Article Text


Original research article
Underuse of an invasive strategy for patients with diabetes with acute coronary syndrome: a nationwide study
  1. Ida Gustafsson1,
  2. Anders Hvelplund2,3,4,
  3. Kim Wadt Hansen2,
  4. Søren Galatius2,
  5. Mette Madsen5,
  6. Jan Skov Jensen2,6,
  7. Hans-Henrik Tilsted7,
  8. Christian Juhl Terkelsen8,
  9. Lisette Okkels Jensen9,
  10. Erik Jørgensen7,
  11. Jan Kyst Madsen2,4 and
  12. Steen Zabell Abildstrøm3,4,10
  1. 1Department of Cardiology, Hvidovre University Hospital, Hvidovre, Denmark
  2. 2Department of Cardiology, Gentofte University Hospital, Hellerup, Denmark
  3. 3National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
  4. 4Danish Heart Registry, Copenhagen, Denmark
  5. 5Institute of Public Health, University of Copenhagen, Copenhagen, Denmark
  6. 6Faculty of Health Sciences, Institute of Surgery and Internal Medicine, University of Copenhagen, Copenhagen, Denmark
  7. 7Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
  8. 8Department of Cardiology, Aarhus University Hospital, Skejby, Denmark
  9. 9Department of Cardiology, Odense University Hospital, Odense, Denmark
  10. 10Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark
  1. Correspondence to Dr Ida Gustafsson; gustafsson{at}


Background Guidelines recommend an early invasive strategy for patients with diabetes with acute coronary syndromes (ACS). We investigated if patients with diabetes with ACS are offered coronary angiography (CAG) and revascularisation to the same extent as patients without diabetes.

Methods and results The study is a nationwide cohort study linking Danish national registries containing information on healthcare. The study population comprises all patients hospitalised with first-time ACS in Denmark during 2005–2007 (N=24 952). Diabetes was defined as claiming of a prescription for insulin and/or oral hypoglycaemic agents within 6 months prior to the ACS event. Diabetes was present in 2813 (11%) patients. Compared with patients without diabetes, patients with diabetes were older (mean 69 vs 67 years, p<0.0001), less often males (60% vs 64%, p=0.0001) and had more comorbidity. Fewer patients with diabetes underwent CAG: cumulative incidence 64% vs 74% for patients without diabetes, HR=0.72 (95% CI 0.69 to 0.76, p<0.0001); adjusted for age, sex, previous revascularisation and comorbidity HR=0.78 (95% CI 0.74 to 0.82, p<0.0001). More patients with diabetes had CAG showing two-vessel or three-vessel disease (53% vs 38%, p<0.0001). However, revascularisation after CAG revealing multivessel disease was less likely in patients with diabetes (multivariable adjusted HR=0.76, 95% CI 0.68 to 0.85, p<0.0001).

Conclusions In this nationwide cohort of patients with incident ACS, patients with diabetes were found to be less aggressively managed by an invasive treatment strategy. The factors underlying the decision to defer an invasive strategy in patients with diabetes are unclear and merit further investigation.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

Statistics from

Request permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.