Elsevier

American Heart Journal

Volume 138, Issue 3, September 1999, Pages 446-455
American Heart Journal

Primary stenting in acute myocardial infarction: Influence of diabetes mellitus in angiographic results and clinical outcome,☆☆,

https://doi.org/10.1016/S0002-8703(99)70146-8Get rights and content

Abstract

Background The outcome of patients with diabetes after myocardial infarction (MI) has traditionally been worse than in their nondiabetic counterparts before and during the thrombolytic therapy era. Whether the fate of patients with diabetes might improve with mechanical intervention, particularly with primary stenting, has not previously been studied. Methods We compared the angiographic and clinical outcome of 76 nondiabetic patients (aged 61 ± 14 years; 66% male) and 28 patients with diabetes (aged 65 ± 12 years; 64% male) consecutively treated with primary stenting for acute MI. Coronary Thrombolysis In Myocardial Infarction grade 3 flow was restored in 96% of diabetic and 97% of nondiabetic patients. Results Angiographic results after stent deployment were similar in the 2 groups. At 1-month follow-up, all patients in both groups were alive. Patients with diabetes had a much higher incidence of stent thrombosis (18% vs 1%; P = .003), which accounted for the majority of the major cardiac events at 1 month (21% vs 4%; P = .009). At a mean follow-up of 315 ± 13 days, 99% of nondiabetic and 89% of patients with diabetes were alive (P = .04). Overall freedom from a major cardiac event (death, MI, target vessel revascularization) at 315 ± 13 day follow-up was 88% for nondiabetics and 54% for patients with diabetes (P = .0003). By multivariate analysis, diabetes mellitus was the most important predictor for development of 1-month (RR 9.89; 95% confidence interval, 1.6-30) and late major cardiovascular events (RR 8.39; 95% confidence interval, 2.93-24). Conclusions Primary stenting in acute MI is highly effective in restoring immediate TIMI 3 coronary flow in nondiabetic patients and patients with diabetes. This procedure may improve benefit in terms of mortality rate to both groups, particularly in patients with diabetes, compared with previous reports with thrombolytic therapy. Nevertheless, stent thrombosis and major cardiovascular events at 1 month and late follow-up are more frequent in patients with diabetes. (Am Heart J 1999;138:446-55.)

Section snippets

Patient selection

From January 1995 to September 1997, a total of 120 consecutive patients were seen at our institution with an acute MI and suitable coronary anatomy for primary coronary stenting. Sixteen patients were excluded from this analysis because of either cardiogenic shock (n = 11) or significant left main coronary disease (n = 5). Diabetes mellitus was present in 28 patients of the remaining 104 patients included in this study.

The possible risks and benefits of the coronary angiogram, coronary

Clinical characteristics

The clinical characteristics of the populations are shown in Table I.

. Baseline clinical characteristics

Empty CellDiabetics (n = 28)Nondiabetics (n = 76)P value
Age65 ± 1261 ± 14.2
Male18 (64%)50 (66%).88
Risk factors
 Hypertension21 (75%)45 (59%).13
 Tobacco use15 (54%)40 (53%).93
 Hypercholesterolemia13 (46%)40 (53%).57
 Previous MI7 (25%)17 (22%).77
Duration of symptoms before procedure (hr)*4.0 (2, 10)3.0 (2, 7).20
Killip class
 121 (75%)62 (82%).30
 26 (21%)8 (11%)
 31 (4%)6 (8%)
Peak CPK*1208 (519, 2414)1006 (460, 2320)

Discussion

The outcome of patients with diabetes after acute MI has been significantly worse than their nondiabetic counterparts.1, 2, 3 Before the thrombolytic era, an in-hospital mortality rate of up to 28% was reported for patients with diabetes with acute MI.2 With the advent of thrombolytic agents, the mortality rate of patients with diabetes markedly improved, although it was still significantly worse than in nondiabetic patients.4, 5, 6, 15 The GISSI-2 Investigators4 reported a mortality rate of

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    From the Department of Cardiology, Ochsner Medical Institutions.

    ☆☆

    Reprint requests: Stephen R. Ramee, MD, Cardiac Catheterization Laboratory, Department of Cardiology, Ochsner Clinic, 1514 Jefferson Highway, New Orleans, LA 70121.E-mail: [email protected]

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