Clinical outcomes of patients with diabetes mellitus and acute myocardial infarction treated with primary angioplasty or fibrinolysis

Abstract

Objective: To compare the early and late outcomes of primary percutaneous transluminal coronary angioplasty (PTCA) with fibrinolytic treatment among diabetic patients with acute myocardial infarction (AMI). Design: Retrospective observational study with data obtained from prospective registries. Setting: Tertiary cardiovascular institution with 24 hour acute interventional facilities. Patients: 202 consecutive diabetic patients with AMI receiving reperfusion treatment within six hours of symptom onset. Interventions: Fibrinolytic treatment was administered to 99 patients, and 103 patients underwent primary PTCA. Most patients undergoing PTCA received adjunctive stenting (94.2%) and glycoprotein IIb/IIIa inhibition (63.1%). Main outcome measures: Death, non-fatal reinfarction, and target vessel revascularisation at 30 days and one year were assessed. Results: Baseline characteristics were similar in these two treatment groups except that the proportion of patients with Killip class III or IV was considerably higher in those treated with PTCA (15.5% v 6.1%, p = 0.03) and time to treatment was significantly longer (103.7 v 68.0 minutes, p < 0.001). Among those treated with PTCA, the rates for in-hospital recurrent ischaemia (5.8% v 17.2%, p = 0.011) and target vessel revascularisation at one year (19.4% v 36.4%, p = 0.007) were lower. Death or reinfarction at one year was also reduced among those treated with PTCA (17.5% v 31.3%, p = 0.02), with an adjusted relative risk of 0.29 (95% confidence interval 0.15 to 0.57) compared with fibrinolysis. Conclusion: Among diabetic patients with AMI, primary PTCA was associated with reduced early and late adverse events compared with fibrinolytic treatment. E ven with the widespread availability of fibrinolytic treatment, diabetes mellitus remains an important adverse prognostic factor in patients with acute myocardial infarction (AMI).1-3 Although recent evidence from randomised trials has shown that primary percutaneous transluminal coronary angioplasty (PTCA) provides significantly better clinical outcomes than fibrinolysis for AMI in general, 4-9 its effect on diabetic patients remains unclear. A post hoc subgroup analysis of the GUSTO-IIb (global use of strategies to open occluded coronary arteries in acute coronary syndromes) angioplasty substudy found modest improvements in short and long term outcomes in diabetic patients treated with primary PTCA compared with fibrinolysis.

Mortality after myocardial infarction in patients with diabetes mellitus

“…The magnitude of benefit and access to reperfusion is greater with a primary PCI strategy 27. A systematic review by Keeley et al 28 and also subgroup analysis data from PRAGUE-229 confirm that those with the highest risk, including those with diabetes, can achieve 30-day mortality rates of 7% with primary PCI compared with 23% for a similar group of patients receiving lysis.…”

Albumin excretion in diabetic patients in the setting of acute myocardial infarction: association with 3-year mortality

“…In fact, diabetic subjects experience greater morbidity during the acute phase of myocardial infarction (AMI) and higher mortality in the post-infarction period [3,5,6]. This fact holds true even in the era of thrombolytics and primary percutaneous transluminal coronary angioplasty [7,8].…”

Impact of diabetes mellitus on myocardial perfusion after primary angioplasty in patients with acute myocardial infarction

“…Recent small studies suggest that acute outcomes in diabetic patients with AMI may be better after reperfusion with primary percutaneous coronary intervention (PCI) than thrombolytic therapy (5,11). However, compared with patients without diabetes, diabetics remain at increased risk for adverse outcomes after primary PCI.…”