Comparison of outcomes of diabetic and nondiabetic patients undergoing primary angioplasty for acute myocardial infarction

We sought to determine whether diabetes mellitus independently conferred poor prognosis in patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI). In 3,742 patients enrolled in the Primary Angioplasty in Myocardial Infarction (PAMI) studies with the intention of undergoing primary PCI, we compared in-hospital mortality, 6-month mortality, and 6-month major adverse cardiovascular events (MACEs), i.e., composite of death, reinfarction, or ischemic target vessel revascularization (TVR), between diabetics (n = 626, 17%) and nondiabetics (n = 3,116, 83%). We evaluated the independent impact of diabetes on outcomes after adjustment for baseline clinical and angiographic differences. Diabetics had worse baseline clinical characteristics, longer pain onset-to-hospital arrival time, and longer door-to-balloon time. They had more multivessel coronary disease and lower left ventricular ejection fractions, but better baseline Thrombolysis In Myocardial Infarction (TIMI) flow. Diabetics underwent primary PCI less often (88% vs 91%, p = 0.01). During the index hospitalization, diabetics were more likely to die (4.6% vs 2.6%, p = 0.005). During 6-month follow-up, diabetics had higher incidences of death (8.1% vs 4.2%, p <0.0001) and MACEs (18% vs 14%, p = 0.036). In multivariate analysis, diabetes was independently associated with 6-month mortality (hazard ratio 1.53, 95% confidence interval 1.03 to 2.26, p = 0.03), but not with in-hospital mortality or 6-month MACEs. We conclude that diabetics with AMI have less favorable baseline characteristics and are less likely to undergo primary PCI than nondiabetics. Despite excellent angiographic results, diabetics had significantly worse 6-month mortality.     

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.     

Outcome of acute ST-segment elevation myocardial infarction in diabetics treated with fibrinolytic or combination reduced fibrinolytic therapy and platelet glycoprotein IIb/IIIa inhibition: lessons from the GUSTO V trial

OBJECTIVES: We studied the outcome of diabetics enrolled in the Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO) V trial to assess whether the combination of half-dose reteplase and abciximab provides any propitious benefits over standard fibrinolytic therapy in diabetic patients. BACKGROUND: Diabetics with acute ST-segment elevation myocardial infarction (MI) have a worse outcome compared with nondiabetics. Higher-risk patients are usually more likely to benefit from advances in medical therapy. METHODS: We analyzed diabetic patients enrolled in the GUSTO V trial to assess the outcome of those randomized to the combination of half-dose reteplase and abciximab versus those randomized to reteplase. We also evaluated whether any differences existed in presentation and outcome of MI among the diabetics versus the nondiabetics enrolled in the study. RESULTS: The trial enrolled 13782 nondiabetics and 2633 diabetics. Compared to nondiabetics, diabetics had a significantly higher mortality at 30 days (8.5% vs. 5.1%, p < 0.001) and at 1 year (12.7% vs. 7.5%, p < 0.001). Among the diabetic subset, no significant difference existed in the incidence of 30-day (8.8% vs. 8.2%, p = 0.52) or 1-year mortality (13.0% vs. 12.4%, p = 0.62) among patients randomized to reteplase compared to those receiving combination of abciximab and reteplase. The incidence of reinfarction (2.5% vs. 4.3%, p = 0.013), recurrent ischemia (11.8% vs. 14.9%, p = 0.017), and urgent revascularization (10.9% vs. 13.3%, p = 0.055) at seven days was lower in diabetics treated with the combination therapy. CONCLUSIONS: Compared to nondiabetics, diabetics continue to have a worse outcome with MI. Although combination therapy did not provide a survival benefit, nonfatal ischemic outcomes, including reinfarction, recurrent ischemia, and urgent revascularization, were substantially reduced.     

Proteinuria is a key determinant of death in patients with diabetes after isolated coronary artery bypass grafting

BACKGROUND: Proteinuria is a marker for underlying diabetic nephropathy and may be a surrogate marker for advanced atherosclerosis. It is unknown if proteinuria is a determinant of death in patients with diabetes after coronary artery bypass grafting. We hypothesized that diabetic patients with evidence of proteinuria would have increased mortality and clinical event rates after isolated coronary artery bypass grafting compared with nonproteinuric diabetic patients. METHODS AND RESULTS: We performed an observational of study of 905 diabetic patients with urinalysis and available follow-up data (nonproteinuria, n = 651; proteinuria, n = 254) after isolated coronary artery bypass grafting at the Cleveland Clinic Foundation between January 1989 and December 1992. The proteinuria group was further prospectively stratified into low-concentration (n = 225) and high-concentration (n = 29) groups. The end points of this study were all-cause mortality and the composite end point of death, nonfatal myocardial infarction, and need for repeat revascularization. The mean follow-up time was 66 months. The 5-year mortality rate for the nonproteinuria and proteinuria groups was 20.2% and 29.1% (P <.001), respectively. The 5-year rate of death, nonfatal myocardial infarction, and need for repeat revascularization for the nonproteinuria and proteinuria groups was 25.2% and 36.2% (P <.001), respectively. Significant multivariate predictors of 5-year mortality included age, not using a left internal mammary artery graft to the left anterior descending coronary artery, proteinuria, lower body weight, and increased creatinine level. CONCLUSIONS: Among diabetic patients, proteinuria appears to be an important predictor of death after isolated coronary artery bypass grafting.     

A comparative analysis of major clinical outcomes using drug‐eluting stents versus bare metal stents in diabetic versus nondiabetic patients

Objectives: We aim to explore the clinical outcome of drug‐eluting stents (DES) versus bare‐metal stents (BMS) implantation in diabetics versus nondiabetic patients. Background: Diabetic patients sustain worse long‐term clinical outcomes after percutaneous coronary interventions (PCI) when compared with nondiabetics. The use of DES decreases the rate of repeat revascularization in this population but data concerning long‐term clinical benefits, such as myocardial infarction (MI) or mortality is scant. Methods: We analyzed data from a comprehensive registry of 6,583 consecutive patients undergoing PCI at our center. A propensity score was used for analysis of outcomes and for matching (DES vs. BMS). Outcome parameters were total mortality, MI, repeat target vessel revascularization (TVR) rates, and risk‐adjusted event‐free survival. Within this cohort, we identified 2,571 nondiabetic patients and these were compared with 1,826 diabetic coronary patients. Results: Mean and median follow up time was 3 and 3.25 years, respectively. Overall, diabetics had higher rates of major‐adverse cardiovascular events (MACE) at 4 years compared with nondiabetics (23.03 vs. 31.96 P > 0.001). DES use was associated with lower rates of TVR in both groups [diabetics hazard ratio (HR) = 0.56, 95% confidence interval (CI): 0.42–0.76, P < 0.001, nondiabetics HR = 0.73, 95% CI: 0.55–0.97, P = 0.03] while sustained decreased rates of both mortality and MI were evident solely among diabetics (HR = 0.71, 95% CI: 0.56–0.89, P = 0.004 in diabetic vs. HR = 0.88, 95% CI: 0.69–1.13, P = 0.3). Conclusions: In a “real‐world,” unselected population and extended clinical use, DES in diabetics was associated with sustained decreased rates of MI, death, TVR, and MACE while this benefit was attenuated in the nondiabetic population. © 2011 Wiley‐Liss, Inc.     

Clinical outcome of primary infrainguinal subintimal angioplasty in diabetic patients with critical lower limb ischemia.

PURPOSE: To evaluate the clinical outcome of subintimal angioplasty in diabetic patients with critical limb ischemia (CLI) compared to nondiabetics irrespective of the patency status of the treated arteries. METHODS: The records of 99 consecutive patients (53 men; median age 78.5 years, range 42-92) suffering from CLI who underwent primary infrainguinal subintimal angioplasty in 112 limbs within a 6-month period were studied retrospectively. A third of the patients (n=33) were diabetic. The technical success, perioperative morbidity/mortality, and clinical success were compared between the diabetic and nondiabetic patients. Kaplan-Meier life-table analysis was used to analyze clinical success, limb salvage, and survival for both groups. RESULTS: The overall technical success was 89% (81% in diabetics, 93% in nondiabetics, p=0.05). Perioperative morbidity was 8% (16.7% in diabetics, 3.9% in nondiabetics, p=0.03). The perioperative mortality was zero. The clinical success at 12, 24, and 36 months was 74%, 72%, and 65% in nondiabetics and 69%, 63%, and 54% in diabetics, respectively (p=0.17). The limb salvage rate at 36 months was 88% overall (90% in nondiabetics, 82% among diabetics, p=0.20). The 36-month survival rate was 61% in nondiabetics and 57% in diabetics (p=0.29). CONCLUSIONS: In terms of clinical outcome, infrainguinal subintimal angioplasty is almost equally effective in diabetics as in nondiabetics suffering from CLI.     

Abciximab reduces mortality in diabetics following percutaneous coronary intervention

OBJECTIVES: We sought to determine whether abciximab therapy at the time of percutaneous coronary intervention (PCI) would favorably affect one-year mortality in patients with diabetes. BACKGROUND: Diabetics are known to have increased late mortality following PCI. METHODS: Data from three placebo-controlled trials of PCI, EPIC, EPILOG, and EPISTENT, were pooled. The one-year mortality rate for patients with a clinical diagnosis of diabetes mellitus was compared with the rate for nondiabetic patients treated with either abciximab or placebo. RESULTS: In the 1,462 diabetic patients, abciximab decreased the mortality from 4.5% to 2.5%, p = 0.031, and in the 5,072 nondiabetic patients, from 2.6% to 1.9%, p = 0.099. In patients with the clinical syndrome of insulin resistance--defined as diabetes, hypertension, and obesity--mortality was reduced by abciximab treatment from 5.1% to 2.3%, p = 0.044. The beneficial reduction in mortality with abciximab use in diabetics classified as insulin-requiring was from 8.1% to 4.2%, p = 0.073. Mortality in diabetics who underwent multivessel intervention was reduced from 7.7% to 0.9% with use of abciximab, p = 0.018. In a Cox proportional hazards survival model, the risk ratio for mortality with abciximab use compared with placebo was 0.642 (95% confidence interval 0.458-0.900, p = 0.010). CONCLUSIONS: Abciximab decreases the mortality of diabetic patients to the level of placebo-treated nondiabetic patients. This beneficial effect is noteworthy in those diabetic patients who are also hypertensive and obese and in diabetics undergoing multivessel intervention. Besides its potential role in reducing repeat intervention for stented diabetic patients, abciximab therapy should be strongly considered in diabetic patients undergoing PCI to improve their survival.     

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.     

Twelve-month outcomes after coronary stenting with the Genous™ bio-engineered R Stent™ in diabetic patients from the e-HEALING registry

Objectives: We compared 12‐month outcomes, regarding ischemic events, repeat intervention, and ST, between diabetic and nondiabetic patients treated with the Genous? EPC capturing R stent? during routine nonurgent percutaneous coronary intervention (PCI) using data from the multicenter, prospective worldwide e‐HEALING registry. Background: Diabetic patients have an increased risk for restenosis and stent thrombosis (ST). Methods: In the 4,996 patient e‐HEALING registry, 273 were insulin requiring diabetics (IRD), 963 were non‐IRD (NIRD), and 3,703 were nondiabetics. The 12‐month primary outcome was target vessel failure (TVF), defined as target vessel–related cardiac death or myocardial infarction (MI) and target vessel revascularization. Secondary outcomes were the composite of cardiac death, MI or target lesion revascularization (TLR), and individual outcomes including ST. Cumulative event rates were estimated with the Kaplan–Meier method and compared with a log‐rank test. Results: TVF rates were respectively 13.4% in IRD, 9.0% in NIRD, and 7.9% in nondiabetics (P < 0.01). This was mainly driven by a higher mortality hazard in IRD (P < 0.001) and NIRD (P = 0.07), compared with nondiabetics. TLR rates were comparable in NIRD and nondiabetics, but significantly higher in IRD (P = 0.04). No difference was observed in ST. Conclusion: The 1‐year results of the Genous stent in a real‐world population of diabetics show higher TVF rates in diabetics compared with nondiabetics, mainly driven by a higher mortality hazard. IRD is associated with a significant higher TLR hazard. Definite or probable ST in all diabetic patients was comparable with nondiabetics. (J Interven Cardiol 2011;24:285–294)     

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.     

Comparison of in-hospital and one-year outcomes in patients with and without diabetes mellitus undergoing percutaneous catheter intervention (from the National Heart,Lung, and Blood Institute Dynamic Registry)

Extrapolation of improvements in percutaneous coronary intervention (PCI) and outcomes to patients with diabetes has not been systematically examined in clinical practice. Two waves of consecutive patients (n = 4,629) who underwent PCI from July 1997 to June 1999 enrolled in the National Heart, Lung, and Blood Institute Dynamic Registry comprise the study population. There were 1,058 patients with treated diabetes and 3,571 patients without clinically evident diabetes. As a group, patients with diabetes tended to have more clinical, angiographic, and procedural risk factors. Although crude in-hospital mortality rates were higher in patients with diabetes (diabetics 2.3%, nondiabetics 1.3%; p = 0.02), the adjusted risk of in-hospital death (odds ratio 1.46, 95% confidence interval [CI] 0.80 to 2.66) was not significantly different. At 1 year, patients with diabetes had a significantly higher adjusted risk of mortality (risk ratio [RR] 1.80, 95% CI 1.35 to 2.41) and need for repeat revascularization (RR 1.40, 95% CI 1.13 to 1.74). There was a significant interaction between stent use and diabetic status with the need for repeat revascularization (adjusted RR in nondiabetics 0.73, 95% CI 0.61 to 0.88; adjusted RR in patients with diabetes 1.20, 95% CI 0.88 to 1.65). Beta blockers at the time of hospital discharge were significantly associated with reduced mortality rates at 1 year in both groups.     

Factors associated with postoperative complications in diabetics after biliary tract surgery

We reviewed all first operations for cholelithiasis at the North Carolina Memorial Hospital from 1973 to 1982 to assess factors associated with postoperative morbidity in diabetics after biliary tract surgery. Diabetics (n = 126) had more frequent postoperative complications (24.6% vs. 12.5%, p less than 0.001) and higher mortality (7.9% vs. 3.0%, p = 0.02) than the nondiabetics (n = 855). Postoperative complications were more frequent in diabetics at both emergency surgery (57.9% vs. 39.1%) and at nonemergency surgery (18.7% vs. 10.2%). Diabetics were older, however, and had more preoperative renal, cardiovascular, and neurologic disease. We used logistic regression analysis to adjust for these differences and to determine independent predictors of postoperative complications. Urgent surgery, operation other than cholecystectomy, cardiovascular disease, and male sex were associated with an increased risk of postoperative morbidity. Diabetes was associated with an increase in risk that was not statistically significant. We conclude that diabetics have increased morbidity primarily because they are older and have other medical problems. The risk conferred by uncomplicated diabetes is modest, and recommendations for prophylactic surgery in asymptomatic diabetics with gallstones should be reexamined in this light.     

Influence of diabetes mellitus on clinical outcome after percutaneous coronary revascularization

INTRODUCTION AND OBJECTIVES: Diabetes mellitus modifies the natural history of patients with coronary artery disease. The aim of this study was to assess the clinical outcome of diabetic patients with successful coronary angioplasty in our environment and to identify the factors predictive of complications during follow-up. METHODS: A retrospective analysis was made of a series of 198 diabetics and who underwent angioplasty from September 1996 to January 2000 in our hospital. A group of 198 nondiabetic patients who subsequently underwent the same procedure was used as the control group. Death, non-fatal myocardial infarction, unstable angina resulting in hospitalization and coronary revascularization were considered adverse events during a 1 year follow-up period. RESULTS: The overall frequency of coronary adverse events in a 1-year follow-up was higher in diabetics (37%) than in non-diabetics (24%; p = 0.03). Diabetics had a less favorable clinical and angiographic profile and more frequent incomplete revascularization (43 vs 30%). Diabetics with incomplete revascularization were older (66.5 vs 53.2 years), had previous angioplasty more often, anatomically more unfavorable lesions (70 vs 51% type B2-C), and a smaller ejection fraction (54.7 vs 59.4%). Diabetics had more complications at 1 year of follow-up (37 vs 24%; p = 0.03), mainly due to increased cardiovascular mortality in diabetics with incomplete revascularization (12 vs 2%). Multivariate analysis identified incomplete revascularization as the only correlate of clinical outcome. Diabetes per se was not predictive of complications during follow-up. CONCLUSIONS: Diabetics who undergo successful coronary revascularization have a less favorable clinical outcome than non-diabetic patients undergoing the same procedure at 1 year of follow up. Incomplete revascularization is associated with a less favorable outcome.     

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.     

Staphylococcus aureus bacteremia in diabetic patients: Endocarditis and mortality

The presentation and course of Staphylococcus aureus bacteremia in 27 diabetic patients (18 insulin-dependent) were compared with those in 34 nondiabetic patients. The groups were comparable in age, proportion with pre-existing cardiac valvular disease, community-acquired bacteremia, fever, and leukocytosis. Endocarditis (vegetation or new regurgitant murmur) was present in eight (30 percent) diabetics and four (12 percent) nondiabetics (p = 0.16). A primary focus of infection was present in 67 percent of diabetics and 65 percent of nondiabetics. Among those with a focus, six of 18 diabetics and none of 22 nondiabetics had endocarditis (p < 0.005). Fifteen of 54 (28 percent) patients who received appropriate antibiotic therapy died. After stratification for underlying illness, there was no mortality difference between those with and without endocarditis (three endocarditis deaths versus 1.78 expected), or between those with and without diabetes (four diabetic deaths versus 4.8 expected). Diabetics with staphylococcal bacteremia were more likely than nondiabetics to have endocarditis in the presence of a primary focus. They had no increase in mortality.     

Beta-blocker therapy for secondary prevention of myocardial infarction in elderly diabetic patients. Results from the National Cooperative Cardiovascular Project.

OBJECTIVES: We sought to determine the use and association with one-year mortality of beta-blocker therapy for the treatment of acute myocardial infarction (AMI) in elderly diabetic patients and to examine whether beta-blocker therapy was associated with increased rates of hospital readmission for diabetic complications traditionally associated with beta-blockers. BACKGROUND: Although many randomized trials have demonstrated that beta-blockers are effective in reducing mortality after AMI, some experts are concerned about the use of beta-blockers in diabetic patients. Little is known about the effectiveness and complication rate of beta-blocker therapy after AMI for elderly diabetics in community practice settings. METHODS: We conducted a retrospective cohort study using the National Cooperative Cardiovascular Project, which contained data abstracted from hospital medical records of Medicare beneficiaries admitted with an AMI during 1994 and 1995. RESULTS: Out of 45,308 patients without contraindications to beta-blocker therapy, 7.4% were insulin-treated diabetics and 18.5% were non-insulin-treated diabetics. Beta-blockers were prescribed at discharge for 45% of insulin-treated diabetics, 48.1% of non-insulin-treated diabetics and 51% of nondiabetics (p < 0.001). After adjusting for demographic and clinical factors, diabetics continued to be less likely to receive beta-blockers at discharge compared with nondiabetics (odds ratio [OR] for insulin-treated diabetics 0.88, 95% confidence interval [CI] 0.82 to 0.96; OR for non-insulin-treated diabetics 0.93, 95% CI 0.88 to 0.98). After adjusting for potential confounders, beta-blockers were associated with lower one-year mortality for insulin-treated diabetics (hazard ratio [HR] = 0.87, 95% CI 0.72 to 1.07), non-insulin-treated diabetics (HR = 0.77, 95% CI 0.67 to 0.88) and nondiabetics (HR = 0.87, 95% CI 0.80 to 0.94). Beta-blocker therapy was not significantly associated with increased six-month readmission rates for diabetic complications among diabetics and nondiabetics. CONCLUSIONS: Beta-blockers are associated with a lower one-year mortality rate for elderly diabetic patients to a similar extent as for nondiabetics, without increased risk of readmission for diabetic complications. Increasing the use of beta-blockers in elderly diabetic patients represents an opportunity to improve the care and outcomes of these patients after AMI.     

Impact of diabetes mellitus on the late clinical outcome of coronary revascularization with stents

INTRODUCTION: The Influence of diabetes mellitus in the late outcome of coronary stenting remains controversial. AIM: The aim of this study was to determine the late clinical outcome of diabetics in comparison with non diabetics and to establish whether there are subgroups of diabetic patients with a greater need for target lesion revascularization. METHODS: Two hundred sixteen consecutive patients (74 diabetics; 95 stents in 90 lesions and 142 non diabetics) who had successfully undergone coronary stenting were included in the study and followed over 17.6 +/- 10 months. The clinical events evaluated were target lesion revascularization, death and acute myocardial infarction. Independent predictive variables of target lesion revascularization were studied in both groups of patients. RESULTS: The diabetic patients presented greater cardiovascular mortality (6.7% vs 1.4%; p=0.02) but the incidence of infarction was similar in the two groups (2.7% vs. 3.5%; p=0.6). The accumulated rate of target lesion revascularization at two years was 18.2% in diabetics vs 13.3% in non diabetics (p=0.09), respectively. The presence of three vessel disease (p=0.014), history of arterial hypertension ([=0.011) and residual stenosis > 0% (p=0.005) were specific predictive factors of target lesion revascularization for diabetic patients and together with vessel diameter < 3mm (p<0.001) subgroups of diabetics were independently selected with a significantly greater incidence of target lesion revascularization than the non diabetic patients. CONCLUSIONS: Following coronary stenting, diabetic patients show a greater cardiovascular mortality than non diabetics, but only some subgroups of diabetics (small vessels extensive coronary disease, associated arterial hypertension, residual stenosis) show a significantly greater risk of target lesion revascularization.     

Prognosis in diabetics with chest pain or other symptoms suggestive of acute myocardial infarction.

We evaluated the prognosis of 599 diabetics who came to the emergency department with chest pain or other symptoms suggestive of acute myocardial infarction (AMI). They made up 8% of the patients with such symptoms (n = 7,157). Diabetics had a 1-year mortality rate of 25% as compared with 10% for nondiabetics (p less than 0.001). The difference remained significant regardless of whether there was a strong or a vague initial suspicion of AMI. On admission, independent risk factors for death were age, acute congestive heart failure and initial degree of suspicion of AMI. We conclude that among diabetics who appear in the emergency department with chest pain or other symptoms suggestive of AMI, 25% are dead within 1 year. The prognosis is directly related to the initial suspicion of AMI.     

Diabetes mellitus and outcome after primary coronary angioplasty for acute myocardial infarction: lessons from the GUSTO-IIb Angioplasty Substudy. Global Use of Strategies to Open Occluded Arteries in Acute Coronary Syndromes

OBJECTIVES: We sought to compare the efficacy of primary angioplasty in diabetics versus nondiabetics and to evaluate the relative benefits of angioplasty over thrombolytic therapy among diabetics. BACKGROUND: Primary angioplasty for myocardial infarction is at least as effective as thrombolytic therapy in the general population. However, the influence of diabetic status on outcome after primary angioplasty versus thrombolysis remains unknown. METHODS: Patients in the Global Use of Strategies To Open Occluded Arteries in Acute Coronary Syndromes (GUSTO-IIb) Angioplasty Substudy were randomized to receive either primary angioplasty or accelerated alteplase. The interaction of diabetic status (diabetics n = 177, nondiabetics n = 961) and treatment strategy with the occurrence of the primary end point (death, nonfatal reinfarction or nonfatal, disabling stroke at 30 days) was analyzed (power to detect a 40% relative reduction in the primary end point with alpha = 0.05 and beta = 0.20). Among patients who were randomized to and underwent primary angioplasty, procedural success (defined as residual stenosis <50% and TIMI grade 3 flow) was assessed based on diabetic status. RESULTS: Compared with nondiabetics, diabetics had worse baseline clinical and angiographic profiles. Despite more severe stenosis and poorer flow in the culprit artery, procedural success with angioplasty was similar for diabetics (n = 81; 70.4%) and nondiabetics (n = 391; 72.4%). Outcome at 30 days was better for nondiabetics randomized to angioplasty versus alteplase (adjusted odds ratio, 0.62; 95% confidence interval, 0.41-0.96) with a similar trend for diabetics (0.70, [0.29-1.72]). We noted no interaction between diabetic status and treatment strategy on outcome (p = 0.88). CONCLUSIONS: Primary angioplasty was similarly successful in diabetics and nondiabetics and appeared to be more effective than thrombolytic therapy among diabetics with acute infarction.     

The influence of diabetes mellitus on the practice and outcomes of percutaneous coronary intervention in the community: a report from the HCA database

BACKGROUND: Diabetics remain a high-risk group for those undergoing percutaneous coronary intervention (PCI) using balloon angioplasty and/or intracoronary stents for myocardial revascularization. The objective of this study is to compare clinical characteristics, demographics, procedure indications, lesion characteristics, and acute and long-term outcomes between diabetic patients and non-diabetic patients in a community based PCI registry. METHODS AND RESULTS: Information on patient demographics, coronary risk factors, lesion characteristics, procedures, and outcomes were derived from an HCA, Inc. database on all patients undergoing a PCI procedure in one of four community cardiac catheterization laboratories (CCL). A total of 3,139 patients who underwent PCI procedures from July 1, 1999 through September 30, 2000 were enrolled in this study. Approximately one-third of these patients completed a follow-up survey one year after their initial encounter. Analysis was limited to those patients undergoing PCI of native vessels with stents or conventional balloon angioplasty; patients with target lesions in bypass grafts or those treated with atherectomy were excluded. Approximately 23.5% of the patients enrolled in the study were diabetic. This study found no significant difference in any acute outcome between diabetic and non-diabetic patients in the hospital episode associated with the index PCI procedure. However, data from the 1-year follow-up survey indicates diabetic patients tended to have more target lesion revascularization (TLR) (13.6% versus 8.9%; p = 0.07) and more target vessel revascularization (TVR) (17.6% versus 12.7%; p = 0.058) than non-diabetic patients. In addition, adjusted odds ratios indicate that diabetic patients were 1.6 times more likely to have a second PCI procedure in another vessel (p = 0.013), 2.4 times more likely to undergo bypass surgery (p = 0.003), 1.9 times more likely to undergo an additional revascularization procedure (p < 0.001) and 1.8 times more likely to experience any major adverse cardiac events (p < 0.001) than non-diabetic patients during the follow-up period. CONCLUSIONS: This study indicates that selected diabetic patients can be treated for myocardial revascularization using PCI procedures with acceptable acute outcomes. However, diabetic patients undergoing PCIs have significantly more disease progression and are more likely to experience the need for recurrent revascularization.