Outcomes/Effectiveness Research

Diabetes increases the risk of dying for patients with suspected acute coronary syndrome

A new study warns that diabetes should be added to the list of high-risk factors that warrant more aggressive treatment of patients with acute coronary syndrome (ACS, heart attack or unstable angina), such as early angiography and use of intravenous glycoprotein inhibitors. About half of ACS patients suffer from diabetes. Current guidelines do not recognize diabetes as a high-risk indicator for ACS patients. Yet the study found that ACS patients with diabetes were at higher risk of dying than ACS patients without diabetes, even after adjustment for elevated troponin-I levels and other high-risk features recognized by the American College of Cardiology (ACC) and American Heart Association (AHA).

The University of Missouri-Mid America Heart Institute researchers analyzed a registry of 864 ACS patients with and without diabetes. More ACS patients with diabetes than those without died within 30 days (1.7 vs. 0.2 percent). The ACC/AHA high-risk features of ACS that doubled or nearly doubled the risk of death at 2 years included rales (abnormal lung sounds), troponin greater than the upper limit of normal, previous heart attack, and each 10-year increase in age. Each 1 percent decrease in ejection fraction (pumping power of the heart) also raised the risk slightly.

Diabetes also nearly doubled the risk of dying within 2 years, a level or risk similar to elevated troponin levels. Yet, in-hospital angiography was performed less often in ACS patients with diabetes than those without (74 vs. 79 percent). Among patients with diabetes, 82 percent with elevated troponin-I levels underwent in-hospital angiography compared with 66 percent with normal troponin-I levels. A significantly greater number of patients with diabetes with normal troponin-I levels were managed medically (63 vs. 42 percent). Administration of glycoprotein inhibitors was about 3 times more common in patients with diabetes with troponin-I elevation compared with patients without diabetes with normal levels (49 vs. 16 percent). The study was supported by the Agency for Healthcare Research and Quality (HS11282).

See "Suspected acute coronary syndrome patients with diabetes and normal troponin-I levels are at risk for early and late death," by Steven P. Marso, M.D., David M. Safley, M.D., John A. House, M.S., and others, in the August 2006 Diabetes Care 29(8), pp. 1931-1932.

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