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

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

What is the real hospital mortality from acute myocardial infarction? Epidemiological vs clinical view.

AIMS: To examine the general influence of the definition of fatal and non-fatal acute myocardial infarction and coronary deaths on the estimation of in-hospital case-fatality, and to show how the definition of acute myocardial infarction influences time-trends of hospital mortality over 11 years. METHODS AND RESULTS: As part of the World Health Organization's MONICA (multinational Monitoring of Trends and Determinants in Cardiovascular Disease) Project in Augsburg all patients aged 25-74 years with a suspected diagnosis of acute myocardial infarction who were hospitalized in the study region's major clinic were registered prospectively between 1985 to 1995 (n=4889). Patient information, including short-term survival status, was obtained from medical records, by interview of surviving patients, and municipal death certificate files which were validated by an extended identification and validation process. In-hospital case fatality was estimated according to different definitions which closely followed the international MONICA criteria. Epidemiological definitions comprised definite and possible acute myocardial infarction, and events with unclassifiable deaths, while the clinical definition was restricted to definite infarction. Overall, case fatality by the epidemiological definitions was 28 to 29.8% (23.5% of those treated in a coronary care unit) compared to 13.5% using the clinical definition. While over the 11 years, the reduction in case fatality according to the epidemiological definitions was modest, highly significant decreases were observed by applying the clinical definition (from 15.8% in 1985-1988 to 10.8% in 1993-1995, P<0.001 adjusted for age and sex). The discrepancy in case fatality between the definitions is explained by the high proportion of patients who die very early (about 70% of all fatal events during the first 24 h) with the consequence of missing data which may preclude a definite diagnosis of acute myocardial infarction. CONCLUSIONS: Applying a broader definition of acute myocardial infarction reveals that in-hospital mortality is higher than believed until now, and it implies that our efforts must be intensified to reduce overall in-hospital coronary heart disease mortality.     

Impact of treatment of coronary artery disease with sirolimus-eluting stents on outcomes of diabetic and nondiabetic patients

Patients with diabetes mellitus are at increased risk for repeat interventions and mortality after coronary angioplasty and stenting. The efficacy of sirolimus-eluting stents (SESs) to improve the outcomes of these patients is a focus of interest. In the first 1,407 patients treated with SESs at our institution, 492 were diabetic (insulin dependent diabetes mellitus [IDDM], n = 160 and non-insulin-dependent DM [NIDDM], n = 332). The in-hospital and 1- and 6-month clinical outcomes were compared with those of 915 patients without DM (non-DM). The baseline characteristics were similar, except for more women, obesity, previous myocardial infarction, coronary artery bypass grafting, and renal insufficiency in the DM group (p <0.001). Compared with non-DM patients, DM patients had higher in-hospital (p <0.05) and 1-month mortality (p = 0.02). IDDM patients had more in-hospital renal failure (p = 0.04) and Q-wave myocardial infarctions (1.6% vs 0%, p = 0.04) compared with NIDDM patients, and higher mortality (3.1% vs 0.8%, p = 0.04) and subacute stent thromboses (2.3% vs 0.5%, p = 0.07) than non-DM patients at 30 days. At 6 months, DM patients had a higher incidence of Q-wave myocardial infarction, target lesion revascularization-major adverse cardiac events, and composite of death and Q-wave myocardial infarction than non-DM patients (6.0% vs 2.7%, p = 0.01). Late outcomes between the IDDM and NIDDM groups were similar. Multivariate analysis showed diabetes and acute renal failure as independent predictors of target lesion revascularization-major adverse cardiac events. In conclusion, our data showed that, despite a reduction in repeat revascularization, coronary intervention with SESs in diabetic patients is limited by higher mortality at 1 month and a higher incidence of Q-wave myocardial infarction and target lesion revascularization-major adverse cardiac events at 6 months compared with non-DM patients. Careful surveillance is required in IDDM patients undergoing SES implantation.     

Clinical course and long-term prognosis in patients with recurrent myocardial infarction

Retrospective study was based on analysis of 881 patients treated in our ward in 1992-1996. Their fate was estimated through 2-6 years after the past myocardial infarction (MI). There were among of them 147 (16.7%) with second and 20 (2.3%) with third or next MI. Then we compared in-hospital course and long-term prognosis in patients with recurrent MI (group I, n = 167) to patients with the first MI (group II, n = 714). We have also evaluated influence of the time-period between the both episodes of myocardial infarctions on the prognosis. The chi-square test was applied to identify the significance of the difference between both groups. Using the Kaplan-Meier method, figures of survival curves were created. Patients in group I were about 4.9 year-older than in group II/(median age was 64.8 +/- 10.7 vs 59.9 +/- +/- 11.3 years p < 0.05). More popular were also diabetes (30.5% vs 18.5%, p < 0.001), advanced hypertension (31.7% vs 20.5% p < 0.01) and higher ratio of current smokers (51.5%) among risk factors in patients from group I. Second myocardial infarction had more serious in-hospital course than the first one. It could be the result of anterior location and more often cardiac complications like ventricular arrhythmias including VF, disturbances of intraventricular conductions, cardiogenic shock and pulmonary oedema with especially of first hours of acute myocardial infarction. Mortality rate in the group I was 2.2 times higher to compare with group II (24.0% vs 10.9%, p < 0.001). Significance higher mortality was in the first year of follow-up and among patients with recurrent myocardial infarction within 12 months after the first one. CONCLUSION: Previous myocardial infarction is significant risk factor that elevate in-hospital course and long-term mortality rate. We observed the higher mortality rate when the recurrent myocardial infarction occurred within 12 months after the first one. The longer time-period since the first myocardial infarction the better prognosis was observed in our analysis.     

Primary percutaneous coronary interventions in acute myocardial infarction in diabetic versus non-diabetic patients. In-hospital and long-term results

BACKGROUND. It has been well established that in the pre-thrombolytic era diabetic patients had poorer clinical outcome after acute myocardial infarction (AMI) compared to non-diabetic patients. Less is known about the impact of diabetes on early and late clinical outcomes in patients with AMI undergoing primary percutaneous coronary interventions (PCI). AIM. To compare the in-hospital and long-term clinical outcomes of AMI patients with and without diabetes. METHODS. Seven hundred seventy-four patients who underwent primary PCI for AMI in our institution between 1997 and 2001 were included in the study. We compared the angiographic and clinical outcomes of 633 (81.8%) non-diabetic (aged 55.9+/-10.6 years; 82.6% male) and 141 (18.2%) diabetic (aged 56.8+/-11.7 years; 63.1% male) patients. RESULTS. Diabetic patients had a higher incidence of hypertension, hyperlipidemia, and unstable hemodynamic status compared to non-diabetic patients (p=0.001, 0.003, 0.001, respectively). Smoking and male gender rates were significantly more frequent in non-diabetic patients (p=0.001, 0.001, respectively). Angiographic success and prominent clinical improvement were achieved in 96.4% and 90.7% of diabetics vs 96.7% and 95.1% of non-diabetics (p=NS and 0.04, respectively). Diabetic patients had a higher incidence of in-hospital deaths and overall events (p=0.028). At one-month follow-up, diabetic patients required more target vessel revascularisation (5.6% vs 1.6%; p=0.006), which accounted for the majority of major cardiac events at one month (20.6% vs 7.4%; p=0.003). At a mean follow-up of 7.2+/-2.7 months, 92.9% of non-diabetic and 88% of diabetic patients were still alive (p=0.05). Overall survival without any major cardiac event (death, new MI or target vessel revascularisation) at 7.2+/-2.7 month follow-up was 75.8% for non-diabetics and 58.1% for diabetic patients (p<0.01). In the multivariate analysis age, diabetes, shock, hemodynamic instability and female gender were the most important predictors for the development of early and late major cardiovascular events. CONCLUSIONS. Primary PCI in acute MI is effective in restoring TIMI 3 coronary flow both in diabetic and non-diabetic patients. This procedure may reduce mortality in both groups, particularly in diabetic patients in whom this benefit is more prominent compared to thrombolytic therapy. Nevertheless, early and long-term event rates are significantly higher in diabetics than in non-diabetic patients.     

The Prehospital Electrocardiogram in Acute Myocardial Infarction: Is Its Full Potential Being Realized?

Objectives. This study sought to examine the management and subsequent outcomes of patients with a prehospital electrocardiogram (ECG) in a large, voluntary registry of myocardial infarction.Background. The prehospital ECG has been proposed as a means of rapidly identifying patients with acute myocardial infarction who might be eligible for reperfusion therapy.Methods. The characteristics and outcomes of patients with a prehospital ECG were compared with those without a prehospital ECG in the National Registry of Myocardial Infarction 2 data base. Included in the analysis were those patients who presented to the hospital within 12 h of an acute myocardial infarction. Excluded were patients with an in-hospital infarction, transferred-in referrals and self-transported patients.Results. Prehospital ECGs were obtained in 3,768 (5%) of 66,995 National Registry of Myocardial Infarction 2 patients meeting study criteria. Median time from myocardial infarction symptom onset until hospital arrival was longer among those having a prehospital ECG (152 vs. 91 min, p < 0.001). However, once in the hospital, the prehospital ECG group experienced a shorter median time to the initiation of either thrombolysis (30 vs. 40 min, p < 0.001) or primary angioplasty (92 vs. 115 min, p < 0.001). The prehospital ECG group was more likely to receive thrombolytic therapy (43% vs. 37%, p < 0.001) and to undergo primary angioplasty (11% vs. 7%, p < 0.001). Also, the prehospital ECG group was more likely to undergo coronary arteriography (55% vs. 40%, p < 0.001), angioplasty (24% vs. 16%, p < 0.001) or bypass surgery (10% vs. 6%, p < 0.001). The in-hospital mortality rate was 8% in patients with a prehospital ECG and 12% in those without a prehospital ECG (p < 0.001). After adjusting for baseline covariates utilizing multiple logistic regression analysis, this mortality difference remained statistically significant (odds ratio 0.83, 95% confidence interval 0.71 to 0.96, p = 0.01).Conclusions. The prehospital ECG is infrequently utilized for diagnosing myocardial infarction, and among patients with a prehospital ECG, is associated with a longer time from symptom onset to hospital arrival. Despite these shortcomings, the prehospital ECG is a test that may potentially influence the management of patients with acute myocardial infarction through wider, faster in-hospital utilization of reperfusion strategies and greater usage of invasive procedures, factors that may possibly reduce short-term mortality. Efforts to implement the prehospital ECG more widely and more rapidly may be indicated.(J Am Coll Cardiol 1997;29:498–505)     

Comparison of the extent and severity of coronary artery disease in patients with acute myocardial infarction with and without microalbuminuria

The extent and severity of coronary atherosclerosis were compared between 43 microalbuminuric and 87 normoalbuminuric nondiabetic patients with acute myocardial infarction. Patients with microalbuminuria had significantly greater scores of the severity (Gensini score) and extent (Hamsten score) of coronary artery disease (p <0.001).     

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

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

Assessment of Holter ST monitoring for risk stratification in patients with acute myocardial infarction treated by thrombolysis.

OBJECTIVES--To evaluate the role of Holter ST monitoring for identifying patients at risk of recurrent ischaemic events after acute myocardial infarction treated by thrombolysis. BACKGROUND--The natural history of myocardial infarction has changed with the introduction of thrombolytic treatment. There is now a lower mortality but a higher incidence of recurrent thrombotic events (reinfarction, unstable angina). Preliminary evidence indicates that Holter ST monitoring may be of prognostic value in patients with acute myocardial infarction, but there are limited data available in patients treated by thrombolysis. METHODS--Prospective observational study of 256 consecutive patients who presented with acute myocardial infarction treated by thrombolysis. All underwent 48 hour Holter ST monitoring early after thrombolysis (mean 83, range 48-180 hours) and were followed up for eight (range three to 12) months. RESULTS--Recurrent ischaemic events occurred in 45 patients (fatal reinfarction 17, non-fatal reinfarction 12, unstable angina 16). Also four patients died as a result of progressive heart failure, and a further 15 patients required revascularisation. Analysis of the Holter data showed that 32% of patients had at least one episode of isolated ST depression (> or = 0.1 mV) and 41% either ST depression or elevation (> or = 0.2 mV). Ischaemic episodes were silent in 95% of cases. Event free survival analysis showed a significant association between Holter findings and recurrent ischaemic events (ST depression: p = 0.009; ST depression or elevation: p = 0.002). The association remained significant when the end point was restricted to fatal or non-fatal reinfarction (ST depression: p = 0.005; ST depression or elevation p = 0.001), the period of greatest risk for patients with an abnormal recording occurred early after investigation. An abnormal Holter recording identified patients at risk of early (within 30 days) reinfarction with 79% sensitivity and 60% specificity. Although positive predictive accuracy was low (11%), a normal Holter recording was associated with 98% negative predictive accuracy. CONCLUSIONS--In patients treated by thrombolysis, ST change on Holter monitoring may be useful for identifying patients at increased risk of recurrent ischaemic events, and in particular early reinfarction.     

中高危非ST段抬高急性冠状动脉综合征早期侵入与早期保守策略的评价

目的　了解早期侵入与早期保守策略对中高危非ST段抬高急性冠状动脉综合征(ACS)患者住院主要不良心脏事件(MACE)发生情况的影响。方法　根据入院后冠状动脉造影(CAG)与否和时间(≤48h与>48h)对910例中高危非ST段抬高ACS患者分为早期侵入策略组(n=237)和早期保守策略(n=673)两组,分析早期策略与血管重建方式对住院MACE(包括死亡、新发心肌梗死和靶血管再次血管重建)的关系。结果　早期侵入与早期保守组的住院病死率和靶血管血管重建率相当,早期侵入组的住院时间较短,住院MACE(6. 3%比2 .5%,OR0 .384, 95% CI0 188~0 .781,P=0 .006)与新发心肌梗死(4. 6%比0 .9%,OR0 .185, 95% CI0 068~0 .505,P=0.001)的发生率更高。早期侵入组MACE与新发心肌梗死的增加可能与其血管重建操作较多( 86 .9%比67. 5%,P<0 .001)有关。亚组分析显示,早期侵入组与早期保守组中接受经皮冠状动脉介入治疗(PCI)的患者新发心肌梗死、靶血管再次血管重建(TVR)和MACE发生率均相当,无1例死亡;而早期侵入组中接受冠状动脉旁路移植术(CABG)的患者新发心肌梗死的发生率高于早期保守组中接受CABG的患者(7 .5%比1 .8%,P=0 .027)。结论　中高危非ST段抬高ACS患者采取早期侵入策略不增加住院病死率,但有可能增加住院心肌梗死。早期PCI安全可行     

Do differences in baseline characteristics or in management account for the poorer in-hospital and subsequent outcome after myocardial infarction in diabetics? Data from a large unselected cohort

OBJECTIVE: There is an excess mortality after myocardial infarction in diabetics, but also documented significant differences in the characteristics of MI and in management between diabetics and non-diabetics. The aim of this prospective study in a large unselected patient cohort in a single French region was to determine if baseline characteristics, management, or in-hospital and one-year mortality differed in diabetic and non-diabetic patients with myocardial infarction. METHODS AND RESULTS: Data were prospectively collected in consecutive patients with myocardial infarction admitted to all hospitals in three departments in the Rhone-Alpes region between September 1, 1993 and January 31,1995. Among the 2,297 patients, 410 patients (17.8%) were diabetic. Although diabetics were older than non-diabetics (70.3 vs. 67.8 years; p < 0.0004), and less likely to receive thrombolysis (31% vs. 36%; p = 0.043), in-hospital mortality was not significantly higher (17.3% vs. 14.7%) than in non-diabetics. In multivariate analysis, diabetes was a significant predictor of one-year mortality (relative risk: 1.41; 95% CI = 1.10 - 1.79; p = 0.0063) but not of in-hospital mortality (relative risk: 1.2; 95% CI = 0.9 - 1.7; p = 0.25). Multivariate predictors of in-hospital and one-year mortality in diabetics were age and Killip class at admission. CONCLUSIONS: In this large unselected French cohort, diabetes mellitus was a significant predictor of one-year but not of in-hospital mortality after myocardial infarction in a French region.This negative effect of diabetes on mortality was not related to differences in baseline characteristics, or in initial or post-discharge management between diabetics and non-diabetics.     

Factors leading to shorter survival after acute myocardial infarction in patients ages 65 to 75 years compared with younger patients

Although the number of elderly patients with acute myocardial infarction (AMI) has steadily increased and these patients are known to have a higher early subsequent mortality than younger patients, the reasons for this adverse prognosis are poorly understood. We compared the clinical courses of 217 patients, ages 65 to 75 years, with 631 patients younger than 65 years of age enrolled in the Multicenter Investigation of the Limitation of Infarct Size (MILIS). The older group had a higher prevalence of adverse baseline risk factors, including history of congestive heart failure (14 vs 7%, p less than 0.001), previous AMI (28 vs 22%, p less than 0.05), angina pectoris (42 vs 34%, p less than 0.05), systemic hypertension (64 vs 52%, p less than 0.01), diabetes mellitus (24 vs 17%, p less than 0.05) and female gender (37 vs 24%, p less than 0.001). Despite having a smaller infarct size index than younger patients (15 +/- 1 vs 18 +/- 1 CK-MB g-Eq/m2, p less than 0.002), the elderly patients had a lower admission left ventricular ejection fraction (43 +/- 1 vs 47 +/- 1%, p less than 0.01) and a higher frequency of clinical congestive heart failure (44 vs 28%, p less than 0.001) and in-hospital death (14 vs 7%, p less than 0.01). The 1-year mortality for elderly hospital survivors was also markedly greater (19 vs 5%, p less than 0.001) as was the 4-year mortality (35 vs 13%, p less than 0.001). Adjustment for 7 adverse baseline characteristics in the elderly could account for their increased in-hospital mortality. However, these and 12 additional in-hospital characteristics did not account for the increased 1- and 4-year mortalities of the elderly hospital survivors, which are presumably affected by variables not included in the present age-associated study.     

Comparison of in-hospital outcomes following early or delayed angioplasty for acute myocardial infarction

BACKGROUND: Studies of primary angioplasty for treatment of acute myocardial infarction (AMI) have not appeared to demonstrate a reduction in efficacy as a function of time to treatment. We sought to compare the outcomes of patients treated in New York State with primary angioplasty within 6 hours of symptom onset to those treated between 6 and 23 hours after the onset of AMI. METHODS: We used data from the 1995 Coronary Angioplasty Reporting System of the New York State Department of Health to compare the in-hospital outcomes of patients treated with early (within 6 hours) or delayed angioplasty (6 23 hours) for AMI. RESULTS: Early angioplasty (within 6 hours after onset of chest pain) was attempted in 957 patients (71.3%), while 385 patients (28.7%) had a delayed procedure (6 23 hours after the onset of chest pain). Patients who underwent delayed angioplasty were older (mean age, 62.6 years versus 60.4 years in the early group; p < 0.01) and more often female (36% vs. 28% in the early treatment group; p < 0.001). Patients treated early more frequently demonstrated hemodynamic instability (13.6% versus 9.1% in the late treatment group; p = 0.02), malignant ventricular arrhythmia (8.5% versus 2.9% in the late treatment group; p < 0.001) and cardiogenic shock (6.6% versus 1.8% in the late treatment group; p < 0.001). Overall in-hospital mortality was 63/1,342 (4.7%) with no difference based on early or delayed angioplasty (5.2% versus 3.4%, respectively; p = NS). The composite of the major adverse cardiac events including in-hospital death, reinfarction and emergency bypass surgery did not differ significantly between the early and delayed groups (7.7% versus 5.5%, respectively; p = NS). In multivariable models, delayed angioplasty was not an independent predictor of either in-hospital mortality or major adverse cardiac events. CONCLUSION: Delayed reperfusion does not influence in-hospital clinical outcomes following PTCA for acute myocardial infarction.     

Comparison of acute coronary syndrome in patients receiving versus not receiving chronic dialysis (from the Global Registry of Acute Coronary Events [GRACE] Registry)

Patients with end-stage renal disease commonly develop acute coronary syndromes (ACS). Little is known about the natural history of ACS in patients receiving dialysis. We evaluated the presentation, management, and outcomes of patients with ACS who were receiving dialysis before presentation for an ACS and were enrolled in the Global Registry of Acute Coronary Events (GRACE) at 123 hospitals in 14 countries from 1999 to 2007. Of 55,189 patients, 579 were required dialysis at presentation. Non-ST-segment elevation myocardial infarction was the most common ACS presentation in patients receiving dialysis, occurring in 50% (290 of 579) of patients versus 33% (17,955 of 54,610) of those not receiving dialysis. Patients receiving dialysis had greater in-hospital mortality rates (12% vs 4.8%; p <0.0001) and, among those who survived to discharge, greater 6-month mortality rates (13% vs 4.2%; p <0.0001), recurrent myocardial infarction (7.6% vs 2.9%; p <0.0001), and unplanned rehospitalization (31% vs 18%; p <0.0001). The outcome in patients receiving dialysis was worse than that predicted by their calculated GRACE risk score for in-hospital mortality (7.8% predicted vs 12% observed; p <0.05), 6-month mortality/myocardial infarction (10% predicted vs 21% observed; p <0.05). In conclusion, in the present large multinational study, approximately 1% of patients with ACS were receiving dialysis. They were more likely to present with non-ST-segment elevation myocardial infarction, and had markedly greater in-hospital and 6-month mortality. The GRACE risk score underestimated the risk of major events in patients receiving dialysis.     

Myocardial infarction in diabetic vs non-diabetic subjects. Survival and infarct size following therapy with sulfonylureas (glibenclamide)

AIMS: Sulfonylureas may interfere with 'ischaemic preconditioning' and worsen the prognosis in diabetic patients with acute myocardial infarction. METHODS AND RESULTS: Three hundred and fifty-seven non-diabetic patients admitted with acute myocardial infarction to one hospital over 6.5 years (72 deaths, in-hospital mortality 20.2%) were compared to 245 Type 2 diabetic patients categorized as having taken sulfonylureas (glibenclamide 7+/-3 mg x day(-1); n = 76, 25 deaths = 32.9%;P = 0.025), not having taken sulfonylureas (n = 89, 29 deaths = 33.0%;P = 0.012), and newly diagnosed as having diabetes (n = 80, 20 deaths = 25.0%). Survival was significantly different (log-rank test: P = 0.03). Increments in creatine kinase and creatine kinase(MB)activity were higher in non-diabetic patients (P<0.01). CONCLUSIONS: In-hospital mortality in Type 2 diabetic patients is higher than in non-diabetic patients suffering acute myocardial infarction regardless of whether or not they had been treated with sulfonylureas. Glibenclamide does not enlarge myocardial necroses.     

入院血糖水平与急诊冠状动脉介入治疗术后患者预后的相关性

目的探讨急性心肌梗死（AMI）患者血糖水平与经皮冠状动脉介入（PCI）干预后住院期间心脏不良事件的相关性。方法入选312例初发AMI患者于入院即刻测定静脉血糖,并于发病24h内行急诊PCI。根据入院即刻血糖水平分为高血糖组（血糖〉11mmol／L,44例）和血糖正常组（血糖≤11mmol／L,268例）;按是否合并糖尿病分为糖尿病组（81例）和非糖尿病组（231例）。随访患者住院期间病死率及术后180d心脏不良事件发生率。结果无论是否合并糖尿病,高血糖组住院期间病死率及PCI术后180d心脏不良事件发生率均明显高于血糖正常组（18．2％比3．0％,P〈0．001;25％比12．7％,P=0．047）,多因素分析显示入院即刻血糖为死亡及心脏不良事件的独立预测因素（OR5．15,95％CI 1．74～15．28,P=0．003及OR 2．84,95％CI 1．18～6．83,P=0．019）,而是否合并糖尿病对上述终点无明显影响。结论无论是否合并糖尿病,入院即刻高血糖是AMI患者PCI术后住院期间病死率和180d心脏不良事件的相对独立危险因素。     

Does the presence of thrombus seen on a coronary angiogram affect the outcome after percutaneous coronary angioplasty? An Angiographic Trials Pool data experience

OBJECTIVES: This study aimed to determine whether pre-existing angiographic thrombus was associated with adverse in-hospital and six-month outcomes after percutaneous coronary interventions. BACKGROUND: There are conflicting data about whether pre-existing thrombus is an independent predictor of adverse in-hospital and short-term outcome after coronary interventions. METHODS: The Angiographic Trials Pool, a data set derived from eight prospective randomized trials, was analyzed. The study population consisted of 7,917 patients who underwent coronary interventions between 1986 and 1995. Two trials were excluded because they did not collect information regarding thrombus. Patients from the other six trials were divided on the basis of the presence or absence of thrombus. RESULTS: In patients with (n = 2,752) and without (5,165) thrombus, in-hospital mortality following angioplasty was low (0.8 vs. 0.6%, p = 0.207). Several adverse outcomes were higher in patients with thrombus: death/myocardial infarction (8.4 vs. 5.5%, p < or = 0.001), in-hospital abrupt closure (5.9 vs. 3.9%, p < or = 0.001) and an in-hospital composite of death, myocardial infarction and/or repeat revascularization (15.4 vs. 11.2%, p < or = 0.001). Six-month mortality was low and comparable between the two groups (2.1 vs. 1.8%, p = 0.34), but the incidence of six-month death/myocardial infarction was higher in patients with thrombus (11.7 vs. 8.7%, p < or = 0.0001). CONCLUSIONS: Percutaneous coronary angioplasty can be performed with low mortality in patients with pre-existing thrombus, although these patients are at higher risk of in-hospital and six-month death/myocardial infarction. Continued efforts are required to optimize the outcome in these high risk patients.     

Complete atrioventricular block complicating inferior wall acute myocardial infarction treated with reperfusion therapy. TAMI Study Group

Previous studies report larger myocardial infarcts and increased in-hospital mortality rates in patients with inferior wall acute myocardial infarction (AMI) and complete atrioventricular block (AV), but the clinical implications of these complications in patients treated with reperfusion therapy have not been addressed. The clinical course of 373 patients--50 (13%) of whom developed complete AV block--admitted with inferior wall AMI and given thrombolytic therapy within 6 hours of symptom onset was studied. Acute patency rates of the infarct artery after thrombolytic therapy were similar in patients with or without AV block. Ventricular function measured at baseline and before discharge in patients with complete AV block showed a decrement in median ejection fraction (-3.5 vs -0.4%, p = 0.03) and in median regional wall motion (-0.14 vs +0.24 standard deviations/chord, p = 0.05). The reocclusion rate was higher in patients with complete AV block (29 vs 16%, p = 0.03). Patients with complete AV block had more episodes of ventricular fibrillation or tachycardia (36 vs 14%, p less than 0.001), sustained hypotension (36 vs 10%, p less than 0.001), pulmonary edema (12 vs 4%, p = 0.02) and a higher in-hospital mortality rate (20 vs 4%, p less than 0.001), although the mortality rate after hospital discharge was identical (2%) in the 2 groups. Multivariable logistic regression analysis revealed that complete AV block was a strong independent predictor of in-hospital mortality (p = 0.0006). Thus, despite initial successful reperfusion, patients with inferior wall AMI and complete AV block have higher rates of in-hospital complications and mortality.     

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

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

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

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