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.     

Prognosis in hypertensives with acute myocardial infarction.

OBJECTIVES: A previous history of hypertension is overrepresented among patients with ischaemic heart disease. The present study aims at describing the influence of a previous history of hypertension upon the prognosis among patients hospitalized due to acute myocardial infarction. DESIGN: Patients were followed for 1 year. Mortality and morbidity are described during hospitalization and after discharge from hospital. SETTING: Sahlgrenska Hospital, serving half of the area of Gothenburg in Sweden. PATIENTS: All patients admitted to Sahlgrenska Hospital during 21 months due to acute myocardial infarction regardless of age and whether they were admitted to the coronary care unit. RESULTS: Among all patients with confirmed acute myocardial infarction (n = 917) a previous history of hypertension was reported in 324 patients. Hypertensives more frequently had a previous history of acute myocardial infarction, angina pectoris, congestive heart failure and diabetes mellitus. Their mortality during hospitalization was similar to that in normotensives. However, the total mortality during 1 year of follow-up was 35% in hypertensives and 25% for normotensives (P < 0.01), and a previous history of hypertension was an independent risk indicator for death after discharge from hospital. Place and mode of death appeared similar in normotensives and hypertensives. Reinfarction was twice as common in hypertensives as in normotensives, and a previous history of hypertension was an independent risk indicator for reinfarction. CONCLUSIONS: Among patients with acute myocardial infarction a previous history of hypertension indicates a poor prognosis, one-third of patients dying and one-quarter developing reinfarction during the first year after onset of acute myocardial infarction.     

Rate and mode of death during five years of follow-up among patients with acute chest pain with and without a history of diabetes mellitus

In order to determine the effect of diabetes on the mortality rate and mode of death during 5 years of follow-up among patients who came to the emergency department with acute chest pain or other symptoms suggestive of acute myocardial infarction (AMI), all patients thus presenting to one single hospital during a period of 21 months were followed for 5 years. In total 5230 patients were included, of whom 402 (8 %) had a history of diabetes. Patients with diabetes differed from those without by being older, having a higher prevalence of previously diagnosed cardiovascular diseases, having less symptoms of chest pain and more symptoms of acute severe heart failure, and more electrocardiographic (ECG) abnormalities on admission. Diabetic patients had a 5-year mortality of 53.5 % as compared with 23.3 % among non-diabetic patients (p < 0.001; adjusted risk ratio 1.60; 95% confidence limits 1.35–1.90). Among diabetic patients the following appeared as independent predictors of death: age (p < 0.001), ST-segment elevation on admission (p < 0.001), a history of myocardial infarction (p < 0.05), and a non-pathological ECG on admission (p < 0.001). We conclude that among diabetic patients admitted to the emergency department with acute chest pain or other symptoms suggestive of AMI more than 50 % are dead 5 years later. Future research should focus on interventions in order to reduce their mortality. © 1998 John Wiley & Sons, Ltd.     

Acute Myocardial Infarction in Diabetic Patients

ABSTRACT. All patients hospitalized during a 3-year period with an acute myocardial infarction were followed for the occurrence of reinfarction or death. The patients with diabetes mellitus (n=95) were compared with the non-diabetic population (n=545). The diabetics had a higher mortality rate (relative death rate of 1.44 vs. 0.93, p<0.01) and a higher frequency of reinfarctions (18.9 vs. 10.8%, p=0.04) than the non-diabetic population. A larger proportion of the diabetics had suffered a previous infarction, but the excess mortality was also present in those without a previous infarction. Established risk factors for death after myocardial infarction, such as age, infarct size, infarct localization and heart size, could not account for the difference in mortality. It is suggested that the increased mortality among the diabetics may be due to an increase in the rate of progression of the atherosclerotic heart disease.     

Five-year prognosis after acute myocardial infarction in relation to a history of hypertension

This study described the prognosis during 5 years of follow-up after acute myocardial infarction (AMI) for patients with a history of hypertension. All patients, regardless of age and whether or not they were admitted to the coronary care unit, were hospitalized in a single hospital due to AMI during a period of 21 months. Overall, 290 (34%) of the 862 AMI patients had a history of hypertension. Hypertensive patients had an overall 5-year mortality rate of 58% v 49% among nonhypertensive patients (P < .05). In a multivariate analysis considering age, gender, and a previous history of cardiovascular diseases, a history of hypertension was not an independent predictor of either the total mortality or mortality after discharge from hospital. The mode of death and the place of death appeared to be similar in hypertensive and nonhypertensive patients. Reinfarction developed in 43% of hypertensive patients versus 31% of nonhypertensive patients (P < .01) and a history of hypertension was an independent predictor of reinfarction (P < .05). In consecutive patients admitted to a single hospital due to AMI, a history of hypertension did not appear as an independent predictor of mortality, but it did appear as an independent predictor of reinfarction during 5 years of follow-up.     

Clinical Characteristics,Left and Right Ventricular Ejection Fraction,and Long-term Prognosis in Patients with Non-insulin-dependent Diabetes Surviving an Acute Myocardial Infarction

Patients with diabetes mellitus have a high morbidity and mortality from acute myocardial infarction, the reason for which is not fully understood. The relationship between congestive heart failure symptoms, left ventricular ejection fraction, and long-term mortality was examined in 578 hospital survivors of acute myocardial infarction, 47 of whom had Type 2 (non-insulin-dependent) diabetes mellitus. None of the patients were treated with insulin. The prevalence of congestive heart failure during hospitalization was similar in patients with and without diabetes, although mean diuretic dose was higher in the former patients. Left and right ventricular ejection fraction was measured with radionuclide ventriculography in the second week after acute myocardial infarction. At discharge from the coronary care unit, patients with and without diabetes had similar left ventricular ejection fraction (with diabetes: median 46% vs without diabetes: median 43%; p = 0.89). Median right ventricular ejection fraction (62 %) was within normal limits in both groups and did not differ statistically. Survival data were obtained for all patients. The 5-year mortality was increased in patients with diabetes compared with non-diabetic patients independent of left ventricular ejection fraction. Univariate analysis showed that the cumulative 5-year mortality rate was 53 % in the group with diabetes compared with 43% in the non-diabetic group (p = 0.007). Using multivariate regression analysis presence of diabetes was found to have a significant association with long-term mortality after myocardial infarction, that was independent of age, history of hypertension, congestive heart failure symptoms during hospitalization or of either left or right ventricular ejection fractions at discharge. We conclude that the excess mortality in patients with non-insulin-dependent diabetes mellitus is not explained by available risk markers after myocardial infarction. Even though left ventricular ejection fraction and serum creatinine did not differ significantly, the apparent higher dose of Frusemide in patients with than without non-insulin-dependent diabetes mellitus might indicate that heart failure, if present, is more severe in patients with than in those without diabetes. The importance of diastolic dysfunction in this context needs to be determined.     

Does diabetes mellitus abolish the beneficial effect of primary coronary angioplasty on long-term risk of reinfarction after acute ST-segment elevation myocardial infarction compared with fibrinolysis? (A DANAMI-2 substudy)

Little is known about the effect of diabetes mellitus on long-term clinical outcome after primary percutaneous coronary intervention (pPCI) compared with fibrinolysis in patients who have acute ST-elevation myocardial infarction. We analyzed 3-year clinical outcome in diabetic patients and nondiabetic patients who had been randomized to fibrinolysis or pPCI in the DANAMI-2 trial to compare long-term clinical outcome. The primary end point was a composite of death, clinical reinfarction, or disabling stroke. Median follow-up was 3.8 years. Among 1,572 consecutive patients who had ST-elevation myocardial infarction and were randomized to pPCI or fibrinolysis, 173 (11.0%) had diabetes mellitus; 60 of these patients received metformin treatment and were excluded. After 3 years no difference was found between diabetic patients who underwent pPCI versus fibrinolysis (combined event p=0.37, reinfarction p=0.06 in favor of fibrinolysis), whereas pPCI was superior to fibrinolysis in nondiabetic patients (combined event p=0.002, clinical reinfarction p<0.001). Three-year incidence of clinical reinfarction analyzed with Cox's regression showed that pPCI compared with fibrinolysis increased the relative risk of clinical reinfarction in diabetic patients (relative risk 2.57, 95% confidence interval 1.48 to 4.46, p <0.001) but decreased the risk in nondiabetic patients (relative risk 0.52, 95% confidence interval 0.36 to 0.74, p<0.001). In conclusion, from the DANAMI-2 trial we hypothesize that diabetes may abolish the beneficial effect of pPCI on long-term risk of clinical reinfarction.     

Long-term prognosis of diabetic patients with myocardial infarction: relation to antidiabetic treatment regimen. The TRACE Study Group.

AIMS: The present study was performed to evaluate pre-admission history, presentation, initial treatment and long-term mortality in patients with myocardial infarction and diabetes. METHODS AND RESULTS: Between 1990 and 1992, 6676 patients with acute myocardial infarction were screened for entry into the Trandolapril Cardiac Evaluation (TRACE) study. In this cohort 719 (11%) of the patients had a history of diabetes. Among the diabetic patients 19% were treated with insulin, 52% with oral hypoglycaemic agents and 29% with diet only. The diabetic patients were slightly older, more likely to be female and had a higher prevalence of known cardiovascular disease. Even though the diabetic patients had the same frequency of ST-segment elevation on the electrocardiogram and the same admission delay, treatment with thrombolysis and aspirin was less frequently prescribed to the diabetic patients than to patients without diabetes. The mortality rate was significantly increased in the diabetic patients, 7-year mortality being 79% in insulin-treated, 73% in tablet-treated and 62% in diet-treated diabetic patients compared with 46% in patients without diabetes. In a multivariate analysis only diabetic patients treated with oral hypoglycaemic agents or with insulin had an increased mortality compared with non-diabetic patients. CONCLUSIONS: Patients with diabetes mellitus and myocardial infarction are treated with thrombolysis to a lesser extent than non-diabetic patients. Diabetic patients treated with oral hypoglycaemic agents or insulin, but not those treated with diet alone, have a significantly increased mortality following acute myocardial infarction compared with non-diabetic patients.     

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.     

Under utilisation of evidence-based treatment partially explains for the unfavourable prognosis in diabetic patients with acute myocardial infarction.

AIMS: The prognosis after an acute myocardial infarction is worse for patients with diabetes mellitus than for those without. We investigated whether differences in the use of evidence-based treatment may contribute to the differences in 1-year survival in a large cohort of consecutive acute myocardial infarction patients with and without diabetes mellitus. METHODS: We included patients below the age of 80 years from the Register of Information and Knowledge about Swedish Heart Intensive care Admissions (RIKS-HIA), which included all patients admitted to coronary care units at 58 hospitals during 1995-1998. In all 5193 patients had the combination of acute myocardial infarction and diabetes mellitus while 20440 had myocardial infarction but no diabetes diagnosed. Multivariate logistical regression analyses were performed to evaluate the influence of diabetes mellitus on the use of evidence-based treatment and its association with survival during the first year after the index hospitalisation. RESULTS: The prevalence of diabetes mellitus was 20.3% (males 18.5%; females 24.4%). The 1-year mortality was substantially higher among diabetic patients compared with those without diabetes mellitus (13.0 vs. 22.3% for males and 14.4 vs. 26.1% for female patients, respectively) with an odds ratio (OR) (95% confidence interval (CI)) in three different age groups: <65 years 2.65 (2.23-3.16); 65-74 years 1.81 (1.61-2.04) and >75 years 1.71 (1.50-1.93). During hospital stay patients with diabetes mellitus received significantly less treatment with heparins (37 vs. 43%; p<0.001), intravenous beta blockade (29 vs. 33%; p<0.001), thrombolysis (31 vs. 41%; p<0.001) and acute revascularisation (4 vs. 5%; p<0.003). A similar pattern was apparent at hospital discharge. After multiple adjustments for dissimilarities in baseline characteristics between the two groups, patients with diabetes were significantly less likely to be treated with reperfusion therapy (OR 0.83), heparins (OR 0.88), statins (OR 0.88) or to be revascularised within 14 days from hospital discharge procedures (OR 0.86) while the use of ACE-inhibitors was more prevalent among diabetic patients compared to non-diabetic patients (OR 1.45). The mortality reducing effects of evidence-based treatment like reperfusion, heparins, aspirin, beta-blockers, lipid-lowering treatment and revascularisation were, in multivariate analyses, of equal benefit in diabetic and non-diabetic patients. INTERPRETATION: Diabetes mellitus continues to be a major independent predictor of 1-year mortality following an acute myocardial infarction, especially in younger age groups. This may partly be explained by less use of evidence-based treatment although treatment benefits are similar in both patients with and without diabetes mellitus. Thus a more extensive use of established treatment has a potential to improve the poor prognosis among patients with acute myocardial infarction and diabetes mellitus.     

Reduced High Density Lipoproteins as a Risk Factor after Acute Myocardial Infarction

ABSTRACT. FranzÉn J, Johansson BW, Gustafson A (Department of Internal Medicine, University Hospital, Lund and Section of Cardiology, Department of Internal Medicine, MalmÖ General Hospital, MalmÖ, Sweden). Reduced high density lipoproteins as a risk factor after acute myocardial infarction. In a group of normocholesterolemic, non-diabetic middle-aged males surviving an acute myocardial infarction for 4±2 years (mean ± SD), we have previously described a low apolipoprotein A-1 and a deficient fibrinolytic activity as two major characteristics. In the present study we have followed morbidity and mortality risk factors for five years in these males. Mortality was 40% in a hypertensive group and 16% in a normotensive group. In the normotensive group mortality was related to reinfarction. Furthermore, patients with a poor prognosis in the normotensive group had lower high density lipoprotein (HDL) cholesterol and lower apolipoprotein A-I concentration in plasma than patients with a good prognosis. Unexpectedly, in the hypertensive group death was related to a low (p<0.05) cortisol concentration in urine. It is concluded that a low HDL level may be a bad prognostic sign in males who have sustained an acute myocardial infarction and show no evidence of other risk factors, such as diabetes, hypercholesterolemia or hypertension.     

Myocardial infarct size and mortality in patients with non-insulin-dependent diabetes mellitus

Abstract. Objectives. To study the infarct size and mortality in patients with non-insulin-dependent diabetes mellitus (NIDDM) and in non-diabetic subjects with their first acute myocardial infarction. Design. Seven year follow-up study of large representative cohorts of patients with non-insulin-dependent diabetes mellitus and non-diabetic subjects (study 1) and the FINMONICA acute myocardial infarction register study in 1988-89 (study 2). Setting. Populations of the districts of the Kuopio University Hospital and Turku University Central Hospital (study 1). Populations of Kuopio and North Karelia provinces and Turku/Loimaa area (study 2). Subjects. Study 1: 1059 patients with non-insulin dependent diabetes mellitus and 1373 non-diabetic subjects aged 45–64 years at baseline; during the follow-up 166 patients with non-insulin-dependent diabetes mellitus (91 men and 75 women) and 30 non-diabetic subjects (25 men and five women) were hospitalized for their first acute myocardial infarction. Study 2: 1622 patients aged 25–64 years hospitalized for their first acute myocardial infarction; 144 patients (90 men and 54 women) had non-insulin-dependent diabetes mellitus and 1153 (890 men and 263 women) were non-diabetic. Main outcome measures. The infarct size was assessed on the basis of maximum levels of serum cardiac enzymes (studies 1 and 2) and QRS-score (study 1). Results. No differences were found in maximum levels of serum cardiac enzymes between diabetic and non-diabetic patients. Similarly QRS-score gave no suggestion of a difference in infarct size between diabetic and non-diabetic patients. In both studies mortality before hospital admission was similar in diabetic and non-diabetic patients, but mortality within 28 days from hospital admission was twice as high in diabetic patients as in non-diabetic patients. Cardiac failure was the main cause of death significantly more often in diabetic patients than in non-diabetic patients (study 2). Conclusions. Poorer prognosis of acute myocardial infarction in diabetic patients appears not to be explained by a larger infarct size but probably by adverse effects of the diabetic state itself on myocardial function.     

Diabetes worsens the outcome of acute ischemic stroke

OBJECTIVE: To characterize acute stroke events in diabetic patients in a population-based stroke register and to determine the influence of diabetes on the outcome of acute stroke. METHODS: Four thousand three hundred and ninety patients were recorded in the FINMONICA and FINSTROKE registers after their first ischemic stroke from 1990 to 1998. We followed mortality and stroke outcome for up to 4 weeks after the onset of acute stroke. RESULTS: Of the 4390 patients who had had an ischemic stroke, 43.6% were male and 25.1% (1103) had diabetes. Their mean age was 72.4 (S.D. 12.0) years and this was similar in patients with and without diabetes (72.9 years versus 72.3 years, p=0.18). Subjects with diabetes were more likely to be hypertensive (55% versus 38%, p<0.001) and have a history of myocardial infarction (20% versus 16%, p<0.001) than the non-diabetic stroke patients. Mortality at 4 weeks from the onset was higher in diabetic than in non-diabetic patients (20.0% versus 16.9% p=0.020). At day 28 after the stroke attack, diabetic patients were more likely to be disabled when compared with non-diabetic subjects (43.3% versus 33.5%, p<0.001). Using logistic regression analysis, adjusted for age-group, sex, previous medical history (MI, AF or TIA), diabetes was found to be a significant predictor of disability after stroke (OR=1.51, 95% CI 1.27-1.81). CONCLUSIONS: Diabetes, which affected one-fourth of the ischemic stroke patients on our register, was associated with a higher risk of death and disability after the onset of stroke. Preventing diabetes in the elderly population improves the short-term prognosis of acute ischemic stroke.     

糖尿病合并非ST段抬高急性冠状动脉综合征患者的临床特点、治疗及远期预后

目的 了解糖尿病合并非ST段抬高急性冠状动脉综合征(ACS)患者的临床特点、治疗及远期预后.方法 在我国北方38个中心连续入选因非ST段抬高ACS住院的患者,记录既往病史、入院情况、住院期间主要治疗和心血管事件,并在发病6、12和24个月对所有患者进行随访.采用Kaplan-Meier牛存分析比较糖尿病和非糖尿病患者2年累计事件发生率,Cox回归多因素分析用于2年累计死亡影响因素的识别.结果 共注册非ST段抬高ACS住院患者2294例,其中已知糖尿病患者420例,占18.3%.平均年龄(64.9±6.7)岁,高于非糖尿病患者的(62.3±8.6)岁(P<0.01),女性患者(占48.1%)、既往有高血压病、心肌梗死、心力衰竭、卒中者均多于非糖尿病患者.合并糖尿病患者住院期间抗血小板约物的应用(92.1%比95.0%,P<0.05)、接受冠状动脉造影(30.0%比36.3%,P<0.05)和冠状动脉介入治疗(12.1%比18.8%,P<0.05)的患者少于非糖尿病者.住院期间以及2年累计的死亡、慢性心力衰竭以及心肌梗死、卒中、心力衰竭和死亡的联合终点事件发生率均明显高于非糖尿病者.多因素回归分析显示,年龄≥70岁、糖尿病、既往心肌梗死、既往心力衰竭、就诊时收缩压<90 mm Hg(1 mm Hg=0.133 kPa)和心率>100次/min是非ST段抬高ACS患者2年死亡的危险因素.结论 合并糖尿病的非ST段抬高ACS患者住院期间和2年死亡、慢性心力衰竭和联合终点事件发牛率明显高于非糖尿病者.糖尿病是非ST段抬高ACS患者2年死亡的独立危险因素.我国非ST段抬高ACS患者住院期间抗血小板治疗和早期介入检杳和治疗有待加强.有必要进行更有针对性的大规模临床研究,以提高糖尿病并发ACS的治疗水平,改善该人群的预后.

Abstract：

Objective To observe the clinical characteristics,treatment options and outcome of diabetic patients with non-ST elevation acute coronary syndromes(NSTEACS).Methods Consecutive patients admitted with NSTEACS from 38 centers in north China were enrolled.Medical histories,clinical characteristics,treatments and outcomes were evaluated and follow-up was made at 6,12,and 24 months 'after their initial hospital admission.Cumulative event rates were compared between diabetic and nondiabetic patients.Results There were 420 diabetic patients out of 2294 NSTEACS patients(18.3%).Diabetic patients were older[(64.9±6.7)years vs.(62.3±8.6)years,P<0.01],more often women (48.1% vs.35.3%,P<0.05)and were associated with higher baseline comorbidities such as previous hypertension,myocardial infarction,congestive heart failure and stroke than non-diabetic patients.The incidence of antiplatelet therapy(92.1% vs.95.O%,P<0.05),coronary angiography(30.0% vs.36.3%,P<0.05)and revascularization(12.1% vs.18.8%,P<0.05)was lower in patients with diabetes than non-diabetic patients.In hospital and 2-year mortality as well as the incidence of congestive heart failure and composite outcomes of myocardial infarction,stroke,congestive heart failure and death were substantially higher in diabetic patients compared with non-diabetic patients.Muhivariative Cox regression analysis revealed that age≥70 years,diabetes,previous myocardial infarction,previous congestive heart failure,systolic blood pressure less than 90 mm Hg(1 mm Hg=0.133 kPa)and heart rate more than 100bpm at admission were risk factors for 2-year death.Conclusion In NSTEACS,diabetes is associated with higher rate of in-hospital and 2-year death,congestive heart failure and composite outcomes of myocardial infarction,stroke,congestive heart failure and death.Diabetes mellitus is a major independent predictor of 2-year mortaliy post NSTEACS.Status of antiplatelet therapy,coronary angiography and revascularization should be improved for diabetic patients with NSTEACS during hospitalization.     

Impact of diabetes mellitus on long-term outcome after unstable angina and non-ST-segment elevation myocardial infarction treated with a very early invasive strategy

Aims/hypothesis We sought to evaluate the impact of diabetes mellitus on long-term outcome in patients with unstable angina and non-ST-segment elevation myocardial infarction treated with a very early invasive strategy.Methods We carried out a prospective cohort study in 270 diabetic and 1163 non-diabetic patients with unstable angina and non-ST-segment elevation myocardial infarction. All patients underwent coronary angiography and, if appropriate, subsequent revascularisation within 24 hours of admission. The primary endpoint was all-cause mortality during follow-up for up to 60 months.Results Diabetic patients had less favourable baseline characteristics including more advanced coronary artery disease and more severe unstable angina and non-ST-segment elevation myocardial infarction. Percutaneous coronary intervention was performed in 53% of diabetic patients and 56% of non-diabetic patients. Coronary artery bypass grafting was done in 21% of diabetic patients and 12% of non-diabetic patients. In-hospital mortality (4.1% vs 1.3%; hazard ratio 3.47; 95% CI: 1.57 to 7.64; p=0.002) and long-term mortality (9.7% vs 4.9%; hazard ratio 2.11; 95% CI: 1.33 to 3.36; p=0.002) were significantly higher in diabetic patients. After adjustment for differences in baseline characteristics, diabetes mellitus was no longer an independent predictor of long-term mortality (hazard ratio 1.43; 95% CI: 0.74 to 2.78; p=0.292).Conclusions/interpretation Diabetic patients treated with a very early invasive strategy for unstable angina and non-ST-segment elevation myocardial infarction have a higher in-hospital and long-term mortality that is largely explained by their less favourable baseline characteristics including more advanced coronary artery disease and more severe unstable angina and non-ST-segment elevation myocardial infarction.Abbreviations CK creatine phosphokinase - FRISC Fragmin and fast Revascularisation during InStability in Coronary artery disease - OASIS Organisation to Assess Strategies for Ischemic Syndromes - TACTICS-TIMI 18 Treat angina with Aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy—Thrombolysis In Myocardial Infarction 18 - UA/NSTEMI unstable angina and non-ST-segment elevation myocardial infarction     

The impact of diabetes mellitus on survival after myocardial infarction: can it be modified by drug treatment?

Aims/hypothesis. Mortality of diabetic patients after myocardial infarction remains high despite recent improvement in their management. This study population-based evaluates the impact of cardiovascular drug therapy on mortality within 28 days and during 5-year follow-up in diabetic compared with non-diabetic patients.¶Methods. Using the MONICA Augsburg register from 1985 to 1992, 2210 inpatients with incident Q-wave myocardial infarction aged 25–74 years were included, of whom 468 had diabetes. Primary end point was mortality within 28 days and over 5 years. General linear model procedures were used for age-adjustment, controlling for sex, and testing significance; hazard risk ratios were calculated using multivariable Cox proportional hazards model procedures.¶Results. During the 5-year follow-up, 598 subjects died (396 diabetic, 202 non-diabetic). The mortality rate within 28 days was 12.6 % in diabetic patients (women 18.0 %, men 9.9 %) and 7.3 % in non-diabetic patients (p = 0.001). Mortality in diabetic patients over 5 years was increased by 64 % (95 % confidence interval 1.39–1.95) compared with non-diabetic patients. This was considerably reduced (p < 0.001) in patients treated with thrombolytic drugs (risk ratio: diabetes 0.57, no diabetes 0.65) and with beta blockers (0.62 and 0.64) and antiplatelets (0.76 and 0.74) at hospital discharge. Mortality of diabetic patients treated with these drugs was reduced to that of non-diabetic patients without such treatment (risk ratio 1.01 to 1.27; p > 0.1).¶Conclusion/interpretation. Diabetic patients after myocardial infarction are at particularly high risk of dying, but benefit clearly from treatment with thrombolytics, beta blockers and antiplatelets. This study does not, however, allow any inferences to be drawn for treatment with angiotensin converting enzyme inhibitors or the impact of left ventricular function. [Diabetologia (2000) 43: 218–226]     

Is diabetes an independent risk factor for mortality after myocardial infarction? The ARIC (Atherosclerosis Risk in Communities) Surveillance Study

Abstract. We investigated the age-, gender- and race-specific 1-year case fatality rates of diabetic and non-diabetic individuals with a myocardial infarction. Data were obtained from the Atherosclerosis Risk in Communities (ARIC) Surveillance Study, which monitors both hospitalized myocardial infarction and coronary heart disease (CHD) deaths in residents aged 35–74 years in four communities in the USA. The study population comprised 3242 hospitalized myocardial infarctions (HMIs) in diabetic subjects and 9826 HMIs in non-diabetic individuals between 1987 and 1997. Age-adjusted and gender- and race-specific odds ratios (OR) for 1-year case fatality comparing diabetic to non-diabetic patients were 2.0 (95% CI, 1.6–2.4) for white men and 1.4 (95% CI, 1.1–1.8) for white women. Further adjustment for severity of HMI, history of previous MI, stroke and hypertension, and therapy variables showed significantly higher case fatality in white diabetic men than in non-diabetic white men (OR=1.5; 95% CI, 1.2–1.9), but no significant association in the other race-gender groups. The age-adjusted odds of out of hospital death was significantly higher among white diabetic men (OR=1.7; 95% CI, 1.2–2.3), white women (OR=2.3; 95% CI, 1.4–3.8), and African-American women (OR=2.9; 95% CI, 1.5–5.9) as compared to their non-diabetic counterparts. In conclusion, diabetes is an independent factor for mortality within one year following a myocardial infarction among white men, and following out-of hospital coronary death in white men and women and in African-American women. It is possible that these differences could be explained, at least in part, by a less than optimal medical management of the high cardiovascular risk profile of these patients after hospital discharge.     

Diabetes as a risk factor for stroke. A population perspective

Summary Stroke incidence, case fatality and mortality in diabetic patients were compared to non-diabetic subjects in a 35–74-year-old population in northern Sweden (target population 241,000). During an 8-year period, 1,544 stroke events in diabetic patients and 4,826 events in non-diabetic subjects were recorded. The crude incidence of stroke was 1,000 per 100,000 in the diabetic men vs 247 in the non-diabetic men (relative risk 4.1; 95% confidence interval 3.2–5.2). Among diabetic women, the crude incidence was 757 per 100,000 and 152 in non-diabetic women (relative risk 5.8; 95% confidence interval 3.7–6.9). The 28-day case fatality among men was similar in the diabetic and non-diabetic stroke patients (18.6 vs 17.1%; p=0.311), but significantly higher in diabetic women compared with non-diabetic women (22.2 vs 17.9%; p=0.02). When compared with the non-diabetic population, the overall mortality from stroke in the diabetic population (first and recurrent) was 4.4-times higher in male and 5.1-times higher in the female patients. Hypertension, atrial fibrillation, heart failure or myocardial infarction were all significantly more common in diabetic than in non-diabetic stroke patients. The population attributable risk, a crude estimate of all strokes ascribed to diabetes mellitus, was 18% in men and 22% in women. In Sweden, about 50 strokes are annually directly attributed to diabetes in a population of 100,000 in this age group.Abbreviations MONICA Multinational Monitoring of Trends and Determinants in Cardiovascular Disease - ICD International Classification of Diseases - CT computerised tomography - CI confidence interval - RR relative risk - CF case fatality     

Outcome of Unstable Angina in Patients with Diabetes Mellitus

This prospective hospital-based, case–control study compares the outcome of unstable angina in non-insulin dependent diabetic patients and non-diabetic control subjects. One hundred and sixty-two diabetic patients and 162 non-diabetic control patients with unstable angina were entered into the study. The 3-month mortality was 8.6 % (95 % confidence interval, CI = 4.4–12.9 %) in diabetic patients and 2.5 % (CI = 0.1–4.9 %) in control patients (p = 0.014). The 1-year mortality was 16.7 % (CI = 10.9 %–22.4 %) in diabetic patients and 8.6 % (CI = 4.4 %–12.9 %) in non-diabetic patients (p = 0.029). Diabetic patients received beta-blockade and underwent coronary angiography and angioplasty less frequently than controls; the frequency of unstable angina, of acute myocardial infarction, and of coronary artery bypass grafting was similar in both groups at 1 year of follow-up. It is concluded that diabetic patients with unstable angina have a higher mortality than non-diabetic patients and that this difference is largely accounted for by early (first 3 months) mortality. © 1997 by John Wiley & Sons, Ltd.     

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.