Mortality and extent of coronary artery disease in 2776 patients with type 1 diabetes undergoing coronary angiography: A nationwide study

Impact of type 1 diabetes mellitus on mortality rate and outcome of hospitalized patients with myocardial infarction

INTRODUCTION

Type 1 diabetes mellitus (T1D) is associated with an increased cardiovascular risk. We aimed to investigate the influence of T1D on myocardial infarction (MI) patients' mortality.

MATERIALS AND METHODS

The German nationwide inpatient sample 2005-2016 was used for statistical analysis. Hospitalized MI patients were stratified for T1D and impact of T1D on in-hospital outcomes was investigated.

RESULTS

In total, 3,307,703 hospitalizations of MI patients (37.6 % females, 56.8 % aged ≥70 years) were counted in Germany 2005-2016 and included in this analysis. In 18,625 (0.6 %) of the cases additionally T1D was coded. Overall, 410,737 (12.4 %) in-hospital deaths occurred within the investigation period. MI patients with T1D were younger (64.0 [IQR 52.0-75.0] vs. 73.0 [62.0-81.0] years, P < 0.001), more often female (38.7 % vs. 37.6 %, P < 0.001) and obese (13.2 % vs. 9.3 %, P < 0.001). Comorbidities like peripheral arterial (14.2 % vs. 6.4 %, P < 0.001) and kidney disease (38.5 % vs. 27.2 %, P < 0.001) were more prevalent in MI patients with T1D. T1D was an independent risk factor for in-hospital death (OR 1.23 [95%CI 1.18-1.29], P < 0.001), recurrent MI (OR 1.56 [95%CI 1.35-1.80], P < 0.001), and stroke (OR 1.75 [95%CI 1.63-1.88], P < 0.001). While percutaneous coronary intervention (PCI, 37.8 % vs. 42.0 %, P < 0.001) was less often, coronary artery bypass grafting (CABG, 7.4 % vs. 4.6 %, P < 0.001) was more often performed in MI patients with T1D, confirmed by regression analysis (PCI: OR 0.66 [95%CI 0.64-0.68], P < 0.001; CABG: OR 1.54 [95%CI 1.45-1.63], P < 0.001).

CONCLUSIONS

T1D represents an important and independent risk factor for mortality in MI patients. The results emphasize the high vulnerability of T1D patients who suffer from MI.

Causes of Excess Mortality in Diabetes Patients Without Coronary Artery Disease: A Cohort Study Revealing Endocrinologic Contributions

Background

Diabetes mellitus (DM) patients without coronary artery disease (CAD) have a higher all-cause mortality rate than patients with neither DM nor CAD. We examined cause-specific death of DM patients with and without CAD.

Methods

We conducted a cohort study of all patients who underwent CAG in Western Denmark between 2003 and 2016. Using Danish health registries, patients were followed for a maximum of 10 years and stratified according to their DM and CAD status. Outcomes included all-cause-, cancer-, circulatory-, and endocrinologic death. Ten-year cumulative risks were computed as well as adjusted and unadjusted hazard ratios (aHR and HR).

Results

A total of 132,432 patients (28,524 deaths, median follow-up of 6.2 years) were included. Compared to patients with neither DM nor CAD, DM patients without CAD had a higher 10-year risk of all-cause death (27.9% versus 19.7%, aHR 1.43 [95% CI 1.35-1.52]), cancer death (7.2% versus 5.4%, aHR 1.29 [95% CI 1.15-1.46]), circulatory death (9.1% versus 6.9%, aHR 1.35 [95% CI 1.22-1.49]), and endocrinologic death (3.9% versus 0.3%, aHR 14.02 [95% CI 10.95-17.95]). Among endocrinologic deaths, 87% were due to classical complications of DM, such as diabetic nephropathy and ketoacidosis, in DM patients without CAD.

Conclusion

Diabetes patients without CAD exhibit a higher risk of all-cause mortality, driven primarily by elevated rates of cancer, circulatory, and endocrinologic deaths, particularly related to diabetic microvascular complications.

Long-term cardiovascular prognosis of patients with type 1 diabetes after myocardial infarction

Background

To explore long-term cardiovascular prognosis after myocardial infarction (MI) among patients with type 1 diabetes.

Methods

Patients with type 1 diabetes surviving 90 days after MI (n = 1508; 60% male, mean age = 62.1 years) or without any type of diabetes (n = 62,785) in Finland during 2005–2018 were retrospectively studied using multiple national registries. The primary outcome of interest was a combined major adverse cardiovascular event (MACE; cardiovascular death, recurrent MI, ischemic stroke, or heart failure hospitalization) studied with a competing risk Fine-Gray analyses. Median follow-up was 3.9 years (maximum 12 years). Differences between groups were balanced by multivariable adjustments and propensity score matching (n = 1401 patient pairs).

Results

Cumulative incidence of MACE after MI was higher in patients with type 1 diabetes (67.6%) compared to propensity score-matched patients without diabetes (46.0%) (sub-distribution hazard ratio [sHR]: 1.94; 95% confidence interval [CI]: 1.74–2.17; p < 0.0001). Probabilities of cardiovascular death (sHR 1.81; p < 0.0001), recurrent MI (sHR 1.91; p < 0.0001), ischemic stroke (sHR 1.50; p = 0.0003), and heart failure hospitalization (sHR 1.98; p < 0.0001) were higher in patients with type 1 diabetes. Incidence of MACE was higher in diabetes patients than in controls in subgroups of men and women, patients aged < 60 and ≥ 60 years, revascularized and non-revascularized patients, and patients with and without atrial fibrillation, heart failure, or malignancy.

Conclusions

Patients with type 1 diabetes have notably poorer long-term cardiovascular prognosis after an MI compared to patients without diabetes. These results underline the importance of effective secondary prevention after MI in patients with type 1 diabetes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-022-01608-3.

Risk of stent failure in patients with diabetes treated with glucagon-like peptide-1 receptor agonists and dipeptidyl peptidase-4 inhibitors: A nationwide observational study

BACKGROUND

Incretins are a group of glucose-lowering drugs with favourable cardiovascular (CV) effects against neoatherosclerosis. Incretins' potential effect in stent failure is unknown. The aim of this study is to determine if incretin treatment decreases the risk of stent-thrombosis (ST), and/or in-stent restenosis (ISR) after percutaneous coronary intervention (PCI) with implanted drug-eluting stents (DES).

METHODS

Observational study including all diabetes patients who underwent PCI with DES in Sweden from 2007 to 2017. By merging 5 national registers, the information on patient characteristics, outcomes and drug dispenses was retrieved. Cox regression analysis with estimated hazard ratios (HRs) adjusted for confounders with 95% confidence intervals (CIs) was used to analyse for the occurrence of ST/ISR, and major adverse cardiovascular events (MACE). A subgroup analysis for the type of incretin treatment was performed.

RESULTS

In total 18,505 diabetes patients (30% women) underwent PCI, and 32,463 DES were implanted. Of those, 10% (3449 DES in 1943 patients) were treated with incretins. Median follow-up time was 995 days (Control Group) vs. 771 days (Incretin Group). No significant difference in the risk of ST/ISR was found neither for the main study group (HR:0.98 95% CI:0.80-1.19) nor for the subgroups. No reduction of the risk of MACE (HR:0.96 95% CI:0.88-1.06) was observed. There was a 26% lower risk for CV death in favour of incretin treated patients (HR:0.74 95% CI:0.57-0.95).

CONCLUSION

In diabetes patients who underwent PCI incretin treatment was not associated with lower risk of stent failure, but with lower risk of CV death.

A DNA Repair Pathway Polymorphism (rs25487) and Angiographically Proven Coronary Artery Patients in a Population of Southern Iran

BACKGROUND

Coronary Artery Disease (CAD), which is a multifactorial genetic disease, is known as one of the most common causes of death worldwide. In this regard, X-ray Repair Cross-Complementing group 1 (XRCC1), a DNA repair protein involved in Single-Strand Breaks (SSBs), and Base Excision Repair (BER) pathways have been reported to be responsible for the efficient repair of single strand breaks and damaged bases in DNA.

OBJECTIVES

In the current study, we analyzed Arg399Gln (rs25487), which is one of the most common polymorphisms of XRCC1 gene that might be associated with the increased risk for CAD.

METHODS

This case-control study was performed to investigate the relationship between this polymorphism and CAD development. In this study, 290 patients and 216 controls were diagnosed by cardiac angiography and then screened for the above-mentioned polymorphism using Restriction Fragment Length Polymorphisms (RFLP) method.

RESULTS

The frequency of the GA genotype of XRCC1 Arg399Gln (rs25487) was significantly higher in CAD patients compared to the controls (p=0.002, OR: 1.21, 95% CI: 1.06-1.37). Moreover, its dominant mode (AA + GA) genotype had a 1.851-fold increase in the risk of CAD (p = 0.005).

CONCLUSION

Our findings demonstrated that Arg399Gln polymorphism of XRCC1 (rs25487) has a significant relationship with CAD and also plays a probable predisposing role in that. Our results support the role of DNA damages and the malfunctions of DNA repair system in the patients with CAD.

Glucagon-like peptide-1 receptor agonists and the risk of cardiovascular events in diabetes patients surviving an acute myocardial infarction

AIMS

Trial evidence indicates that glucagon-like peptide-1 receptor agonists (GLP-1 RAs) may reduce the risk of cardiovascular (CV) events in patients with diabetes and myocardial infarction (MI). We aimed to expand this observation to routine care settings.

METHODS AND RESULTS

Prospective observational study including all patients with diabetes surviving an MI and registered in the nationwide SWEDEHEART registry during 2010-17. Multivariable Cox regression analyses were used to estimate the association between GLP-1 RAs use and the study outcome, which was a composite of stroke, heart failure, Re-infarction, or CV death. Covariates included demographics, comorbidities, presentation at admission, and use of secondary CV prevention therapies. In total, 17 868 patients with diabetes were discharged alive after a first event of MI. Their median age was 71 years, 36% were women and their median estimated glomerular filtration rate was 75 mL/min/1.73m2. Of those, 365 (2%) were using GLP-1 RAs. During median 3 years of follow-up, 7005 patients experienced the primary composite outcome. Compared with standard of diabetes care, use of GLP-1 RAs was associated with a lower event risk [adjusted hazard ratio (HR) 0.72; 95% confidence interval (CI): 0.56-0.92], mainly attributed to a lower rate of re-infarction and stroke. Results were similar after propensity score matching or when compared with users of sulfonylurea. There was no suggestion of heterogeneity across subgroups of age, sex, chronic kidney disease, and STEMI.

CONCLUSION

GLP-1 RAs use, compared with standard of diabetes care, was associated with lower risk for major CV events in healthcare-managed survivors of an MI.

Healthcare Cost Development in a Type 2 Diabetes Patient Population on Glucose-Lowering Drug Treatment: A Nationwide Observational Study 2006-2014

OBJECTIVE

The objective of this study was to describe healthcare resource use and cost development in Sweden during 2006-2014 in a type 2 diabetes (T2D) population receiving glucose-lowering drugs (GLDs).

METHODS

In- and outpatient healthcare resource use and costs were extracted from mandatory national registries: the Cause of Death Register; the National Patient Register; and the Prescribed Drug Register. Primary care data were estimated based on an observational study including patients from 84 primary care centers in Sweden. Numbers of any cause inpatient, outpatient, and primary care contacts were extracted and direct healthcare costs were estimated.

RESULTS

During 2006-2014, the number of inpatient and primary care contacts increased by approximately 70% (from 45,559 to 78,245 and from 4.9 to 8.8 million, respectively) and outpatient care contacts almost doubled (from 105,653 to 209,417). Mean annual per patient costs increased by 13%, reaching €4594. Total healthcare costs increased from €835 million to €1.684 billion. Inpatient care costs constituted 47% of total costs in 2014 (€783 million), primary care accounted for 24% (€405 million), outpatient care 18% (€303 million), non-GLD medications 6% (€109 million), and GLDs 5% (€84 million). Cardiovascular diseases (CVDs) were the most costly disease group in inpatient care (26%), whereas managing unspecified factors influencing health and T2D-associated diseases were the most costly in outpatient care (16 and 11%, respectively).

CONCLUSIONS

The healthcare costs of the GLD-treated T2D population doubled during 2006-2014, mostly driven by the increasing size of this population, of which inpatient care accounted for 47%. GLDs constituted the smallest share of costs. CVD was the most resource-requiring disease group.

Characteristics and Prognosis in Women and Men With Type 1 Diabetes Undergoing Coronary Angiography: A Nationwide Registry Report

OBJECTIVE

To describe sex aspects on extent of coronary artery disease (CAD) and prognosis in a contemporary population with type 1 diabetes.

RESEARCH DESIGN AND METHODS

All patients undergoing coronary angiography, 2001-2013, included in the Swedish Coronary Angiography and Angioplasty Registry and the Swedish National Diabetes Register as type 1 diabetes were followed for mortality until 31 December 2013. The coronary angiogram was classified into normal, one-vessel disease, two-vessel disease, three-vessel disease, and left main stem disease.

RESULTS

In all, 2,776 patients (42% women) with mean age 58 years (SD 11) were followed for 7.2 years (SD 2.2). Diabetes duration was longer in women (37 ± 14 vs. 34 ± 14 years in men; P < 0.001), who also had more retinopathy (68% vs. 65%; P = 0.050), whereas microalbuminuria was less common (41% vs. 51%; P < 0.001). Indications for coronary angiography did not substantially differ in women and men. The extent of CAD was somewhat less severe in women (normal angiogram 23.5% vs. 19.1%, three-vessel and left main stem disease 34.5% vs. 40.4%; P = 0.002), whereas mortality did not differ (adjusted hazard ratio 1.03 [95% CI 0.88-1.20]; P = 0.754). The standard mortality ratio for women the first year was 7.49 (5.73-9.62) and for men was 4.58 (3.60-5.74).

CONCLUSIONS

In patients with type 1 diabetes admitted for coronary angiography, the extent of CAD was almost similar in women and men, and total long-term mortality did not differ. Type 1 diabetes was associated with higher mortality risk in women than in men when compared with the general population. These data support that type 1 diabetes attenuates the cardiovascular risk difference seen in men and women in the general population.

Survival in Type 1 and Type 2 Diabetes in a Population Referred for Invasive Evaluation of Coronary Disease

OBJECTIVES

To evaluate long-term and time trends of survival in patients with a clinical diagnosis of type 1 and type 2 diabetes compared to patients without diabetes in a population referred for invasive treatment of coronary disease.

METHODS

Patients examined for heart disease at the Feiring LHL Clinics from March 1999 until December 2014 were followed for survival until 20 September, 2015. This yielded 43,872 patients with a known survival status including 1,326 (3.0%) patients with type 1 diabetes and 4,564 (10.9%) with type 2 diabetes.

RESULTS

Cox regression revealed a hazard ratio (HR) in type 1 and type 2 diabetes, respectively, of 1.78 (95% confidence interval [CI] 1.60-1.99) and 1.29 (95% CI 1.21-1.37). Comparing survival in the treatment periods before and after 2007, patients without diabetes and with type 2 diabetes had a reduced HR of 0.78 (95% CI 0.72-0.84) and 0.76 (95% CI 0.63-0.91), respectively, but there was no reduction in type 1 diabetes (HR 1.03; 95% CI 0.74-1.42).

CONCLUSIONS

Type 1 and type 2 diabetes have excess long-term mortality. In the nondiabetic and type 2 diabetic patients, a reduction in mortality has been noted in recent years, but has not been observed in type 1 diabetic patients.