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Diabetes Care 30:731-733, 2007
DOI: 10.2337/dc06-1367
© 2007 by the American Diabetes Association
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Cardiovascular and Metabolic Risk
Brief Report

Characterizing Young Patients With Diabetes and Non–ST-Segment Elevation Acute Coronary Syndromes

Rajendra H. Mehta, MD, MS1, Sarah Milford-Beland, MS1, Eric D. Peterson, MD, MPH1, Deepak L. Bhatt, MD2, Michael E. Farkouh, MD3, Gerald X. Brogan, MD4, W. Brian Gibler, MD5, E. Magnus Ohman, MD1 and Matthew T. Roe, MD, MHS1

1 Duke Clinical Research Institute, Durham, North Carolina
2 Cleveland Clinic Foundation, Cleveland, Ohio
3 New York University, New York, New York
4 North Shore University Hospital, Manhasset, New York
5 University of Cincinnati, Cincinnati, Ohio

Address correspondence and reprint requests to Rajendra H. Mehta, MD, Duke Clinical Research Institute, P.O. Box 17969, Durham, NC 27715. E-mail: mehta007{at}dcri.duke.edu

Abbreviations: ACS, acute coronary syndrome • CRUSADE, Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association Guidelines? • NSTE, non–ST-segment elevation


   INTRODUCTION
TOP
 INTRODUCTION
RESEARCH DESIGN AND METHODS--
 RESULTS--
 CONCLUSIONS--
 References
 
Most information regarding the prognosis and quality of care of patients with diabetes and acute coronary syndromes (ACSs) is derived from studies that have largely focused on middle-aged and older populations (1–3). Thus, data regarding the presenting features, treatment patterns, and outcomes in smaller proportions of ACS patients with diabetes who are young (an age wherein insulin-dependent diabetes manifests, often portending poor prognosis) has been less well characterized. Accordingly, we sought to evaluate clinical features, management, and in-hospital clinical events among young patients (aged ≤45 years) with and without diabetes who presented with non–ST-segment elevation ACS (NSTE ACS) and who were included in the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association Guidelines?) Quality Improvement Initiative (4–6).


   RESEARCH DESIGN AND METHODS—
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS--
RESULTS--
 CONCLUSIONS--
 References
 
The details of the CRUSADE Initiative have been previously published (4–6). In brief, patients included in the CRUSADE Quality Improvement Initiative were admitted to 498 participating U.S. hospitals with ischemic symptoms at rest within 24 h before presentation and high-risk features including ST-segment depression, transient ST-segment elevation, and/or positive cardiac markers (elevated troponin I or T and/or creatine kinase-MB more than the upper limit of normal for participating institutions). For this study, we analyzed data from 9,643 patients aged ≤45 years out of a total of 138,719 NSTE ACS patients enrolled in the CRUSADE Quality Improvement Initiative between January 2001 and March 2005. Hospitals participating in the CRUSADE Quality Improvement Initiative anonymously collect detailed demographics, clinical and laboratory features, process of care, and in-hospital outcomes data through retrospective chart review. Patients were categorized into two groups: those with and without history of known diabetes as noted on the case-report forms.

Statistical analysis
Quality-of-care indicators for both acute care and discharge care were compared for patients with class IA or IB indication and without any contraindications to such treatments (7). Care patterns and in-hospital events were adjusted for a broad range of patient and hospital characteristics using multivariate logistic regression analysis.


   RESULTS—
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS--
 RESULTS--
CONCLUSIONS--
 References
 
Among patients aged ≤45 years, 18.8% (n = 1,808) had diabetes. In contrast, 34% of patients aged >45 years had diabetes. Furthermore, younger patients with diabetes comprised 1.3% of overall and 4% of all patients with diabetes in the CRUSADE Quality Improvement Initiative. Young diabetic patients were slightly older and more likely to be female (Table 1). Obesity was more prevalent in diabetic patients, as were most comorbid conditions such as hypertension; dyslipidemia; prior myocardial infarction, revascularization, heart failure, or stroke; peripheral arterial disease; and renal insufficiency. Presenting heart rate and systolic blood pressure were higher and signs of heart failure less frequent in patients with diabetes. Serum triglyceride and LDL were higher in patients with diabetes. The use of all evidence-based therapies (adjusted for confounding factors) were similar in the two groups with the exception of discharge aspirin, clopidogrel, ACE inhibitor, dietary counseling, and referral for cardiac rehabilitation—all of which were significantly higher in patients with diabetes.


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  		Table 1— Acute medications and discharge therapies and interventions*

 
After adjusting for confounding, no differences were noted in the incidence of in-hospital mortality (1.4 vs. 1.0%, odds ratio [OR] 0.62 [95% CI 0.31–1.23]), death or re-infarction (3.4 vs. 2.6%, 0.90 [0.61–1.33]), heart failure (4.6 vs. 2.0%, 1.21 [0.86–1.70]), or shock (1.2 vs. 1.3%). However, patients with diabetes were more likely to receive a blood transfusion (9.4 vs. 4.7%, 1.35 [1.07–1.69]).


   CONCLUSIONS—
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS--
 RESULTS--
 CONCLUSIONS--
References
 
Our data suggest that the presence of diabetes among young NSTE ACS patients is common. We have demonstrated (8) that diabetes was more prevalent among female patients and African Americans with NSTE ACS, and patients with diabetes more commonly had other comorbid medical conditions and high-risk features such as multivessel coronary disease. Most striking was the fact that ~60% of young patients with diabetes were morbidly obese (BMI >30 kg/m2). Additionally, even among young NSTE ACS patients without diabetes, 40% were obese. Obesity is commonly recognized to be interrelated with glucose intolerance and insulin resistance, among other factors, as a component of metabolic syndrome (9).

We found no difference in the use of acute medications during hospitalization. More impressive was the somewhat better adherence to discharge medications and lifestyle modification strategies in younger patients with diabetes compared with those without diabetes. While overall revascularization rates were similar in the two groups, the choice of revascularization strategy was somewhat different; more patients with diabetes underwent coronary artery bypass surgery, and more nondiabetic patients were treated with percutaneous coronary interventions. This may have been a result of higher prevalence of multivessel coronary disease and more left ventricular systolic dysfunction among patients with diabetes, as well as better survival reported with bypass surgery compared with percutaneous coronary interventions among those with diabetes and multivessel disease (10).

Finally, in-hospital outcomes, particularly mortality, were not significantly different between the two groups. This is in contrast with previously published studies (11,12) (predominantly consisting of middle-aged or older patients) that found diabetes to be an important predictor of increased mortality and myocardial infarction among patients presenting with NSTE ACS. Only the risk of blood transfusion was increased by twofold among young patients with diabetes and remained significantly higher despite adjustments for confounding clinical variables. This increased risk of bleeding is somewhat counterintuitive, as diabetes has long been recognized as a prothrombotic state (9) and requires future investigations.

In conclusion, our findings indicate that, despite a higher prevalence of comorbid conditions among young NSTE ACS patients with diabetes compared with those without diabetes, adherence to guideline-based therapies and in-hospital mortality are similar among these two groups. Future studies are needed to address the influence of diabetes on long-term outcomes in young patients with NSTE ACS and to decrease the alarming rates of obesity among this population.


   Acknowledgments
 
The CRUSADE Quality Improvement Initiative is funded by the Schering-Plough Corporation, and the Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership provides additional funding support.


   Footnotes
 
E.D.P., W.B.G., and E.M.O. have received research grants from Millenium Pharmaceuticals, Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership, and Schering Corporation. D.L.B. has received research grants and honoraria from Bristol-Myers Squibb, Millenium Pharmaceuticals, Sanofi-Aventis, and Schering Corporation. M.E.F. has received research grants from and is a member of the speaker’s bureau for Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership. M.T.R. has received research grants from and is a member of the speaker’s bureau for Millenium Pharmaceuticals, Bristol-Myers Squibb/Sanofi-Aventis Pharmaceuticals Partnership, and Schering Corporation.

A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances.

The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked "advertisement" in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.

Received for publication June 30, 2006. Accepted for publication December 9, 2006.


   References
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS--
 RESULTS--
 CONCLUSIONS--
 References
 

  1. Lee KL, Woodlief LH, Topol EJ, Weaver WD, Betriu A, Col J, Simoons M, Aylward P, Van de Werf F, Califf RM: Predictors of 30-day mortality in the era of reperfusion for acute myocardial infarction: results from an international trial of 41,021 patients. Circulation 91:1659–1668, 1995[Abstract/Free Full Text]
  2. Mehta RH, Ruane TJ, McCargar PA, Eagle KA, Stalhandske EJ: The treatment of elderly diabetic patients with acute myocardial infarction: insight from Michigan’s Cooperative Cardiovascular Project. Arch Intern Med 160:1301–1306, 2000[Abstract/Free Full Text]
  3. Brogan GX Jr, Peterson ED, Mulgund J, Bhatt DL, Ohman EM, Gibler WB, Pollack CV Jr, Farkouh ME, Roe MT: Paradoxical care of the diabetic acute coronary syndrome patient: lack of utilization of ACC/AHA guidelines in the high-risk diabetic patient. Diabetes Care 29:9–14, 2006[Abstract/Free Full Text]
  4. Bhatt DL, Roe MT, Peterson ED, Li Y, Chen AY, Harrington RA, Greenbaum AB, Berger PB, Cannon CP, Cohen DJ, Gibson CM, Saucedo JF, Kleiman NS, Hochman JS, Boden WE, Brindis RG, Peacock WF, Smith SC Jr, Pollack CV Jr, Gibler WB, Ohman EM, the CRUSADE Investigators: Utilization of early invasive management strategies for high-risk patients with non–ST-segment elevation acute coronary syndromes: results from the CRUSADE Quality Improvement Initiative. JAMA 292:2096–2104, 2004[Abstract/Free Full Text]
  5. Roe MT, Ohman EM, Pollack CV Jr, Peterson ED, Brindis RG, Harrington RA, Christenson RH, Smith SC Jr, Califf RM, Gibler WB: Changing the model of care for patients with acute coronary syndromes. Am Heart J 146:605–612, 2003[Medline]
  6. Sonel AF, Good CB, Mulgund J, Roe MT, Gibler WB, Smith SC Jr, Cohen MG, Pollack CV Jr, Ohman EM, Peterson ED, the CRUSADE Investigators: Racial variations in treatment and outcomes of black and white patients with high-risk non–STelevation acute coronary syndromes: insights from CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines?). Circulation 111:1225–1232, 2005[Abstract/Free Full Text]
  7. Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitlin MD, Hochman JS, Jones RH, Kereiakes D, Kupersmith J, Levin TN, Pepine CJ, Schaeffer JW, Smith EE III, Steward DE, Theroux P: ACC/AHA 2002 guideline update for the management of patients with unstable angina and non–ST-segment elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina) [article online], 2002. Washington, DC, American College of Cardiology Foundation. Available from http://www.acc.org/qualityandscience/clinical/guidelines/unstable/incorporated/index.htm. Accessed 20 September 2005
  8. Diabetes statistics [article online]. Alexandria, VA, American Diabetes Association. Available from www.diabetes.org/diabetes-statistics.jsp. Accessed 20 September 2005
  9. Beckman JA, Creager MA, Libby P: Diabetes and atherosclerosis: epidemiology, pathophysiology, and management. JAMA 287:2570–2581, 2002[Abstract/Free Full Text]
  10. The Bypass Angioplasty Revascularization Investigation (BARI) Investigators: Comparison of coronary bypass surgery with angioplasty in patients with multivessel disease. N Engl J Med 335:217–225, 1996[Abstract/Free Full Text]
  11. Kjaergaard SC, Hansen HH, Fog L, Bulow I, Christensen PD: In-hospital outcome for diabetic patients with acute myocardial infarction in the thrombolytic era. Scand Cardiovasc J 33:166–170, 1999[Medline]
  12. Malmberg K, Yusuf S, Gerstein HC, Brown J, Zhao F, Hunt D, Piegas L, Calvin J, Keltai M, Budaj A: Impact of diabetes on long-term prognosis in patients with unstable angina and non–Q-wave myocardial infarction: results of the OASIS (Organization to Access Strategies for Ischemic Syndromes) Registry. Circulation 102:1014–1019, 2000[Abstract/Free Full Text]

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HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
Diabetes Diabetes Care Clinical Diabetes Diabetes Spectrum