 16.6%, p = 0.007) that was driven by more frequent ischemic target vessel revascularization (21.8% vs 11.9%, p <0.0001). In conclusion, patients with acute MI without STE who are treated with primary PCI have marked delays to treatment, similar late mortality, and increased rates of ischemic target vessel revascularization compared with patients with STEMI, despite more favorable angiographic features at presentation and similar reperfusion success. The adverse prognosis of patients with NSTEMI should be recognized and efforts made to decrease reperfusion times.

Infarctus du myocarde chez le diabétique

OBJECTIVES

The aim of this study was to determine the clinical characteristics, treatment and development of myocardial infarction in patients with diabetes.

METHODS

From September 1999 through December 2003, 191 patients with myocardial infarction were hospitalized in the cardiology department of the Mohamed V military teaching hospital in Rabat, Morocco. They included 85 patients with diabetes (D) and 106 without it (ND).

RESULTS

Comparison of these two groups showed a higher percentage of women among the patients with diabetes. Hypertension was more frequent in patients with diabetes, while smoking was frequent in both groups. The clinical picture was similar in both groups, as was the frequency of left ventricular dysfunction, determined by transthoracic echocardiography. Coronary angiography showed damage in three arteries was more common in the D group, while single-artery damage was more frequent in the ND group. Treatment was similar in both groups. In all, 49 patients underwent myocardial revascularization, and its method (angioplasty or aortic surgery) did not differ by group. Neither hospital mortality nor other complications differed between the two groups, with a follow-up of 3.98 +/- 1.99 years for ND patients and 2.68 +/- 1.32 years for D patients.

CONCLUSION

Correct management of myocardial infarction and its cardiovascular risk factors, development of means of revascularization, and close collaboration between cardiologists and endocrinologists should improve prognosis for patients with diabetes who have myocardial infarctions.

Does diabetes mellitus abolish the beneficial effect of primary coronary angioplasty on long-term risk of reinfarction after acute ST-segment elevation myocardial infarction compared with fibrinolysis? (A DANAMI-2 substudy)

Little is known about the effect of diabetes mellitus on long-term clinical outcome after primary percutaneous coronary intervention (pPCI) compared with fibrinolysis in patients who have acute ST-elevation myocardial infarction. We analyzed 3-year clinical outcome in diabetic patients and nondiabetic patients who had been randomized to fibrinolysis or pPCI in the DANAMI-2 trial to compare long-term clinical outcome. The primary end point was a composite of death, clinical reinfarction, or disabling stroke. Median follow-up was 3.8 years. Among 1,572 consecutive patients who had ST-elevation myocardial infarction and were randomized to pPCI or fibrinolysis, 173 (11.0%) had diabetes mellitus; 60 of these patients received metformin treatment and were excluded. After 3 years no difference was found between diabetic patients who underwent pPCI versus fibrinolysis (combined event p=0.37, reinfarction p=0.06 in favor of fibrinolysis), whereas pPCI was superior to fibrinolysis in nondiabetic patients (combined event p=0.002, clinical reinfarction p<0.001). Three-year incidence of clinical reinfarction analyzed with Cox's regression showed that pPCI compared with fibrinolysis increased the relative risk of clinical reinfarction in diabetic patients (relative risk 2.57, 95% confidence interval 1.48 to 4.46, p <0.001) but decreased the risk in nondiabetic patients (relative risk 0.52, 95% confidence interval 0.36 to 0.74, p<0.001). In conclusion, from the DANAMI-2 trial we hypothesize that diabetes may abolish the beneficial effect of pPCI on long-term risk of clinical reinfarction.

Is primary angioplasty more effective than prehospital fibrinolysis in diabetics with acute myocardial infarction? Data from the CAPTIM randomized clinical trial

AIMS

The CAPTIM study randomized patients managed within 6 h of acute ST-segment elevation myocardial infarction to primary angioplasty or prehospital fibrinolysis (rt-PA), with immediate transfer to a centre with interventional facilities. It found a similar incidence of the primary endpoint of death, recurrent MI, or stroke at 30 days with both strategies. We report here the outcome in the diabetic subgroup.

METHODS AND RESULTS

The relationship of diabetic status (diabetics, n=103, non-diabetics, n=731) and treatment strategy with the occurrence of the primary endpoint and of death was analysed. Compared with non-diabetics, diabetics had a higher baseline risk profile, a higher rate of the primary endpoint (14.6 vs. 5.6%; P=0.002), and a high rate of mortality (8.7 vs. 3.1%; P=0.01) at 30 days. The incidence of the primary endpoint tended to be higher in diabetics randomized to prehospital fibrinolysis compared with those randomized to primary angioplasty [21.7 vs. 8.8% (10/46 vs. 5/57); RR: 2.47 (0.91-6.74); P=0.09]. This difference was driven by the higher mortality in the fibrinolysis group [13.0 vs. 5.3% (6/46 vs. 3/57); RR: 2.47 (0.7-9.4); P=0.29]. For non-diabetics, no such trend was observed. Compared with non-diabetics, diabetics had a much higher rate of rescue angioplasty (41.4 vs. 23.5%; P=0.01) and a higher mortality after rescue angioplasty [17.4 vs. 0% (4/23 vs. 0/90); P=0.001].

CONCLUSION

These results suggest that diabetic patients presenting within 6 h of an acute myocardial infarction may derive particular benefit from a strategy of primary angioplasty. However, the small number of diabetic patients in this subgroup analysis does not allow a final conclusion and a specifically designed study is warranted.

Impact of diabetes mellitus on myocardial perfusion after primary angioplasty in patients with acute myocardial infarction

OBJECTIVES

We investigated the impact of diabetes mellitus on myocardial perfusion after primary percutaneous coronary intervention (PCI) utilizing myocardial blush grade (MBG) and ST-segment elevation resolution (STR).

BACKGROUND

Diabetes is an independent predictor of outcomes after primary PCI for acute myocardial infarction (AMI). Whether the poor prognosis is due to lower rates of myocardial reperfusion is unknown.

METHODS

Reperfusion success in those with and without diabetes mellitus was determined by measuring MBG (n = 1,301) and STR analysis (n = 700) in two substudies of the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial among patients undergoing primary PCI for AMI.

RESULTS

There were no differences between those with or without diabetes with regard to postprocedural Thrombolysis In Myocardial Infarction (TIMI) flow grade 3 (>95%), distribution of infarct-related artery, and the frequency of stent deployment or abciximab administration. Patients with diabetes mellitus were more likely to have absent myocardial perfusion (MBG 0/1, 56.0% vs. 47.1%, p = 0.01) and absent STR (20.3% vs. 8.1%, p = 0.002). Diabetes mellitus (hazard ratio [HR] 1.63 [95% confidence interval (CI) 1.17 to 2.28], p = 0.004) was an independent predictor of absent myocardial perfusion (MBG 0/1) and absent STR (HR 2.94 [95% CI 1.64 to 5.37], p = 0.005) by multivariate modeling.

CONCLUSIONS

Despite similar high rates of TIMI flow grade 3 after primary PCI in patients with and without diabetes, patients with diabetes are more likely to have abnormal myocardial perfusion as assessed by both incomplete STR and reduced MBG. Diminished microvascular perfusion in diabetics after primary PCI may contribute to adverse outcomes.

Impact of stenting and abciximab in patients with diabetes mellitus undergoing primary angioplasty in acute myocardial infarction (the CADILLAC trial)

We sought to determine the benefits of stent implantation and abciximab in patients with diabetes mellitus and acute myocardial infarction (AMI) who underwent primary angioplasty. In a 2-by-2 factorial design, 2,082 patients with AMI were randomly assigned to balloon angioplasty versus stenting, with or without abciximab. Diabetes was present in 346 patients (16.6%). The primary end point was the composite incidence of death, disabling stroke, reinfarction, and ischemic target vessel revascularization (TVR). The primary end point at 1 year occurred significantly more frequently in diabetic than nondiabetic patients (21.9% vs 16.8%, p <0.02), driven by increased rates of death (6.1% vs 3.9%, p = 0.04) and TVR (16.4% vs 12.7%, p = 0.07). Among patients with diabetes, TVR at 1 year was significantly reduced with routine stenting compared with balloon angioplasty (10.3% vs 22.4%, p = 0.004), with no differences in death, reinfarction, or stroke. Angiographic restenosis was also greatly reduced in diabetics randomized to stenting (21.1% vs 47.6%, p = 0.009). No beneficial effects were apparent with abciximab in diabetic patients at 1 year. Despite the improved outcomes with stenting in patients with diabetes, 1-year mortality remained increased in diabetic patients who received stents compared with nondiabetics (8.2% vs 3.6%, p = 0.005). Thus, routine stent implantation in diabetic patients with AMI significantly reduces restenosis and enhances survival free from TVR, independent of abciximab use, although survival remains reduced compared with survival in nondiabetic patients regardless of reperfusion modality.

Acute coronary syndromes and diabetes mellitus

Patients with diabetes mellitus who present with acute ST-segment elevation myocardial infarction or non-ST-segment elevation acute coronary syndromes have a higher risk of adverse outcomes than patients without diabetes, and appear to derive greater benefit from evidence-based therapies. However, patients with diabetes mellitus are less commonly treated with proven therapies, so renewed efforts are needed to improve the quality of care and outcomes for patients with diabetes mellitus who present with acute coronary syndromes.

Impact of insulin-requiring diabetes mellitus on effectiveness of reperfusion and outcome of patients undergoing primary percutaneous coronary intervention for acute myocardial infarction

The relation between diabetes mellitus (DM) and outcome was assessed in a series of 1,061 patients with acute myocardial infarction (AMI) who underwent primary percutaneous coronary intervention (PCI). The efficacy of reperfusion was assessed by ST-segment resolution analysis. Of 1,061 patients, 166 had DM (15.6%), and 84 had insulin-requiring DM (51% of DM patients). The 6-month mortality rate was 26% in insulin-requiring DM patients, 7% in non-DM patients, and 4% in non-insulin-requiring DM patients (p <0.001). The early ST-segment resolution rate was lower in insulin-requiring DM patients (52%) compared with the other DM patients (78%) and non-DM patients (76%; p <0.001). Multivariate analysis showed insulin-requiring DM to be independently related to the risk for death (hazard ratio 1.94, 95% confidence interval 1.17 to 3.22, p = 0.009). Insulin-requiring DM is a strong predictor of mortality in patients who undergo PCI for AMI, and this relation may be explained by a less effective myocardial reperfusion despite the mechanical restoration of normal epicardial flow in most patients.

Hospital outcome of acute myocardial infarction in patients with and without diabetes mellitus

AIMS

To assess hospital mortality and morbidity in diabetic and non-diabetic patients with acute myocardial infarction and to compare the results between the two groups.

METHODS

All patients admitted in 1999 to the intensive care unit of the Schwabing City Hospital with diagnosis of acute myocardial infarction were assessed for hospital mortality and co-morbidity.

RESULTS

Three hundred and thirty patients with acute myocardial infarction were admitted. Of those, 126 (38%) were diabetic and 204 (62%) were non-diabetic patients. Mortality within 24 h after admission was 13.5% in diabetic patients and 5.4% in non-diabetic patients (P<0.01). Mortality during entire hospitalization was higher in diabetic than in non-diabetic patients (29.4% vs. 16.2%; P=0.004). Diabetic patients were resuscitated more frequently than non-diabetic patients (24% vs. 11%, P<0.01). In diabetic patients, heart rate at admission was increased (91 +/- 27 vs. 82 +/- 23/min; P<0.01) and presence of angina pectoris was reported less frequently (59% (n=72) vs. 82% (n=167); P<0.001). Preceding myocardial infarction, microalbuminuria, peripheral artery disease and arterial hypertension were more frequent in diabetic than in non-diabetic patients. Diabetic patients demonstrated higher C-reactive protein (CRP) levels than non-diabetic patients (91.4 +/- 78.2 mg/l vs. 45.2 +/- 62.4 mg/l; P<0.001).

CONCLUSIONS

In diabetic patients with acute myocardial infarction, early hospital mortality is increased and signs of cardiac autonomic dysfunction and microangiopathy are detected more frequently than in non-diabetic patients. The need for advanced treatment strategies early in the course of diabetic patients with myocardial infarction is emphasized.

Acute coronary syndromes in patients with diabetes mellitus: diagnosis, prognosis, and current management strategies

The incidence of type-2 diabetes mellitus is rising rapidly both in the United States and worldwide. Because of its presence in so many patients with acute coronary syndromes, it is becoming essential for cardiologists to understand the basic pathophysiology of insulin resistance, its role in the development of type-2 diabetes, and its association with accelerated atherosclerosis. Because diabetes imparts a worse prognosis among patients with acute coronary syndromes, these patients warrant aggressive antiplatelet and antithrombotic therapy, as well as a more invasive management strategy.

Management and short-term outcome of diabetic patients hospitalized for acute myocardial infarction: results of a nationwide French survey

OBJECTIVES

To compare management and short-term outcome of diabetic and non-diabetic patients hospitalized for acute myocardial infarction.

METHODS

This was a prospective epidemiological survey. All patients admitted in coronary care units in France in November 2000 for confirmed acute myocardial infarction were eligible to enter the study.

RESULTS

Of the 2320 patients recruited from 369 centers, 487 were diabetic (21%). Compared to non-diabetic patients, diabetic patients were 5 years older, more often female, obese and hypertensive; they had more often a history of cardiovascular disease; they had a lower ejection fraction and worse Killip class. Reperfusion therapy was less frequent among diabetic patients (39% versus 51%; p=0.0001), as was the use of beta-blockers (61% versus 72%; p=0.0001), aspirin (83% versus 89%; p=0.0001) and statins (52% versus 60%; p=0.001) during hospitalization. Conversely, the use of ACE-inhibitors was more frequent (54% versus 44%; p=0.0001). 58% of diabetic patients received insulin during hospitalization. Twenty-eight-day mortality was 13.1% in diabetic patients and 7.0% in non-diabetic patients (risk ratio: 1.87; p=0.001). Diabetes remained associated with increased mortality after adjustment for relevant risk factors including age and ejection fraction (risk ratio: 1.51; p=0.07). In patients treated with antidiabetic drugs (chiefly sulfonylureas) before admission, 28-day mortality was 10.4% compared with 19.9% in diabetic patients on diet alone or untreated (p=0.005).

CONCLUSION

Despite higher cardiovascular risk and worse prognosis, in-hospital management of diabetic patients with acute myocardial infarction remains sub-optimal. Patients previously treated with antidiabetic drugs including sulfonylureas had a better prognosis than untreated diabetic patients.

Comparison of outcomes of diabetic and nondiabetic patients undergoing primary angioplasty for acute myocardial infarction

We sought to determine whether diabetes mellitus independently conferred poor prognosis in patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI). In 3,742 patients enrolled in the Primary Angioplasty in Myocardial Infarction (PAMI) studies with the intention of undergoing primary PCI, we compared in-hospital mortality, 6-month mortality, and 6-month major adverse cardiovascular events (MACEs), i.e., composite of death, reinfarction, or ischemic target vessel revascularization (TVR), between diabetics (n = 626, 17%) and nondiabetics (n = 3,116, 83%). We evaluated the independent impact of diabetes on outcomes after adjustment for baseline clinical and angiographic differences. Diabetics had worse baseline clinical characteristics, longer pain onset-to-hospital arrival time, and longer door-to-balloon time. They had more multivessel coronary disease and lower left ventricular ejection fractions, but better baseline Thrombolysis In Myocardial Infarction (TIMI) flow. Diabetics underwent primary PCI less often (88% vs 91%, p = 0.01). During the index hospitalization, diabetics were more likely to die (4.6% vs 2.6%, p = 0.005). During 6-month follow-up, diabetics had higher incidences of death (8.1% vs 4.2%, p <0.0001) and MACEs (18% vs 14%, p = 0.036). In multivariate analysis, diabetes was independently associated with 6-month mortality (hazard ratio 1.53, 95% confidence interval 1.03 to 2.26, p = 0.03), but not with in-hospital mortality or 6-month MACEs. We conclude that diabetics with AMI have less favorable baseline characteristics and are less likely to undergo primary PCI than nondiabetics. Despite excellent angiographic results, diabetics had significantly worse 6-month mortality.

Angiographic findings, time course of regional and global left ventricular function, and clinical outcome in diabetic patients with acute myocardial infarction treated with primary percutaneous transluminal coronary angioplasty

There is scarce information available about the outcome of diabetic patients with acute myocardial infarction (AMI) treated with percutaneous transluminal coronary angioplasty (PTCA). We sought to compare left ventricular (LV) function, and angiographic and clinical outcomes in diabetics versus nondiabetics with AMI treated with primary PTCA. This study examined 720 consecutive patients with AMI treated with primary PTCA, 102 of whom had diabetes. Six-month follow-up coronary angiography was obtained in 560 patients (88% of eligible patients). In a subgroup of 284 patients, LV function was serially determined by 2-dimensional echocardiography. During 6-month follow-up no significant differences were observed between diabetics and nondiabetics with regard to restenosis rates (31.6% vs 28.2%, p = 0.6), recovery of LV function (6-month wall motion score index: 1.8 +/- 0.7 vs 1.8 +/- 0.7, p = 0.88; 6-month LV ejection fraction: 48.5 +/- 12% vs 51.2 +/- 13%, p = 0.173), nonfatal re-AMI rates (2.9% vs 1.3%, p = 0.2), and target vessel revascularization rates (21.6% vs 16.8%, p = 0.2). Early and late mortality were higher in diabetics than in nondiabetic patients (8.8% vs 4.2%, p = 0.045 and 11.7% vs 5.5%, p = 0.016, respectively). By Cox analysis, diabetes was an independent predictor of both early (odds ratio [OR] 2.4, 95% confidence interval [CI] 1.1 to 5.3, p = 0.03) and late mortality (OR 2.37, 95% CI 1.16 to 4.84, p = 0.017) as well as 6-month major adverse cardiac events (MACEs): death, re-AMI, target vessel revascularization (OR 1.51, 95% CI 1.04 to 2.18, p = 0.03). Thus, diabetes is an independent predictor of clinical outcome even if PTCA is used as the primary reperfusion strategy.

[Coronary angioplasty in diabetic patients. Current and future perspectives]

It has been estimated that 15-25% of patients who undergo percutaneous or surgical coronary angioplasty are diabetics. The indications for coronary revascularization and initial results of the procedure do not differ substantially between patients with diabetes mellitus and non-diabetics. However, the long-term results of both percutaneous and surgical coronary angioplasty are less favorable in diabetics in terms of mortality and the need for new revascularization procedures. The development and widespread use of stents and glycoprotein IIb/IIIa receptor inhibiting drugs have improved the clinical evolution of diabetics treated with angioplasty. Currently available data show that the administration of glycoprotein IIb/IIIa inhibitors to patients undergoing coronary angioplasty is especially useful in diabetics and improves short-term and long-term results, decreasing one-year mortality by 45%. There seem to be indications for the routine use of glycoprotein IIb/IIIa inhibitors in diabetics treated with angioplasty. While the use of stents has improved long-term and short-term results in diabetics, the success rates of angioplasty in diabetics are still lower than in non-diabetics. Diabetes is still an independent predictor of restenosis and long-term events after stenting interventions. Analysis of the studies comparing percutaneous and surgical revascularization in diabetic patients with multivessel disease shows that surgery is superior in terms of long-term mortality and need for new revascularization procedures. Stenting has improved, but not substantially, the results of multivessel angioplasty in diabetics. Therefore, the indications for angioplasty in multivessel diabetics should be evaluated individually. Factors that contribute to the less favorable post-angioplasty evolution of diabetic patients are more rapid progression of atherosclerosis and, especially, a higher rate of restenosis. New angioplasty techniques, such as brachytherapy and drug-eluting stents, are likely to significantly improve the results of percutaneous interventions in diabetics, thus allowing the indications for angioplasty in diabetics to be extended even further in the near future.

Impact of diabetes mellitus on epicardial and microvascular flow after fibrinolytic therapy

BACKGROUND

Patients with diabetes are at increased risk of death after acute myocardial infarction, independent of other baseline risk factors and more severe coronary artery disease. We studied the angiographic and electrocardiographic responses to thrombolytic agents in patients with diabetes; in particular ST-segment resolution as a measure of microvascular flow.

METHODS

Angiography was performed in 2588 patients at 90 minutes after thrombolytic agent administration as well as after percutaneous coronary intervention (PCI) in the Thrombolysis In Myocardial Infarction (TIMI) 4, 10A, 10B, and 14 trials. Electrocardiographic parameters were assessed at baseline and at 90 minutes in the TIMI 14 trial.

RESULTS

Compared with those without diabetes, patients with diabetes (347/2588 [13.4%]) were older, more often female, heavier, and less often smokers, and they had higher systolic blood pressure on admission. At angiography, they more frequently had 3-vessel disease, well-developed collateral vessels, more distal culprit lesions, and smaller reference segment diameters. In the infarct-related artery, there was no relationship between diabetes and TIMI 3 flow at 90 minutes (55.4% vs 59.0% without diabetes) or after PCI, (83.7% vs 84.2%, both P = NS). Corrected TIMI frame counts were also similar at both time points. However, there was less frequent complete ST-segment resolution among diabetic patients after thrombolysis (38.6% vs 49.2%, adjusted P =.04).

CONCLUSION

Thrombolysis and adjunctive/rescue PCI achieved equal rates of epicardial flow in patients with and without diabetes. However, diabetic patients had less complete ST-segment resolution, suggesting impaired microvascular flow. Abnormal microvascular flow may contribute at least in part to the poorer outcomes observed in patients with diabetes and acute myocardial infarction.

[Prevention and treatment of ischemic heart disease in patients with diabetes mellitus]

The incidence of cardiovascular diseases among diabetic patients is so high that diabetes mellitus is currently defined as a cardiovascular disease equivalent. Furthermore, diabetic patients who develop acute coronary syndromes have a poorer short-term and long-term prognosis, so primary and secondary preventive measures are critically important in this population subgroup. There is substantial evidence that pharmacological therapy for primary and secondary cardiovascular prevention is more effective in diabetic patients than in non-diabetics. This article reviews the evidence of the efficacy of pharmacological prevention therapies in diabetic patients in favor of an aggressive pharmacological preventive strategy. Every diabetic patient without known cardiovascular disease should be treated with angiotensin-converting enzyme inhibitors and statins. High-risk patients should also receive low-dose aspirin.Compared with non-diabetics, diabetic patients who develop acute coronary events benefit more from the addition of intensive antithrombotic therapy to aspirin treatment. Diabetic patients presenting with non-ST segment elevation syndromes have better outcomes when treated with clopidogrel or glycoprotein IIb/IIIa inhibitors, and diabetics presenting with ST-segment elevation or left bundle-branch block have a greater survival benefit when given thrombolytic therapy compared with non-diabetic patients.Unless formal contraindications are present, diabetic patients with ischemic heart disease, particularly those with previous myocardial infarction, should always be treated with aspirin, betablockers, angiotensin converting enzyme inhibitors, and statins, regardless of lipid levels, left ventricular systolic function or the presence of congestive heart failure.

Clinical outcomes of patients with diabetes mellitus and acute myocardial infarction treated with primary angioplasty or fibrinolysis

OBJECTIVE

To compare the early and late outcomes of primary percutaneous transluminal coronary angioplasty (PTCA) with fibrinolytic treatment among diabetic patients with acute myocardial infarction (AMI).

DESIGN

Retrospective observational study with data obtained from prospective registries.

SETTING

Tertiary cardiovascular institution with 24 hour acute interventional facilities.

PATIENTS

202 consecutive diabetic patients with AMI receiving reperfusion treatment within six hours of symptom onset.

INTERVENTIONS

Fibrinolytic treatment was administered to 99 patients, and 103 patients underwent primary PTCA. Most patients undergoing PTCA received adjunctive stenting (94.2%) and glycoprotein IIb/IIIa inhibition (63.1%).

MAIN OUTCOME MEASURES

Death, non-fatal reinfarction, and target vessel revascularisation at 30 days and one year were assessed.

RESULTS

Baseline characteristics were similar in these two treatment groups except that the proportion of patients with Killip class III or IV was considerably higher in those treated with PTCA (15.5% v 6.1%, p = 0.03) and time to treatment was significantly longer (103.7 v 68.0 minutes, p < 0.001). Among those treated with PTCA, the rates for in-hospital recurrent ischaemia (5.8% v 17.2%, p = 0.011) and target vessel revascularisation at one year (19.4% v 36.4%, p = 0.007) were lower. Death or reinfarction at one year was also reduced among those treated with PTCA (17.5% v 31.3%, p = 0.02), with an adjusted relative risk of 0.29 (95% confidence interval 0.15 to 0.57) compared with fibrinolysis.

CONCLUSION

Among diabetic patients with AMI, primary PTCA was associated with reduced early and late adverse events compared with fibrinolytic treatment.

Influence of diabetes mellitus on outcome in the era of primary stenting for acute myocardial infarction

The purpose of the present study was to examine the influence of diabetes mellitus (DM) on the clinical and angiographic outcomes in 62 diabetic and 152 nondiabetic patients with acute myocardial infarction (AMI) treated with primary coronary stenting within 12 h of the onset of symptoms. The diabetic patients had a greater incidence of hyperlipidemia, prior myocardial infarction (MI) and multivessel disease. There were no statistically significant differences in other variables. Procedural success was similar in the 2 groups. At a mean follow-up of 2.1 +/- 0.6 years, 13% of diabetic and 11% of nondiabetic patients had died (p = 0.70). The percentage of target vessel revascularization (TVR) was 37% of diabetic and 20% of nondiabetic patients (p = 0.003). Rates of major adverse cardiac events (MACE: death, non-fatal MI, TVR) were 50% of diabetic and 32% of nondiabetic patients (p = 0.007). On multivariate analysis, DM was not a predictor of death. Independent predictors of death were age, multivessel disease, TIMI < or = 2 and cardiogenic shock. However, DM and age were independent predictors of MACE. In conclusion, DM is not an independent predictor of death in patients with AMI after stenting, but diabetic patients had a higher incidence of TVR, making DM an independent predictor of MACE.

Acute myocardial infarction in the elderly with diabetes

OBJECTIVE

Diabetes mellitus (DM) has been associated with an elevated, short-term risk of death after myocardial infarction (MI). Among the studies of DM, however, few studies have included elderly subjects. The purpose of the present investigation was to determine if non-insulin-treated DM (NIRxDM) and insulin-treated DM (IRxDM) were associated with specific comorbid conditions, clinical findings on arrival, and MI characteristics, as well as a higher 30-day mortality rate in elderly patients with acute MI.

DESIGN

The study design was a retrospective medical record review and secondary data analysis of previously collected data from the Cooperative Cardiovascular Project.

SETTING

Study setting was Connecticut from June 1, 1992, through February 28, 1993.

PATIENTS

Subjects included the entire Medicare population (n = 2050), aged 65 years or older who were hospitalized for acute MI.

OUTCOME MEASURES

Mortality rate at 30 days after MI was measured.

RESULTS

A history of DM was observed in 29% of the study population. DM status was associated with previous comorbid conditions, poorer functional status, higher body mass index, heart failure on arrival, non-Q-wave MI, and development of atrial fibrillation and oliguria during hospitalization. Patients with DM were less likely to have chest pain on arrival to the hospital. Diabetic status was not a significant predictor of short-term mortality; at 30 days after MI, 17% (n = 242) of the subjects without DM, 19% (n = 71) of those with NIRxDM, and 18% (n = 39) of the subjects with IRxDM died (P = .460). After adjustment for other prognostic factors, it was noted that MI characteristics present on hospital arrival predicted mortality at 30 days in both patients with NIRxDM and patients with IRxDM.

CONCLUSIONS

The slightly, but not significantly, increased mortality risk in patients with DM should not minimize the importance of monitoring DM in the acute MI setting. Hospitalization for MI provides an opportunity to provide aggressive lipid and blood pressure management, optimize blood glucose, control heart failure, and institute other secondary preventive interventions in the elderly population with DM.

Diabetes mellitus and cardiovascular disease

Diabetes is associated with a high incidence and poor prognosis of cardiovascular disease, and with high short- and long-term mortality. Adequate treatment of cardiovascular disorders and aggressive management of coexisting risk factors have proved to be at least as effective in diabetic as in nondiabetic patients in randomized, controlled studies. Indeed, treating diabetic patients with cardiovascular disease results in a larger absolute risk reduction than in nondiabetic subjects. Nevertheless, diabetic patients often receive inadequate therapy, which may, to a certain extent, explain their poor prognosis. Recommendations for the treatment of diabetic patients with acute myocardial infarction should include beta-blockers, aspirin, and ACE-inhibitors in all patients in whom no specific contraindications exist. Fibrinolysis should be administered when indicated, and the benefits of improving glycemic control should not be forgotten either. In patients with multi-vessel disease who need revascularization, when selecting the type of procedure, the superiority of surgical revascularization over angioplasty should be borne in mind. Even heart transplantation should be included as a therapeutic option since there are no data to support the exclusion of patients on account of their diabetes. Finally, coexisting risk factors should be intensively treated through lifestyle intervention, with or without drug therapy, in order to achieve secondary prevention goals.

Predictors of good outcome after intravenous tPA for acute ischemic stroke

BACKGROUND

Thrombolytic therapy for acute ischemic stroke with IV alteplase is increasingly well established in North America but not elsewhere. Baseline factors that altered the response to alteplase were not identified by the National Institute of Neurological Disorders and Stroke tPA Stroke Study Group.

METHODS

The authors gathered information from centers in the United States, Canada, and Germany on 1,205 patients with acute ischemic stroke treated with IV alteplase. The purpose was to identify independent factors that were predictive of good outcome using multivariable logistic regression modelling. The modified Rankin Scale score was dichotomized into good outcome (mRS 0 to 1) and poor outcome (mRS >1) as the primary outcome measure.

RESULTS

In relative order of decreasing magnitude, milder baseline stroke severity, no history of diabetes mellitus, normal CT scan, normal pretreatment blood glucose level, and normal pretreatment blood pressure were independent predictors of good outcome among patients treated with IV alteplase for acute ischemic stroke. Confounding was observed among history of diabetes mellitus, CT scan appearance, baseline serum glucose level, and blood pressure, suggesting important relationships among these variables.

CONCLUSIONS

Several factors were independently predictive of good outcome among patients with acute ischemic stroke treated with alteplase. These results require further confirmation before clinical implementation.

Managing myocardial infarction in the diabetic patient

Myocardial infarction is the leading cause of death among persons with diabetes. Recent advances in the understanding and treatment of cardiovascular disease in diabetes have made it increasingly important to tailor therapy when treating this high-risk population. Because patients with diabetes are at significantly higher risk for complications and death from MI, these patients are most likely to benefit from early and aggressive therapeutic intervention. Strong recommendations can be given for the use of beta-blockers, ACE inhibitors, and thrombolysis when indicated in the management of acute MI in the diabetic patient. Acetylsalicylic acid is also likely to be beneficial with little risk of adverse events in this setting. In the absence of more definitive data, cautious use of mechanical intervention in diabetic patients is recommended. The use of intravenous insulin therapy may benefit diabetic patients during the acute phase of MI, but more definitive studies are required before it can be recommended for broad use.

Diabetes mellitus in cardiogenic shock complicating acute myocardial infarction: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK?

OBJECTIVES

We sought to examine the role of diabetes mellitus in cardiogenic shock (CS) complicating acute myocardial infarction (AMI) in the SHOCK Trial Registry.

BACKGROUND

The characteristics, outcomes and optimal treatment of diabetic patients with CS complicating AMI have not been well described.

METHODS

Baseline characteristics, clinical and hemodynamic measures, treatment variables, shock etiologies and comorbid conditions were compared for 379 diabetic and 784 nondiabetic patients. Logistic regression was used to examine the association between diabetes and in-hospital mortality, after adjustment for baseline differences.

RESULTS

Diabetics were less likely than nondiabetics to undergo thrombolysis (28% vs. 37%; p = 0.002) or attempted revascularization (40% vs. 49%; p = 0.008). The survival benefit for diabetics selected for percutaneous or surgical revascularization (55% vs. 19% without revascularization) was similar to that for nondiabetics (59% vs. 25%). Overall unadjusted in-hospital mortality was significantly higher for diabetics (67% vs. 58%; p = 0.007), but diabetes was only a borderline predictor of mortality after adjustment for baseline and treatment differences (odds ratio for death, 1.36; 95% confidence interval, 1.00 to 1.84; p = 0.051).

CONCLUSIONS

Diabetics with CS complicating AMI have a higher-risk profile at baseline, but after adjustment, diabetics have an in-hospital survival rate that is only marginally lower than that of nondiabetics. Diabetics who undergo revascularization derive a survival benefit similar to that of nondiabetics.