Intensive treatment of coronary artery disease in diabetic patients in clinical practice: results of the MITRA study

Impact of Diabetes Mellitus on Long-Term Mortality in Patients Presenting for Coronary Angiography

To understand the current impact of diabetes mellitus (DM) on long-term outcomes among patients referred for coronary angiography, we studied 14,337 consecutive patients (5,279 diabetic patients [37%]) referred to coronary angiography for assessment or treatment of coronary artery disease. We investigated long-term all-cause mortality and its interaction with hypoglycemic therapy and presenting coronary status. At baseline, patients with DM had more hypertension, hyperlipidemia, and renal failure; more were women, overweight, and more had previous coronary interventions. Mortality was higher in those with DM and was related to treatment status: multivariate adjusted hazard ratio during a median follow-up period of 78 months was 1.41 (95% CI 1.11 to 1.80, p = 0.006) for diet only-treated DM, 1.63 (95% CI 1.51 to 1.77, p <0.001) for DM treated with oral hypoglycemics, and 2.50 (95% CI 2.20 to 2.85, p <0.001) for DM requiring insulin therapy. The earlier findings were similar in magnitude in patients presenting with acute or stable coronary syndromes. In addition, long-term mortality of medically treated DM presenting with a stable coronary syndrome was even higher than that of nondiabetic patients presenting with an acute coronary syndrome (hazard ratio 1.21, 95% CI 1.08 to 1.35, p = 0.001). In conclusion, in patients referred for coronary angiography in the current era, DM remained an independent predictor of long-term mortality regardless of the coronary presentation and mortality increased in direct relation to intensity of hypoglycemic therapy at presentation.

Management of coronary artery disease in patients with and without diabetes mellitus. Acute management reasonable but secondary prevention unacceptably poor: a report from the Euro Heart Survey on Diabetes and the heart

OBJECTIVE

To investigate the diagnostic and therapeutic strategies applied to patients currently treated for coronary artery disease (CAD) in relation to the presence of diabetes mellitus (DM).

BACKGROUND

Despite the declining mortality related to CAD, patients with DM have not experienced similar benefits and still have a deleterious prognosis compared to their non-DM counterparts.

METHODS

The Euro Heart Survey on Diabetes and the Heart was conducted between February 2003 and January 2004 in 110 centres across 25 countries. Consecutive patients were recruited while referred to a cardiologist due to CAD, when admitted to hospital wards or visiting outpatient clinics. DM was defined as a diagnosis established before enrollment.

RESULTS

DM was reported in 1524 (31%) of 4961 patients enrolled. Among the 1872 patients with acute coronary syndrome (ACS), adjusting for differences in clinical characteristics at baseline, DM status did not influence the propensity to use different pharmacological agents (except renin-angiotensin-aldosterone system blockers) or coronary interventions. In patients with stable CAD (n=2854) secondary prevention guidelines were poorly adhered to: 30% achieved blood pressure targets (<140/90 mmHg), and lipid control was adequate in a minority of DM and non-DM patients (total cholesterol >5 mmol/l: 55 versus 47%; low-density lipoprotein cholesterol >3 mmol/l: 57 versus 51%).

CONCLUSIONS

Differences in the treatment and intervention patterns of patients with ACS disappear when corrected for the clinical confounders detected. Despite the recommendations and the high cardiovascular risk, an inadequate and less aggressive management was demonstrated in the contemporary patients with diabetes and stable CAD compared with the non-diabetic counterparts.

Patients with chronic kidney disease/diabetes mellitus: the high-risk profile in acute coronary syndrome

Chronic kidney disease (CKD) and diabetes mellitus (DM) are highly prevalent, morbid diseases that are very common among patients presenting with acute coronary syndromes (ACS). Despite significant reductions in cardiovascular morbidity and mortality over the last half century, residual vascular risk remains disproportionately high in these populations. In large part, this is attributable to pre-existing vascular morbidity and substantial enrichment of traditional risk factors among those with either CKD or DM. Other factors, such as less aggressive therapeutic intervention and a unique atherothrombotic phenotype, are also contributory. The introduction of novel antiplatelet and antithrombotic agents over the last several years provides fresh opportunities to improve the adverse prognosis among patients with CKD or DM and concomitant ACS.

Risk of ischemic stroke after an acute myocardial infarction in patients with diabetes mellitus

BACKGROUND

Incidence, any trend over time, and predictors of ischemic stroke after an acute myocardial infarction (AMI) in diabetic patients are unknown.

METHODS AND RESULTS

Data for 173,233 unselected patients with an AMI, including 33,503 patients with diabetes mellitus, were taken from the Swedish Register of Information and Knowledge about Swedish Heart Intensive Care Admissions (RIKS-HIA) during 1998 to 2008. Ischemic stroke events were recorded during 1 year of follow-up. Patients with diabetes mellitus more often had a history of cardiovascular disease, received less reperfusion therapy, and were treated with acetylsalicylic acid, P2Y12 inhibitors, and statins to a lesser extent compared with patients without diabetes mellitus. However, the use of evidence-based therapies increased markedly in both groups during the study period. The incidence of ischemic stroke during the first year after AMI decreased from 7.1% to 4.7% in patients with diabetes mellitus and from 4.2% to 3.7% in patients without diabetes mellitus. Risk reduction was significantly larger in the diabetic subgroup. Reperfusion therapy, acetylsalicylic acid, P2Y12 inhibitors, and statins were independently associated with the reduced stroke risk.

CONCLUSIONS

Ischemic stroke is a fairly common complication after an AMI in patients with diabetes mellitus, but the risk of stroke has decreased during recent years. The increased use of evidence-based therapies contributes importantly to this risk reduction, but there is still room for improvement.

Diabetes mellitus abrogates the cardioprotection of sufentanil against ischaemia/reperfusion injury by altering glycogen synthase kinase-3β

BACKGROUND

Sufentanil is widely used in clinical anaesthesia because of its protective effects against ischaemia/reperfusion injury. Diabetes mellitus elevates the activity of glycogen synthase kinase-3β (GSK-3β), thereby increasing the permeability of mitochondrial transition pore. This study investigated the role of GSK-3β in ameliorating the cardioprotective effect of sufentanil post-conditioning in diabetic rats.

METHODS

Streptozotocin-induced diabetic rats and age-matched non-diabetic rats were subjected to 30 min of ischaemia and 120 min of reperfusion. Five minutes before reperfusion, rats were administered one of the following: a vehicle, sufentanil (1 μg/kg), or a GSK-3β inhibitor SB216763 (0.6 mg/kg). Myocardial infarct size, cardiac troponin I, and the activity of GSK-3β were then assessed.

RESULTS

Sufentanil post-conditioning significantly reduced myocardial infarct size in the non-diabetic, but not in diabetic rats. SB216763 reduced infarct size in both diabetic and non-diabetic animals. Sufentanil-induced phospho-GSK-3β was reduced 5 min after reperfusion in diabetic rats, but not in non-diabetic rats.

CONCLUSIONS

Sufentanil treatment was ineffective in preventing against ischaemia/reperfusion in diabetic rats, which is associated with the activation of GSK-3β. Our results also suggest that direct inhibition of GSK-3β may provide a strategy to protect diabetic hearts against ischaemia/reperfusion injury.

Pathways leading to coronary revascularisation among patients with diabetes in Finland: a longitudinal register-based study

Background

Chronic conditions such as coronary heart disease (CHD) challenge health care to provide systematic and long-lasting disease management. In this study of patients who were revascularized, we examine whether treatment pathways leading to coronary revascularisation differ between patients with and without diabetes.

Methods

This retrospective, nationwide register-based study in Finland in 1998-2007 describes temporal trends in the proportions of 1) revascularisations performed at the first treatment period, and 2) suboptimal treatment pathways to revascularisations, i.e. pathways containing several cardiac emergency hospitalisations. Differences between patient groups were examined using a logistic regression model adjusting for age, comorbidity, and region.

Results

Among patients who underwent revascularisation, upward trends were found in the proportions of revascularisations performed during first hospital admission: among men with CHD alone, the percentages were 28% in 1998 and 77% in 2007; among men with insulin-dependent diabetes (IDD) they were 16% vs. 58% for the respective years; and among men with non-insulin dependent diabetes (NIDD) they were 25% vs. 69%, respectively. Among women the percentages were for non-diabetic group 32% vs. 77%; for IDD group 36% vs. 64%; and for NIDD group 33% vs. 73% for the respective years. Patients with diabetes were less likely to undergo revascularisation during the first hospital admission, in 2005-2007, the odds ratio (OR) for IDD among men was 0.52 (95% confidence interval 0.42-0.64) and for NIDD among men it was 0.79 (95% CI 0.73-0.86) compared to patients with CHD alone. The respective ORs among women were 0.59 (95% CI 0.44-0.78), and 0.83 (95% CI 0.74-0.93).

Conclusions

Treatment practices changed substantially during the study period to favour performing revascularisation during the first hospital admission. The large increase in coronary angioplasty operations is likely to be an important factor behind these changes. However, fewer operations are performed during the first CHD hospitalisation of diabetic patients who undergo coronary revascularisation and they experience more often emergency hospital admissions before the operation than patients without diabetes. To avoid adverse cardiac events, more attention is needed in managing diabetic CHD patients' referral pathways to revascularisation.

Increasing resources effected equity in access to revascularizations for patients with diabetes

OBJECTIVES

To examine differences in access to coronary revascularization among a cohort of coronary patients with and without diabetes in 1995-2002 in Finland and to examine how rapidly increasing resources effected socioeconomic equity in access to these operations.

DESIGN

An individual level nationwide register-based study of newly diagnosed CHD (coronary heart disease) patients (aged 40-79) in Finland. Rates for revascularizations were calculated per 1 000 person years. Socioeconomic differences were examined using Cox regression.

RESULTS

Revascularization rates increased from 354 to 443 per 1 000 person years among men with CHD and from 301 to 366 among patients with diabetes. Among women with CHD the numbers were 224 and 249 and among patients with diabetes 208 and 325. Comparing trends for first revascularization between patient groups with and without diabetes differences increased somewhat among men. Among women, revascularization rates increased more among diabetic patients. Lower revascularization rates among lower socioeconomic groups were found throughout the study period in both patient groups.

CONCLUSIONS

Simultaneously with large increase in cardiac operation rates, revascularization observed more common among women with diabetes compared to those without. However socioeconomic inequity in access to revascularizations among both genders remained even after increase in resources.

Mortality trends in subjects with and without diabetes during 33 years of follow-up

OBJECTIVE Mortality rates have declined substantially over the past decades in the general population, but the situation among diabetic subjects is less clear. The aim of this study was to analyze mortality trends in diabetic and nondiabetic subjects during 1972-2004. RESEARCH DESIGN AND METHODS Since 1972, all patients with diabetes are entered in a diabetes register at Laxå Primary Health Care Center; 776 incident cases were recorded up to 2001. The register has been supplemented with a nondiabetic population of 3,880 subjects and with data from the National Cause of Death Register during 1972 to 2004. RESULTS During the 33-year follow-up period, 233 (62.0%) diabetic women and 240 (60.0%) diabetic men and 995 (52.9%) nondiabetic women and 1,082 (54.1%) nondiabetic men died. The age-adjusted hazard ratio (HR) for all-cause mortality among diabetic and nondiabetic subjects was 1.17 (P < 0.0021) for all, 1.22 (P < 0.007) for women, and 1.13 (P = 0.095) for men. The corresponding cardiovascular disease (CVD) mortality HRs were 1.33 (P < 0.0001), 1.41 (P < 0.0003), and 1.27 (P < 0.0093), respectively. The CVD mortality reduction across time was significant in nondiabetic subjects (P < 0.0001) and in men with diabetes (P = 0.014) but not in diabetic women (P = 0.69). The results regarding coronary heart disease (CHD) were similar (P < 0.0001, P < 0.006, and P = 0.17, respectively). The CVD and CHD mortality rate change across time was fairly linear in all groups. CONCLUSIONS Diabetic subjects had less mortality rate reduction during follow-up than nondiabetic subjects. However the excess mortality risk for diabetic subjects was smaller than that found in other studies.

Treatment disparities and effect on late mortality in patients with diabetes presenting with acute myocardial infarction: observations from the ACACIA registry

OBJECTIVES

To compare the use of evidence-based pharmacological and invasive treatments and 12-month mortality rates between patients with and without diabetes who present with acute myocardial infarction (MI), and to explore the relationship between these treatments and late clinical outcomes.

DESIGN AND SETTING

Prospective, nationwide multicentre registry: the Acute Coronary Syndrome Prospective Audit (ACACIA).

PATIENTS

Patients presenting to 24 metropolitan and 15 non-metropolitan hospitals with acute coronary syndrome (ACS) and a final discharge diagnosis of acute MI between November 2005 and July 2007.

MAIN OUTCOME MEASURE

All-cause mortality at 12 months.

RESULTS

Nearly a quarter of 1744 patients with a final diagnosis of acute MI had a history of diabetes on presentation. Patients with diabetes were older, with a greater prevalence of comorbidities than non-diabetic patients, and were less likely to be treated at discharge with evidence-based medications (aspirin, clopidogrel, a statin and/or a beta-blocker) or to receive early invasive procedures. After adjusting for baseline characteristics and therapeutic interventions, diabetes at presentation was independently associated with a higher mortality at 12 months after MI (hazard ratio, 1.79; 95% CI, 1.18-2.72; P=0.007). Early invasive management and discharge prescription of guideline-recommended medications were associated with a significantly reduced hazard of mortality at 12 months.

CONCLUSION

Patients with diabetes have a higher risk than non-diabetic patients of late mortality following an acute MI, yet receive fewer guideline-recommended medications and early invasive procedures. Increased application of proven pharmacotherapies and an early invasive management strategy in patients with diabetes presenting with ACS might improve their outcomes. STUDY PROTOCOL NUMBER (SANOFI-AVENTIS): PML-0051.

Improved but still high short- and long-term mortality rates after myocardial infarction in patients with diabetes mellitus: a time-trend report from the Swedish Register of Information and Knowledge about Swedish Heart Intensive Care Admission

OBJECTIVE

The aim of the study was to compare time-trends in mortality rates and treatment patterns between patients with and without diabetes based on the Swedish register of coronary care (Register of Information and Knowledge about Swedish Heart Intensive Care Admission [RIKS-HIA]).

METHODS

Post myocardial infarction mortality rate is high in diabetic patients, who seem to receive less evidence-based treatment. Mortality rates and treatment in 1995-1998 and 1999-2002 were studied in 70,882 patients (age <80 years), 14 873 of whom had diabetes (the first registry recorded acute myocardial infarction), following adjustments for differences in clinical and other parameters.

RESULTS

One-year mortality rates decreased from 1995 to 2002 from 16.6% to 12.1% in patients without diabetes and from 29.7% to 19.7%, respectively, in those with diabetes. Patients with diabetes had an adjusted relative 1-year mortality risk of 1.44 (95% CI 1.36 to 1.52) in 1995-1998 and 1.31 (95% CI 1.24 to 1.38) in 1999-2002. Despite improved pre-admission and in-hospital treatment, diabetic patients were less often offered acute reperfusion therapy (adjusted OR 0.85, 95% CI 0.80 to 0.90), acute revascularisation (adjusted OR 0.78, 95% CI 0.69 to 0.87) or revascularisation within 14 days (OR 0.80, 95% CI 0.75 to 0.85), aspirin (OR 0.90, 95% CI 0.84 to 0.98) and lipid-lowering treatment at discharge (OR 0.81, 95% CI 0.77 to 0.86).

CONCLUSION

Despite a clear improvement in the treatment and myocardial infarction survival rate in patients with diabetes, mortality rate remains higher than in patients without diabetes. Part of the excess mortality may be explained by co-morbidities and diabetes itself, but a lack of application of evidence-based treatment also contributes, underlining the importance of the improved management of diabetic patients.

Evidence-based cardiovascular therapies and achievement of therapeutic goals in diabetic patients with coronary heart disease attended in primary care

BACKGROUND

Diabetic patients have a higher rate of recurrent cardiovascular events and death than nondiabetic individuals. Although partially attributable to lower use of evidence-based preventive therapies, studies are lacking on the prescription rate during the stable phase of the disease.

METHODS

Between June 1 and October 19, 2004, we obtained, from 1799 primary care centers throughout Spain, data on 8817 subjects (mean age 65.4 years, 73.7% male, 32.7% with diabetes) who had had a coronary event requiring hospitalization in the previous 6 months to 10 years.

RESULTS

After adjustment for confounding variables, the diabetic patients received more frequent treatment with angiotensin-renin system blockers (73.5% vs 61%, P < .001), calcium channel blockers (29.8% vs 21.9%, P < .001), nitrates (58% vs 47.5%, P < .001), digoxin (6.6% vs 3.9%, P < .001), and diuretics (46.2% vs 32.2%, P < .001), but it is similar with respect to lipid-lowering drugs (81.1% vs 80.3%), antiplatelet drugs (80.2% vs 80.2%), or beta-blockers (45.4% vs 47.7%). The percentage of diabetic subjects attaining objectives for smoking habit, low-density lipoprotein cholesterol, blood pressure, and glycated hemoglobin were 90.7%, 29%, 38.2%, and 49.7%, respectively. Only 7% had optimum control of all their risk factors. The parameters most closely related to optimum treatment and risk-factor control were the specialist follow-up and the attending physician's awareness of appropriate treatment objectives.

CONCLUSIONS

A significant percentage of diabetic patients with stable coronary disease receive evidence-based preventive medications in primary care. However, the percentage achieving adequate control of their risk factors is low and is related to the level of physician awareness of appropriate therapeutic targets.

Diabetes mellitus: clinical presentation and outcome in men and women with acute coronary syndromes. Data from the Euro Heart Survey ACS

AIMS

To study clinical presentation, in-hospital course and short-term prognosis in men and women with diabetes mellitus and acute coronary syndromes (ACS).

METHODS

Men (n = 6488, 21.2% with diabetes) and 2809 women (28.7% with diabetes) < or = 80 years old, with a discharge diagnosis of ACS were prospectively enrolled in the Euro Heart Survey of ACS.

RESULTS

Women with diabetes were more likely to present with ST elevation than non-diabetic women, a difference that became more marked after adjustment for differences in smoking, hypertension, obesity, medication and prior disease [adjusted odds ratio (OR) 1.46 (1.20, 1.78)], whereas there was little difference between diabetic and non-diabetic men [adjusted OR 0.99 (0.86, 1.14)]. In addition, women with diabetes were more likely to develop Q-wave myocardial infarction (MI) than non-diabetic women [adjusted OR 1.61 (1.30, 1.99)], while there was no difference between men with and without diabetes [adjusted OR 0.99 (0.85, 1.15)]. There were significant interactions between sex, diabetes and presenting with ST-elevation ACS (P < 0.001), and Q-wave MI (P < 0.001), respectively. Of the women with diabetes, 7.4% died in hospital, compared with 3.6% of non-diabetic women [adjusted OR 2.13 (1.39, 3.26)], whereas corresponding mortality rates in men with and without diabetes were 4.1% and 3.3%, respectively [OR 1.13 (0.76, 1.67)] (P for diabetes-sex interaction 0.021).

CONCLUSION

In women with ACS, diabetes is associated with higher risk of presenting with ST-elevation ACS, developing Q-wave MI, and of in-hospital mortality, whereas in men with ACS diabetes is not significantly associated with increased risk of either. These findings suggest a differential effect of diabetes on the pathophysiology of ACS based on the patient's sex.

Management of patients with type 2 diabetes after acute coronary syndromes

Acute coronary syndromes are associated with a high risk for subsequent major cardiovascular events and with a risk for mortality that remains substantially increased for many months following the acute phase. Patients with type 2 diabetes mellitus are especially vulnerable and encounter excessive long-term mortality. Effective management of patients with type 2 diabetes following acute coronary syndromes requires aggressive multidisciplinary efforts for reduction of several risk factors, including meticulous control of blood glucose. The evidence for different medication and treatment strategies capable of improving the outcomes is reviewed and the currently available recommendations are summarised.

Intense metabolic control by means of insulin in patients with diabetes mellitus and acute myocardial infarction (DIGAMI 2): effects on mortality and morbidity

AIMS

Patients with diabetes have an unfavourable prognosis after an acute myocardial infarction. In the first DIGAMI study, an insulin-based glucose management improved survival. In DIGAMI 2, three treatment strategies were compared: group 1, acute insulin-glucose infusion followed by insulin-based long-term glucose control; group 2, insulin-glucose infusion followed by standard glucose control; and group 3, routine metabolic management according to local practice.

METHODS AND RESULTS

DIGAMI 2 recruited 1253 patients (mean age 68 years; 67% males) with type 2 diabetes and suspected acute myocardial infarction randomly assigned to groups 1 (n=474), 2 (n=473), and 3 (n=306). The primary endpoint was all-cause mortality between groups 1 and 2, and a difference was hypothesized as the primary objective. The secondary objective was to compare total mortality between groups 2 and 3, whereas morbidity differences served as tertiary objectives. The median study duration was 2.1 (interquartile range 1.03-3.00) years. At randomization, HbA1c was 7.2, 7.3, and 7.3% in groups 1, 2, and 3, respectively, whereas blood glucose was 12.8, 12.5, and 12.9 mmol/L, respectively. Blood glucose was significantly reduced after 24 h in all groups, more in groups 1 and 2 (9.1 and 9.1 mmol/L) receiving insulin-glucose infusion than in group 3 (10.0 mmol/L). Long-term glucose-lowering treatment differed between groups with multidose insulin (> or =3 doses/day) given to 15 and 13% of patients in groups 2 and 3, respectively compared with 42% in group 1 at hospital discharge. By the end of follow-up, HbA1c did not differ significantly among groups 1-3 ( approximately 6.8%). The corresponding values for fasting blood glucose were 8.0, 8.3, and 8.6 mmol/L. Hence, the target fasting blood glucose for patients in group 1 of 5-7 mmol/L was never reached. The study mortality (groups 1-3 combined) was 18.4%. Mortality between groups 1 (23.4%) and 2 (22.6%; primary endpoint) did not differ significantly (HR 1.03; 95% CI 0.79-1.34; P=0.831), nor did mortality between groups 2 (22.6%) and 3 (19.3%; secondary endpoint) (HR 1.23; CI 0.89-1.69; P=0.203). There were no significant differences in morbidity expressed as non-fatal reinfarctions and strokes among the three groups.

CONCLUSION

DIGAMI 2 did not support the fact that an acutely introduced, long-term insulin treatment improves survival in type 2 diabetic patients following myocardial infarction when compared with a conventional management at similar levels of glucose control or that insulin-based treatment lowers the number of non-fatal myocardial reinfarctions and strokes. However, an epidemiological analysis confirms that the glucose level is a strong, independent predictor of long-term mortality in this patient category, underlining that glucose control seems to be an important part of their management.