Raiza Gandola, Mercer University College of Pharmacy
Patients with acute coronary syndrome (ACS) and diabetes have a worse prognosis in coronary artery disease (CAD)-related deaths than non-diabetic patients. However, it is still unclear whether the negative prognostic implications of diabetes apply equally to the different types of ACS (ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation ACS (NSTE-ACS)). 
Patients with diabetes mellitus (DM) are considered to be at risk for CAD and have a three-fold increase in age-adjusted cardiovascular mortality. An increase in platelet reactivity associated with hyperglycemia is suggested to provide a proinflammatory and prothrombotic state, further potentiating the inflammatory state during an acute coronary event.  When comparing an ACS in diabetic patients versus non-diabetic patients, there is an increased risk for adverse outcomes in diabetic patients.  However, it is still considered unclear how DM affects adverse events in patients with ACS undergoing percutaneous coronary intervention (PCI). 
|Title: Effect of Diabetes Mellitus on Frequency of Adverse Events in Patients With Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention|
|Design||Retrospective analysis; N= 9,942|
|Objective||To determine the timing of mortality and other nonfatal adverse events according to diabetic status and type ACS: STEMI vs. NSTE-ACS|
|Study Groups||Diabetes mellitus (DM) with STEMI (n= 591); DM with NSTE-ACS (n= 1,336); no DM with STEMI (n= 3,339); no DM with NSTE-ACS (n= 4,226)|
|Methods||Individual patient data was pooled from five randomized clinical trials conducted in Europe. Study participants were classified according to diabetic status at the time of PCI and stratified by ACS type: STEMI or NSTE-ACS.|
|Duration||2004 – 2014|
|Primary Outcome Measure||All-cause mortality|
|Baseline Characteristics||No DM||DM|
|Average age, y||68.2||66.2||67.2||69.1|
|Female, n (%)||743 (22.3)||1,057 (25)||150 (25.4)||411 (30.8)|
|Average body mass index, kg/m2||26.7||27.0||28.9||29.0|
|Hypertension, n (%)||1,679 (50.4)||2,874 (68.2)||432 (74.0)||1,129 (84.7)|
|Previous myocardial infarction, n (%)||308 (9.2)||1,045 (24.8)||35 (6.0)||219 (16.4)|
|Results||Rate of mortality at one year was 13.4% in diabetic patients with STEMI, 10.3% in diabetic patients with NSTE-ACS, 6.4% in non-diabetic patients with STEMI, and 4.4% in non-diabetic patients with NSTE-ACS|
|Adverse Events||Common Adverse Events: Revascularization (6.2, 5.6, 8.0, 7.6%) and definite stent thrombosis (9.1, 0.8, 3.1, 1.5%) in non-diabetic patients with STEMI, NSTE-ACS, diabetic patients with STEMI, and NSTE-ACS, respectively|
|Serious Adverse Events: Death (6.4, 4.4, 13.4, 10.3%) and myocardial infarction (3.7, 5.2, 6.2, 8.6%) in non-diabetic patients with STEMI, NSTE-ACS, diabetic patients with STEMI, and NSTE-ACS, respectively|
|Percentage that Discontinued due to Adverse Events: N/A|
|Study Author Conclusions||Patients with DM had a twofold-increased risk of mortality compared with non-diabetic patients in the setting of STEMI and NSTE-ACS at one-year follow-up. Despite the high event rate, the temporal distribution of adverse events related to the type of ACS throughout the follow-up was similar compared with NSTE-ACS patients.|
This study reveals the increased risk of mortality associated in ACS patients with DM undergoing PCI. Further evaluation of differences in diabetic patients with STEMI and NSTE-ACS show STEMI ACS patients are at higher risk for mortality as well as occurrence of adverse events. One limitation to consider is the unclear definition of DM, as patients diagnosed with DM during or after index hospitalization were excluded. Additionally, the trials analyzed in this study did not disclose the type or duration of diabetes in their patients. Despite this, the two-fold increased risk of mortality and distribution of adverse events of ACS patients with DM is comparable to that of non-diabetic patients.
- Franklin K, Goldberg RJ, Spencer F, et al. Implications of Diabetes in Patients with Acute Coronary Syndromes. Arch Intern Med. 2004;164(13):1457-1463.
- Sanon S, Patel R, Eshelbrenner C, et al. Acute coronary syndrome in patients with diabetes mellitus: perspectives of an interventional cardiologist. Am J Cardiol. 2012;110(9 Suppl):13B-23B.
- Piccolo R, Franzone A, Konskinas KC, et al. Effect of Diabetes Mellitus on Frequency of Adverse Events in Patients with Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention. Am J Cardiol. 2016;118(3):345-352.