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Mak KH, Vidal-Petiot E, Young R, Sorbets E, Greenlaw N, Ford I, Tendera M, Ferrari R, Tardif JC, Udell JA, Escobedo J, Fox KM, Steg PG. Prevalence of diabetes and impact on cardiovascular events and mortality in patients with chronic coronary syndromes, across multiple geographical regions and ethnicities. Eur J Prev Cardiol 2022; 28:1795-1806. [DOI: 10.1093/eurjpc/zwab011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 11/20/2020] [Accepted: 01/11/2021] [Indexed: 01/01/2023]
Abstract
Abstract
Background
In contrast with the setting of acute myocardial infarction, there are limited data regarding the impact of diabetes mellitus on clinical outcomes in contemporary cohorts of patients with chronic coronary syndromes. We aimed to investigate the prevalence and prognostic impact of diabetes according to geographical regions and ethnicity.
Methods and results
CLARIFY is an observational registry of patients with chronic coronary syndromes, enrolled across 45 countries in Europe, Asia, America, Middle East, Australia, and Africa in 2009–2010, and followed up yearly for 5 years. Chronic coronary syndromes were defined by ≥1 of the following criteria: prior myocardial infarction, evidence of coronary stenosis >50%, proven symptomatic myocardial ischaemia, or prior revascularization procedure.
Among 32 694 patients, 9502 (29%) had diabetes, with a regional prevalence ranging from below 20% in Northern Europe to ∼60% in the Gulf countries. In a multivariable-adjusted Cox proportional hazards model, diabetes was associated with increased risks for the primary outcome (cardiovascular death, myocardial infarction, or stroke) with an adjusted hazard ratio of 1.28 (95% confidence interval 1.18, 1.39) and for all secondary outcomes (all-cause and cardiovascular mortality, myocardial infarction, stroke, heart failure, and coronary revascularization). Differences on outcomes according to geography and ethnicity were modest.
Conclusion
In patients with chronic coronary syndromes, diabetes is independently associated with mortality and cardiovascular events, including heart failure, which is not accounted by demographics, prior medical history, left ventricular ejection fraction, or use of secondary prevention medication. This is observed across multiple geographic regions and ethnicities, despite marked disparities in the prevalence of diabetes.
ClinicalTrials identifier
ISRCTN43070564
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Affiliation(s)
- Koon-Hou Mak
- Mak Heart Clinic, Gleneagles Medical Centre, 6 Napier Road, # 08-13, 258499, Singapore
| | - Emmanuelle Vidal-Petiot
- Physiology Department, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat and INSERM U1149, Centre for Research in Inflammation, 46 rue Henri Huchard, Paris 75018, France
- Université de Paris, 16 rue Henri Huchard, 75018 Paris, France
| | - Robin Young
- Robertson Centre for Biostatistics, Boyd Orr Building, University Avenue, University of Glasgow, Glasgow G12 8QQ, UK
| | - Emmanuel Sorbets
- Université de Paris, 16 rue Henri Huchard, 75018 Paris, France
- Centre de Diagnostic et de Thérapeutique, Assistance Publique-Hôpitaux de Paris, Hôpital Hôtel Dieu, 1, place du Parvis Notre Dame, Paris 75004, France
- FACT (French Alliance for Cardiovascular Trials) and INSERM U1148, Laboratory for Vascular Translational Science, 46, rue Henri Huchard, Paris 75018, France
| | - Nicola Greenlaw
- Robertson Centre for Biostatistics, Boyd Orr Building, University Avenue, University of Glasgow, Glasgow G12 8QQ, UK
| | - Ian Ford
- Robertson Centre for Biostatistics, Boyd Orr Building, University Avenue, University of Glasgow, Glasgow G12 8QQ, UK
| | - Michal Tendera
- Department of Cardiology and Structural Heart Disease, Medical University of Silesia, Ziolowa Str. 45/47, 40-635 Katowice, Poland
| | - Roberto Ferrari
- Cardiovascular Centre, University of Ferrara, Via Aldo Moro 8, 44124 Cona (FE), Italy
- Maria Cecilia Hospital, GVM Care & Research, Via Corriera 1 48033 Cotignola (RA), Italy
| | - Jean-Claude Tardif
- Department of Medicine, Montreal Heart Institute, Université de Montreal, 5000 Belanger Street, Montreal, PQ H1T1C8, Canada
| | - Jacob A Udell
- Women’s College Research Institute, Women’s College Hospital, University of Toronto, 76 Grenville St, Toronto, ON M5S 1B1, Canada
| | - Jorge Escobedo
- Unidad de Investigación en Epidemiología Clínica, Hospital General Regional 1, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Kim M Fox
- NHLI Imperial College, Dovehouse Street, London SW3 6LP ICMS, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
| | - Philippe Gabriel Steg
- Université de Paris, 16 rue Henri Huchard, 75018 Paris, France
- FACT (French Alliance for Cardiovascular Trials) and INSERM U1148, Laboratory for Vascular Translational Science, 46, rue Henri Huchard, Paris 75018, France
- NHLI Imperial College, Dovehouse Street, London SW3 6LP ICMS, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
- Cardiology Department, Assistance Publique-Hôpitaux de Paris, Hopital Bichat, Paris 75018, France
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Zibaeenezhad MJ, Mohammadi SS, Sayadi M, Khorshidi S, Bahramali E, Razeghian-Jahromi I. The impact of diabetes mellitus and hypertension on clinical outcomes in a population of Iranian patients who underwent percutaneous coronary intervention: A retrospective cohort study. J Clin Hypertens (Greenwich) 2019; 21:1647-1653. [PMID: 31553131 DOI: 10.1111/jch.13705] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 08/07/2019] [Accepted: 08/18/2019] [Indexed: 01/19/2023]
Abstract
There are heterogeneous data regarding the impact of diabetes mellitus (DM) and hypertension (HTN) on clinical outcomes after percutaneous coronary intervention (PCI). This study explored the effect of history of DM (hDM) and HTN (hHTN), separately and in combination with each other, on major adverse cardiac events (MACE) in short-, mid-, and long-term intervals after PCI. Between 2000 and 2017, 1799 patients who had PCI were registered. They were categorized in four different groups: hDM, hHTN, hDM + hHTN, and no hDMQuery no hHTN. Incidence of myocardial infarction, revascularization, and coronary death totally considered as MACE was sought in short- (<24 hours), mid- (24 hours up to 6 months), and long-term (more than 6 months) intervals after PCI. Among the subjects, 176 had hDM, 648 had hHTN, 370 had hDM + hHTN, and 605 were in no hDM no hHTN group. The median follow-up time was 66.5 months. Time-to-event (time to the first MACE) was not significantly different between four groups. hHTN group was older and hDM group was younger at the time of enrollment PCI. Female gender was dominant only in hDM + hHTN group. Of the total, 130 patients (7.22%) experienced MACE. There was no MACE in short term, 23.07% of the MACEs were in mid-term, and the remaining happened in long term. However, according to the rate ratio, incidence rate of MACE in mid-tem was significantly higher than the long term. Also, MACE occurrence was significantly higher in hDM + hHTN and hHTN groups than the no hDM no hHTN group. Our study showed that the history of HTN significantly increases post-PCI MACE rather than the history of DM. Having history of both DM and HTN synergistically raised MACE incidence. Incidence of MACE per month was higher in mid-term than the long-term interval.
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Affiliation(s)
| | | | - Mehrab Sayadi
- Cardiovascular Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Soorena Khorshidi
- Cardiovascular Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ehsan Bahramali
- Non communicable Disease Research Center, Fasa University of Medical Sciences, Fasa, Iran
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3
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The impact of diabetes on electrocardiographic ST resolution and clinical outcome of acute ST elevation myocardial infarction following fibrinolytic therapy. COR ET VASA 2016. [DOI: 10.1016/j.crvasa.2015.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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4
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Fu KL, Fan GQ, Han L, Wang XZ, Wang J, Wang YS, Zhong M, Zhang Y, Zhang W, Wang ZH. Impact of type 2 diabetes mellitus on hospitalization costs in older patients with acute myocardial infarction. Clin Interv Aging 2014; 9:711-8. [PMID: 24812498 PMCID: PMC4008285 DOI: 10.2147/cia.s59802] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background The purpose of this study was to evaluate the impact of type 2 diabetes mellitus on hospitalization costs in older patients with acute myocardial infarction (MI). Methods Retrospective analysis of data from the case retrieval system of Qilu Hospital of Shandong University located in Jinan city of Shandong Province was done for patients with acute MI from January 1, 2011 to December 31, 2012. Results Stenting was an important factor affecting older patients’ total hospitalization costs (β=0.685, P=0.000) and treatment costs during the follow-up period (duration of hospital stay only, β=0.508, P=0.000). Stenting was also a protective factor in the prevention of acute heart failure (HF) in older patients with acute MI during the follow-up period (odds ratio 0.189, 95% confidence interval 0.059–0.602, P=0.005). Implementation of percutaneous coronary intervention reduced the incidence of acute HF in older inpatients with acute MI (27.8% versus 4.3%, P=0.001) and without diabetes (18.2% versus 3.8%, P=0.001). Moreover, among the elderly, the incremental cost-effectiveness ratio estimate for implementing percutaneous coronary intervention in diabetic patients was higher than in nondiabetic patients. Conclusion Stenting was a protective factor for preventing acute HF in the elderly during the follow-up period. From the perspective of reducing the incidence of acute HF in inpatients, implementation of percutaneous coronary intervention after an acute MI is more cost-effective in older patients with diabetes mellitus than in those without it.
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Affiliation(s)
- Kai-li Fu
- Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Public Health, and Department of Cardiology, Qilu Hospital of Shandong University, Ji'nan, People's Republic of China
| | - Guan-qi Fan
- Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Public Health, and Department of Cardiology, Qilu Hospital of Shandong University, Ji'nan, People's Republic of China
| | - Lu Han
- Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Public Health, and Department of Cardiology, Qilu Hospital of Shandong University, Ji'nan, People's Republic of China
| | - Xiao-zhen Wang
- Shandong University of Traditional Chinese Medicine, Ji'nan, People's Republic of China
| | - Jia Wang
- Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Public Health, and Department of Cardiology, Qilu Hospital of Shandong University, Ji'nan, People's Republic of China
| | - Yu-shu Wang
- Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Public Health, and Department of Cardiology, Qilu Hospital of Shandong University, Ji'nan, People's Republic of China
| | - Ming Zhong
- Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Public Health, and Department of Cardiology, Qilu Hospital of Shandong University, Ji'nan, People's Republic of China
| | - Yun Zhang
- Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Public Health, and Department of Cardiology, Qilu Hospital of Shandong University, Ji'nan, People's Republic of China
| | - Wei Zhang
- Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Public Health, and Department of Cardiology, Qilu Hospital of Shandong University, Ji'nan, People's Republic of China
| | - Zhi-hao Wang
- Department of Geriatric Medicine, Qilu Hospital of Shandong University, Ji'nan, People's Republic of China
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Kmet M, Rajer B, Pernat A. Hemoglobin A1c is a better predictor of prognosis following the non-ST elevation acute coronary syndrome than fasting and admission glucose. Wien Klin Wochenschr 2013; 126:156-62. [PMID: 24297265 DOI: 10.1007/s00508-013-0468-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2013] [Accepted: 11/06/2013] [Indexed: 01/04/2023]
Abstract
BACKGROUND Glucometabolic status is an important predictor of prognosis in patients with acute myocardial infarction. Both plasma glucose levels and glycosylated hemoglobin A1c (HbA1c) were implicated as predictors of prognosis. However, previous data yielded conflicting results. We evaluated the prognostic role of plasma glucose levels and HbA1c in patients with non-ST elevation acute coronary syndrome (NSTEACS). METHODS A total of 106 consecutive patients with NSTEACS (55 with unstable angina and 51 with non-ST elevation myocardial infarction) were included. The average age was 66.1 years; 61% were male. HbA1c was measured at admission, along with other standard laboratory values. The follow-up period lasted for a year. The main combined outcome variable included death from cardiovascular causes and rehospitalization due to another acute coronary syndrome or due to heart failure. RESULTS Combined end point occurred in 43 (41%) patients. Mean HbA1c value was significantly higher in the group of patients who had complications (7.6 ± 2.6 vs. 5.8 ± 1.2, p < 0.05). Logistic regression identified HbA1c [odds ratio (OR): 1.6] and male sex (OR: 0.25) as the only independent predictors of major adverse cardiac events (MACE). A Kaplan-Meier analysis showed a 2.7 times higher risk of MACE in patients with HbA1c > 6.5%. CONCLUSIONS Results from our study indicate that the admission level of HbA1c, but not admission or fasting glucose, is a predictor of mortality and major adverse events in patients with NSTEACS. These results identify HbA1c to be an independent predictor also in patients with NSTEACS, and not only in those with ST elevation myocardial infarction as observed before our study.
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Affiliation(s)
- Marko Kmet
- Medical Intensive Care Unit, Novo mesto General Hospital, Novo mesto, Slovenia
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Sen S, Davies JE, Malik IS, Foale RA, Mikhail GW, Hadjiloizou N, Hughes A, Mayet J, Francis DP. Why Does Primary Angioplasty Not Work in Registries? Quantifying the Susceptibility of Real-World Comparative Effectiveness Data to Allocation Bias. Circ Cardiovasc Qual Outcomes 2012; 5:759-66. [DOI: 10.1161/circoutcomes.112.966853] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background—
Meta-analysis of registries (comparative effectiveness research) shows that primary angioplasty and fibrinolysis have equivalent real-world survival. Yet, randomized, controlled trials consistently find primary angioplasty superior. Can unequal allocation of higher-risk patients in registries have masked primary angioplasty benefit?
Methods and Results—
First, we constructed a model to demonstrate the potential effect of allocation bias. We then analyzed published registries (55022 patients) for allocation of higher-risk patients (Killip class ≥1) to determine whether the choice of reperfusion therapy was affected by the risk level of the patient. Meta-regression was used to examine the relationship between differences in allocation of high-risk patient to primary angioplasty or fibrinolysis and mortality. Initial modeling suggested that registry outcomes are sensitive to allocation bias of high-risk patients. Across the registries, the therapy receiving excess high-risk patients had worse mortality. Unequal distribution of high-risk status accounted for most of the between-registry variance (adjusted
R
2
meta
=83.1%). Accounting for differential allocation of higher-risk patients, primary angioplasty gave 22% lower mortality (odds ratio, 0.78; 95% confidence interval, 0.64–0.97;
P
=0.029). We derive a formula, called the number needed to abolish, highlighting situations in which comparative effectiveness studies are particularly vulnerable to this bias.
Conclusions—
In ST-segment elevation myocardial infarction, clinicians’ preference for management of a few high-risk patients can shift mortality substantially. Comparative effectiveness research in any disease is vulnerable to this, especially diseases with an immediately identifiable high-risk subgroup that clinicians prefer to allocate to 1 therapy. For this reason, preliminary indications from registry-based comparative effectiveness research should be definitively tested by randomized, controlled trials.
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Affiliation(s)
- Sayan Sen
- From the Imperial College Healthcare National Health Service Trust, St. Mary’s Hospital, Imperial College London, London, UK
| | - Justin E. Davies
- From the Imperial College Healthcare National Health Service Trust, St. Mary’s Hospital, Imperial College London, London, UK
| | - Iqbal S. Malik
- From the Imperial College Healthcare National Health Service Trust, St. Mary’s Hospital, Imperial College London, London, UK
| | - Rodney A. Foale
- From the Imperial College Healthcare National Health Service Trust, St. Mary’s Hospital, Imperial College London, London, UK
| | - Ghada W. Mikhail
- From the Imperial College Healthcare National Health Service Trust, St. Mary’s Hospital, Imperial College London, London, UK
| | - Nearchos Hadjiloizou
- From the Imperial College Healthcare National Health Service Trust, St. Mary’s Hospital, Imperial College London, London, UK
| | - Alun Hughes
- From the Imperial College Healthcare National Health Service Trust, St. Mary’s Hospital, Imperial College London, London, UK
| | - Jamil Mayet
- From the Imperial College Healthcare National Health Service Trust, St. Mary’s Hospital, Imperial College London, London, UK
| | - Darrel P. Francis
- From the Imperial College Healthcare National Health Service Trust, St. Mary’s Hospital, Imperial College London, London, UK
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Lee MG, Jeong MH, Lee KH, Park KH, Sim DS, Yoon HJ, Yoon NS, Kim KH, Park HW, Hong YJ, Kim JH, Ahn Y, Cho JG, Park JC, Kang JC. Prognostic impact of diabetes mellitus and hypertension for mid-term outcome of patients with acute myocardial infarction who underwent percutaneous coronary intervention. J Cardiol 2012; 60:257-63. [DOI: 10.1016/j.jjcc.2012.06.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Revised: 05/19/2012] [Accepted: 06/06/2012] [Indexed: 12/20/2022]
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Saucedo JF. Antiplatelet therapy for patients with diabetes mellitus and acute coronary syndrome. Prim Care Diabetes 2012; 6:167-177. [PMID: 22410305 DOI: 10.1016/j.pcd.2012.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Revised: 01/10/2012] [Accepted: 02/11/2012] [Indexed: 12/20/2022]
Abstract
In diabetes mellitus, platelet hyperreactivity is common and may contribute to the high incidence of cardiovascular disease; dual antiplatelet therapy reduces the risk of recurrence. Prasugrel or ticagrelor provides a greater, more consistent antiplatelet effect than clopidogrel. Prasugrel provides greater clinical benefit than clopidogrel in patients with diabetes (hazard ratio [HR], 0.70; P<0.001) versus those without diabetes (HR, 0.86; P=0.02), due to greater reductions in cardiovascular events and no increased major bleeding. Similar clinical benefits are seen with ticagrelor versus clopidogrel in patients with and without diabetes. Evidence suggests that prasugrel/aspirin may provide particular advantages for patients with diabetes mellitus.
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Knudsen EC, Seljeflot I, Abdelnoor M, Eritsland J, Mangschau A, Müller C, Arnesen H, Andersen GØ. Impact of newly diagnosed abnormal glucose regulation on long-term prognosis in low risk patients with ST-elevation myocardial infarction: A follow-up study. BMC Endocr Disord 2011; 11:14. [PMID: 21801387 PMCID: PMC3173358 DOI: 10.1186/1472-6823-11-14] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Accepted: 07/29/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with acute myocardial infarction and newly detected abnormal glucose regulation have been shown to have a less favourable prognosis compared to patients with normal glucose regulation. The importance and timing of oral glucose tolerance testing (OGTT) in patients with acute myocardial infarction without known diabetes is uncertain. The aim of the present study was to evaluate the impact of abnormal glucose regulation classified by an OGTT in-hospital and at three-month follow-up on clinical outcome in patients with acute ST elevation myocardial infarction (STEMI) without known diabetes. METHODS Patients (n = 224, age 58 years) with a primary percutanous coronary intervention (PCI) treated STEMI were followed for clinical events (all-cause mortality, non-fatal myocardial re-infarction, recurrent ischemia causing hospital admission, and stroke). The patients were classified by a standardised 75 g OGTT at two time points, first, at a median time of 16.5 hours after hospital admission, then at three-month follow-up. Based on the OGTT results, the patients were categorised according to the WHO criteria and the term abnormal glucose regulation was defined as the sum of impaired fasting glucose, impaired glucose tolerance and type 2-diabetes. RESULTS The number of patients diagnosed with abnormal glucose regulation in-hospital and at three-month was 105 (47%) and 50 (25%), respectively. During the follow up time of (median) 33 (27, 39) months, 58 (25.9%) patients experienced a new clinical event. There were six deaths, 15 non-fatal re-infarction, 33 recurrent ischemia, and four strokes. Kaplan-Meier analysis of survival free of composite end-points showed similar results in patients with abnormal and normal glucose regulation, both when classified in-hospital (p = 0.4) and re-classified three months later (p = 0.3). CONCLUSIONS Patients with a primary PCI treated STEMI, without previously known diabetes, appear to have an excellent long-term prognosis, independent of the glucometabolic state classified by an OGTT in-hospital or at three-month follow-up. TRIAL REGISTRATION The trial is registered at http://www.clinicaltrials.gov, NCT00926133.
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Affiliation(s)
- Eva C Knudsen
- Center for Clinical Heart Research, Oslo University Hospital, Ullevål, Oslo, Norway
- Department of Cardiology, Oslo University Hospital, Ullevål, Oslo, Norway
- Center for Heart Failure Research, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Ingebjørg Seljeflot
- Center for Clinical Heart Research, Oslo University Hospital, Ullevål, Oslo, Norway
- Department of Cardiology, Oslo University Hospital, Ullevål, Oslo, Norway
- Center for Heart Failure Research, Oslo University Hospital, Ullevål, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Michael Abdelnoor
- Center of Clinical Research, Unit of Epidemiology and Biostatistics, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Jan Eritsland
- Department of Cardiology, Oslo University Hospital, Ullevål, Oslo, Norway
- Center for Heart Failure Research, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Arild Mangschau
- Department of Cardiology, Oslo University Hospital, Ullevål, Oslo, Norway
- Center for Heart Failure Research, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Carl Müller
- Nuclear Medicine, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Harald Arnesen
- Center for Clinical Heart Research, Oslo University Hospital, Ullevål, Oslo, Norway
- Department of Cardiology, Oslo University Hospital, Ullevål, Oslo, Norway
- Center for Heart Failure Research, Oslo University Hospital, Ullevål, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Geir Ø Andersen
- Center for Clinical Heart Research, Oslo University Hospital, Ullevål, Oslo, Norway
- Department of Cardiology, Oslo University Hospital, Ullevål, Oslo, Norway
- Center for Heart Failure Research, Oslo University Hospital, Ullevål, Oslo, Norway
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Huffman JC, Celano CM, Januzzi JL. The relationship between depression, anxiety, and cardiovascular outcomes in patients with acute coronary syndromes. Neuropsychiatr Dis Treat 2010; 6:123-36. [PMID: 20505844 PMCID: PMC2874336 DOI: 10.2147/ndt.s6880] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Depression and anxiety occur at high rates among patients suffering an acute coronary syndrome (ACS). Both depressive symptoms and anxiety appear to adversely affect in-hospital and long term cardiac outcomes of post-ACS patients, independent of traditional risk factors. Despite their high prevalence and serious impact, mood and anxiety symptoms go unrecognized and untreated in most ACS patients and such symptoms (rather than being transient reactions to ACS) persist for months and beyond. The mechanisms by which depression and anxiety are linked to these negative medical outcomes are likely a combination of the effects of these conditions on inflammation, catecholamines, heart rate variability, and endothelial function, along with effects on health-promoting behavior. Fortunately, standard treatments for these disorders appear to be safe, well-tolerated and efficacious in this population; indeed, selective serotonin reuptake inhibitors may actually improve cardiac outcomes. Future research goals include gaining a better understanding of the combined effects of depression and anxiety, as well as definitive prospective studies of the impact of treatment on cardiac outcomes. Clinically, protocols that allow for efficient and systematic screening, evaluation, and treatment for depression and anxiety in cardiac patients are critical to help patients avoid the devastating effects of these illnesses on quality of life and cardiac health.
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Affiliation(s)
- Jeff C Huffman
- Department of Psychiatry, Massachusetts General Hospital, 55 Fruit Street/Blake 11, Boston, MA, USA.
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11
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Lee MG, Jeong MH, Ahn Y, Chae SC, Hur SH, Hong TJ, Kim YJ, Seong IW, Chae JK, Rhew JY, Chae IH, Cho MC, Bae JH, Rha SW, Kim CJ, Choi D, Jang YS, Yoon J, Chung WS, Cho JG, Seung KB, Park SJ. Comparison of clinical outcomes following acute myocardial infarctions in hypertensive patients with or without diabetes. Korean Circ J 2009; 39:243-50. [PMID: 19949630 PMCID: PMC2771834 DOI: 10.4070/kcj.2009.39.6.243] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2008] [Revised: 01/16/2009] [Accepted: 02/17/2009] [Indexed: 01/19/2023] Open
Abstract
Background and Objectives It is thought that patients with diabetes mellitus (DM) have a poor prognosis after an acute myocardial infarction (AMI), but the effect of diabetes on the outcomes of hypertensive patients with AMIs has not been elucidated in the Korean population. The aim of this study was to investigate the effects of diabetes on long-term clinical outcomes following AMIs in patients with hypertension. Subjects and Methods Using data from the Korea Acute Myocardial Infarction Registry (November 2005 to December 2006), 2,233 hypertensive patients with AMIs were grouped as follows based on the presence of DM: group I, diabetic hypertension (n=892, 544 men, mean age=66.2±10.9 years); and group II, non-diabetic hypertension (n=1341, 938 men, mean age=63.9±12.8 years). The primary study outcomes included in-hospital death and major adverse cardiac events (MACE; cardiac death, myocardial infarction (MI), repeat percutaneous coronary intervention, and coronary artery bypass surgery) at the 1 year follow-up. Results Hypertensive patients with DM were older and more likely to be women. The diabetic group had lower blood pressure (p<0.001), a lower left ventricular ejection fraction (p<0.001), a more severe degree of heart failure (p<0.001), a longer duration of coronary care unit admission (p<0.001), and a higher incidence of hyperlipidemia (p=0.007). The N-terminal pro-brain natriuretic peptide level (4602.5±8710.6 pg/mL vs. 2320.8±5837.9 pg/mL, p<0.001) was higher and the creatinine clearance (62.4±29.9 mL/min vs. 73.0±40.8 mL/min, p<0.001) was lower in the diabetic group than the non-diabetic group. Coronary angiographic findings revealed more frequent involvement of the left main stem (p=0.002) and multiple vessels (p<0.001) in the diabetic group. The rate of in-hospital death was higher in the diabetic group (p<0.001). During follow-up, the rates of composite MACE at 1 month, 6 months, and 12 months were higher in the diabetic group (p<0.001). Conclusion In hypertensive patients with AMI, DM was associated with worse clinical and angiographic features, with a higher risk of development of severe heart failure, and an increased risk of MACE on long-term clinical follow-up.
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Affiliation(s)
- Min Goo Lee
- Korea Acute Myocardial Infarction Registry Investigators of Korean Society of Cardiology, Korea
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Huynh T, Perron S, O'Loughlin J, Joseph L, Labrecque M, Tu JV, Théroux P. Comparison of Primary Percutaneous Coronary Intervention and Fibrinolytic Therapy in ST-Segment-Elevation Myocardial Infarction. Circulation 2009; 119:3101-9. [PMID: 19506117 DOI: 10.1161/circulationaha.108.793745] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Published meta-analyses comparing primary percutaneous coronary intervention with fibrinolytic therapy in patients with ST-segment-elevation myocardial infarction include only randomized controlled trials (RCTs). We aim to obviate the limited applicability of RCTs to real-world settings by undertaking meta-analyses of both RCTs and observational studies.
Methods and Results—
We included all RCTs and observational studies, without language restriction, published up to May 1, 2008. We completed separate bayesian hierarchical random-effect meta-analyses for 23 RCTs (8140 patients) and 32 observational studies (185 900 patients). Primary percutaneous coronary intervention was associated with reductions in short-term (≤6-week) mortality of 34% (odds ratio, 0.66; 95% credible interval, 0.51 to 0.82) in randomized trials, and 23% lower mortality (odds ratio, 0.77; 95% credible interval, 0.62 to 0.95) in observational studies. Primary percutaneous coronary intervention was associated with reductions in stroke of 63% in RCTs and 61% in observational studies. At long-term follow-up (≥1 year), primary percutaneous coronary intervention was associated with a 24% reduction in mortality (odds ratio, 0.76; 95% credible interval, 0.58 to 0.95) and a 51% reduction in reinfarction (odds ratio, 0.49; 95% credible interval, 0.32 to 0.66) in RCTs. However, there was no conclusive benefit of primary percutaneous coronary intervention in the long term in the observational studies.
Conclusions—
Compared with fibrinolytic therapy, primary percutaneous coronary intervention was associated with short-term reductions in mortality, reinfarction, and stroke in ST-segment-elevation myocardial infarction. Primary percutaneous coronary intervention was associated with long-term reductions in mortality and reinfarction in RCTs, but there was no conclusive evidence for a long-term benefit in mortality and reinfarction in observational studies.
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Affiliation(s)
- Thao Huynh
- From the McGill Health University Center (T.H.) and Department of Epidemiology and Biostatistics (L.J.), McGill University, Montreal; Direction of Public Health of Montreal (S.P.), Department of Social and Preventive Medicine (J.O.), and Montreal Heart Institute (P.T.), University of Montreal, Montreal; Department of Family Medicine, Laval University, Quebec (M.L.); and Institute for Clinical Evaluative Sciences, University of Toronto, Toronto (J.V.T.), Canada
| | - Stephane Perron
- From the McGill Health University Center (T.H.) and Department of Epidemiology and Biostatistics (L.J.), McGill University, Montreal; Direction of Public Health of Montreal (S.P.), Department of Social and Preventive Medicine (J.O.), and Montreal Heart Institute (P.T.), University of Montreal, Montreal; Department of Family Medicine, Laval University, Quebec (M.L.); and Institute for Clinical Evaluative Sciences, University of Toronto, Toronto (J.V.T.), Canada
| | - Jennifer O'Loughlin
- From the McGill Health University Center (T.H.) and Department of Epidemiology and Biostatistics (L.J.), McGill University, Montreal; Direction of Public Health of Montreal (S.P.), Department of Social and Preventive Medicine (J.O.), and Montreal Heart Institute (P.T.), University of Montreal, Montreal; Department of Family Medicine, Laval University, Quebec (M.L.); and Institute for Clinical Evaluative Sciences, University of Toronto, Toronto (J.V.T.), Canada
| | - Lawrence Joseph
- From the McGill Health University Center (T.H.) and Department of Epidemiology and Biostatistics (L.J.), McGill University, Montreal; Direction of Public Health of Montreal (S.P.), Department of Social and Preventive Medicine (J.O.), and Montreal Heart Institute (P.T.), University of Montreal, Montreal; Department of Family Medicine, Laval University, Quebec (M.L.); and Institute for Clinical Evaluative Sciences, University of Toronto, Toronto (J.V.T.), Canada
| | - Michel Labrecque
- From the McGill Health University Center (T.H.) and Department of Epidemiology and Biostatistics (L.J.), McGill University, Montreal; Direction of Public Health of Montreal (S.P.), Department of Social and Preventive Medicine (J.O.), and Montreal Heart Institute (P.T.), University of Montreal, Montreal; Department of Family Medicine, Laval University, Quebec (M.L.); and Institute for Clinical Evaluative Sciences, University of Toronto, Toronto (J.V.T.), Canada
| | - Jack V. Tu
- From the McGill Health University Center (T.H.) and Department of Epidemiology and Biostatistics (L.J.), McGill University, Montreal; Direction of Public Health of Montreal (S.P.), Department of Social and Preventive Medicine (J.O.), and Montreal Heart Institute (P.T.), University of Montreal, Montreal; Department of Family Medicine, Laval University, Quebec (M.L.); and Institute for Clinical Evaluative Sciences, University of Toronto, Toronto (J.V.T.), Canada
| | - Pierre Théroux
- From the McGill Health University Center (T.H.) and Department of Epidemiology and Biostatistics (L.J.), McGill University, Montreal; Direction of Public Health of Montreal (S.P.), Department of Social and Preventive Medicine (J.O.), and Montreal Heart Institute (P.T.), University of Montreal, Montreal; Department of Family Medicine, Laval University, Quebec (M.L.); and Institute for Clinical Evaluative Sciences, University of Toronto, Toronto (J.V.T.), Canada
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Abstract
Diabetic patients with acute coronary syndromes (ACSs) are at a high risk for subsequent cardiovascular events but derive, at the same time, greater benefit from evidence-based therapy than non-diabetic individuals. State-of-the-art anti-thrombotic therapy includes a triple anti-platelet combination - aspirin, clopidogrel and glycoprotein (GP) IIb/IIIa receptor inhibitors - and unfractionated heparin or enoxaparin. For low- or medium-risk individuals, a treatment based on aspirin, clopidogrel and bivalirudin is a valuable alternative. Prasugrel, a new and more potent inhibitor of the platelet P2Y(12) receptor, has to be regarded as the most promising anti-thrombotic agent for diabetic patients with ACS. This agent may replace clopidogrel - and possibly GP IIb/IIIa inhibitors - in the future. In addition to aggressive anti-thrombotic therapy, diabetic patients should undergo systematic early invasive angiography if presenting with non-ST-segment elevation ACS, and immediate percutaneous coronary intervention if presenting with ST-segment elevation myocardial infarction. Indeed, the benefit derived from these strategies appears to be more pronounced in the diabetic population than in non-diabetic individuals. Despite the benefit, multiple surveys have demonstrated that, in the setting of ACS, diabetic patients receive evidence-based therapy less frequently than non-diabetic counterparts.
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Affiliation(s)
- Marco Roffi
- Division of Cardiology, University Hospital, Geneva, Switzerland.
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14
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Gregoratos G, Leung G. Diabetes Mellitus and Cardiovascular Disease in the Elderly. FUNDAMENTAL AND CLINICAL CARDIOLOGY SERIES 2008. [DOI: 10.3109/9781420061710.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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15
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Cubbon R, Kahn M, Kearney MT. Secondary prevention of cardiovascular disease in type 2 diabetes and prediabetes: a cardiologist's perspective. Int J Clin Pract 2008; 62:287-99. [PMID: 18036163 DOI: 10.1111/j.1742-1241.2007.01646.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Patients with type 2 diabetes mellitus (T2DM) and prediabetes have a substantially greater risk of developing cardiovascular (CV) disease than the general population. This increased risk of CV disease is due to a complex cluster of risk factors including insulin resistance, hyperglycaemia, diabetic dyslipidaemia, hypertension and systemic inflammation. As a result of this cluster of risk factors, life expectancy is reduced by up to 10 years upon diagnosis of T2DM, principally because of fatal CV events. Patients with T2DM are not only more likely to sustain a CV event, but also have a higher risk of a fatal outcome from this event. Therefore, whilst primary prevention is critical in determining the prognosis of patients newly diagnosed with T2DM, many will go on to suffer CV events and represent a high-risk group requiring intensive secondary prevention techniques. Recent data demonstrate that contemporary prevention therapies do not afford equal benefits to T2DM sufferers after acute myocardial infarction compared with their non-diabetic counterparts. This finding highlights the need for more effective secondary preventative strategies to prevent recurrent CV events in patients with T2DM and prediabetes. The cardiologist's role in the multidisciplinary management of T2DM is to improve patient outcomes by optimising use of evidence-based strategies for the prevention of recurrent CV events.
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Affiliation(s)
- R Cubbon
- Leeds Institute of Genetics, Health and Therapeutics, University of Leeds, Leeds, UK
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17
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Guías de práctica clínica sobre diabetes, prediabetes y enfermedades cardiovasculares: versión resumida. Rev Esp Cardiol 2007. [DOI: 10.1016/s0300-8932(07)75070-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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18
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Legrand V. Therapy insight: diabetes and drug-eluting stents. ACTA ACUST UNITED AC 2007; 4:143-50. [PMID: 17330126 DOI: 10.1038/ncpcardio0804] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2006] [Accepted: 11/21/2006] [Indexed: 11/08/2022]
Abstract
Individuals with diabetes mellitus usually present with accelerated atherosclerosis, more diffuse disease, concomitant comorbidities and have an increased risk for restenosis. Evidence confirmed the superiority of CABG surgery over balloon angioplasty with or without bare-metal stenting for diabetic patients requiring multivessel revascularization. More recently, drug-eluting stents (DESs) have emerged as the predominant percutaneous strategy in patients with coronary artery disease. This Review summarizes the knowledge on coronary stenting in diabetics. Although the rate of restenosis is dramatically reduced with the use of DESs compared with bare-metal stents, diabetic patients continue to face higher adverse cardiac event rates when compared with nondiabetic patients. Whether there are differences in the effectiveness of paclitaxel-eluting or sirolimus-eluting stents is still debated. Late outcome might be overshadowed by clinical issues such as late stent thrombosis or restenosis, particularly in diabetic patients with renal failure or complex lesions, and after premature interruption of antiplatelet agents. Longer follow-up in larger populations is thus needed to confirm the long-term safety and efficacy. The superiority or the equivalence of DESs over CABG surgery for multivessel disease has not yet been demonstrated. Thus, although evidence supports DES use in diabetics, further data are needed to better define the management of diabetic patients with coronary artery disease.
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Affiliation(s)
- Victor Legrand
- Service de Cardiologie, CHU de Liège Sart-Tilman, 4000 Liège, Belgium.
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Kosuge M, Kimura K, Kojima S, Sakamoto T, Matsui K, Ishihara M, Asada Y, Tei C, Miyazaki S, Sonoda M, Tsuchihashi K, Yamagishi M, Ikeda Y, Shirai M, Hiraoka H, Inoue T, Saito F, Ogawa H. Effects of glucose abnormalities on in-hospital outcome after coronary intervention for acute myocardial infarction. Circ J 2005; 69:375-9. [PMID: 15791028 DOI: 10.1253/circj.69.375] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The effects of glucose abnormalities on outcomes after percutaneous coronary intervention (PCI) remain unclear. We examined the association between glucose abnormalities and in-hospital outcome in patients undergoing PCI for acute myocardial infarction (AMI). METHODS AND RESULTS A total of 849 patients with AMI who were admitted within 12 h after symptom onset and underwent emergency PCI were classified according to the presence or absence of admission hyperglycemia, defined as a blood glucose level on admission of >11 mmol/L and whether they had a history of diabetes mellitus: group 1 (n = 504), non-diabetic patients without admission hyperglycemia; group 2 (n = 111), diabetic patients without admission hyperglycemia; group 3 (n = 87), non-diabetic patients with admission hyperglycemia; and group 4 (n = 147), diabetic patients with admission hyperglycemia. Among groups 1, 2, 3 and 4, in-hospital mortality was 2.6, 2.7, 11.5 and 8.8%, respectively (p < 0.01). Multivariate analysis showed that compared with group 1 patients, the odds ratio (95%confidence interval) for in-hospital mortality among those in groups 2, 3, and 4 were 0.80 (0.24-2.60, p = 0.708), 2.29 (1.10-5.49, p = 0.039), and 2.14 (1.14-4.69, p = 0.048), respectively. CONCLUSIONS In-patients undergoing PCI for AMI, admission hyperglycemia, irrespective of the presence or absence of diabetes, is associated with increased in-hospital mortality, whereas diabetes without admission hyperglycemia is not.
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Affiliation(s)
- Masami Kosuge
- Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
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20
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van der Schaaf RJ, Henriques JPS, Wiersma JJ, Koch KT, Baan J, Mulder KJJ, Durrer JD, Tijssen JGP, Piek JJ, de Winter RJ. Primary percutaneous coronary intervention for patients with acute ST elevation myocardial infarction with and without diabetes mellitus. Heart 2005; 92:117-8. [PMID: 15890764 PMCID: PMC1861002 DOI: 10.1136/hrt.2004.059675] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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21
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Bonnefoy E, Steg PG, Chabaud S, Dubien PY, Lapostolle F, Boudet F, Lacroute JM, Dissait F, Vanzetto G, Leizorowicz A, Touboul P. Is primary angioplasty more effective than prehospital fibrinolysis in diabetics with acute myocardial infarction? Data from the CAPTIM randomized clinical trial. Eur Heart J 2005; 26:1712-8. [PMID: 15840623 DOI: 10.1093/eurheartj/ehi269] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Eric Bonnefoy
- Service de Cardiologie, Hôpital Cardio-Vasculaire et Pneumologique Louis Pradel, BP Lyon-Montchat, 69394 Lyon Cedex 03, France.
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22
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Prasad A, Stone GW, Stuckey TD, Costantini CO, Zimetbaum PJ, McLaughlin M, Mehran R, Garcia E, Tcheng JE, Cox DA, Grines CL, Lansky AJ, Gersh BJ. Impact of diabetes mellitus on myocardial perfusion after primary angioplasty in patients with acute myocardial infarction. J Am Coll Cardiol 2005; 45:508-14. [PMID: 15708696 DOI: 10.1016/j.jacc.2004.10.054] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2004] [Revised: 10/18/2004] [Accepted: 10/26/2004] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Abhiram Prasad
- Division of Cardiovascular Diseases and Department of Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
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23
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Impact of stenting and abciximab in patients with diabetes mellitus undergoing primary angioplasty in acute myocardial infarction (the CADILLAC trial). Am J Cardiol 2005; 95:1-7. [PMID: 15619385 DOI: 10.1016/j.amjcard.2004.08.054] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2004] [Revised: 08/21/2004] [Accepted: 08/20/2004] [Indexed: 11/19/2022]
Abstract
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.
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Berton G, Cordiano R, Palmieri R, De Toni R, Guarnieri GL, Palatini P. Albumin excretion in diabetic patients in the setting of acute myocardial infarction: association with 3-year mortality. Diabetologia 2004; 47:1511-8. [PMID: 15322753 DOI: 10.1007/s00125-004-1486-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2004] [Accepted: 06/11/2004] [Indexed: 10/26/2022]
Abstract
AIMS/HYPOTHESIS Diabetes mellitus is associated with increased mortality in subjects with acute myocardial infarction (AMI). We aimed to estimate the risk of mortality in AMI patients with and without diabetes using the urinary albumin : creatinine ratio (ACR). METHODS This is a prospective study of 121 consecutive, non-selected diabetic AMI patients, 121 age- and sex-matched non-diabetic AMI patients and 61 diabetic non-AMI outpatients as control subjects. All data were obtained during the first 7 days of hospitalisation and each AMI patient was followed for a period of exactly 3 years. Baseline ACR RIA measurements were made on the 1st, 3rd and 7th days of admission. RESULTS Adjusted ACR values were significantly higher in the diabetic AMI patients than in the diabetic control outpatients ( p<0.0001), and a significant difference was observed between the weekly ACR slopes for these two groups ( p<0.0001). Microalbuminuria was more prevalent in the diabetic AMI patients than in the non-diabetic AMI patients on the 1st day (62% vs 46%, p=0.01) and 3rd day (41% vs 29%, p=0.04). Among the AMI patients with normoalbuminuria (ACR <30 microg/mg), the mortality rate was 11.6% for the patients without diabetes and 33.8% for those with diabetes ( p=0.001). The mortality rate was much higher among the AMI patients with microalbuminuria (ACR >/=30 microg/mg) and similar for the diabetic (68.0%) and non-diabetic patients (74.3%). In a multivariable Cox model, ACR ( p<0.0001) and diabetes status ( p=0.01) were associated with adverse outcome even when several other clinical variables were included in the model. Furthermore, a negative interaction was found between diabetes and ACR ( p=0.01). CONCLUSIONS/INTERPRETATION Microalbuminuria frequently occurs in diabetic and non-diabetic AMI patients during the first 3 days of admission to hospital and can be used to identify subjects at high risk of mortality.
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Affiliation(s)
- G Berton
- Department of Internal Medicine and Cardiology, Conegliano General Hospital, Conegliano, Italy
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25
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Timmer JR, van der Horst ICC, Henriques JPS, Thomas K, Bilo HJG, Hoorntje JCA, de Boer MJ, Suryapranata H, Zijlstra F. Long-term clinical outcome of ST-segment elevation myocardial infarction patients with and without diabetes mellitus in the Zwolle trial. Neth Heart J 2003; 11:387-393. [PMID: 25696147 PMCID: PMC2499982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023] Open
Abstract
OBJECTIVES We sought to compare long-term survival after ST-segment elevation myocardial infarction (STEMI) in patients with and without diabetes mellitus (DM) treated with primary percutaneous coronary intervention (PCI) or thrombolytic therapy. BACKGROUND DM is an adverse prognostic factor after STEMI. However, there is only limited information about long-term clinical outcome in STEMI patients with DM treated with PCI or thrombolysis. METHODS Patients with STEMI (n=395) were randomised to treatment either with intravenous streptokinase or PCI. Mean follow-up was 8±2 years. We studied long-term mortality of patients with DM (n=32) and without DM (n=363) and the interaction with the treatment regimen. RESULTS After eight years, a total of 17 patients with DM (53%) died compared with 88 (24%) patients without DM (OR 3.5, p<0.001). Reduced left ventricular ejection fraction (LVEF) after STEMI was more often present in patients with DM compared with patients without DM (31% vs. 15%, p=0.01). Multivariate analysis revealed that DM (OR 2.6, 95% CI 1.4-4.7, p=0.002), reduced LVEF (OR 2.4, 95% CI 1.5-3.8, p<0.001) and age ≥60 years (OR 2.4, 95% CI 1.5-3.8, p<0.001) were independent risk factors for long-term mortality. Patients with DM treated with PCI had less LVEF (13% vs. 53%, p=0.01) and lower long-term mortality rates (38% vs. 69%, p=0.08) compared with treatment with thrombolysis. CONCLUSIONS STEMI patients with DM are a high-risk group with higher long-term mortality rates compared with patients without DM. PCI is the treatment of choice, particularly in DM patients.
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