'Just like a normal pain', what do people with diabetes mellitus experience when having a myocardial infarction: a qualitative study recruited from UK hospitals

Emerging opportunities to target inflammation: myocardial infarction and type 2 diabetes

After myocardial infarction (MI), patients with type 2 diabetes have an increased rate of adverse outcomes, compared to patients without. Diabetes confers a 1.5-2-fold increase in early mortality and, importantly, this discrepancy has been consistent over recent decades, despite advances in treatment and overall survival. Certain assumptions have emerged to explain this increased risk, such as differences in infarct size or coronary artery disease severity. Here, we re-evaluate that evidence and show how contemporary analyses using state-of-the-art characterization tools suggest that the received wisdom tells an incomplete story. Simultaneously, epidemiological and mechanistic biological data suggest additional factors relating to processes of diabetes-related inflammation might play a prominent role. Inflammatory processes after MI mediate injury and repair and are thus a potential therapeutic target. Recent studies have shown how diabetes affects immune cell numbers and drives changes in the bone marrow, leading to pro-inflammatory gene expression and functional suppression of healing and repair. Here, we review and re-evaluate the evidence around adverse prognosis in patients with diabetes after MI, with emphasis on how targeting processes of inflammation presents unexplored, yet valuable opportunities to improve cardiovascular outcomes in this vulnerable patient group.

Do patients with diabetes with new onset acute myocardial infarction present with different symptoms than non-diabetic patients?

Background

The objective of this study was to investigate the differences in presenting symptoms between patients with and without diabetes being diagnosed with an acute myocardial infarction (AMI).

Methods

A total of 5,900 patients with a first-time AMI were included into the analysis. All patients aged between 25 and 84 years were recorded by the population-based Myocardial Infarction Registry in Augsburg, Germany, between 2010 and 2017. The presence (yes/no) of 12 AMI typical symptoms during the acute event was assessed within the scope of a face-to-face interview. Multivariable adjusted logistic regression models were calculated to analyze the associations between presenting symptoms and diabetes mellitus in AMI patients.

Results

Patients with diabetes had significantly less frequent typical pain symptoms, including typical chest pain. Also, other symptoms like sweating, vomiting/nausea, dizziness/vertigo and fear of death/feeling of annihilation occurred significantly more likely in non-diabetic patients. The only exception was the symptom of shortness of breath, which was found significantly more often in patients with diabetes. In multivariable-adjusted regression models, however, the observed effects were attenuated. In patients younger than 55 years, the associations between diabetes and various symptoms were mainly missing.

Conclusions

Type 2 diabetes mellitus is a risk factor not only for the development of AMI, but is also associated with an adverse outcome after AMI. Atypical clinical presentation additionally complicates the diagnostic process. It is therefore essential for physicians to be aware of the more often atypical symptoms that diabetic AMI patients report.

Clinical outcomes of myocardial infarction with non-obstructive coronary arteries presenting with diabetic ketoacidosis: a propensity score-matched analysis

INTRODUCTION AND OBJECTIVE

There is a paucity of data on patients with myocardial infarction with nonobstructive coronary arteries (MINOCA) and a decompensated diabetic state, diabetic ketoacidosis (DKA). Therefore, we aimed to investigate the outcomes of patients with MINOCA presenting with or without DKA.

METHODS

We conducted this retrospective propensity score-matched analysis from January 1, 2015, to December 4, 2022. The patients with a principal admission diagnosis of ST-Elevation MI (STEMI) and discharge labeled as MINOCA (ICD-10-CM code 121.9) with DKA were analyzed. We performed a comparative analysis for MINOCA with and without DKA before and after propensity score matching for primary and secondary endpoints.

RESULTS

Three thousand five hundred sixty-three patients were analyzed, and 1150 (32.27%) presented with DKA, while 2413 (67.72%) presented as non-DKA. The DKA cohort had over two-fold mortality (5.56% vs. 1.19%; p = 0.024), reinfarction (5.82% vs. 1.45%; p = 0.021), stroke (4.43% vs. 1.36%; p = 0.035), heart failure (6.89% vs. 2.11%; p = 0.033), and cardiogenic shock (6.43% vs. 1.78%; p = 0.025) in a propensity score-matched analysis. There was an increased graded risk of MINOCA with DM (RR (95% CI): 0.50 (0.36-0.86; p = 0.023), DKA (RR (95% CI): 0.46 (0.24-0.67; p = 0.001), and other cardiovascular (CV) risk factors.

CONCLUSION

DKA complicates a portion of MINOCA and is associated with increased mortality and major adverse cardiovascular events (MACE).

Artificial intelligence for secondary prevention of myocardial infarction: A qualitative study of patient and health professional perspectives

BACKGROUND

Artificial intelligence (AI) has potential to improve self-management of several chronic conditions. However, the perspective of patients and healthcare professionals regarding AI-enabled health management programs, which are key to successful implementation, remains poorly understood.

PURPOSE

To explore the opinions of people with a history of myocardial infarction (PHMI) and health professionals on the use of AI for secondary prevention of MI.

PROCEDURE

Three rounds of focus groups were conducted via videoconferencing with 38 participants: 22 PHMI and 16 health professionals.

FINDINGS

We identified 21 concepts stemming from participants' views, which we classified into five categories: Trust; Expected Functions; Adoption; Concerns; and Perceived Benefits. Trust covered the credibility of information and safety to believe health advice. Expected Functions covered tailored feedback and personalised advice. Adoption included usability features and overall interest in AI. Concerns originated from previous negative experience with AI. Perceived Benefits included the usefulness of AI to provide advice when regular contact with healthcare services is not feasible. Health professionals were more optimistic than PHMI about the usefulness of AI for improving health behaviour.

CONCLUSIONS

Altogether, our findings provide key insights from end-users to improve the likelihood of successful implementation and adoption of AI-enabled systems in the context of MI, as an exemplar of broader applications in chronic disease management.

Predictors of acute coronary syndrome symptom knowledge, attitudes, and beliefs in adults without self-reported heart disease

BACKGROUND

The time of symptom onset to the time an individual decides to seek care is the most significant contributor to total treatment delay.

OBJECTIVES

To explore predictors of ACS symptom knowledge, attitudes, and beliefs in adults without diagnosed heart disease.

METHODS

We used a cross-sectional, descriptive, and correlational design, employing an online survey including the ACS Response Index and the avoidance subscale of the Coping Strategy Indicator. We leveraged social media platforms and a university email list-serv to enroll participants. Stepwise hierarchical linear regressions were used.

RESULTS

We analyzed responses from 981 participants, with a mean age of 35.2 years (SD 16.5) and 75% female. The regression analyses yielded models that explained 14%, 23%, and 25% of the variance for knowledge, beliefs, and attitudes, respectively. Ethnicity, race, exposure to ACS symptom information (in the media or by teaching), and perceived health were the predictors of ACS symptom knowledge, attitudes, and beliefs with the largest effect, though others were statistically significant.

CONCLUSIONS

The findings underscore the importance of community education to raise awareness of ACS symptoms while considering social determinants of health. Future research and clinician interventions for ACS symptom knowledge, attitudes and beliefs should be expanded with a focus on ethnicity and gender.

Validity of regional network systems on reperfusion therapy in diabetes mellitus and non-diabetes mellitus patients with ST-segment elevation myocardial infarction

Background

Patients with ST-segment elevation myocardial infarction (STEMI) with diabetes mellitus (DM) had higher mortality and poorer prognosis than those without DM. Previous studies had demonstrated the effectiveness of regional network systems (RNS) for reperfusion therapy in patients with STEMI. However, the differences in nursing care with RNS in subgroups of patients with DM with STEMI were unclear. Our study aimed to evaluate the validity of RNS in reperfusion therapy in patients with STEMI with or without DM.

Methods

We retrospectively enrolled patients with STEMI who received reperfusion therapy at the chest pain center of the 920th Hospital in Kunming City, Yunnan Province from 2019 to 2021. Personal information and hospitalization information for patients with STEMI were collected through the chest pain center registration system. Univariate and multivariate logistic regression were used to analyze factors associated with outcomes in patients with STEMI who received RNS. Wilcoxon rank-sum test and chi-squared test were used to analyze the differences in reperfusion therapy times and clinical outcomes between RNS and non-RNS in patients with STEMI with or without DM.

Results

This study enrolled 1,054 patients with STEMI, including 148 patients with DM and 906 patients without DM. Logistic regression analysis indicated that DM was associated with patients with STEMI who received RNS [OR 1.590 95% CI (1.034-2.446), P = 0.035]. RNS may decrease the reperfusion therapy time in patients with STEMI and patients without DM with STEMI, including the first medical contact (FMC) to door, FMC to wire and FMC to catheterization laboratory activity (all P < 0.05). However, we found no significant difference in reperfusion therapy times with and without RNS in patients with DM (all P > 0.05).

Conclusion

Regional network systems may decrease the reperfusion therapy time in patients without DM with STEMI, but no decrease was found in patients with DM with STEMI.

Acute Coronary Syndrome in Patients with Diabetes mellitus: Features of the Course and Manifestations of Pain Syndrome

Acute coronary syndrome (ACS) remains a common cause of hospitalization for patients with diabetes mellitus (DM). Due to development of diabetic neuropathy, it is believed that this category of patients is characterized by a high frequency of atypical acute coronary syndrome, but data on this are quite contradictory. The objective: to determine the features of the pain syndrome and its severity in patients with acute coronary syndrome and concomitant diabetes. Materials and methods. The study involved 36 patients with diabetes (22 men and 14 women) aged 44–86 years, hospitalized urgently for ACS. Pain syndrome was assessed at the time of hospitalization and immediately after coronary artery revascularization according to the following criteria: visual analog scale (VAS), Numerical Rating Scale (NRS), clinical data, and biochemical markers. Results. The majority of patients (91.67%) at the time of hospitalization complained of chest pain, the rest were not bothered by any pain. During the survey, patients described pain as «burning» (30.56%), «squeezing» (30.56%), «squeezing» (25.0%), «tingling» (5.56%). There were also complaints of difficulty breathing (13.89%), shortness of breath (11.1%), palpitations (41.67%). The appearance of excessive sweating was noticed by 16.67% of patients. There was no statistically significant difference between the results of pain assessment by VAS and NRS (p>0.1). The average value of glycemia at the time of hospitalization was 8.19±3.45 mmol/l (men – 8.17±3.61 mmol/l, women – 8.28±3.13 mmol/l). Glycemia greater than 10.0 mmol/l was detected in 8 patients, which was 22.22% of all patients. This category of patients was dominated by patients with severe pain (62.5%). Conclusions. In patients with ACS and diabetes, the typical clinical picture of ACS prevailed (91.67% of patients) over the painless form. Prior to revascularization, moderate and severe pain occurred with equal frequency; there is no statistical difference between blood pressure, heart rate and glycemia (p>0.1) in patients with severe and moderate pain. Hyperglycemia (≥10.0 mmol/l) was found in 22.22%, among this category of patients was dominated by patients with severe pain.

Perceived personal risk and vulnerability in recognizing and responding to symptoms of acute coronary syndrome: an integrative review

BACKGROUND

Simply knowing the common symptoms of acute coronary syndrome (ACS) is not sufficient to ensure prompt care-seeking when these symptoms occur. Factors other than symptom knowledge contribute to prompt care-seeking behaviours and correct symptom attribution to the heart.

OBJECTIVES

To explore how perceived personal risk and perceived personal vulnerability towards ACS affect a person's ACS symptom recognition and attribution and also how this perception affects a person's response to ACS symptoms.

DESIGN

An integrative review, using Whittemore and Knafl's approach.

DATA SOURCES

PubMed, Academic Search Complete, CINAHL Complete, APA PsycINFO, and APA PsycARTICLES.

ELIGIBILITY CRITERIA FOR STUDY SELECTION

We included studies that (i) were original human-subjects research or secondary analyses of human-subjects research, (ii) provided information about how perceptions of risk or perceptions of vulnerability towards ACS or heart disease affect symptom recognition, attribution, and/or response to symptoms, and (iii) were published in English.

RESULTS

Thirteen articles were included. Studies were conducted in nine different countries and were descriptive or exploratory in nature. The existing evidence suggests that perceived personal risk or vulnerability towards heart disease may promote earlier care-seeking for ACS symptoms and facilitates attribution of symptoms to the heart.

CONCLUSION

The designs of the included studies limit causal attribution, and additional prospective and intervention-based research is needed to determine how perceived risk/vulnerability may affect care-seeking and ACS symptom attribution. Increasing perceptions of vulnerability towards heart disease may reduce care seeking delay.

Patient-level and system-level barriers associated with treatment delays for ST elevation myocardial infarction in China

OBJECTIVE

This study aims to understand the current ST elevated myocardial infarction (STEMI) treatment process in Guangdong Province and explore patient-level and system-level barriers associated with delay in STEMI treatment, so as to provide recommendations for improvement.

METHODS

This is a qualitative study. Data were collected using semistructured, face-to-face individual interviews from April 2018 to January 2019. Participants included patients with STEMI, cardiologists and nurses from hospitals, emergency department doctors, primary healthcare providers, local health governors, and coordinators at the emergency medical system (EMS). An inductive thematic analysis was adopted to generate overarching themes and subthemes for potential causes of STEMI treatment delay. The WHO framework for people-centred integrated health services was used to frame recommendations for improving the health system.

RESULTS

Thirty-two participants were interviewed. Patient-level barriers included poor knowledge in recognising STEMI symptoms and not calling EMS when symptoms occurred. Limited capacity of health professionals in hospitals below the tertiary level and lack of coordination between hospitals of different levels were identified as the main system-level barriers. Five recommendations were provided: (1) enhance public health education; (2) strengthen primary healthcare workforce; (3) increase EMS capacity; (4) establish an integrated care model; and (5) harness government's responsibilities.

CONCLUSIONS

Barriers associated with delay in STEMI treatment were identified at both patient and system levels. The results of this study provide a useful evidence base for future intervention development to improve the quality of STEMI treatment and patient outcomes in China and other countries in a similar situation.

Impact of acute diabetes decompensation on outcomes of diabetic patients admitted with ST-elevation myocardial infarction

BACKGROUND

Acute hyperglycemia is associated with worse outcomes in diabetic patients admitted with ST-elevation myocardial infarction (STEMI). However, the impact of full-scale decompensated diabetes on STEMI outcomes has not been investigated.

METHODS

We utilized the national inpatient sample (2003-2014) to identify adult diabetic patients admitted with STEMI. We defined decompensated diabetes as the presence of diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar state (HHS). We compared in-hospital morbidity and mortality and cost between patients with and without diabetes decompensation before and after propensity-score matching.

RESULTS

A total of 73,722 diabetic patients admitted with STEMI were included in the study. Of those, 1131 (1.5%) suffered DKA or HSS during the hospitalization. After propensity-score matching, DKA/HHS remained associated with a significant 32% increase in in-hospital mortality (25.6% vs. 19.4%, p = 0.001). The DKA/HHS group also had higher incidences of acute kidney injury (39.4% vs. 18.9%, p < 0.001), sepsis (7.3% vs. 4.9%, p = 0.022), blood transfusion (11.3% vs. 8.2%) and a non-significant trend towards higher incidence of stroke (3.8% vs. 2.4%, p = 0.087). Also, DKA/HHS diagnosis was associated with lower rates of referral to coronary angiography (51.5% vs. 55.5%, p = 0.023), coronary stenting (26.1% vs. 34.8%, p < 0.001), or bypass grafting (6.2% vs. 8.7%, p = 0.033). Referral for invasive angiography was associated with lower odds of death during the hospitalization (adjusted OR 0.66, 95%CI 0.44-0.98, p = 0.039).

CONCLUSIONS

Decompensated diabetes complicates ~ 1.5% of STEMI admissions in diabetic patients. It is associated with lower rates of referral for angiography and revascularization, and a negative differential impact on in-hospital morbidity and mortality and cost.