Predictive Value of Gensini Score in the Long-Term Outcomes of Patients With Coronary Artery Disease Who Underwent PCI

Objective

Gensini score is an effective tool used to evaluate the severity of coronary artery disease (CAD). Whether the Gensini score has predictive value for the clinical outcomes of patients with CAD after percutaneous coronary intervention (PCI) has not been investigated.

Methods

All patients were from the Clinical Outcomes and Risk Factors of Patients with Coronary Heart Disease after PCI (CORFCHD-PCI), a retrospective cohort study involving 5,672 patients with CAD who underwent PCI, such as 2,110 patients with diabetes and 3,562 patients without diabetes, from January 2008 to December 2017. Patients were divided into three groups according to the tertile of Gensini score: first tertile (Gensini score <11 points), second tertile (Gensini score 11–38 points), and third tertile (Gensini score >38 points). The median follow-up time was 31.0 (interquartile range, IQR: 30.0) months. Compared the differences in clinical outcomes between the groups. Multivariate Cox regression analyses were performed to assess the predictive value of the Gensini score for outcomes over up to 10 years of follow-up.

Results

In the population without diabetes, there were significant differences between the three groups in the incidences of all-cause mortality (ACM, p = 0.048), cardiac mortality (CM, p = 0.024), major adverse cardiovascular (CV) events (MACEs, p = 0.006), and major adverse cardiovascular and cerebrovascular events (MACCEs, p = 0.009). In the population with diabetes, there were significant differences between the three groups in the incidences of ACM, CM, MACEs, and MACCEs (all p < 0.001). After multivariate Cox regression analyses, in the population without diabetes, the respective risks of ACM, CM, MACEs, and MACCEs were increased 89.9% [hazard ratio (HR) = 1.899, 95% CI: 1.285–2.807, p = 0.001], 115.1% (HR = 2.151, 95% CI: 1.378–3.356, p = 0.001), 48.1% (HR = 1.481, 95% CI: 1.152–1.904, p = 0.002), and 49.8% (HR = 1.498, 95% CI: 1.176–1.907, p = 0.001) in the third tertile compared with those in the first tertile. In the population with diabetes, the respective risks of ACM, CM, MACEs, and MACCEs were increased 248.5% (HR = 3.485, 95% CI: 1.973–6.154, p < 0.001), 260.4% (HR = 3.604, 95% CI: 1.866–6.963, p < 0.001), 130.2% (HR = 2.302, 95% CI: 1.649–3.215, p < 0.001), and 119.8% (HR = 2.198, 95% CI: 1.600–3.018, p < 0.001) in the third tertile compared with those in the first tertile.

Conclusion

The present study indicated that the Gensini score is an independent predictor of long-term adverse outcomes in patients with CAD who underwent PCI, and it has more predictive value in the population with diabetes.

Chronic kidney disease and diabetes associated with long-term outcomes in patients receiving percutaneous coronary intervention

Background

The effect of diabetes mellitus (DM) and chronic kidney disease (CKD) on long-term outcomes in patients receiving percutaneous coronary intervention (PCI) is unclear.

Methods

A total of 1394 patients who underwent PCI were prospectively enrolled and divided into 4 groups according to the presence or absence of DM or CKD. Baseline characteristics, risk factors, medications, and angiographic findings were compared. Determinants of long-term outcomes in patients undergoing PCI were analyzed.

Results

Patients with DM and CKD had the highest all-cause mortality and cardiovascular mortality (both P < 0.01) but there were no differences existed in myocardial infarction (MI) or repeated PCI among the 4 groups (P = 0.19, P = 0.87, respectively). Patients with DM and CKD had the lowest even-free rate of all-cause mortality, cardiovascular mortality, MI, and repeated PCI (P < 0.001, P < 0.001, P < 0.001, and P = 0.002, respectively). In the Cox proportional hazard model, patients with both DM and CKD had the highest risk of all-cause mortality (HR: 3.25, 95% CI: 1.85–5.59), cardiovascular mortality (HR: 3.58, 95% CI: 1.97–6.49), MI (HR: 2.43, 95% CI: 1.23–4.08), and repeated PCI (HR: 1.79, 95% CI: 1.33–2.41). Patients with CKD alone had the second highest risk of all-cause mortality (HR: 2.04, 95% CI: 1.15–3.63), cardiovascular mortality (HR: 2.13, 95% CI: 1.13–4.01), and repeated PCI (HR: 1.47, 95% CI: 1.09–1.97).

Conclusions

DM and CKD had additive effect on adverse long-term outcomes in patients receiving PCI; CKD was a more significant adverse predictor than DM.

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.

Long-term mortality after acute myocardial infarction among individuals with and without diabetes: A systematic review and meta-analysis of studies in the post-reperfusion era

AIMS

To conduct a systematic review and meta-analysis with the aim of providing robust estimates of the association between diabetes and long-term (≥1 year) mortality after acute myocardial infarction (AMI).

MATERIAL AND METHODS

Medline, Embase and Web of Science databases were searched (January 1985 to July 2016) for terms related to long-term mortality, diabetes and AMI. Two authors independently abstracted the data. Hazard ratios (HRs) comparing mortality in people with and without diabetes were pooled across studies using Bayesian random-effects meta-analysis.

RESULTS

A total of 10 randomized controlled trials and 56 cohort studies, including 714 780 patients, reported an estimated total of 202 411 deaths over the median (range) follow-up of 2.0 (1-20) years. The risk of death over time was significantly higher among those with diabetes compared with those without (unadjusted HR 1.82, 95% credible interval [CrI] 1.73-1.91). Mortality remained higher in the analysis restricted to 23/64 cohorts reporting data adjusted for confounders (adjusted HR 1.48, 95% CrI 1.43-1.53). The excess long-term mortality in diabetes was evident irrespective of the phenotype and modern treatment of AMI, and persisted in early survivors (unadjusted HR 1.82, 95% CrI 1.70-1.95).

CONCLUSIONS

Despite medical advances, individuals with diabetes have a 50% greater long-term mortality compared with those without. Further research to understand the determinants of this excess risk are important for public health, given the predicted rise in global diabetes prevalence.

High event rate after a first percutaneous coronary intervention in patients with diabetes mellitus: results from the Swedish coronary angiography and angioplasty registry

BACKGROUND

Patients with diabetes mellitus have reduced longevity after acute coronary syndromes and revascularization. However, knowledge of the long-term complication rates and patterns from an everyday life setting is lacking.

METHODS AND RESULTS

Consecutive patients undergoing percutaneous coronary intervention included in the Swedish Coronary Angiography Angioplasty Registry (SCAAR) between 2006 and 2010 and with no previous revascularization were prospectively followed up for combined cardiovascular events (first of all-cause mortality, myocardial infarction, stroke, and heart failure) until December 31, 2010. The mean follow-up period was 920 days (SD, 530 days). Differences in background and procedural characteristics were adjusted for in a multivariate Cox regression model. Of 58 891 patients, mean age 67 years, 19% had diabetes mellitus; 27% of them were on diet treatment, 33% on oral glucose lowering, and 40% on insulin treatment. At admission, cardiovascular risk factors, multiple coronary vessel, and left main stem disease were more frequent in patients with diabetes mellitus and their revascularization was less often complete. The adjusted risk for combined cardiovascular events was higher in patients on insulin (hazard ratio [95% confidence interval], 1.63 [1.55-1.72]), on oral treatment (1.23 [1.15-1.31]), and on diet alone (1.21 [1.12-1.29]) compared with patients without diabetes mellitus. Insulin-treated patients ran an increased risk of restenosis (1.54 [1.39-1.71]) and stent thrombosis (1.56 [1.25-1.96]).

CONCLUSIONS

The prognosis after a first percutaneous coronary intervention is more severe in patients with diabetes mellitus, in particular, in patients treated with insulin, with higher rates of mortality, cardiovascular events, and stent thrombosis over the following 5 years.

Clinical outcomes and medication adherence in acute coronary syndrome patients with and without type 2 diabetes mellitus: a longitudinal analysis 2006-2011

BACKGROUND

The presence of type 2 diabetes mellitus magnifies the risks associated with acute coronary syndrome (ACS), increasing the risk of recurrent cardiovascular events (CVEs) and doubling the risk of death. Managing cardiovascular risk factors has little effect on lowering the mortality risk in patients with type 2 diabetes.

OBJECTIVE

To evaluate the relationship between type 2 diabetes mellitus and subsequent CVEs and medication adherence following ACS hospitalization.

METHODS

Patients with ACS were identified using ICD-9-CM codes for acute myocardial infarction or unstable angina. The risk of subsequent CVEs was assessed at 1 and 3 years after the index ACS event based on type 2 diabetes status, adjusting for baseline demographic characteristics, comorbidities, medication use, and index ACS characteristics.

RESULTS

Of 140,903 patients with ACS (mean age 66.8 years, 58.6% male), 27.4% had type 2 diabetes. During follow-up, 22.0% had subsequent CVEs (26.2% type 2 diabetes, 19.0% nondiabetes). After adjusting for other covariates, type 2 diabetes was associated with increased risk of subsequent CVEs by 9.7% at 1 year and 10.2% at 3 years (both P < 0.001). Most patients were not revascularized at first recurrence after index ACS discharge (79.2% type 2 diabetes, 77.5% nondiabetes). Patients with type 2 diabetes had statistically significant higher adherence rates for antiplatelet agents at 1 year and antihypertensives at 1 and 3 years versus nondiabetes patients. Persistence was higher in the type 2 diabetes group for antihypertensives and in the nondiabetes group for antiplatelet agents and statins.

CONCLUSIONS

This analysis demonstrates that patients with type 2 diabetes have a higher risk of subsequent CVEs following an initial event versus those without diabetes, despite evidence of higher treatment persistence for certain medications. Adherence rates remained suboptimal, suggesting a continuing need for patient education.

Long-term mortality after primary percutaneous coronary intervention for ST-segment elevation myocardial infarction in patients with insulin-treated versus non-insulin-treated diabetes mellitus

AIMS

We investigated the impact of preadmission diabetic status on long-term outcome in patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI), to improve risk stratification.

METHODS AND RESULTS

Between 1997 and 2007, 4,402 STEMI patients were admitted to our hospital and stratified as having insulin-treated diabetes mellitus (ITDM) (n=176), non-ITDM (NITDM) (n=354) and non-DM (n=3,872). Five-year mortality was significantly higher in patients with DM compared to non-DM (29% vs. 18%, p<0.01). After stratification for preadmission glucose-lowering therapy, five-year mortality was significantly higher in ITDM patients compared to NITDM (36% vs. 25%, p=0.01) and in NITDM patients compared to non-DM patients (25% vs. 18%, p<0.01). After adjustment for age and gender the mortality risk between patients with NITDM versus non-DM was comparable (HR: 1.1, 95% CI: 0.9-1.4, p=0.38), in contrast to patients with ITDM (HR: 1.9, 95% CI: 1.5-2.5, p<0.01) and ITDM versus NITDM (HR: 1.7, 95% CI: 1.2-2.4, p<0.01). After adjustment for all baseline characteristics, the results were comparable to the age and gender adjusted model.

CONCLUSIONS

ITDM was a strong predictor for long-term mortality when compared to non-DM and NITDM. The mortality between patients without DM and NITDM was comparable after adjustment for age and gender.

A review of cardiovascular outcomes in the treatment of people with type 2 diabetes

INTRODUCTION

Cardiovascular disease (CVD) is a common and serious complication of type 2 diabetes mellitus (T2DM) often linked to the increased morbidity and mortality associated with T2DM. Monitoring and treating risk factors for CVD are important elements of diabetes management. This review aims to examine CV risk in people with relatively early and mild diabetes who are at substantial risk of CVD; it considers the impact of insulin therapy on this risk by focusing on key studies in patients with diabetes.

METHODS

A literature search was carried out using PubMed to identify key publications, between 2008 and 2013, related to insulin and its possible effect on CVD. This review examines CV risk in diabetes and the impact of insulin therapy on this risk.

RESULTS

Studies have shown that treatment with insulin glargine is associated with marked improvement in the lipid profile of people with T2DM. Intensive insulin therapy has been shown to lower mortality rates in people with diabetes following acute myocardial infarction after 1 year. Retrospective data also indicate that insulin reduces the risk of CVD events, regardless of whether people had comorbidities known to increase CV risk. The prospective ORIGIN (Outcome Reduction with Initial Glargine Intervention) trial found that treatment with insulin glargine had a neutral effect with regard to CV outcomes in people with prediabetes or early diabetes, compared with standard care.

CONCLUSIONS

Other ongoing, large-scale studies of insulin therapy should provide further insights into whether or not insulin therapy can influence long-term CV outcomes.

The clinical burden of type 2 diabetes in patients with acute coronary syndromes: prognosis and implications for short- and long-term management

Type 2 diabetes mellitus (T2DM) is associated with increased morbidity and mortality in patients with acute coronary syndromes (ACS). Cardiometabolic risk factors, including hyperglycaemia, insulin resistance, atherogenic dyslipidaemia, increased visceral fat and inflammation, are associated with increased risk in this population and represent potential targets for treatment. In this review, management strategies for patients with T2DM post-ACS, both in the acute-care setting and in the long-term, are discussed. Although the benefits of long-term, aggressive, multifactorial risk factor modification are well established, a significant burden of recurrent events remains and the search for novel strategies continues. Several studies are assessing the potential cardiovascular (CV) benefits and safety of various classes of newer agents. Of these, AleCardio (aleglitazar), Examination of Cardiovascular Outcomes With Alogliptin versus Standard of Care in Patients With Type 2 Diabetes Mellitus and Acute Coronary Syndrome (EXAMINE; alogliptin) and Evaluation of LIXisenatide in Acute Coronary Syndrome (ELIXA; lixisenatide) specifically address patients with type 2 diabetes post-ACS. The mechanisms of action of these new therapies and aims of the CV outcome studies are briefly reviewed. The prevalence of type 2 diabetes continues to increase worldwide highlighting the need for new strategies that address the complex underlying processes that drive atherosclerosis and CV events in this high-risk patient population.

Effectiveness of percutaneous coronary intervention within 12 hours to 28 days of ST-elevation myocardial infarction in a real-world Chinese population

Objectives

Percutaneous coronary intervention( PCI) for ST-elevation myocardial infarction (STEMI) has been widely accepted for patient who come within 12 hours, but for those who come to the hospital late (12 hours to 28 days) the long-term data and possible predictors are limited regarding ‘hard’ endpoints in ‘real world’.

Methods

The registry data of all 5523 consecutive patients admitted due to an incident STEMI (12 hours to 28 days) in our center were analyzed. Patients were divided into 3 age groups (age<65; age = 65–74; age ≥75) and two therapeutic groups including conservative and PCI group. The primary endpoints included 30-day mortality and 1-year mortality.

Results

The clinical characteristics include female gender; history of diabetes mellitus, previous myocardial infarction, cerebral vascular disease, chronic renal failure, atrial fibrillation, hypertension, anemia, gastric bleeding; presentation of ventricular tachycardia/ventricular fibrillation, pneumonia, heart failure, multiple organ failure and cardiogenic shock. The ratio of all the above factors increased with the age getting older (all p<0.05), while that of the PCI decreased significantly with ageing (53.9%, 36.3% and 21.7%). Except hypertension, all the other factors were less seen in the PCI group than in the conservative group (p<0.01). Pooled estimates, based on type of therapy and age groups, PCI resulted in significantly lower 30-day and 1-year mortality. Cox analysis showed the positive predictors for 30 days and 1 year mortality were heart failure, cerebral vascular disease, chronic renal failure, ventricular tachycardia/ventricular fibrillation, age, female, gastric intestinal bleeding, cardiogenic shock, multiple organ failure, while PCI was a negative predictor. ROCs analysis showed AUCs were always higher for PCI group.

Conclusions

The elderly have more comorbidities and higher rates of mortality, mandating thorough evaluation before acceptance for PCI. PCI between 12 hours to 28 days in all ages of patients including the elderly with STEMI is significantly more effective than conservative therapy.

Type 2 diabetes and cardiovascular disease in women

Cardiovascular disease is the leading cause of death in both men and women. This is also true for patients with diabetes. In general, differences between the sexes are present in several areas, such as epidemiology, pathophysiology, diagnostics, treatment response and prognosis, as well as the way in which disease is experienced and expressed. Cardiovascular disease presents later in life in women, who are therefore more likely to suffer from comorbidities. However, this age-related difference is attenuated in women with diabetes, who suffer their first myocardial infarction at about the same age as men with diabetes. Diabetes mellitus increases the risk of cardiovascular disease by three to four times in women and two to three times in men, after adjusting for other risk factors. This paper describes the differences in cardiovascular disease in men and women and the special situation of women with type 2 diabetes when it comes to risk factors, symptoms and the setting of acute coronary syndromes. Furthermore, it highlights the importance of sex-specific analyses in clinical research to improve our knowledge of cardiovascular disease in women in general and in women with diabetes in particular. The importance of taking sex into account when treating women and men at risk of cardiovascular disease is discussed.

Long-term mortality in patients with type 2 diabetes undergoing coronary angiography: the impact of glucose-lowering treatment

AIMS/HYPOTHESIS

The aim of this study was to analyse whether the increased mortality rates observed in insulin-treated patients with type 2 diabetes and coronary artery disease are explained by comorbidities and complications.

METHODS

A retrospective analysis of data from two Swedish registries of type 2 diabetic patients (n = 12,515) undergoing coronary angiography between the years 2001 and 2009 was conducted. The association between glucose-lowering treatment and long-term mortality was studied after extensive adjustment for cardiovascular- and diabetes-related confounders. Patients were classified into four groups, according to glucose-lowering treatment: diet alone; oral therapy alone; insulin in combination with oral therapy; and insulin alone.

RESULTS

After a mean follow-up time of 4.14 years, absolute mortality rates for patients treated with diet alone, oral therapy alone, insulin in combination with oral therapy and insulin alone were 19.2%, 17.4%, 22.9% and 28.1%, respectively. Compared with diet alone, insulin in combination with oral therapy (HR 1.27; 95% CI 1.12, 1.43) and insulin alone (HR 1.62; 95% CI 1.44, 1.83) were associated with higher mortality rates. After adjustment for baseline differences, insulin in combination with oral glucose-lowering treatment (HR 1.22; 95% CI 1.06, 1.40; p < 0.005) and treatment with insulin only (HR 1.17; 95% CI 1.02, 1.35; p < 0.01) remained independent predictors for long-term mortality.

CONCLUSIONS/INTERPRETATION

Type 2 diabetes patients treated with insulin and undergoing coronary angiography have a higher long-term mortality risk after adjustment for measured confounders. Further research is needed to evaluate the optimal glucose-lowering treatment for these high-risk patients.

Impact of metabolic syndrome on clinical outcomes after drug-eluting stent implantation in patients with coronary artery disease

Metabolic syndrome (MetS) is regarded as a risk factor for coronary artery disease (CAD). However, the influence of MetS on morbidity and mortality after drug-eluting stent (DES) implantation in Chinese patients with CAD remains unknown. We evaluated the impact of MetS on the clinical outcome of 1224 patients following DES implantation. After a mean follow-up of 35.4 months, patients with MetS had a significantly higher incidence of all-cause death and major adverse cardiovascular events (MACE) compared with patients without MetS (P < .001). Analyses of individual MetS components showed that dysglycemia at the time of DES implantation predicted increased all-cause mortality, while the presence of hypertension and dysglycemia predicted increased incidence of MACE.

Paclitaxel-eluting stents compared with bare metal stents in diabetic patients with acute myocardial infarction: the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial

BACKGROUND

In the prospective, randomized Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial, implantation of paclitaxel-eluting stents (PES) safely reduced the rates of ischemic target lesion revascularization (TLR) compared with bare metal stents (BMS) in patients with ST-segment-elevation myocardial infarction (STEMI) undergoing primary percutaneous intervention. Diabetes mellitus is a known predictor of adverse outcomes after percutaneous intervention in STEMI. We therefore sought to assess the impact of PES in diabetic patients with STEMI from the HORIZONS-AMI trial.

METHODS AND RESULTS

A total of 478 patients with diabetes and 2527 without diabetes were randomly assigned to receive PES versus BMS. The 12-month rates of ischemic TLR were significantly reduced by PES compared with BMS in both diabetic (11.2% versus 5.2%; hazard ratio [95% confidence interval]=0.45 [0.21 to 0.93]; P=0.03) and nondiabetic (6.8% versus 4.3%, hazard ratio [95% confidence interval]=0.63 [0.44 to 0.92]; P=0.02) patients. In patients with insulin-treated diabetes, PES compared with BMS reduced the 12-month TLR rate from 21.4% to 7.3% (hazard ratio [95% confidence interval]=0.35 [0.12 to 1.03]; P=0.046). Angiographic late loss and binary restenosis at 13 months were also significantly reduced in PES-treated diabetic patients. There were no significant differences between the BMS and PES groups in the 12-month rates of death, reinfarction, stroke, or stent thrombosis in either diabetic or nondiabetic patients.

CONCLUSIONS

In the large-scale, prospective, randomized HORIZONS-AMI trial, implantation of PES compared with BMS in patients with STEMI and diabetes mellitus resulted in significant reductions in ischemia-driven TLR and angiographic restenosis at 1 year, with comparable safety outcomes, including stent thrombosis. These results suggest that PES can safely be used to reduce restenosis in high-risk diabetic patients presenting with STEMI.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00433966.

Impact of drug-eluting stents and diabetes mellitus in patients with coronary bifurcation lesions: a survey from the Italian Society of Invasive Cardiology

BACKGROUND

We investigated the long-term impact of different stent types and diabetes mellitus (DM) in patients undergoing percutaneous coronary intervention (PCI) of bifurcation lesions, based on a large multicenter survey endorsed by the Italian Society of Invasive Cardiology.

METHODS AND RESULTS

Relative benefits of drug eluting stent (DES) over bare metal stent (BMS) in patients with (n=1049) and without (n=3020) DM were analyzed with extensive multivariable adjustment. At 3 years, stenting with DES was associated with lower adjusted risk of major adverse cardiac events (MACE, adjusted hazard ratio [HR] 0.27, 95% confidence interval [CI] 0.15 to 0.49, P<0.001), cardiac death, and target lesion revascularization in DM patients but failed to demonstrate any significant benefit in patients without DM.

CONCLUSIONS

In a large observational registry with admitted potential for selection bias and residual confounding, DES in DM patients with coronary bifurcation lesions were associated with improved outcomes in terms of MACE, cardiac death, and repeat revascularization at long-term follow up. These figures were not replicated in non-DM subjects.