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

Acute coronary syndromes in diabetic patients, outcome, revascularization, and antithrombotic therapy

Diabetes exacerbates the progression of atherosclerosis and is associated with increased risk of developing acute coronary syndrome (ACS). Approximatively 25-30% of patients admitted for ACS have diabetes. ACS occurs earlier in diabetics and is associated with increased mortality and a higher risk of recurrent ischemic events. An increased proinflammatory and prothrombotic state is involved in the poorer outcomes of diabetic patients. In the past decade advancement in both percutaneous coronary intervention (PCI) and coronary artery by-pass graft (CABG) techniques and more potent antiplatelet drugs like prasugrel and ticagrelor improved outcomes of diabetic patients with ACS, but this population still experiences worse outcomes compared to non-diabetic patients. While in ST elevation myocardial infarction urgent PCI is the method of choice for revascularization, in patients with non-ST elevation ACS an early invasive approach is suggested by the guidelines, but in the setting of multivessel (MV) or complex coronary artery disease (CAD) the revascularization strategy is less clear. This review describes the accumulating evidence regarding factors involved in promoting increased incidence and poor prognosis of ACS in patients with diabetes, the evolution over time of prognosis and outcomes, revascularization strategies and antithrombotic therapy studied until now.

A systematic review and meta-regression of temporal trends in the excess mortality associated with diabetes mellitus after myocardial infarction

BACKGROUND/OBJECTIVES

It is not well known whether the gap in outcomes after myocardial infarction (MI) between patients with and without diabetes mellitus (DM) has changed over time. We performed a systematic review and metaregression of temporal trends in the excess mortality associated with DM after MI.

METHODS

We searched the PubMed database for studies reporting mortality data according to diabetic status in patients hospitalized for MI or acute coronary syndromes (ACS). We included 139 studies/cohorts for analysis (432,066 diabetic patients and 1,182,108 nondiabetic patients).

RESULTS

When compared to their non-diabetic counterparts, patients with DM had an odds ratio (OR) [95% CI] of 1.66 [1.59-1.74] (P<0.0001) for early mortality, and of 1.86 [1.75-1.97] (P<0.0001) for 6-12months mortality. When all data from the 116 studies reporting early mortality were pooled, there was no significant relationship between calendar year and Log (OR). Likewise, when considering the 61 studies reporting 6-12months mortality, there was no significant relationship between calendar year and Log (OR). Similar to the overall pooled analysis, no significant relationship between inclusion year and Log (OR) for mortality in diabetic patients was observed in sensitivity analyses performed in studies with ST-elevation MI as inclusion criteria, in randomized trials, in studies including >2000 patients, and in studies with DM prevalence >20%.

CONCLUSIONS

We found no evidence for temporal changes in the incremental mortality risk associated with DM in the setting of MI. The improvements in management of MI patients during the last decades have not been associated with a reduction of the gap between diabetic and non-diabetic patients.

ST-segment elevation myocardial infarction in women with type 2 diabetes

OBJECTIVE

To evaluate the effect of type 2 diabetes on the clinical course and prognosis of women with ST-segment elevation myocardial infarction (STEMI) and diabetes.

RESEARCH DESIGN AND METHODS

A total of 26,035 consecutive patients with STEMI who were hospitalized in 456 hospitals in Poland during 1 year were analyzed. The data were obtained from the Polish Registry of Acute Coronary Syndromes (PL-ACS).

RESULTS

Type 2 diabetes occurred more frequently in women than in men (28 vs. 16.6%; P < 0.0001). The proportion of women was larger among patients with diabetes (47.1 vs. 31.3%; P < 0.0001), and compared with women without diabetes, diabetic women had worse clinical profiles. Women with diabetes were most frequently treated conservatively. Both women and men with diabetes had significantly more advanced atherosclerotic lesions than women without diabetes. Women with diabetes had the highest in-hospital, 6-month, and 1-year mortality rates. Multivariate analysis indicated that type 2 diabetes was a significant independent risk factor for in-hospital and 1-year mortality in women with STEMI. Primary percutaneous coronary intervention (pPCI) was a significant factor associated with the decreased 1-year mortality in women without diabetes.

CONCLUSIONS

Type 2 diabetes was a significant independent risk factor for in-hospital and 1-year mortality in women with STEMI. Women with diabetes had the poorest early and 1-year prognoses after STEMI when compared with women without diabetes and men with diabetes. Although pPCI improves the long-term prognosis of women with diabetes, it is used less frequently than in women without diabetes or men with diabetes.

Costs of cardiovascular events of diabetic patients in the French hospitals

AIMS

To test the assumption that hospital management of macro-vascular complications of Diabetes is more resource consuming in diabetic than in non-diabetic patients and to estimate, if relevant, the extra costs for diabetic patients.

METHODS

The French national DRG database (PMSI- 2003) was analysed for the following cardio-vascular events (CVE): Stroke, Myocardial Infarction, Unstable Angina, Cardiac Arrest and Coronary Revascularization. Diabetic patients (Type 1 and 2) were identified using co-morbidity diagnosis. Differences in various indicators of resource consumption were tested between diabetic and non-diabetic patients. Using length of stay (LOS) as a cost driver, the extra hospital costs of each CVE were then estimated by reference to mean costs measured on the whole database.

RESULTS

Average LOS of patients with diabetes were significantly longer than of non diabetic patients. (stroke: +2.5 days, myocardial infarction: +1.5 days, unstable angina: +1.3 days, revascularisation: +2.8 days; P<0.001). The mean numbers of medical procedures by stay were also higher in the diabetic group. Extra hospital costs of CVE for diabetic patients as compared with mean costs were the following: +23.9% (non fatal stroke), +10.4% (non fatal myocardial infarction), +6.1% (unstable angina), +9.1% (coronary revascularization).

CONCLUSION

The hospital costs of CVE in diabetic patients are higher than average. Specific costs for these complications should be used to improve the relevance of economic studies of Diabetes.

Hormones and cardiovascular health in women

Cardiovascular diseases (CVDs) may have their origin before birth: the combination of being small at birth and having an overly rich post-natal diet increases the likelihood of obesity and of acquiring a specific metabolic syndrome in adulthood that carries an increased risk of CVD. The incidence of CVD and mortality is very low in women of reproductive age but rises to a significant level in older women. In this article, we discuss CVD in relation to hormonal contraception, pregnancy and polycystic ovarian syndrome (PCOS) in younger women and menopause in older women. Women with PCOS have a higher risk of diabetes and hypertension, but studies to date have not shown an effect on CVD events. Use of combined hormonal contraception has only small effects on CVD because of the low baseline incidence of myocardial infarction (MI), stroke and venous thromboembolism (VTE) among young women. Women with existing risk factors or existing CVD, however, should consider alternative contraception. In pregnancy, CVD is rare, although, in the West, it now accounts for a significant proportion of maternal mortality as the frequency of obstetrical causes of mortality has substantially declined. The frequency of VTE is 15 per 10,000 during pregnancy and the post-partum period. In older women, menopause causes a slightly higher risk of MI after allowing for age, although there is substantial heterogeneity in the results of studies on menopause and age at menopause and MI. A larger effect might have been expected, because estrogen reduces the risk of developing atherosclerosis in premenopausal women, whereas in post-menopausal women who may have established atherosclerotic disease, estrogen increases the risk of myocardial disease through the effects on plaque stability and clot formation. Recent trial results indicate that hormone treatment in menopause does not favourably affect the risk of MI, stroke or other vascular disease. Thus, prevention of CVD should rely on diet and fitness, low-dose aspirin and treatment of hypertension, hyperglycaemia and hyperlipidaemia.

Impact of age and gender on in-hospital and late mortality after acute myocardial infarction: increased early risk in younger women: results from the French nation-wide USIC registries

AIMS

To determine whether sex differences of in-hospital and after-discharge mortality differ according to the age.

METHODS AND RESULTS

Data of 4347 consecutive patients hospitalized within 48 h of the onset of acute myocardial infarction (AMI) were analysed. Patients were classified according to median age (68 years): Group 1 (G1) (308 women, 30-67 years), G2 (1878 men, 30-67 years), G3 (860 women, 68-89 years), and G4 (1301 men, 68-89 years). In both age groups, women were older, had more frequent co-morbidities, lower rate of reperfusion therapy, and received less anti-platelet agents, beta-blockers, and statins than men. The overall 1-year mortality was higher in women (25% vs. 16% in men, P<0.0001). After adjustment, in-hospital mortality was higher only for the women in the younger age group. (G1 vs. G2: OR=2.2, 95%CI=1.3-3.8; G3 vs. G4: OR=1.1, 95%CI=the risk of death, after hospital discharge, was no longer related to gender in any age group.

CONCLUSION

The higher 1-year mortality following AMI in women is explained by the higher risk of death in young women during the first days of hospitalization. Further investigations are crucial to determine the cause in order to improve the chance of survival in younger women.

The acute reperfusion management of STEMI in patients with impaired glucose tolerance and type 2 diabetes

Diabetes mellitus (DM) remains an important predictor for mortality in patients with ST-segment Elevation Myocardial Infarction (STEMI) although the use of reperfusion therapy has resulted in a considerable improvement of survival. Of importance, newly diagnosed diabetic patients and those with fasting glycaemia in the diabetes range have even worse outcomes compared to patients with known diabetes. Overall, 50% of all patients presenting with STEMI have abnormal glucose metabolism of which fewer than 50% are known diabetics. Obviously, the efficacy of reperfusion therapy in reopening the occluded artery is similar in STEMI patients with or without impaired fasting glycaemia, while the pre-existing decreased myocardial perfusion in STEMI patients with impaired fasting glycaemia persists after successful epicardial revascularisation. There is no doubt that improving microvascular perfusion within the ischaemic myocardium remains the ultimate goal of managing STEMI patients with impaired glucose metabolism. Identification of defective myocardial perfusion together with an aggressive antithrombotic regimen, reduction of the inflammatory response of the ischaemic myocardium and improvement of glycaemia control represent promising therapeutic approaches that deserve additional specific clinical investigations. This review examines all these important issues.