Elsevier

American Heart Journal

Volume 147, Issue 2, February 2004, Pages 246-252
American Heart Journal

Clinical investigation: acute ischemic heart disease
Association of diabetes mellitus and glycemic control strategies with clinical outcomes after acute coronary syndromes

https://doi.org/10.1016/j.ahj.2003.07.024Get rights and content

Abstract

Background

Diabetes is associated with an increased risk for coronary artery disease (CAD) and its complications. The relative effect of glucose-lowering strategies of “insulin provision” versus “insulin sensitization” among patients with CAD remains unclear.

Methods

To evaluate the associations of diabetes and hypoglycemic strategies with clinical outcomes after acute coronary syndromes, we analyzed data from 15,800 patients enrolled in the SYMPHONY and 2nd SYMPHONY trials.

Results

Compared with nondiabetic patients, patients with diabetes (n = 3101; 19.6%) were older, more often female, more often had prior CAD, hypertension, and hyperlipidemia, and less often were current smokers. The diabetic cohort had higher 90-day unadjusted risk of the composite of death/myocardial infarction (MI)/severe recurrent ischemia (SRI), death/MI, and death alone, as well as a near doubling of 1-year mortality rates. At 1 year, diabetes was associated with significantly higher adjusted risks of death/MI/SRI (OR, 1.3 [95% confidence interval, 1.1, 1.5]) and death/MI (OR, 1.2 [1.0, 1.4]). Hypoglycemic therapy including only insulin and/or sulfonylurea (insulin-providing; n = 1473) was associated with higher 90-day death/MI/SRI compared with therapy that included only biguanide and/or thiazolidinedione therapy (insulin-sensitizing; n = 100) (12.0% vs 5.0%); (adjusted OR, 2.1 [1.2, 3.7]).

Conclusions

Diabetic patients with acute coronary syndromes had worse clinical outcomes. Although the findings regarding the influence of glycemic-control strategies should be interpreted with caution because of the exploratory nature of the analyses and the relatively small sample size of the insulin-sensitizing group, the improved risk-adjusted outcomes associated with insulin-sensitizing therapy underscore the need to further evaluate treatment strategies for patients with diabetes and CAD.

Section snippets

Study population

The SYMPHONY and 2nd SYMPHONY studies evaluated the effect of sibrafiban, an oral glycoprotein IIb/IIIa antagonist, in patients after ACS. Together, they enrolled 15,904 patients between 1997 and 1999 at 931 clinical centers in 37 countries. The primary results from both trials have been published.6, 7 Patients were enrolled ≤7 days after ACS. SYMPHONY randomly assigned 9233 patients to 90 days of treatment with aspirin or 1 of 2 dosing strategies of sibrafiban. The 2nd SYMPHONY randomly

Results

Of the 15,800 patients evaluated, 3101 (19.6%) had diabetes. Diabetic patients were older, heavier, more often female and hypertensive, less often smokers, and had a higher prevalence of prior MI, revascularization, and congestive heart failure (Table I). Diabetic patients were also more likely to have unstable angina and less likely to have ST-segment elevation MI as their qualifying ACS.

Diabetes was associated with a higher unadjusted 90-day risk of death/MI/SRI (11.4% vs 9.0%, P < .001) (

Discussion

Our findings demonstrate the substantial cardiovascular risk associated with diabetes after ACS and are consistent with prior studies.2, 3, 4 In addition, since concomitant medication use was collected throughout the period of observation in the SYMPHONY trials, we were able to explore the association of various glycemic control strategies with outcomes. A novel finding from these analyses is that a glycemic control strategy using insulin-providing versus insulin-sensitizing therapy was

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    The SYMPHONY and 2nd SYMPHONY trials were supported by a grant from F. Hoffmann-La Roche, Ltd, Basel, Switzerland.

    Guest Editor for this manuscript was W. Douglas Weaver, MD, Henry Ford Heart and Vascular Institute, Detroit, Mich.

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