Comparison of short-term and long-term results after aortocoronary bypass in ischemic heart disease in diabetics and non-diabetics

In the presented study we have evaluated short-term and long-term results of the multiple aortocoronary bypass surgery in the patients with ischemic heart disease. We have compared the incidence of the preoperative and postoperative complications, short-term and long-term mortality in the group of diabetics in comparison to nondiabetics as well as the entry characteristics of both groups. Among 2518 patients who were treated with aortocoronary bypass surgery there were 773 (30.6%) diabetics. The diabetic patients were significantly elder, we have found more women among them, more frequent presence of hypertension, chronic heart failure and peripheral vascular disease. Contrary in the incidence of the previous myocardial infarction we have not found any significant difference between both groups. The patients with diabetes mellitus had lower ejection fraction of the left ventricle and significantly more extensive coronary artery disease which explains that in this group of patients the number of coronary bypasses was significantly higher. Comparing the incidence of preoperative complications we have not seen any significant difference between the patients with and without diabetes mellitus. Out of the postoperative complications we have noticed significantly more renal failure, infectious complications, low cardiac output syndrome and bleeding disorders in the diabetic patients. The duration of hospitalisation in the intensive care unit was significantly longer in diabetics (55.11 +/- 89.09 hours to 47.84 +/- 65.18 hours in nondiabetics, p < 0.05). 30 days mortality in diabetics was 3.75% and 2.4% in nondiabetics (p < 0.05). This difference was mainly due to the significantly higher incidence of multiorgans failure as a cause of death among diabetics (1.3% in diabetics, 0.5% in nondiabetics, p < 0.05). 89.1% of nondiabetics and 86.9% of diabetics lived 2-6 years after aortocoronary bypass surgery (n.s.). We have found the significantly higher long-term cardiovascular mortality (2-6 years) in diabetics (10.3%) then in nondiabetics (7.6%, p < 0.05).     

Comparison of atherosclerotic plaque by computed tomography angiography in patients with and without diabetes mellitus and with known or suspected coronary artery disease

The aim of this study was to compare coronary artery plaque burden, composition, distribution, and the degree of coronary artery stenosis in diabetic and nondiabetic patients with known or suspected coronary artery disease (CAD). The study group consisted of 594 patients with known or suspected CAD, including 122 diabetics, who underwent multidetector computed tomographic coronary angiography and traditional invasive coronary artery angiography. Coronary artery calcium scores were compared in different age subgroups. Noncalcified plaque, calcified plaque, and mixed plaque were analyzed by coronary segment on computed tomographic coronary angiography, as well as the degree of coronary stenosis on coronary artery angiography. Obstructive vessels were compared between the 2 groups. Total coronary artery calcium score was higher in patients with diabetes compared to those without (378.4 ± 613.0 vs 226.0 ± 408.4, p = 0.003). The percentage of patients with coronary artery calcium scores >400 among diabetics (22.1%) was higher than among nondiabetics (14.2%) (p = 0.032). Diabetics had a higher percentage of coronary segments with noncalcified plaque, calcified plaque, and mixed plaque than nondiabetics (35.3% vs 26.2%, p <0.001; 17.5% vs 11.6%, p = 0.017; and 9.8% vs 7.9%, p = 0.008). More diabetics had multivessel obstructive disease compared to nondiabetics (p <0.05). With longer duration of diabetes mellitus, the stenosed segments of coronary arteries increased accordingly. In conclusion, diabetics have more atherosclerotic plaque burden and more severe coronary atherosclerosis than nondiabetics. Most obstructive lesions were caused by mixed plaques in diabetics and nondiabetics.     

Diabetes and outcomes of coronary artery bypass graft surgery in patients with severe left ventricular dysfunction: results from The CABG Patch Trial database. The CABG Patch Trial Investigators and Coordinators

OBJECTIVES: We examined the relationship between diabetes mellitus and outcomes after coronary artery bypass graft (CABG) surgery in patients with severe left ventricular (LV) dysfunction. BACKGROUND: Although diabetes is associated with poor outcomes after CABG surgery among unselected patients, the relationship between diabetes and mortality after CABG surgery among patients with LV dysfunction is less certain. METHODS: Using data from The CABG Patch Trial, a study of implantable cardiac defibrillator therapy, we analyzed 900 patients with ejection fraction <0.36 who underwent CABG surgery from 1990 to 1996. RESULTS: Diabetics comprised 38% of the patients, and 48% of diabetics were prescribed insulin. Diabetes was associated with hypertension, peripheral vascular disease, history of stroke, clinical heart failure and rales on physical exam. Diabetics were at higher risk for postoperative superficial sternal wound infection and renal failure. With an average follow-up time of 32 +/-16 months, actuarial all-cause mortality 48 months after CABG surgery was 26% in diabetics and 24% in nondiabetics (p = 0.66, log-rank test). Diabetes was not associated with long-term mortality in Cox multiple regression analyses. Actuarial re-hospitalization rates 48 months after CABG surgery were 85% in diabetics and 69% in nondiabetics (p = 0.0001, log-rank test). Diabetics had a 44% higher risk of re-hospitalization for any cause (p = 0.0001) and a 24% higher risk of re-admission for cardiac causes (p < 0.05). Unexpectedly, fewer arrhythmic events were found in diabetics. CONCLUSIONS: Diabetes was not a predictor of mortality after CABG surgery among patients with LV dysfunction despite associated comorbidities. However, diabetes was associated with increased postoperative complications and re-hospitalization.     

Influence of diabetes mellitus and complications on long-term outcome of coronary artery bypass surgery

The influence of diabetes mellitus and complications on the long-term outcome of coronary artery bypass graft surgery (CABG) was investigated in 192 consecutive patients who underwent elective CABG between January 1992 and March 1996. Of these, 102 patients were diabetic and 90 were nondiabetic. Preoperative and postoperative left ventricular ejection fraction, number of grafts, use of arterial conduit, and frequency of perioperative infarction were all similar in the 2 groups. During a mean follow-up of 3.2 years, diabetics showed higher cardiac mortality than nondiabetics (15% vs 3%, p = 0.01). Cardiac event-free survival was also low in diabetics, and this difference increased throughout the period (91% vs 99% at 2 years, 74% vs 90% at 4 years in diabetics and nondiabetics, respectively, by Kaplan-Meier analysis, p = 0.008). Multivariate Cox regression analysis revealed postoperative low ejection fraction and diabetes mellitus as independent predictors of late cardiac death. Major causes of cardiac death in diabetics were sudden death, pump failure and acute myocardial infarction. Additionally, subgroup analysis in diabetics using the Cox regression model identified postoperative low ejection fraction, female gender and diabetic nephropathy as independent predictors of late cardiac death. Thus, patients with diabetes have a worse clinical outcome after CABG, especially when associated with low ejection fraction, female gender and diabetic nephropathy. Intensive management of heart failure, prevention of myocardial infarction and specific strategy for female patients are all essential to improve the long-term outcome of diabetics after CABG.     

Coronary artery disease in diabetic patients]

Although it is well known that diabetics have high mortality rates due to ischemic heart disease (IHD), controversies still exist about the severity of coronary artery disease in diabetics compared to nondiabetics. We compared coronary arteriographies of 50 diabetics with IHD to those of 50 nondiabetics with IHD. In regard to coronary risk factors, incidence of obesity was significantly higher in diabetics. Incidence of hypertension, hypercholesteremia, hyperuricemia was higher, although not significant, in diabetics. Incidence of smoking was significantly higher in nondiabetics. The diabetic group showed a significantly higher incidence of patients with more than two or three diseased vessels, and a significantly higher number of diseased coronaries with more than 50% stenosis per patient compared to nondiabetics (5.6 +/- 3.7 vs 3.7 +/- 3.2). The distribution of diseased coronaries with more than 75% stenosis showed no difference between diabetics and nondiabetics. The incidence of coronary spasm was significantly lower in diabetics (12% vs 28%). The high incidence of multiple vessel disease in diabetics was thought to be due to other complicated coronary risk factors, especially hypertension and hypercholesteremia.     

Elderly diabetics with peripheral arterial disease and no coronary artery disease have a higher incidence of new coronary events than elderly nondiabetics with peripheral arterial disease and prior myocardial infarction treated with statins and with no lipid-lowering drug

BACKGROUND: We report data showing the incidence of new coronary events in diabetics with prior myocardial infarction (MI), nondiabetics with prior MI, diabetes with no coronary artery disease (CAD), and nondiabetics with no CAD who were treated with and without statins. METHODS: We investigated-in an observational prospective study of 274 diabetics and 386 nondiabetics with peripheral arterial disease, mean age years, and a serum low-density lipoprotein cholesterol level of >/=125 mg/dl-the incidence of new coronary events in diabetics with prior MI, nondiabetics with prior MI, diabetics with no CAD, and nondiabetics with no CAD who were treated with and without statins. Follow-up was months. RESULTS: In patients treated with statins, the incidence of new coronary events was 73% in diabetics with prior MI (group 1), 37% in nondiabetics with prior MI (group 2), 57% in diabetics with no CAD (group 3), and 27% in nondiabetics with no CAD (group 4). In patients treated with no lipid-lowering drug, the incidence of new coronary events was 91% in diabetics with prior MI (group 5), 72% in nondiabetics with prior MI (group 6), 86% in diabetics with no CAD (group 7), and 52% in nondiabetics with no CAD (group 8). Significant p values were p<.0001 for group 1 versus 2, group 7 versus 8, and group 2 versus 6; p=.0006 for group 3 versus 4; p=.0007 for group 3 versus 7; p=.001 for group 5 versus 6; p=.002 for group 4 versus 8; p=.003 for group 1 versus 5; p=.015 for group 2 versus 3; and p=.047 for group 6 versus 7. CONCLUSIONS: In patients treated with and without statins, diabetics with no CAD had a higher incidence of new coronary events than did nondiabetics with prior MI.     

Difference in the mortality of the CABRI diabetic and nondiabetic populations and its relation to coronary artery disease and the revascularization mode

In diabetics with coronary artery disease (CAD), there remains uncertainty as to whether revascularization by percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass surgery (CABG) is preferable. To address this, 4-year mortality and level of pre- and postrevascularization angiographic CAD (measured by a series of coronary scores) were compared between both diabetics and nondiabetics and between revascularization modes in the Coronary Angioplasty versus Bypass Revascularization Investigation population as a whole, and then substratified by diabetic status and then by procedure to which they were randomized. The 1,054 randomized subjects contained 125 diabetics (11.9%) who had significantly greater mortality than nondiabetics (RR 2.19, p = 0.001). Among diabetics or nondiabetics, there was no significant mortality difference between those randomized to PTCA versus those to CABG. Diabetics randomized to PTCA and those to CABG had higher mortalities than respective nondiabetics; the association reached significance only in the former (RR 2.41, p = 0.002). All subgroups had similar prerevascularization CAD. Postrevascularization residual CAD was consistently significantly greater in PTCA than in respective CABG subgroups. Most measurements of CAD were greater in diabetic than in nondiabetic subgroups, but none was significant. In the Coronary Angioplasty versus Bypass Revascularization Investigation, diabetics had double the mortality of nondiabetics; this difference was statistically significant both for the entire population and for those randomized to PTCA, but not for those randomized to CABG. Among diabetics or nondiabetics, there was no significant mortality difference between PTCA and CABG. The higher diabetic mortality was more likely related to more rapid disease progression than to greater postrevascularization disease.     

Increased mortality of diabetics after acute myocardial infarction attributed to diffusely impaired left ventricular performance as assessed by echocardiography

Five hundred and forty-eight patients who sustained their first acute myocardial infarction (AMI) were admitted to the coronary care unit (CCU). Ninety-eight of them were known diabetics. The diabetic patients were younger, 50 +/- 12 vs. 64 +/- 18 years of age (p less than 0.05), and the proportion of females in their group was higher than in the nondiabetics, 44% vs. 33.4% (p less than 0.05). The in hospital mortality rate was 30% for diabetics and 16% for nondiabetics (p less than 0.001). Diabetics had a higher percentage of mortality caused by left ventricular failure (LVF) (p less than 0.025) and a tendency for more frequent complete A-V block (p less than 0.01) compared to nondiabetics. Obesity and a positive family history for coronary heart disease were more prevalent in the diabetic group (both p less than 0.01). The echocardiographic assessment of left ventricular function, performed in 125 consecutively admitted patients (25 diabetics and 100 nondiabetics) on the 3rd-5th post-infarct day, showed that the indices of myocardial contractility, that is, E point septal separation (EPSS), ejection fraction (EF) and fractional shortening (FS) were far more impaired in diabetics than in nondiabetics (p less than 0.01, p less than 0.005, p less than 0.005, respectively). No significant difference was found in the prevalence of dyskinetic, akinetic and hypokinetic segments between the two categories of patients, suggesting no difference in the amount of myocardial mass affected by the AMI. Our results indicate that the increased incidence of LVF developed in diabetics after an AMI compared to nondiabetics may be caused by other factors, probably some form of latent diabetic cardiomyopathy as a result of either small vessel disease or metabolic disorder.     

Diabetes mellitus increases short-term mortality and morbidity in patients undergoing coronary artery bypass graft surgery

OBJECTIVES: The aim of this study was to determine the impact of diabetes mellitus (DM) on short-term mortality and morbidity in patients undergoing coronary artery bypass surgery (CABG). BACKGROUND: Diabetes mellitus is present in approximately 20% to 30% of patients undergoing CABG, and the impact of diabetes on short-term outcome is unclear. METHODS: We performed a retrospective cohort study in 434 hospitals from North America. The study population included 146,786 patients undergoing CABG during 1997: 41,663 patients with DM and 105,123 without DM. The primary outcome was 30-day mortality. Secondary outcomes were in-hospital morbidity, infections and composite outcomes of mortality or morbidity and mortality or infection. RESULTS: The 30-day mortality was 3.7% in patients with DM and 2.7% in those without DM; the unadjusted odds ratio was 1.40 (95% confidence interval [CI], 1.31 to 1.49). After adjusting for other baseline risk factors, the overall adjusted odds ratio for diabetics was 1.23 (95% CI, 1.15 to 1.32). Patients treated with oral hypoglycemic medications had adjusted odds ratio 1.13; 95% CI, 1.04 to 1.23, whereas those on insulin had an adjusted odds ratio 1.39; 95% CI, 1.27 to 1.52. Morbidity, infections and the composite outcomes occurred more commonly in diabetic patients and were associated with an adjusted risk about 35% higher in diabetics than nondiabetics, particularly among insulin-treated diabetics (adjusted risk between 1.5 to 1.61). CONCLUSIONS: Diabetes mellitus is an important risk factor for mortality and morbidity among those undergoing CABG. Research is needed to determine if good control of glucose levels during the perioperative time period improves outcome.     

Relation of microalbuminuria and coronary artery disease in patients with and without diabetes mellitus

Microalbuminuria (MA) is a well-known risk factor for coronary artery disease (CAD) in diabetics and nondiabetics. It is associated with higher cardiovascular mortality, especially in diabetics. However, there are few data linking angiographic severity of CAD to microalbuminuria. We examined coronary angiograms for extent of severe CAD (luminal narrowing > or = 50%) in patients with type 2 diabetes mellitus (DM) and MA (DM+MA+, n = 101), patients with DM and without MA (DM+MA-, n = 101), patients without DM and with MA (DM-MA+, n = 64), and patients without DM and MA (DM-MA-, n = 64). We also evaluated fasting glucose levels in all patients and glycosylated hemoglobin in diabetics. Patients' mean age in the DM+MA+, DM+MA-, DM-MA+, and DM-MA- groups was similar. Gender distribution across the 4 groups was also not significantly different. There were no significant differences in the prevalence of hypertension, hypercholesterolemia, and current smoking across the 4 groups. The presence of 2- or 3-vessel CAD showed a linear increase from group DM-MA- to group DM+MA+ (p < 0.001). Diabetics with MA had higher fasting glucose and glycosylated hemoglobin levels than diabetics without MA (p < 0.001). Thus, patients with MA have more severe angiographic CAD than those without MA. This relation is independent of other risk factors and is particularly evident in patients with DM.     

The importance of proteinuria as a determinant of mortality following percutaneous coronary revascularization in diabetics

OBJECTIVES: The aims of this study were to compare mortality and clinical events following percutaneous coronary intervention (PCI) between nondiabetics and diabetics with and without proteinuria. BACKGROUND: Diabetics have increased rates of late myocardial infarction, repeat revascularization and mortality when compared with nondiabetics following PCI. Proteinuria is a marker for diabetic nephropathy and potentially a surrogate marker for advanced atherosclerosis. It is unknown if proteinuria is a predictor of outcome in diabetics following PCI. METHODS: We performed an observational study of 2,784 patients who underwent PCI at the Cleveland Clinic between January 1993 and December 1995. There were 2,247 nondiabetics and 537 diabetics with urinalysis and follow-up data available (proteinuria n = 217, nonproteinuria n = 320). The diabetic proteinuria group was further prospectively stratified into low concentration (n = 182) and high concentration (n = 35). The end points were all-cause mortality and the composite end point of death, nonfatal myocardial infarction (MI) and need for revascularization. RESULTS: The mean follow-up time was 20.2 months. The two-year mortality rate was 7.3% and 13.5% for nondiabetics and diabetics, respectively (p < 0.001). The two-year mortality rate was 9.1% and 20.3% for the nonproteinuria and proteinuria groups, respectively (p < 0.001). There was a graded increase in mortality comparing the diabetic group. The two-year mortality rate was 9.1%, 16.2% and 43.1% for the nonproteinuria, low concentration and high concentration groups, respectively (p < 0.001). The difference in survival between the nondiabetic and nonproteinuric diabetics was not significant (p = 0.8). CONCLUSIONS: The presence of proteinuria is the key determinant of risk following PCI for diabetics. Diabetics without evidence of proteinuria have similar survival compared with nondiabetics.     

Comparison of short- and long-term outcomes of coronary angioplasty in patients with and without diabetes mellitus and with and without hemodialysis

In-hospital and long-term outcomes after coronary angioplasty in 28 dialysis diabetic and 84 dialysis nondiabetic patients were compared with clinical outcomes after coronary angioplasty in 28 nondialysis diabetic and 84 nondialysis, nondiabetic patients matched according to clinical and angiographic characteristics. The rate of angiographic success in diabetic dialysis patients was high and similar in the 4 groups. The risk of 4-year cardiac death and nonfatal myocardial infarction was higher in dialysis diabetics than in dialysis nondiabetics (odds ratio [OR] 1.88, 95% confidence interval [CI] 1.01 to 2.75, p <0.05), nondialysis diabetics (OR 4.27, 95% CI 2.87 to 5.67, p <0.008), and nondialysis nondiabetics (OR 5.2, 95% CI 4.17 to 6.23, p <0.0001).     

Comparative ability of myocardial perfusion single-photon emission computed tomography to detect coronary artery disease in patients with and without diabetes mellitus

BACKGROUND: Diabetics generally have more frequent and extensive silent myocardial ischemia than nondiabetics, increasing the importance of noninvasive detection of coronary artery disease (CAD) in this cohort. However, little is known regarding the diagnostic accuracy of myocardial perfusion single-photon emission computed tomography (SPECT) in patients with diabetes. This study was undertaken to compare the diagnostic value of rest thallium-201/stress technetium-99m sestamibi dual-isotope myocardial perfusion SPECT in patients with and without diabetes. METHODS: Of the 203 patients with diabetes and 260 patients without diabetes who underwent dual-isotope myocardial perfusion SPECT with exercise or pharmacologic stress testing, 138 diabetics (12% type 1 diabetics) and 188 nondiabetics had coronary angiography within 6 months of the nuclear test, and 65 diabetics and 72 nondiabetics had a low likelihood (<10%, mean 6% +/- 3% and 6% +/- 3%) of CAD. RESULTS: The angiographic data showed that patients with diabetes had less incidence of 1-vessel disease and a higher incidence of 3-vessel/left main artery disease than patients without diabetes (P <.05). The overall sensitivity and specificity, respectively, of SPECT for detecting CAD with the criterion of >/=50% diameter stenosis were 86% (95 of 111) and 56% (15 of 27) in diabetics, 86% (122 of 142) and 46% (21 of 46) in nondiabetics (P = not significant). With the criterion of >/=70% diameter stenosis the corresponding results were 90% (86 of 96) and 50% (21 of 42) in diabetics, and 91% (108 of 119) and 43% (30 of 69) in nondiabetics, respectively (P = not significant). The normalcy rate for low likelihood patients was 89% (58 of 65) in diabetics and 90% (65 of 72) in nondiabetics (P = not significant). The sensitivity and specificity for individual vessel detection were also similar in patients with and without diabetes (P = not significant) except for a lower sensitivity and a higher specificity for detecting left anterior descending coronary artery disease in the diabetic group (P <.05). CONCLUSION: Dual-isotope myocardial perfusion SPECT has comparable accuracy for the diagnosis of CAD in diabetic and nondiabetic patients.     

Prevalence and impact on prognosis of glucometabolic states in acute coronary syndrome in a middle eastern country: The GLucometabolic abnOrmalities in patients with acute coronaRY syndrome in Jordan (GLORY) study

Western studies have shown that diabetes mellitus and other glucometabolic states are highly prevalent among patients with Acute Coronary Syndrome (ACS), and are associated with worse adverse cardiovascular outcome. Whether this also applies to Middle Eastern patients is largely unknown. We studied the prevalence of glucometabolic states (known diabetes, newly diagnosed diabetes, impaired fasting glucose (IFG), and no diabetes) in 656 ACS patients, who were followed up prospectively for total mortality, and composite events of death, readmission for myocardial infarction, or urgent coronary revascularization for 1?year after admission. Of the whole group, 291 (44.6%) were known diabetics, 69 (10.6%) had newly diagnosed diabetes, 86 (13.2%) had impaired fasting glucose, and 206 (31.6%) were nondiabetics. The overall in-hospital mortality rate was 2.6%, and was not significantly different between the four groups. At 1?year; overall mortality was 7.2%, and was significantly higher (p?=?0.002) among diabetics (newly diagnosed; 17.1%, and known diabetics; 7.8%) compared with patients who had IFG (3.4%) and nondiabetics (4.4%). Composite events at 6?months was significantly higher (p?=?0.016) in known diabetics (14.7%), compared with newly diagnosed diabetics (7.1%), IFG (9.2%) and nondiabetics (6.3%). At 1?year, composite events occurred in 15.9% of the whole group, and was significantly higher (p?=?0.049) in known diabetics (20.1%), compared with newly diagnosed diabetics (10%), IFG (11.5%) and nondiabetics (13.6%). In Middle Eastern ACS patients, 70% have abnormal glucometabolic states. Newly diagnosed diabetics and known diabetics have higher risk of cardiovascular events than patients with impaired fasting glucose and nondiabetics after 1?year of admission.     

Semi-skeletonized internal mammary artery grafts and sternal wound complications

This study aimed to evaluate the risk factors for sternal wound complications in patients undergoing myocardial revascularization using bilateral semi-skeletonized internal mammary arteries. Prospectively collected data on 751 patients undergoing coronary artery surgery from September 1994 to August 2002 were analyzed. The mean age of the patients was 56 years, 633 (84%) were male, 44 (6%) were over 66 years of age, and 170 (23%) were diabetic. Forty-four (5.9%) patients developed sternal wound complications. Among these cases, sternal infection occurred in 22 (2.9%) patients, of which 15 (2.0%) had sternal infection with mediastinitis and 7 (0.9%) had sternal infection alone. Independent risk factors for any sternal wound complications were peripheral vascular disease, diet-controlled diabetes, and delayed sternal closure. The risk factors for sternal infection were diabetes, postoperative pulmonary complications, and postoperative stroke. The perioperative mortality rate was 1.5% (11 patients), including 2 patients who had sternal wound complications. The use of bilateral semi-skeletonized internal mammary artery conduits carries a comparable sternal wound complication rate as conduits harvested by other techniques.     

Anaerobic wound infection: Bacteroides mediastinitis after cardiovascular surgery

A case of postoperative anaerobic mediastinitis after coronary artery bypass grafting is reviewed. One of the causative organisms, Bacteroides oralis, has never previously been described as a pathogen causing mediastinitis after median sternotomy incision. There was associated Bacteroides fragilis bacteremia. Only three cases of Bacteroides species mediastinitis after open heart surgery have been reported. This anaerobic bacterium remains a rare pathogen in median sternotomy infections despite the increasing number of cases of mediastinitis seen in association with the burgeoning number of patients undergoing cardiac surgery. Multiple risk factors may contribute to mediastinal infections, which occur in about 2% of patients undergoing coronary artery surgery. When infection occurs, aerobic and anaerobic wound cultures should be made and appropriate antimicrobial and surgical therapy instituted.     

Coronary artery surgery in diabetic patients

Currently, 15% to 30% of the patients that undergo coronary artery surgery are diabetics. As a group, they have less favorable anatomic and clinical characteristics than the general population. Specifically, diabetics have more extensive coronary disease, more vessels involved, and more diffuse stenosis, so they need a higher number of distal anastomoses to achieve complete revascularization. In spite of these drawbacks, they can undergo coronary artery bypass procedures with an operative mortality similar to that of non-diabetic patients. However, some postoperative complications are significantly more prevalent among diabetics, mainly renal failure, neurological accidents, sternal dehiscence, and infection. In early studies of the late results of surgical revascularization, mainly based on venous grafts, late survival and clinical improvement were less satisfactory in diabetics than in non-diabetics. However, in recent experiences, in which the internal mammary artery has been used extensively, the clinical outcome of diabetics has been similar to that of non-diabetics, confirming this procedure as the preferred one in revascularizing the coronary arteries of diabetics with multivessel disease. Off-pump surgery and extensive use of arterial grafts are becoming established strategies for reducing operative risk and improving long-term clinical results. However, continuous, strict medical management of hyperglycemia and other known coronary risk factors, especially lipid levels, is essential.     

Prevalence and prognostic significance of unrecognized systemic hypertension in patients with diabetes mellitus and healed myocardial infarction and/or stable angina pectoris.

Few data are available regarding the prevalence and prognostic significance of the triple coexistence of undiagnosed systemic hypertension, diabetes mellitus, and coronary heart disease. This study aimed to evaluate the prevalence and prognostic significance of unrecognized hypertension in cardiac diabetic patients previously defined as "normotensives" over a 5-year follow-up period. The study sample comprised 11,515 patients aged 45 to 74 years with a previous myocardial infarction and/or anginal syndrome who were screened but not included in the Bezafibrate Infarction Prevention study. Among them, 9,033 were nondiabetics and 2,482, diabetics. The diabetics were divided into 3 groups: (1) 1,272 normotensives, (2) 152 patients without history of hypertension but with elevated blood pressure ("unrecognized hypertensives"), and (3) 1,058 hypertensives with established diagnosis. The prevalence of both diagnosed and unrecognized hypertension in diabetics pooled together increased from 49% to 69% when World Health Organization and new Joint National Committee-VI criteria were compared. Crude all-cause mortality was lower in nondiabetics than in diabetics (11.2% vs 22.0%; p <0.001). Among diabetics the lowest all-cause mortality was documented for normotensives (19.3%), whereas the highest mortality was observed in unrecognized hypertensives (26.3%, p = 0.003). Both unrecognized and established hypertensives demonstrated a significant stroke-related mortality excess: about four- and threefold increases in cerebrovascular accident-related death, respectively, were observed (p = 0.002). On multivariate analysis, both unrecognized and diagnosed hypertension were consistent predictors of increased all-cause mortality, with a hazard ratio of 1.28 (95% confidence interval 0.90 to 1.82) and 1.24 (95% confidence interval 1.03 to 1.49), respectively. Our findings demonstrate widespread undiagnosed hypertension in diabetic coronary patients; their 5-year mortality was significantly increased compared with normotensives, and tended to be even higher than in diabetics previously identified as hypertensives.     

Comparison of morbidity and mortality in diabetics versus nondiabetics having isolated coronary bypass versus coronary bypass plus valve operations versus isolated valve operations

The impact of diabetes mellitus (DM) on the outcome of patients requiring cardiac surgery has been investigated in previous decades. However, the profile of cardiac surgical practice is changing in addition to changes in patients' risk profile, making the results inconclusive. In this study we sought to investigate the impact of DM on operative mortality and morbidity in patients undergoing cardiac surgery and adjust for patient and disease characteristics. In total 10,709 patients (9,229 nondiabetics and 1,480 diabetics) were admitted to the study; 5,557 patients (1,012 diabetics) underwent an isolated coronary operation, 1,775 patients (278 diabetics) underwent coronary plus valve operations, and 3,337 patients (209 diabetics) underwent valve operations. To control for differences in patient and disease characteristics, a propensity score (for DM) was performed. DM increased crude morbidity and this difference was maintained after risk adjustment for propensity score; conversely, the crude operative mortality risk was higher in diabetics but not significantly after adjustment for propensity score. Thereafter, DM remained independently associated to operative mortality risk in the valve population only (odds ratio 2.53, 95% confidence interval 1.45 to 4.4, p = 0.001). In conclusion, DM has a significant impact on operative mortality of patients undergoing heart valve surgery. Although diabetic patients undergoing coronary operations are not at increased risk of operative mortality, morbidity is significantly affected in the overall population.     

Diabetes, blood lipids, lipoproteins, and change of environment: restudy of the "new immigrant Yemenites" in Israel.

Restudy of 306 "new immigrant Yemenite" Jews, an ethnic group in which, upon their arrival in Israel, no diabetes was detected, revealed, 25 yr after their immigration, an increased incidence of diabetes and higher plasma and lipoprotein-lipid levels. The prevalence of diabetes (defined as "glucose intolerance") rose to 11.8% (13.2% males and 9.7% females). Obesity in females resulted in increased prevalence of diabetes in all age groups, while in males it affected the older age group only. The male/female diabetic ratio was affected by weight status--in the underweight, diabetes was more prevalent in males, in the overweight, the rate of diabetes in females equaled that of males. In nondiabetics (those with normal glucose tolerance), neither the glucose tolerance nor the insulin response deteriorated with aging. Most diabetics had a delayed insulin response. However, about 50% of nondiabetics and diabetics had insulin response peak at 60 min and similar insulin levels. It appears that in newly discovered adult-onset diabetics in this population there is no shortage of insulin, but rather shortage of insulin action. In nondiabetics, the levels of plasma cholesterol and triglycerides (TG) were higher than levels upon their arrival. In diabetics, the plasma TG, cholesterol, and LDL-cholesterol levels were higher when compared to those of nondiabetics, especially in the group of overweight males. Hyperlipoproteinemia was diagnosed in 27.7% of diabetics and 11.0% of nondiabetics. In diabetics, the HDL/LDL cholesterol ratio was found to be reduced, significantly so in overweight diabetics.