The effect of diabetes mellitus on the outcome of angioplasty for lower limb ischaemia.

Angioplasty is an important tool in the armamentarium of the clinician dealing with atherosclerotic disease. Diabetic patients with occlusive disease pose special problems. Four hundred and twenty-five lesions were dilated in 370 patients. No difference in site was found when comparing the diabetic and non-diabetic groups (p less than 0.001), but a significant difference in indication for treatment was observed. Cumulative patency at 5 years for iliac lesions in non-diabetic patients was 61.2% and in diabetic patients was 35.6% (p less than 0.05), for superficial femoral and popliteal artery lesions in non-diabetic patients it was 49.7% and in diabetic patients it was 38.8% (NS). The need for subsequent surgical intervention (p less than 0.01) and risk of death (p less than 0.001) are both significantly greater in the diabetic group. This study shows that angioplasty is a technique that can be used with success in diabetic patients and if the indications for interventions are compared, diabetic patients do not worse.     

Hospital outcome of acute myocardial infarction in patients with and without diabetes mellitus.

AIMS: To assess hospital mortality and morbidity in diabetic and non-diabetic patients with acute myocardial infarction and to compare the results between the two groups. METHODS: All patients admitted in 1999 to the intensive care unit of the Schwabing City Hospital with diagnosis of acute myocardial infarction were assessed for hospital mortality and co-morbidity. RESULTS: Three hundred and thirty patients with acute myocardial infarction were admitted. Of those, 126 (38%) were diabetic and 204 (62%) were non-diabetic patients. Mortality within 24 h after admission was 13.5% in diabetic patients and 5.4% in non-diabetic patients (P<0.01). Mortality during entire hospitalization was higher in diabetic than in non-diabetic patients (29.4% vs. 16.2%; P=0.004). Diabetic patients were resuscitated more frequently than non-diabetic patients (24% vs. 11%, P<0.01). In diabetic patients, heart rate at admission was increased (91 +/- 27 vs. 82 +/- 23/min; P<0.01) and presence of angina pectoris was reported less frequently (59% (n=72) vs. 82% (n=167); P<0.001). Preceding myocardial infarction, microalbuminuria, peripheral artery disease and arterial hypertension were more frequent in diabetic than in non-diabetic patients. Diabetic patients demonstrated higher C-reactive protein (CRP) levels than non-diabetic patients (91.4 +/- 78.2 mg/l vs. 45.2 +/- 62.4 mg/l; P<0.001). CONCLUSIONS: In diabetic patients with acute myocardial infarction, early hospital mortality is increased and signs of cardiac autonomic dysfunction and microangiopathy are detected more frequently than in non-diabetic patients. The need for advanced treatment strategies early in the course of diabetic patients with myocardial infarction is emphasized.     

Causes of death in patients with peptic ulcer perforation: a long-term follow-up study

BACKGROUND: Survival is lower in ulcer perforation patients than in the general population. This study assesses the causes of death in patients treated for peptic ulcer perforation. METHODS: Cause-specific mortality in a population-based cohort of 817 patients treated for ulcer perforation in western Norway during the period 1962-1990 was compared with cause-specific population death rates. Analyses were based on observed and expected mortality curves for major causes of death and on standardized mortality rates (SMRs). Cox regression models were used to analyse possible differences on the basis of sex, birth cohort, surgical procedure, and ulcer location. RESULTS: Ulcer perforation patients experienced increased mortality from neoplasms (SMR = 1.8; 95% confidence interval (CI) = 1.4-2.1), lung cancer (SMR = 3.6; 95% CI = 2.3-4.9), circulatory diseases (SMR = 1.3; 95% CI = 1.1-1.6), ischaemic heart disease (SMR = 1.3; 95% CI = 1.03-1.6), and respiratory diseases (SMR = 1.9; 95% CI = 1.3-2.6). Postoperative deaths accounted for 38% of all excess deaths. Death from recurrent peptic ulcer was increased also in subjects who survived the 1st year after the perforation (SMR = 5.8; 95% CI = 1.2-10.4) but accounted for only a few deaths. The increase in mortality from lung cancer was higher in subjects born after 1910 than in patients of older generations. Excess mortality from lung cancer and from circulatory diseases was higher in male than in female patients. CONCLUSIONS: Increased mortality in ulcer perforation patients could mainly be attributed to smoking-related diseases. This is indirect evidence that smoking may be an important aetiologic factor for ulcer perforation.     

Influence of diabetes mellitus on the clinical manifestations and prognosis of infective endocarditis: a report from the International Collaboration on Endocarditis-Merged Database

The purpose of this investigation was to study the influence of diabetes mellitus (DM) on outcomes of infective endocarditis (IE). Outcomes were compared between 150 diabetic and 905 non-diabetic patients with IE from the International Collaboration on Endocarditis Merged Database. Compared to non-diabetic patients, diabetic patients were older (median age 63 vs 57 y, p<0.001), were more often female (42.0% vs 31.9%, p=0.01), more often had comorbidities (41.5% vs 26.7%, p<0.001), and were more likely to be dialysis dependent (12.7% vs 4.0%, p<0.001). S. aureus was isolated more often (30.7% vs 21.7%, p=0.02), and microorganisms from the viridans Streptococcus group less often (16.7% vs 28.2%, p = 0.001) in the diabetic group. There was no difference with respect to the presence of congestive heart failure, embolism, intra-cardiac abscess, new valvular regurgitation, or valvular vegetation. Diabetic patients underwent surgical intervention less frequently (32.0% vs 44.9%, p = 0.003), and had higher overall in-hospital mortality (30.3% vs 18.6%, p = 0.001). On multivariable analysis, DM was an independent predictor of mortality (odds ratio (OR) = 1.71, 95% confidence interval (CI) 1.08-2.70), especially in male patients, as diabetic males had higher mortality than non-diabetic males (OR 2.18, CI 1.08-4.35). DM is an independent predictor of in-hospital mortality among patients hospitalized with IE.     

Myocardial infarct in diabetes mellitus: short- and long-term prognostic factors

To determine the evolution of acute myocardial infarction in patients with diabetes we study 207 consecutive patients with myocardial infarction. Using WHO's criteria 23% of our cases were diagnosed of diabetes mellitus. Diabetic patients were older than non diabetic (67.9 +/- 10 years vs. 62.4 +/- 11 years, p less than 0.05) and had a higher ratio of females (52% vs. 21%, p less than 0.001). Cigarette smoking was infrequent in diabetic population. Incidence of other risk factors was comparable. Despite an increased proportion on no q-wave myocardial infarction in the diabetic patients (12.5% vs. 6.9%, p NS), the site of infarction was similar into the two groups. Acute phase mortality was higher in the diabetic group (37.5% vs. 16.3%, p less than 0.001). This increased mortality is, partially, related to an increased incidence of pump failure, but a multivariate analysis using stepwise logistic regression, selected diabetes as an independent predictor of prognosis. Survivors were followed for 41 +/- 20 months; diabetic patients showed a poor prognosis with a higher incidence of congestive heart failure (42.8% vs. 13.7%, p less than 0.01), reinfarction (16.6% vs. 8.5%) and death. Cox proportional hazard model selected diabetes as an independent predictor of survival. We conclude that patients with diabetes mellitus constitute a subgroup into the myocardial infarction population; this subgroup had greater mortality than non diabetic patients in relation to increased incidence of pump failure, but multivariate analysis indicates that other factors not considered in the present study may play a role in their poor prognosis.     

Relation of lipid peroxides to macrovascular disease in type 2 diabetes.

Lipid peroxides are thought to be formed by free radicals and may play an important role in the development of atheromatous vascular disease. We have investigated the relationship between lipids, lipoproteins, coagulation factors, and lipid peroxides (measured as thiobarbituric acid reacting species (TBARS) in Type 2 diabetic patients with macrovascular disease. Eighteen diabetic and 20 non-diabetic subjects with clinical evidence of ischaemic heart disease and/or peripheral vascular disease were investigated, together with 28 healthy subjects without evidence of vascular disease. TBARS concentrations in non-diabetic (mean 5.0 (95% Cl 4.5-5.7) mumol l-1) and diabetic groups (5.6 (5.1-6.0) mumol l-1) with macrovascular disease were not significantly different although values were higher in both groups of patients with vascular disease by comparison with control subjects (2.7 (2.4-3.1) mumol l-1, p less than 0.001). Significant univariate correlations between TBARS concentrations and measures of blood glucose control (fructosamine, blood glucose and HbA1) were found for all 66 subjects (r = 0.35-0.42, p less than 0.01-p less than 0.001), although no independent association between these parameters and TBARS was demonstrated in multiple regression analysis.(ABSTRACT TRUNCATED AT 250 WORDS)     

National study of cause-specific mortality in rheumatoid arthritis,juvenile chronic arthritis,and other rheumatic conditions: a 20 year followup study

OBJECTIVE: To quantify risks for cause-specific mortality among hospitalized patients with rheumatoid arthritis (RA), juvenile chronic arthritis (JCA), and 4 other rheumatic conditions in a nationwide, population based cohort over a 20 year period. METHODS: All subjects were identified from Scottish hospital inpatient records from 1981 to 2000 and were followed up by computer linkage to the national registry of deaths. Expected mortality was calculated from national mortality rates and was related to the observed incidence by the standardized mortality ratio (SMR) and the corresponding 95% confidence interval (95% CI). RESULTS: Overall mortality was elevated in each of the 6 rheumatic conditions examined, most notably in JCA (males: SMR 3.4, 95% CI 2.0,5.5; females: SMR 5.1, 95% CI 3.2,7.8). Among patients with RA, there was an increased risk for death in all International Classification of Disease chapters other than those relating to mental disorders. Specific causes of death with an increased risk for subjects with RA included lung cancer [males: 1.4 (1.2,1.5); females: 1.6 (1.5,1.8)], hematopoietic malignancies [M: 1.8 (1.4,2.3); F: 2.0 (1.7,2.3)], coronary artery disease (CAD) [M: 1.6 (1.5,1.7); F: 1.95 (1.9,2.0)], respiratory infections [M: 1.9 (1.7,2.2); F: 2.4 (2.3,2.6)], chronic obstructive pulmonary disease [M: 1.8 (1.6,2.0); F: 2.1 (1.9,2.3)], and renal failure [M: 3.1 (2.5,3.9); F: 3.5 (3.0,4.0)]. Conversely, RA subjects were less likely to die from gastrointestinal tract malignancies [M: 0.82 (0.7,1.0); F: 0.8 (0.7,0.9)]. CONCLUSION: Population studies for primary data collection are required to extend our knowledge about the underlying mechanisms of early mortality in patients with rheumatic conditions.     

Long-term mortality in a nationwide cohort of childhood-onset type 1 diabetic patients in Norway

Aims/hypothesis We examined long-term total and cause-specific mortality in a nationwide, population-based Norwegian cohort of patients with childhood-onset type 1 diabetes. Materials and methods All Norwegian type 1 diabetic patients who were diagnosed between 1973 and 1982 and were under 15 years of age at diagnosis were included (n=1,906). Mortality was recorded from diabetes onset until 31 December 2002 and represented 46,147 person-years. The greatest age attained among deceased subjects was 40 years and the maximum diabetes duration was 30 years. Cause of death was ascertained by reviews of death certificates, autopsy protocols and medical records. The standardised mortality ratio (SMR) was based on national background statistics. Results During follow-up 103 individuals died. The mortality rate was 2.2/1000 person-years. The overall SMR was 4.0 (95% CI 3.2–4.8) and was similar for males and females. For ischaemic heart disease the SMR was 20.2 (7.3–39.8) for men and 20.6 (1.8–54.1) for women. Acute metabolic complications of diabetes were the most common cause of death under 30 years of age (32%). Cardiovascular disease was responsible for the largest proportion of deaths from the age of 30 years onwards (30%). Violent death accounted for 28% of the deaths in the total cohort (35% among men and 11% among women). Conclusions/interpretation Childhood-onset type 1 diabetes still carries an increased mortality risk when compared with the general population, particularly for cardiovascular disease. To reduce these deaths, attention should be directed to the prevention of acute metabolic complications, the identification of psychiatric vulnerability and the early detection and treatment of cardiovascular disease and associated risk factors. Electronic Supplementary Materials Supplementary material is available in the online version of this article at . T. Skrivarhaug et al.: Mortality of type 1 diabetes in Norway     

Interferon treatment improves survival in chronic hepatitis C patients showing biochemical as well as virological responses by preventing liver-related death

Interferon therapy for chronic hepatitis C reduces the risk of hepatocellular carcinoma, especially among virological and biochemical responders. However, little is known about the effect of interferon therapy on mortality. We studied the long-term effect of interferon therapy on mortality in patients with chronic hepatitis C. For this retrospective cohort study, 2954 patients with chronic hepatitis C were recruited, of whom 2698 received interferon therapy and 256 did not. The effect of interferon therapy on survival was assessed by standardized mortality ratio (SMR) based on published mortality data for the general Japanese population and by risk ratio calculated by proportional hazard regression. Over 6.0 +/- 2.2 years follow-up, death from liver-related diseases was observed in 69 (68%) of 101 deaths among interferon-treated patients and in 42 (81%) of 52 deaths among untreated patients. Compared with the general population, overall mortality was high among untreated patients (SMR: 2.7; 95% CI: 2.0-3.6) but not among interferon-treated patients (SMR: 0.9; 95% CI: 0.7-1.1). Liver-related mortality was extremely high among untreated patients (SMR: 22.2; 95% CI: 16.0-30.0) and less among interferon-treated patients (SMR: 5.5; 95% CI: 4.3-6.9). The risk of death from all causes was lower for interferon-treated than untreated patients (risk ratio: 0.47; 95% CI: 0.261-0.836; P = 0.01). The risk of death from liver-related diseases was significantly lower for sustained virological responders (risk ratio: 0.04; 95% CI: 0.005-0.301; P = 0.002) compared with untreated patients, but not for nonsustained virological responders. Sustained biochemical responders (risk ratio: 0.03; 95% CI: 0.004-0.230; P < 0.001) and transient biochemical responders (risk ratio: 0.18; 95% CI: 0.063-0.532; P = 0.002) showed a significantly reduced risk of death from liver-related death, whereas biochemical nonresponders did not. Hence interferon treatment improved survival in chronic hepatitis C patients showing a biochemical as well as a virological response by preventing liver-related deaths.     

Prognosis after stroke in diabetic patients. A controlled prospective study

Summary Cohorts of diabetic (n=121) and non-diabetic (n=584) patients were prospectively followed for up to ten years after having suffered from a stroke. All but six of the diabetic patients had Type 2 (non-insulin-dependent) diabetes mellitus. The diabetic patients had more risk factors associated with stroke: heart failure (p<0.001) and angina pectoris (p<0.001), than the non-diabetic patients. Neither body mass index nor blood pressure levels differed between the groups at admission. Haematocrit levels were higher in the diabetic group (p<0.01). The diabetic patients were more commonly afflicted by cerebral embolism and to a lesser extent by transient ischaemic attacks than the nondiabetic patients. When calculated by log-rank tests, the diabetic group had an increased risk of death (p<0.001), recurrent stroke (p=0.001), and of myocardial infarction (p=0.001) after the initial stroke. Autopsy-verified causes of death between the groups did not differ significantly, although half of all deaths during the period one to six months after stroke were caused by pulmonary embolism in the diabetic group. Thus, diabetes increases the risk of death after a stroke, and it also increases among stroke survivors the risk of recurrent stroke and myocardial infarction.     

Long-term outcome in diabetic heart failure patients treated with cardiac resynchronization therapy

BACKGROUND: Diabetes mellitus is an independent risk factor for increased morbidity and mortality in heart failure (HF) patients. AIMS: To compare functional and structural improvement, as well as long-term outcome, between diabetic and non-diabetic HF patients treated with cardiac resynchronization therapy (CRT). METHODS: We compared response to CRT in 141 diabetic and 214 non-diabetic consecutive patients. Major events were; death from any cause, urgent heart transplantation and implantation of a left ventricular (LV) assist device. Frequencies of hospitalisation and defibrillator (CRT-D) discharges were also analyzed. RESULTS: CRT was able to significantly improve functional capacity, ventricular geometry and neurohumoral imbalance in both diabetic and non-diabetic patients over a median follow-up time of 34 months. Overall event-free survival was similar in diabetic and non-diabetic patients (HR 1.23, p=0.363), as was survival free from CRT-D interventions (HR 1.72; p=0.115) and hospitalisations (HR 1.12; p=0.500). On multivariable analysis, NYHA class IV (p=0.002), low LV ejection fraction (p=0.002), absence of beta-blocker therapy (p<0.001), impaired renal function (p=0.003), presence of an epicardial lead (p=0.025), but not diabetes (p=0.821) were associated with a poor outcome after CRT. CONCLUSIONS: Diabetic HF patients treated with CRT had a very favourable functional and survival outcome, which was comparable to non-diabetic patients.     

Prognostic significance of diabetes in acute myocardial infarction. Are the differences linked to female gender?

A prospective study of acute myocardial infarction was carried out in 1239 patients in order to assess both the prognostic significance of diabetes mellitus and the clinical characteristics associated with age and gender. Diabetes mellitus (DM) was found in 386 cases, often associated with old age, female gender, and more prevalent history of angina, heart failure, and hypertension. DM patients were admitted later and they were less likely to receive thrombolytic therapy, 47.9 vs. 58.1% (P<0.001). Complications more often associated with DM were: heart failure, 45 vs. 24.5% (P<0.01), and early, in-hospital and 1-year mortalities, 7.2 vs. 3.9% (P<0.05), 17.6 vs. 9.1% (P<0.001), and 29.2 vs. 16.2% (P<0.001), respectively. Compared with diabetic men, diabetic women were older and had a more prevalent history of hypertension and congestive heart failure. Diabetic women also had a higher rate of heart failure during hospitalisation, and of mortality, than diabetic men: early: 11.7 vs. 4.5% (P<0.01); in-hospital: 29.6 vs. 10.3% (P<0.001); and 1-year: 42.7 vs. 21.1% (P>0.001). DM was not selected by the multivariate analysis as a variable with independent prognostic value for mortality. In separate multivariate analysis for diabetic and non-diabetic patients, female gender had independent prognostic value for mortality only in the case of the diabetic population.     

Mortality in celiac disease

The mortality experienced by a cohort of 653 patients with celiac disease in Edinburgh and the Lothian region has been analyzed. Mortality overall was 1.9-fold (95% confidence limits, 1.5-2.2) that of the general population (115 deaths observed, 61.8 expected; p less than 0.0001). The increased mortality was greatest within 1 yr of diagnosis of celiac disease and steadily declined over time with the excess mortality being concentrated at ages 45-54 yr in men and 55-64 yr in women. Celiac disease was mentioned on the death certificate in 33 cases but in only 10 was it given as the underlying cause of death. Of 17 deaths from lymphoproliferative diseases (0.55 expected, p less than 0.001), 8 occurred within 2 yr of diagnosis of celiac disease compared with 8 (0.37 expected, p less than 0.001) occurring greater than 5 yr after diagnosis. Esophageal cancer was certified as the cause of four deaths (0.47 expected, p less than 0.01). In men mortality from all other malignant disease was also increased (15 deaths observed; 6.4 expected, p less than 0.01), but most of these deaths occurred within 5 yr of the diagnosis of celiac disease. In contrast, there was no deficit in deaths from ischemic heart disease or stroke and the mortality rate in those diagnosed in childhood as having celiac disease was similar to the general population.     

Mortality, mode of death and risk indicators for death during 5 years after coronary artery bypass grafting among patients with and without a history of diabetes mellitus

OBJECTIVE: To describe mortality, mode of death, risk indicators for death and symptoms of angina pectoris among survivors during 5 years after coronary artery bypass grafting (CABG) among patients with and without a history of diabetes mellitus. METHODS: All patients in western Sweden who underwent CABG without concomitant valve surgery and who had no previous CABG between June 1988 and June 1991 were entered prospectively in this study. After 5 years, information on deaths that had occurred was obtained for the analysis. RESULTS: In all, 1998 patients were included in the analysis; 242 (12%) had a history of diabetes. Among the non-diabetic patients, 5-year mortality was 12.5%; the corresponding relative risk for diabetic patients was 2.1 (95% confidence interval 1.6 to 2.9). A history of diabetes was an independent risk indicator of death; there was no significant interaction between any other risk indicator and diabetes. Independent risk indicators for death among diabetic patients were: current smoking, renal dysfunction and left ventricular ejection fraction < 0.40. Compared with non-diabetic patients, those with diabetes more frequently died in hospital, died a cardiac death, or had death associated with the development of acute myocardial infarction and with symptoms of congestive heart failure. Among survivors, diabetic patients tended to have more angina pectoris 5 years after CABG than did those without diabetes. CONCLUSION: During a period of 5 years after CABG, diabetic patients had a mortality twice that of non-diabetic patients. The increased risk included death in hospital, cardiac death and death associated with development of acute myocardial infarction and with symptoms of congestive heart failure.     

Multiple risk factors in coronary artery disease patients with abnormal glucose tolerance

Two hundred twenty five anginal symptomatic patients (37-75 years) undergoing selective coronary angiography were studied to clarify the importance of risk factors for coronary artery disease (CAD). Serum lipids, apolipoproteins, fasting blood glucose, hemoglobin A1 and A1c, serum insulin levels, hypertension, smoking and obesity were examined as coronary risk factors in 64 newly diagnosed non-insulin dependent diabetic patients (60 +/- 1 (+/- SE)yr), 88 impaired glucose tolerant (IGT) patients (58 +/- 1 yr) and 73 non-diabetic patients (62 +/- 1 yr). Diabetic and IGT patients showed significantly higher coronary atherosclerosis indices than non-diabetic patients (p less than 0.05). In the diabetic and IGT groups, the plasma triglyceride concentrations were significantly higher in the patients with coronary atherosclerosis (CAS) than in either patients without CAS (p less than 0.05) or non-diabetic patients with CAS (p less than 0.05). The prevalence of hypertension in the diabetic patients with CAS was higher than in the non-diabetic patients with CAS. These data suggest that hypertriglyceridemia and hypertension might be important as risk factors in the development of coronary atherosclerosis in persons with an abnormal glucose tolerance.     

Cardiac disease in diabetic end-stage renal disease

Summary Little is known about the epidemiology of cardiac disease in diabetic end-stage renal disease. We therefore prospectively followed a cohort of 433 patients who survived 6 months after the inception of dialysis therapy for an average of 41 months. Clinical and echocardiographic data were collected yearly. At baseline, diabetic patients (n = 116) had more echocardiographic concentric left ventricular hypertrophy (50 vs 38 %, p = 0.04), clinically diagnosed ischaemic heart disease (32 vs 18 %, p = 0.003) and cardiac failure (48 vs 24 %, p < 0.00 001) than non-diabetic patients (n = 317). After adjusting for age and sex, diabetic patients had similar rates of progression of echocardiographic disorders, and de novo cardiac failure, but higher rates of de novo clinically diagnosed ischaemic heart disease (RR 3.2, p = 0.0002), overall mortality (RR 2.3, p < 0.0001) and cardiovascular mortality (RR 2.6, p < 0.0001) than non-diabetic patients. Mortality was higher in diabetic patients following admission for clinically diagnosed ischaemic heart disease (RR 1.7, p = 0.05) and cardiac failure (RR 2.2, p = 0.0003). Among diabetic patients older age, left ventricular hypertrophy, smoking, clinically diagnosed ischaemic heart disease, cardiac failure and hypoalbuminaemia were independently associated with mortality. The excessive cardiac morbidity and mortality of diabetic patients seem to be mediated via ischaemic disease, rather than progression of cardiomyopathy while on dialysis therapy. Potentially remediable risk factors include smoking, left ventricular hypertrophy, and hypoalbuminaemia. [Diabetologia (1997) 40: 1307–1312] Received: 25 March 1997 and in final revised form: 23 June 1997     

Comparison of diabetic and non-diabetic patients referred for coronary angiography.

AIM: To evaluate whether diabetic patients differ from non-diabetic patients when referred for coronary angiography regarding previous history, indication for and findings at coronary angiography, use of medication, exercise test results and mortality. METHODS: Data were prospectively collected on patients referred for consideration of coronary revascularization to seven of the eight public Swedish heart centers that performed approximately 92% of all bypass operations in Sweden in 1994. RESULTS: 2762 patients were included of whom 406 (15%) had a history of diabetes mellitus. There was no difference in age or sex in the two groups. Chronic stable angina was the most common indication (73% in both groups) and only 3% were admitted due to silent ischemia. Diabetic patients had more severe symptoms (Canadian Cardiovascular Society III-IV) than non-diabetic patients (66% vs. 58%, p<0.01). They more frequently used ACE-inhibitors (33% vs. 19%, p<0.0001) and calcium channel blockers (47% vs. 40%, p<0.01) and more often had a diagnosis of arterial hypertension than non-diabetic patients (50% vs. 33%, p<0.0001). Diabetic patients more often had depressed myocardial function (EF<35%); 12% and 8%, respectively (p<0.01), and more extensive coronary artery disease (left main/3-VD; 48% vs. 37%, p<0.001). The mortality during the subsequent 21 months was 7.9% among diabetic patients and 3.6% among non-diabetic patients (p<0.001). CONCLUSION: Among patients being referred for coronary angiography in Sweden, 15% were patients with a history of diabetes. They differed from patients without such a history by more often having severe symptoms and a higher prevalence of left main/triple vessel disease. Coronary angiography may thus be underused in diabetic patients with chest pain.     

Management and short-term outcome of diabetic patients hospitalized for acute myocardial infarction: results of a nationwide French survey

OBJECTIVES: To compare management and short-term outcome of diabetic and non-diabetic patients hospitalized for acute myocardial infarction. METHODS: This was a prospective epidemiological survey. All patients admitted in coronary care units in France in November 2000 for confirmed acute myocardial infarction were eligible to enter the study. RESULTS: Of the 2320 patients recruited from 369 centers, 487 were diabetic (21%). Compared to non-diabetic patients, diabetic patients were 5 years older, more often female, obese and hypertensive; they had more often a history of cardiovascular disease; they had a lower ejection fraction and worse Killip class. Reperfusion therapy was less frequent among diabetic patients (39% versus 51%; p=0.0001), as was the use of beta-blockers (61% versus 72%; p=0.0001), aspirin (83% versus 89%; p=0.0001) and statins (52% versus 60%; p=0.001) during hospitalization. Conversely, the use of ACE-inhibitors was more frequent (54% versus 44%; p=0.0001). 58% of diabetic patients received insulin during hospitalization. Twenty-eight-day mortality was 13.1% in diabetic patients and 7.0% in non-diabetic patients (risk ratio: 1.87; p=0.001). Diabetes remained associated with increased mortality after adjustment for relevant risk factors including age and ejection fraction (risk ratio: 1.51; p=0.07). In patients treated with antidiabetic drugs (chiefly sulfonylureas) before admission, 28-day mortality was 10.4% compared with 19.9% in diabetic patients on diet alone or untreated (p=0.005). CONCLUSION: Despite higher cardiovascular risk and worse prognosis, in-hospital management of diabetic patients with acute myocardial infarction remains sub-optimal. Patients previously treated with antidiabetic drugs including sulfonylureas had a better prognosis than untreated diabetic patients.     

Short- and long-term results after multivessel stenting in diabetic patients

OBJECTIVES: The present study evaluated clinical outcomes in diabetic patients after multivessel stenting. BACKGROUND: Multivessel angioplasty studies have reported decreased survival in diabetic patients undergoing conventional balloon angioplasty compared with coronary artery bypass graft surgery (CABG). However, several studies have demonstrated excellent procedural success and acceptable clinical outcomes after multivessel stenting. METHODS: Multivessel stenting was performed in 689 patients with 1,639 native coronary lesions. Patients were classified into three groups according to diabetes mellitus (DM) status: 1) no DM (501 patients/1,200 lesions); 2) DM treated with oral agents (102 patients/235 lesions); and 3) DM treated with insulin (86 patients/204 lesions). RESULTS: Procedural success was high overall. In-hospital CABG was higher in diabetics treated with insulin compared with the other two groups (3.5% vs. 0.4% vs. 1.0%, p = 0.02). There were no significant differences in the incidence of in-hospital cardiac death and myocardial infarction. Diabetic patients treated with oral agents or insulin had higher one-year target lesion revascularization rates than non-diabetic patients (25% vs. 35% vs. 16%, p < 0.001). Lower one-year survival was observed in diabetic patients treated with either oral agents or insulin, compared with non-diabetic patients (85% vs. 86% vs. 95%, p < 0.001). On multivariable analysis, DM was an independent predictor of one-year mortality, myocardial infarction, and target lesion revascularization after multivessel stenting. CONCLUSIONS: Despite a high technical success rate of multivessel stenting, diabetic patients, especially those treated with insulin, have higher in-hospital CABG, higher subsequent revascularization rates, and lower one-year survival than non-diabetic patients.     

Mortality in Diabetic Subjects: An Eleven-year Follow-up of a Community-based Population

In 1979, all the known diabetic subjects (849) were identified from a community (population 81851), of whom 717 (85%) were reviewed by a single observer. Using the NHS Central Register, follow-up was completed for 98% of subjects. After 11 years, 306 (42.7%) diabetic subjects had died, of whom 65 were insulin treated and 241 were non-insulin treated. Circulatory disease accounted for 168 (54.9%) deaths, of which 124 (73.8%) were due to ischaemic heart disease. The standardized mortality ratio (SMR) for all causes of death, based on data from England and Wales, was significantly raised for both insulin-treated and non-insulin-treated patients (1.75, 95% CI 1.35 to 2.24 and 1.32, 95% CI 1.15 to 1.50, respectively). SMRs for all cause mortality were significantly greater for diabetic subjects in the 45–64 (SMR, 1.97, 95% CI 1.34 to 2.80), 65–74 (SMR 1.59, 95% CI 1.27 to 1.97 and 75 years and over (SMR, 1.26, 95% CI 1.08 to 1.45) age ranges. Using a proportional hazards model, after adjusting for age and gender, systolic blood pressure and vibration threshold were significant predictors of all cause mortality in insulin-treated subjects. For non-insulin-treated subjects, blood glucose, systolic blood pressure, glycated haemoglobin, retinopathy, proteinuria, coronary artery disease, and stroke were significant baseline predictors of mortality. No association was found for serum cholesterol, body mass index, diastolic pressure or cigarette smoking in either treatment group.