Underuse of evidence-based treatment modalities in diabetic patients with non-ST elevation acute coronary syndrome. A prospective nation wide study on acute coronary syndrome (FINACS)

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Abstract

This study was designed to evaluate how new treatment guidelines of acute coronary syndrome (ACS) without ST elevation have been implemented in clinical practice especially in diabetic patients. A prospective follow-up was performed on 501 consecutive patients with suspected ACS without ST elevation admitted to nine hospitals in Finland between 15 January and 11 March 2001. The study group included 143 (29%) diabetic patients. Their risk profile was more severe than in non-diabetic patients; ST-depression on admission electrocardiography 57 versus 38%; P<0.0001, elevated troponin levels 66 versus 56%; P<0.05. Six months composite incidence of death, new myocardial infarction (MI), refractory angina or readmission for unstable angina was 39% in diabetic patients and 20% in non-diabetic patients (P<0.0001). In spite of this more severe risk profile, glycoprotein (GP) IIb/IIIa receptor antagonists and statins were used with similar frequency in non-diabetic and diabetic patients (15 vs. 19 and 48 vs. 54%, respectively; P=NS for both). In diabetic patients mean delay for in hospital coronary angiography was longer (6.4 vs. 4.2 days, P<0.05) and it was performed less often (32 vs. 45% P<0.05). Our results show that diabetic patients with ACS have higher risk profile and worse outcome than non-diabetic patients. Despite their indisputable benefits in diabetic patients, statins, GP IIb/IIIa receptor antagonists and invasive strategy were underused or often neglected. Further education is needed to change attitudes and to better implement new guidelines into clinical practice.

Introduction

The acute coronary syndromes (ACS) range from the occurrence of unstable angina to ST elevation myocardial infarction (MI). The diagnostic criteria and major treatment strategies, including reperfusion therapy, for ST elevation MI are well established [1]. Despite this, about one third of patients with ST elevation MI do not receive reperfusion therapy [2] and the underuse of thrombolytic therapy is even more evident among diabetic than non-diabetic patients [3], [4]. The diagnostic criteria and treatment of ACS without ST elevation are more heterogeneous and have greater variation. Patients with a presumed ACS without ST elevation have chest pain of cardiac origin, most of them having electrocardiographic (ECG) abnormalities suggesting acute ischaemic heart disease. They do not have persistent ST elevation but rather persistent or transient ST depression or T-wave inversion, flat T waves, pseudo-normalisation of T waves, non-specific ECG changes, or normal ECG at presentation. Approximately half of these patients will have elevated troponin levels at presentation or within the observation period. In the 1990s the number of patients hospitalised with a principal diagnosis of unstable angina or non-Q-wave MI has increased sharply. Today these patients account for the majority of admissions to coronary care units in most European countries [5].

Diabetic patients have a 3- to 5-fold greater risk of developing coronary artery disease than non-diabetic patients, even after adjustment for other risk factors [6]. Furthermore, the prognosis of diabetic patients is worse as the risk for cardiovascular death in diabetic patients with no history of coronary artery disease is as high as in non-diabetic subjects with a history of MI [7]. The impact of diabetes on cardiovascular morbidity and mortality is steadily increasing, because the prevalence of diabetes is estimated to double during the first quarter of the 21st century, reaching 300 million in the year 2025 [8].

Patients with diabetes have higher short- and long-term mortality and morbidity rates than non-diabetic patients in the settings of both ST elevation MI [9], [10] and ACS without ST elevation [11], [12], [13]. Diabetes appears to be associated with a less satisfactory outcome after revascularisation procedures, particularly after percutaneous coronary intervention (PCI) [14], [15], [16], [17], [18]. In spite of this bad reputation of revascularisation procedures, several recent trials suggest that diabetic patients derive the same relative therapy benefit as patients without diabetes, when all the new treatment modalities in ACS are being used [19], [20], [21], [22], [23], [24]. Recently, new European guidelines have been published on the diagnosis and treatment of patients with ACS without ST elevation [25]. According to these guidelines, high risk patients (Table 1) should receive optimal antithrombotic treatment including glycoprotein (GP) IIb/IIIa receptor antagonists and they should be referred for early coronary angiography [25]. This study was designed to investigate the implementation of the European guidelines for ACS without ST elevation in real life practice with a special emphasis on diabetic patients.

Section snippets

Subjects and methods

This nation wide survey was designed as a prospective observational cohort of patients admitted to Finnish hospitals with clinical suspicion of ACS without ST elevation. Included patients had chest pain of cardiac origin, most of whom had ECG abnormalities suggesting acute ischaemic heart disease. Data were collected from all five university hospitals and from four representative central hospitals without catheterisation facilities to cover different regions of the country. All patients

Patients

A total of 501 patients were entered into the registry. Complete follow-up data at 6 months were available for 492 (98%) of the patients and according to hospital records the remaining nine patients were alive without hospitalisations. Diabetes was registered in 143 (28.5%) patients; 23% of diabetic patients were treated by diet only, 35% with oral hypoglycaemic agents and 42% by insulin treatment. All patients were caucasians. Diabetic patients were older, had more treated hypertension, more

Discussion

The main finding of this prospective nation wide study was that in the real word the new effective treatment modalities of ACS are underused in diabetic patients although they have more severe risk profiles than non-diabetic patients. Specifically, diabetic patients had longer delays and were less often referred for in hospital angiography, and against current evidence statins and GP inhibitors were often neglected. The discrepancy between guidelines and clinical practice was most obvious in

Acknowledgements

FINACS Study group: Tampere; Kari Niemelä, Saila Vikman, Turku; Juhani Airaksinen, Tuomo Ilva, Kuopio; Keijo Peuhkurinen, Helsinki; Ilkka Tierala, Oulu; Kirsi Majamaa-Voltti, Matti Niemelä, Jyväskylä; John Melin, Kotka; Eero Koskela, Ransu Ryysy, Rovaniemi; Petri Haataja, Tapio Raasakka, Seinäjoki; Aija Iivanainen. This study was supported in part by a grant from MSD, Finland.

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