Influence of Diabetes Mellitus on Clinical Outcomes Following Primary Percutaneous Coronary Intervention in Patients With ST-Segment Elevation Myocardial Infarction

doi:10.1016/j.amjcard.2011.10.018

The American Journal of Cardiology

Volume 109, Issue 5, 1 March 2012, Pages 629-635

https://doi.org/10.1016/j.amjcard.2011.10.018 Get rights and content

Patients with diabetes mellitus (DM) have a worse outcome after percutaneous coronary intervention (PCI) than nondiabetic patients. The purpose of this study was to compare rates of stent thrombosis, myocardial infarction (MI), target lesion revascularization (TLR), and death in diabetic and nondiabetic patients treated with primary PCI for ST-segment elevation MI (STEMI) in Western Denmark. From January 2002 through June 2005, 3,655 consecutive patients with STEMI treated with primary PCI and stent implantation (316 patients with DM, 8.6%; 3,339 patients without DM, 91.4%) were recorded in the Western Denmark Heart Registry. All patients were followed for 3 years. Cox regression analysis was used to compute hazard ratios (HRs), controlling for potential confounding. Three-year rates of definite stent thrombosis were 1.6% in the DM group and 1.5% in the non-DM group (adjusted HR 1.15, 95% confidence interval [CI] 0.50 to 2.67). The rate of MI was 12.3% in the DM group versus 5.6% in the non-DM group (adjusted HR 2.56, 95% CI 1.81 to 3.61). Rates of TLR were 12.1% in the DM group and 8.7% in the non-DM group (adjusted HR 1.55, 95% CI 1.14 to 2.11). All-cause mortality was 23.7% in patients with DM versus 12.7% in patients without DM (adjusted HR 2.03, 95% CI 1.59 to 2.59). In conclusion, stent thrombosis rate was similar in patients with and without DM and STEMI treated with primary PCI, whereas the presence of DM increased the risk of MI, TLR, and death.

Section snippets

Methods

The study was conducted using western Denmark's health care databases, which cover the region's entire population of approximately 3.0 million inhabitants (55% of Danish population). All patients were followed for 36 months. A detailed description of the databases has been reported previously.¹⁵

Primary PCI for STEMI has been the recommended treatment in Denmark since the publication of results from the Danish Trial in Acute Myocardial Infarction-2 (DANAMI 2)⁵ study in 2003. To be eligible for

Results

In total 3,655 patients with STEMI (with 4,356 lesions) treated with primary PCI and stenting were followed for 36 months. Of these, 316 patients (8.6%) with 380 lesions had DM, whereas 3,339 patients (91.4%) with 3,976 lesions did not have DM. Patients' median age was 63 years (interquartile range 54 to 73) and 30.9% of patients were >75 years old. DM was associated with a higher prevalence of hypertension, hypercholesterolemia, previous MI, previous PCI, and a higher co-morbidity index score (

Discussion

The findings of the present study showed that in patients with STEMI treated with primary PCI, presence of DM clearly increases the rate of cardiovascular events. Although the rate of definite stent thrombosis was not higher, risks of all-cause mortality, cardiac mortality, and MI were >2 times in patients with DM. In addition, need for TLR and target vessel revascularization was increased in patients with DM. Our study represents the largest cohort of patients with STEMI treated with primary

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Cited by (51)

Regional differences in percutaneous coronary intervention outcomes in STEMI patients with diabetes: The Asia-Pacific evaluation of cardiovascular therapies (ASPECT) collaboration
2023, International Journal of Cardiology
Citation Excerpt :
Our study demonstrates an overall association between Diabetes and higher rates of 30-day MACE and mortality, with a significantly higher prevalence of adverse outcomes observed in patients with Diabetes across all regions. These findings are concordant with existing literature – meta-analyses, [5,18] randomized trials [8] and cohort studies [1,19,20] have consistently demonstrated that in patients undergoing primary PCI, Diabetes is associated with higher rates of impaired reperfusion, reinfarction, restenosis, and worse long term mortality. The proposed underlying mechanisms are both pathophysiologic and anatomical.
Diabetes is associated with poorer outcomes and increased complication rates in STEMI patients undergoing percutaneous coronary intervention (PCI). Data are notably lacking in the Asia-Pacific region. We report the overall association of Diabetes with clinical characteristics and outcomes in STEMI patients undergoing PCI across the Asia-Pacific, with a particular focus on regional differences.
The Asia Pacific Evaluation of Cardiovascular Therapies (ASPECT) collaboration consists of data from various PCI registries across Australia, Hong Kong, Singapore, Malaysia, Indonesia and Vietnam. Clinical characteristics, lesion characteristics, and outcomes were provided for STEMI patients. Key outcomes included 30-day overall mortality and major adverse cardiovascular events (MACE).
A total of 12,144 STEMI patients (mean(SD) age 59.3(12.3)) were included, of which 3912 (32.2%) had diabetes. Patients with diabetes were likely to have a higher baseline risk profile, poorer clinical presentation, and more complex lesion patterns (all p < 0.05). Across all regions, patients with diabetes had a higher rate of 30-day mortality and MACE (all p < 0.05). After multivariable adjustment, diabetes was significantly associated with both increased 30-day mortality (9.6%vs 5.5%, OR 1.79 [95% CI 1.40–2.30]) and MACE (13.3% vs 8.6%, R 1.73 [1.44–2.08]). The association between diabetes and 30-day MACE varied by region (p_interaction = 0.041), with the association (OR) ranging from 1.34 [1.08–1.67] in Malaysia, to 2.39 [1.66–3.45] in Singapore.
Diabetes portends poorer clinical outcomes in STEMI patients undergoing PCI in the Asia-Pacific with regional variations noted. The development of effective preventative measures and interventional strategies targetted at this high-risk group is crucial.
Drug-Eluting Stents Versus Bare-Metal Stents in Large Coronary Artery Revascularization: Systematic Review and Meta-Analysis
2021, Cardiovascular Revascularization Medicine
Citation Excerpt :
BASKET-LATE (Basel Stent Kosten Effektivitäts Trial - Late Thrombotic Events) was a prospective study that showed higher late stent thrombosis events in the first-generation DES compared to BMS [35]. This finding was later confirmed in a pooled analysis of clinical trials [36], meta-analysis of RCTs [37] and large registry studies [38,39]. Subsequently, BASKET PROVE (Basel Stent Kosten-Effektivitäts Trial–Prospective Validation Examination) randomized 2314 patients and compared cardiovascular outcomes using DES (first and second generation) as compared to BMS in large coronary artery PCI.
We aim to determine if drug eluting stents (DES) are better than bare-metal stents (BMS) in large coronary artery (diameter ≥ 3 mm) percutaneous coronary intervention (PCI).
DES have become the standard of care for PCI in coronary artery disease (CAD). However, the superiority of DES over BMS in large vessel CAD is not clear and previous studies have shown conflicting results.
Randomized controlled trials (RCTs) comparing outcomes of PCI with BMS and DES for large vessel CAD were identified from the year 2000 to August 2019. The outcomes were studied individually and included all-cause mortality, myocardial infarction (MI), target lesion revascularization (TLR), and stent thrombosis. Aggregated odds ratio and 95% CI were calculated using a random-effects model.
Eight RCTs were included (4 with data for first-generation DES, 3 with data for second-generation DES, and 1 with data for both first- and second-generation DES). Compared to BMS, second generation DES had a significantly lower rate of all-cause mortality (2.4% vs. 3.9%, OR 0.74, 95% CI 0.56–0.98, P 0.04), TLR (3.5% vs. 8.6% OR 0.38 95% CI 0.28–0.53, P < 0.001), and MI (2.1% vs. 2.9% OR 0.73 95% CI 0.53–1.0, P 0.05). The difference in all-cause mortality was not seen with first-generation DES.
Newer DES are associated with a lower mortality, TLR, and MI and thus should be preferred over BMS for large coronary artery PCI.
Use of prasugrel vs clopidogrel and outcomes in patients with and without diabetes mellitus presenting with acute coronary syndrome undergoing percutaneous coronary intervention
2019, International Journal of Cardiology
Citation Excerpt :
Patients with diabetes mellitus presenting with acute coronary syndromes have a higher risk of short and long-term outcomes compared with non-diabetics [1–3].
Clinical trial data studies suggest superiority of prasugrel over clopidogrel in patients with diabetes. However, the use, safety and efficacy profile of prasugrel in unselected diabetic patients presenting with acute coronary syndromes (ACS) remain unclear.
PROMETHEUS was a prospective multicenter observational study of 19,919 ACS PCI patients enrolled between 2010 and 2013. The primary endpoint was 90-day major adverse cardiovascular events (MACE), comprising all-cause death, myocardial infarction, stroke or unplanned revascularization. The safety endpoint was bleeding requiring hospitalization.
We identified 7580 (38%) subjects with and 12,329 (62%) without diabetes. Diabetic patients were older and had significantly higher rates of cardiovascular risk factors. However, they were less likely to receive prasugrel (18.2% vs. 21.7%). Use of prasugrel did not increase with the severity of clinical presentation in diabetics, whereas, among non-diabetics, prescription of prasugrel was higher in NSTEMI and STEMI compared to unstable angina. The 90-day and 1-year adjusted risk of MACE was greater in diabetics (at 1 year: 22.7% vs. 16.5%; HR 1.22 [1.14–1.33], p < 0.001). At 1 year, the risk of bleeding was also higher in diabetics (4.9% vs. 4.1%, HR 1.19 [1.01–1.39], p = 0.035). After multivariable adjustment, use of prasugrel was associated with a lower risk of death in diabetic patients both at 90 days and 1 year.
Use of prasugrel in diabetic patients with PCI-treated ACS was lower than in non-diabetics despite their high-risk profile and the severity of their clinical presentation. In diabetics, prasugrel was associated with a lower adjusted risk of 90-day death compared with clopidogrel.
Incidence of cardiovascular events and vascular interventions in patients with type 2 diabetes
2017, International Journal of Cardiology
Citation Excerpt :
Diabetes is associated with an increased risk of atherosclerotic cardiovascular complications such as MI, stroke, renal disease and peripheral artery disease [2,3]. For example, T2DM is associated with a more than two-fold increase in the rate of MI and all-cause mortality [4], while having a poorer outcome after coronary revascularization [5–8] and bypass grafting [9–10]. This increased risk associated with T2DM is not limited to coronary artery disease (CAD) but extends to both ischemic and haemorrhagic stroke [11], including a poorer functional outcome and cognitive recovery afterwards [12–14].
Diabetes mellitus is associated with an increased risk for cardiovascular morbidity and mortality. The vascular burden in terms of incidence of cardiovascular events (CVE) and vascular interventions is however poorly quantified. In this study we evaluated the incidence rates of CVE and vascular interventions in patients with type 2 diabetes (T2DM) with and without cardiovascular disease (CVD) in comparison to patients without type 2 diabetes.
In a cohort of 9.808 high-risk patients with and without cardiovascular disease and type 2 diabetes originated from the ongoing, single-center prospective SMART (Second Manifestations of ARTerial disease) cohort, the number and incidence rates of CVE and interventions were calculated. The incidence rates were adjusted for confounders using Poisson regression models. CVE were defined as vascular death, stroke and myocardial infarction (MI). Interventions were defined as percutaneous coronary intervention, coronary artery bypass grafting, percutaneous transluminal angioplasty or stenting of the peripheral arteries and amputation.
Patients with T2DM and CVD had a 4-fold higher incidence rate of CVE and a 8-fold higher incidence rate of vascular interventions compared to high-risk patients without T2DM and CVD after adjusting for confounders. The incidence rate for the composite of non-fatal MI, non-fatal stroke and vascular death was 5.8 per 1000 person-years in patients without T2DM or CVD at baseline, 15.2 per 1000 person-years in patients with T2DM but without CVD at baseline, 26.0 per 1000 person-years in patients without T2DM but with CVD and 40.7 per 1000 person-years in patients with both T2DM and CVD at baseline. A similar increasing incidence rate was seen for all vascular interventions from patients without T2DM or CVD to patients with both T2DM and CVD.
Patients with type 2 diabetes or CVD are subject to an increased incidence of cardiovascular events and interventions compared to high-risk patients without type 2 diabetes or vascular disease. Patients with type 2 diabetes and CVD have the highest incidence of new cardiovascular diseases and vascular interventions when compared to patients without type 2 diabetes and CVD. These results underline the need for optimal risk factor treatment as well as the need for new prevention and treatment strategies in this very high risk population.
A Narrative Review of Diabetic Macroangiopathy: From Molecular Mechanism to Therapeutic Approaches
2024, Diabetes Therapy
Exploring new insights in coronary lesion assessment and treatment in patients with diabetes mellitus: the impact of optical coherence tomography
2023, Cardiovascular Diabetology

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Coronary artery diseaseInfluence of Diabetes Mellitus on Clinical Outcomes Following Primary Percutaneous Coronary Intervention in Patients With ST-Segment Elevation Myocardial Infarction

Section snippets

Methods

Results

Discussion

Lancet

Atherosclerosis

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Chronic Dis

Rev Esp Cardiol

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

Prevention Conference VI: diabetes and cardiovascular disease: Writing Group VI: revascularization in diabetic patients

Circulation

Global prevalence of diabetes: estimates for the year 2000 and projections for 2030

Diabetes Care

Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction

N Engl J Med

Management of the patient with diabetes mellitus and myocardial infarction: clinical trials update

Am J Med

Coronary artery disease
Influence of Diabetes Mellitus on Clinical Outcomes Following Primary Percutaneous Coronary Intervention in Patients With ST-Segment Elevation Myocardial Infarction