THE IMPACT OF PRIMARY ANGIOPLASTY IN DIABETICS VERSUS NON-DIABETICS PATIENTS WITH MYOCARDIAL INFARCTION WITH ST ELEVATION AT 12 HOURS AFTER THE ACUTE EVENT
Received for publication: 15th of November, 2013
Revised: 11th of December, 2013
SUMMARY: (Hide the summary)
It is well known that the diabetic patients have a poor prognosis after transluminal percutaneous angioplasty for acute myocardial infarction. We need to mention the benefit of stenting in patients presenting with acute myocardial infarction at more than 12 hours after symptoms onset. Brave- 2 study concluded that primary angioplasty reduces the infarction scar in these patients. Our study consisted was retrospective and consisted in the analysis of 165 patients' charts admitted in the Cardiovascular Disease Institute between 2009 and 2012 with acute myocardial infarction with symptoms onset more than 12 hours upon admission which underwent PTCA. We analyzed as primary end-points end-diastolic volume and ejection fraction, and as secondary end-points mortality, reinfarction rate, NYHA IV cardiac failure and intrasent thrombosis rate. In conclusion, the diabetes has a negative impact on PTCA success in patients presenting at more than 12 hours until symptoms onset.
primary angioplasty, diabetes mellitius, myocardial infarction.
Diabetes is an independent risk factor for the development of coronary artery disease (CAD).(1)
Patients with diabetes have considerably higher mortality and morbidity rates than non-diabetic patients. Although diabetic patients have more severe baseline characteristics than non-diabetics, most studies concur that diabetes mellitus independently predicts morbidity and mortality after acute myocardial infarction (AMI).(2) Diabetic patients treated for CAD with percutaneous transluminal coronary angioplasty (PTCA) appear to have a particularly unfavorable prognosis compared with nondiabetic patients.
Another aspect is that 8.5-40% of STEMI patients came into emergency room at over 12 hours after symptom onset. Brave 2 study shows that primary angioplasty reduces the scar dimension in STEMI patients even after 12-48 hours after symptoms onset.(3)
The present study compares two different populations of STEMI patients - diabetics versus non-diabetics in terms of primary and secondary endpoints. Primary endpoints are telediastolic volume and ejection fraction. Secondary endpoints are mortality rate, reinfarction rate, NYHA IV cardiac insufficiency and intrastent thrombosis.
MATERIAL AND METHODS
The studied sample consisted of 165 patients admitted for acute myocardial infarction with symptom onset for more than 12 hours upon admission in the Cardiology Department, Cardiovascular Disease Institute Timisoara from 2009 until 2013. The studied parameters were recorded at the time of the procedures, at 1 and at 3 months after that.
Including criteria were symptoms onset more than 12 hours upon admission and ST segment elevation for more than 2 mm in at least 2 ECG derivations.
Excluding criteria were left bundle branch block, coronary trunk stenosis with surgical indication, triple artery involvement, mechanical ventilation upon admission, past CABG procedures, usage of thrombus aspiration catheter.
All procedural decisions, including device selection and adjunctive pharmacotherapy, were made at the discretion of the individual physician. Stents were deployed at high pressure, and patients were maintained on ticlopidine or clopidogrel for 4 weeks in addition to aspirin following implantation unless contraindicated. Cardiac enzymes (creatine kinase and creatine kinase MB isoenzyme or troponin) were obtained by protocol before and at 8 and 24 h following PCI.
Table 1. Demographic data for the studied sample.
Table 2. Clinical presentation and coronary artery involvement.
Primary endpoints are telediastolic volume (VTD) and ejection fraction (FE). Secondary endpoints are mortality rate, reinfarction rate, NYHA IV cardiac insufficiency and intrastent thrombosis. The follow-up was at one month and at three months.
Statistical analysis was performed with SPSS software. Differences between diabetic and nondiabetic patients were compared using x2 statistics for categorical variables and t tests for continuous variables. A p value <0.05 was considered statistically significant.
RESULTS AND DISCUSSIONS
The patients' demographic data are presented in table 1.
The presence of diabetes has long been associated with higher rates of long-term adverse events for patients undergoing PTCA. High restenosis rates, persistent hemostatic abnormalities, and uninterrupted progression of atherosclerosis potentially contribute to the poor outcomes seen among diabetic patients treated with PTCA. The risk of restenosis is significantly greater for diabetic than nondiabetic patients following PTCA.(4,5)
Table 3. In-hospital endpoints.
Mortality rate was greater in diabetic patients both at one month and at three months. The end-diastolic volume increased better in non-diabetic patients during the entire follow-up. The ejection fraction is improved both at one month and at three months, but more in non-diabetic patients. (6-9)
Table 4. One month end-points.
Table 5. Three months end-points.
These findings are pleading for the use of an invasive strategy in patients with acute myocardial infarction presenting at more than 12 hours after symptom onset, with the mention that diabetic population have a poor prognosis and a higher rate of complications that the non-diabetic one.
- Araz M, Celen Z, Akdemir I, Okan V. Frequency of silent myocardial ischemia in type 2 diabetic patients and the relation with poor glycemic control. Acta Diabetol 2004;41:38-43.
- Stein B, Weintraub WS, Gebhart SP, Cohen-Bernstein CL, Grosswald R, Liberman HA, Douglas JS Jr, Morris DC, King SB 3rd: Influence of diabetes mellitus on early and late outcome after percutaneous transluminal coronary angioplasty. Circulation 91:979-989, 1995.
- Gruberg L. Brave-2 Beyond 12 hours reperfusion alternative evaluation trial http://www.medscape.org/viewarticle/501432
- Barsness GW, Peterson ED, Ohman EM, Nelson CL, DeLong ER, Reves JG, Smith PK, Anderson RD, Jones RH, Mark DB, Califf RM: Relationship between diabetes mellitus and long-term survival after coronary bypass and angioplasty. Circulation 96:2551-2556, 1997.
- King H, Aubert RE, Herman WH: Global burden of diabetes, 1995-2025: prevalence, numerical estimates, and projections. Diabetes Care 21:1414-1431, 1998.
- Abizaid A, Kornowski R, Mintz GS, Hong MK, Abizaid AS, Mehran R, Pichard AD, Kent KM, Satler LF, Wu H, Popma JJ, Leon MB: The influence of diabetes mellitus on acute and late clinical outcomes following coronary stent implantation. J Am Coll Cardiol 32:584-589, 1998.
- Grundy SM, Benjamin IJ, Burke GL, Chait A, Eckel RH, Howard BV, Mitch W, Smith SC Jr, Sowers JR: Diabetes and cardiovascular disease: a statement for healthcare professionals from the American Heart Association. Circulation 100:1134-1146, 1999.
- Koek HL, Soedamah-Muthu SS, Kardaun JWPF, Gevers E, de Bruin A, Reitsma JB, Bots ML, Grobbee DE. Short- and long-term mortality after acute myocardial infarction: comparison of pateints with and without diabetes mellitus. Eur J Epidemiol 2007;22:883-888.
- Norhammar A, Lindbach J, Ryde n L, Wallentin L, Stenestrand U, on behalf of the Register of Information Knowledge about Swedish Heart Intensive Care Admission (RIKS-HIA). Improved but still high short- and long-term mortality rates after myocardial infarction in patients with diabetes mellitus: a time-trend report from the Swedish Register of Information and Knowledge about Swedish Heart Intensive Care Admission. Heart 2007;93:1577-1583.