|Year : 2018 | Volume
| Issue : 1 | Page : 60-66
Clinical outcome of patients with diabetes mellitus and acute myocardial infarction treated with primary angioplasty
Saad M Ammar, Reda B Bayoumi, Mohamed Abd El-Kader Elian, Kerolus K Gad
Department of Cardiology, Faculty of Medicine, Benha University, Banha, Egypt
|Date of Submission||29-Jun-2016|
|Date of Acceptance||29-Dec-2016|
|Date of Web Publication||28-Feb-2018|
Kerolus K Gad
16th Diaa Street Haram, Giza
Source of Support: None, Conflict of Interest: None
Purpose The purpose of the present study was to examine the influence of diabetes mellitus (DM) on the clinical outcome in patients with acute myocardial infarction (MI) treated with primary coronary stenting within 24 h of the onset of symptoms.
Methods We enrolled 100 patients (50 diabetics and 50 nondiabetics) admitted to the coronary care units of Benha University hospitals and National Heart Institute from January 2015 to December 2015 with acute MI treated with primary coronary stenting within 24 h of the onset of symptoms. Clinical outcome was observed in every patient for major adverse cardiac events and hospital stay. Echocardiography was also performed before the patient’s discharge from the hospital. Patients were followed up at 3 months for the occurrence of major adverse cardiac events.
Results The diabetic patients showed higher incidence of hypertension (P=0.003), renal impairment (P=0.045) and dyslipidemia (P=0.05) and also higher incidence of heart failure (P=0.013) during admission and higher mean serum creatinine kinase MB mass assay levels (P=0.005). There were no statistically significant differences in other variables. Procedural success was similar in the two groups. With regard to in-hospital clinical course, diabetic patients were more likely to have early post-MI heart failure (P=0.013), target vessel revascularization (P=0.037) and longer hospital stay (P=0.019). At 3 months, diabetic patients were significantly more likely to experience revascularization (P=0.045) and were more likely to be rehospitalized for acute coronary syndrome and decompensated heart failure (P=0.037); however, there was no significant difference in mortality (P=0.307).
Conclusion Compared with nondiabetics, diabetic patients are more likely to have early post-MI heart failure, target vessel revascularization, and longer hospital stay. Moreover, diabetic patients are significantly more likely to experience revascularization and are more likely to be rehospitalized for acute coronary syndrome or decompensated heart failure.
Keywords: acute myocardial infarction, diabetes mellitus, primary coronary stenting
|How to cite this article:|
Ammar SM, Bayoumi RB, El-Kader Elian MA, Gad KK. Clinical outcome of patients with diabetes mellitus and acute myocardial infarction treated with primary angioplasty. Benha Med J 2018;35:60-6
|How to cite this URL:|
Ammar SM, Bayoumi RB, El-Kader Elian MA, Gad KK. Clinical outcome of patients with diabetes mellitus and acute myocardial infarction treated with primary angioplasty. Benha Med J [serial online] 2018 [cited 2018 Sep 22];35:60-6. Available from: http://www.bmfj.eg.net/text.asp?2018/35/1/60/226419
| Introduction|| |
Diabetes is now considered to be a risk equivalent of coronary artery disease for future myocardial infarction (MI) and cardiovascular death . The acute and long-term management of acute coronary syndromes (ACSs) does not differ for persons with diabetes; yet previous studies have suggested that patients with diabetes have not had a similar reduction in cardiovascular mortality as those of patients without diabetes despite receiving modern therapies ,. In addition to being a risk factor for the development of coronary disease, diabetes influences outcomes following ACS. A subgroup analysis of patients with diabetes with ST-segment elevation MI (STEMI) in the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-1) trial  demonstrated significantly higher all-cause mortality at 30 days compared with patients without diabetes (10.5 vs. 6.2%). Similarly, the Organization to Assess Strategies for Ischemic Syndromes (OASIS) registry  of patients with unstable angina/non-STEMI observed an increased rate of post-MI complications and mortality among patients with diabetes compared with patients without diabetes (odds ratio, 1.57) during 2 years of follow-up. The independent association of diabetes with mortality following ACS, especially STEMI, in the present era of coronary care remains uncertain. Primary percutaneous coronary intervention (PCI) is effective in securing and maintaining coronary artery patency and avoids some of the bleeding risks of fibrinolysis.
| Patients and methods|| |
This is a prospective observational study that included 100 consecutive patients admitted to the coronary care unit of Cardiology Department, Benha Faculty of Medicine and National Heart Institute from January 2015 to December 2015. All patients selected had acute STEMI and underwent primary PCI within 24 h from the onset of chest pain. Fifty of them were diabetic and the other 50 were nondiabetic.
Patients who refused to participate in the study; patients presented with cardiogenic shock or cardiac arrest that required cardiopulmonary resuscitation; patients who received thrombolytic therapy, PCI-related MI, coronary artery bypass grafting-related MI; patients with established MI with onset of symptoms of at least 24 h and patients with left main significant lesions.
All the patients were assessed by clinical history, Full clinical data were obtained from every patient; clinical evaluation and electrocardiographic analysis of standard 12-lead ECG were recorded at admission, then every 6 h in the first day, then every 12 h in the following days and whenever the patient had chest pain. Significant ST-elevation was measured at 60 msec from the J point. Then laboratory data: creatine kinase (CK) MB was measured at baseline and serially, plasma glucose, serum creatinine, hemoglobin levels, and complete blood count were measured. Following that primary PCI coronary angiography and subsequently angioplasty was performed in the conventional manner (GE Health care New York, 2009 or Siemens, German, Berlin 2013). Target lesion revascularization was performed in all patients. Before hospital discharge, every patient was assessed by clinical history, clinical examination, and transthoracic echocardiogram.
Successful angioplasty which was defined as post-treatment residual stenosis less than 30% with thrombolysis in myocardial infarction flow grade.
Major adverse cardiac events
- Recurrent ischemia.
- Target vessel revascularization (TVR) procedures.
- Major bleeding complications.
- Ischemic and hemorrhagic stroke.
- Heart failure.
- Incidence of death.
Duration of hospitalization
Three months follow-up
Patients were followed up for the occurrence of major adverse cardiac events (MACE) during 3 months after discharge from hospital (by telephone or during readmission).
Study end points
Primary end points
Assessing the potential role of diabetes on:
- The occurrence of in-hospital MACE as early post-MI angina, development of heart failure, significant arrhythmias, major bleeding, stroke or mortality.
- Development of MACE, cardiac mortality, revascularization (PCI or coronary artery bypass grafting), hospitalization for ACSs or heart failure and functional class after 3 months.
Secondary end points
Comparing the two groups regarding the occurrence of successful angioplasty and predischarge left ventricular global and regional function.
The statistical analysis was done using SPSS, version 17 (SPSS IBM 2016). Descriptive statistics were done to obtain frequencies, mean±SD of the required variables. The tests that were used to test the differences among different variables: t-test for the numerical variables and χ2-test for the categorical variables. Correlation analysis was done using Spearman’s correlation coefficient. Univariate analysis was used to determine the variables that predicted major cardiac adverse effects at follow-up. A two-sided P value up to 0.05 was considered to indicate statistical significance.
| Results|| |
This study was a prospective observational study that included 100 consecutive patients with STEMI who were admitted to Benha University Hospital and National Heart Institute Coronary Care Units from January 2015 to December 2015 where they underwent primary angioplasty.
Baseline characteristics and risk factors for coronary artery disease are shown in [Table 1].
|Table 1 Baseline characteristics and risk factors for CAD in both groups|
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Clinical and ECG parameters at presentation
There was only a significant difference regarding time from onset of chest pain and location of MI as described in [Table 2].
Diabetic patients had a significantly higher mean blood myocardial specific creatine kinase (CK-MB) level, Random Blood Sugar (RBS), and lower mean hemoglobin level as described in [Table 3].
Diagnostic catherization laboratory data
There was no difference between both groups as regards target vessels and the number of vessels affected ([Table 4]).
|Table 4 Diagnostic catherization laboratory data across diabetic and nondiabetic groups|
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There was significant difference regarding adjuvant therapy and suction device during and after PCI ([Table 5]).
|Table 5 Coronary revascularization across diabetic and nondiabetic groups|
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There was a trend toward increase in left ventricular end diastolic dimension and left ventricular end systolic dimension and higher diastolic dysfunction in diabetics ([Table 6]).
|Table 6 Echocardiographic parameters across diabetic and nondiabetic groups|
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In-hospital clinical course
There was significant difference between diabetic and nondiabetic patients as regards TVR and duration (days) of hospital stay. There was no report of stroke or mortality among both groups ([Table 7]).
|Table 7 In-hospital clinical course across diabetic and nondiabetic groups|
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At 3 months, diabetic patients were significantly more likely to undergo revascularization, rehospitalized for ACS, and decompensated heart failure; however, they had a nonsignificant increase in mortality ([Table 8]).
|Table 8 MACE at 3 months follow-up across diabetic and nondiabetic groups|
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| Discussion|| |
In this study, there was no significant difference in the diagnostic angiographic criteria while in Fujiwara et al.  there was a higher prevalence of multivessel disease in diabetics. In Syed et al.  there was also a higher prevalence of multivessel disease and Saphenous Venous Graft (SVG) occlusion or left circumflex as the target vessel in diabetics. In the GUSTO IIb substudy , the multivessel disease was more prevalent in diabetic patients than it was in nondiabetics and the minimum luminal diameter was smaller in diabetics resulting in a greater percent diameter stenosis among diabetics. These differences may be attributed to the lower mean age of diabetics in the present study (53.16±6.94 years) than in Fujiwara and colleagues study (64.2±11.2 years), while in Syed and colleagues (63.85±12.95 years), even though the GUSTO IIb substudy has shown that the diabetic patients were older (64.8±6.1 years).
In this study, while diabetics and nondiabetics had no significant differences as regards target vessel and type of stent implanted, diabetics had higher incidence of procedure failure, higher percentage of those who need adjuvant therapy, and higher percentage of those who need suction devices than in nondiabetics; use of GP IIb/IIIa inhibitors in diabetic patients was significantly higher than in diabetics, also the use of drug eluting stent (DES) was higher in diabetics (though in small numbers). Both had a significant effect on the outcome but both were not reported in Fujiwara and colleagues, and there was no clinical difference in the use of DES, GP IIb/IIIa, or suction devices in Syed and colleagues, while in Shaikh et al.  all cases used DES with no differences between both groups. On the other hand, in the GUSTO IIb substudy balloon angioplasty alone was the major modality used in both groups.
According to the procedure success defined (as thrombolysis in myocardial infarction flow grade 3 flow and ≤50% residual stenosis), the present study showed that there was one case of procedure failure in the diabetic group while no patient in the nondiabetic group showed such complication. In the GUSTO IIb substudy that examined angiographic success there were no significant differences between diabetic and nondiabetic groups who underwent balloon angioplasty without stenting, while in Syed and colleagues there was significant difference toward a higher percentage of success in nondiabetics than in diabetic patients although that significant difference was in the use of intravascular ultrasound in diabetic patients than in nondiabetics.
In-hospital clinical outcome
As regards in-hospital clinical outcomes in the present study, there was significant difference between diabetic and nondiabetic patients as regards target vessel revascularization (TVR), heart failure, and duration (days) of hospital stay. However there was a trend for increasing rate of MI and major bleeding in diabetics compared with nondiabetics, but the difference did not reach a statistically significant value. There was no report of stroke or mortality among both groups.
In accordance with the results of the present study, Fujiwara and colleagues also reported that significant difference had occurred only in the incidence of TVR (P=0.04) in diabetics than in nondiabetics.
In Sayed and colleagues study there were no significant difference in in-hospital outcomes except for in-hospital stay which was longer in diabetic patients compared with nondiabetic patients.
The GUSTO IIb substudy showed that there were higher incidence in both in-hospital heart failure and cardiogenic shock among diabetic patients compared with nondiabetic patients (P=0.001 and 0.04, respectively).
Three months clinical follow-up
At 3 months follow-up, diabetic patients were significantly more likely to experience rehospitalization, revascularization, and had a trend toward higher recurrent MI despite being insignificant statistically than nondiabetics.These results matched the results of Fujiwara and colleagues by the end of 6 months follow-up. While in the study of Syed and colleagues by the end of 1 year follow-up, there was significant difference in mortality (P=0.001) and less event-free survival in diabetics (especially revascularization) than nondiabetics.
In Aronson et al.  there was significant difference toward higher mortality (P=0.001) and higher incidence of readmission by heart failure in diabetics compared with nondiabetics (P=0.003) but these results had included in-hospital and subsequent follow-up for 14 months. On the contrary, in the GUSTO IIb substudy within 6 months of follow-up after acute MI, there was no significant difference in the cumulative incidence of death/reinfarction between diabetic and nondiabetic patients.
Diabetes and the factors before reperfusion therapy
The present study highlighted many important pretreatment factors that may partly explain the worse outcome of diabetics.
The first is the significant delay from symptom onset to first medical contact in diabetic patients compared with nondiabetic patients in the present study resulted in a significant delay in reperfusion.
A similar finding was also recorded in the study by Fujiwara and colleagues and GUSTO IIb substudy.
In the study by Fujiwara and colleagues there was relative delay in mean time from the onset of symptoms to device in diabetics which was 4.3±2.2 versus 4.3±2.5 h in nondiabetics.
In GUSTO IIb substudy the significant delay for the diabetic patients was 3.51±2.50 h than in nondiabetics (3.20±2.35).
The relative delay in the presentation of symptoms in diabetic patients may be explained by diabetic neuropathy, vague symptoms, and difficulty in interpreting the ECG of diabetic patients due to common prevalence of nonspecific ECG changes (Fujiwara and colleagues)
The second is the significant higher prevalence of coronary risk factors in diabetic patients compared with nondiabetic patients, current smoking, hypertension, and dyslipidemia
In accordance with the results of the present study, Fujiwara and colleagues, Sayed and colleagues, and GUSTO IIb substudy found a higher prevalence of hyperlipidemia, associated hypertension and history of renal insufficiency in diabetics compared with nondiabetics.
The third, diabetic patients in this study had large infarct size than nondiabetics as reflected by the higher mean of CK-MB and higher prevalence of extensive anterior MI than nondiabetics. In previous studies, the difference between diabetic and nondiabetic patients as regards enzyme release was not reported.
The fourth, as regards echocardiographic parameters, there was a trend toward an increase in left ventricular end diastolic dimension and left ventricular end systolic dimension, lower ejection fraction, higher diastolic dysfunction grade III than that in the nondiabetic group.
- The study was underpowered to detect the difference in major adverse events between both groups due to its small sample size with small variability range and due to the multivariables involved.
- DES was used in few patients instead of their indications because of financial and/or other causes not related to clinical judgment.
- Long delay before presentation which affect the clinical outcome of all patients.
- Short follow-up period and difficult communication.
- Higher percentage of patients who refused to enter the study.
- Only two centers of Egypt included.
According to this study we can conclude the following:
- Compared with nondiabetics, diabetic patients are more likely to have early post-MI heart failure, TVR, and hospital stay.
- Diabetic patients are significantly more likely to experience revascularization and are more likely to be hospitalized for ACS or decompensated heart failure
- Multicenters, larger study population, and longer period of follow-up are highly recommended to highlight this issue.
The author first and foremost extends his deepest gratitude to God Almighty, the Most Gracious, for helping him in successfully accomplishing this endeavor, and for granting him a team without whose magnificent effort this work would have never been brought to light.
The author also extends his appreciation and gratitude to Professor Dr Saad Mahmoud Ammar for his support, supervision, and sincere advice, which are at the very ‘heart’ of this work, and for having devoted his precious time to making this study a reality.
The author acknowledges the valuable assistance of Professor Dr Reda Bastaweesy Bayoumi, who deserves utmost recognition for his outstanding effort and professional expertise.
He also extends his sincere gratitude to Professor Dr Mohamed Abd El-Kader Elian for her valuable help, advice, and support throughout the course of the study.
Last, but not least, he expresses deep appreciation to his family for their unlimited support and help: his wife Erini who was a pillar of support during hard times and throughout the course of this study and his beloved daughter Klara, who is a gift of God.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Haffner SM, Lehto S, Rönnemaa TR, Pyörälä K, Laakso M. 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 1998; 339:229–234.
Gu K, Cowie CC, Harris MI. Diabetes and decline in heart disease mortality in US adults. JAMA 1999; 281:1291–1297.
Fox CS, Coady S, Sorlie PD, Levy D, Meigs JB, D’Agostino RB et al.
Trends in cardiovascular complications of diabetes. JAMA 2004; 292:2495–2499.
Mak KH, Moliterno DJ, Granger CB, Miller DP, White HD, Wilcox RG et al.
Influence of diabetes mellitus on clinical outcome in the thrombolytic era of acute myocardial infarction: GUSTO-I Investigators (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries). J Am Coll Cardiol 1997; 30:171–179.
Malmberg K, Yusuf S, Gerstein HC, Brown J, Zhao F, Hunt D et al.
Impact of diabetes on long-term prognosis in patients with unstable angina and non-Q-wave myocardial infarction: results of the OASIS (Organization to Assess Strategies for Ischemic Syndromes) registry. Circulation 2000; 102:1014–1019.
Fujiwara K, Hiasa Y, Takahashi T. Influence of diabetes mellitus on outcome in the era of primary stenting for acute myocardial infarction. Circ J 2002; 66:800–804.
Syed AI, Ben-Dor I, Li Y. Outcomes in diabetic versus nondiabetic patients who present with acute myocardial infarction and are treated with drug-eluting stents. Am J Cardiol 2010; 105:819–825.
Hasdai D, Granger CB, Srivatsa SS, Criger DA, Ellis SG, Califf RM et al.
Diabetes mellitus and outcome after primary coronary angioplasty for acute myocardial infarction: lessons from the GUSTO-I angioplasty substudy. J Am Coll Cadiol 2000; 35:1502–1512.
Shaikh AH, Siddiqui MS, Hanif B, Malik F, Hasan K, Adhi F. Outcomes of primary percutaneous coronary intervention (PCI) in a tertiary care cardiac centre. JPMA 2009; 59:426.
Aronson D, Kapeliovich M, Nikolsky E, Kerner A. Clinical outcomes of patients with diabetes mellitus and acute myocardial infarction treated with primary angioplasty. Eur Heart J 2010; 31(Abstract Suppl):347–348.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]