Timing of invasive strategy in diabetic and non-diabetic patients with non-ST-segment elevation acute coronary
Nikolay G Dimitrov1, Iana I Simova, Hristo F Mateev
1Department of Invasive Cardiology, St. Ekaterina University Hospital, Sofia, Bulgaria.
Insights
For patients with non-ST-segment elevation acute coronary syndrome, an early invasive strategy significantly reduces major adverse cardiac events (MACE) in those with diabetes mellitus. This approach also delays the occurrence of MACE in diabetic patients.
Area of Science:
- Cardiology
- Interventional Cardiology
- Acute Coronary Syndromes
Background:
- Non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients exhibit heterogeneous risks for major adverse cardiac events (MACE).
- Diabetes Mellitus (DM) is a significant risk factor, increasing MACE risk in NSTE-ACS patients.
Purpose of the Study:
- To compare the efficacy of an early invasive strategy versus a selective invasive strategy.
- To specifically evaluate these strategies in patients with and without diabetes mellitus.
Main Methods:
- 178 patients with unstable angina or NSTEMI were randomized into early invasive or selective invasive groups.
- Early invasive: coronary arteriography and PCI within 24 hours.
- Selective invasive: initial medical stabilization, with intervention only if needed.
Main Results:
- Diabetic patients on early invasive strategy had significantly lower angina recurrence, rehospitalization, fewer arteriographies/interventions, and lower MACE rates (p<0.008).
- Kaplan-Meier analysis showed a significantly longer time to MACE for diabetics in the early invasive group.
- Non-diabetic patients showed no significant difference in MACE rates between the two strategies.
Conclusions:
- An early invasive strategy is associated with reduced MACE and a longer time to MACE in diabetic patients with NSTE-ACS.
- The benefits of an early invasive strategy are less clearly defined in non-diabetic patients with NSTE-ACS.
Introduction:
Patients with acute coronary syndrome without ST segment elevation are a heterogeneous group with respect to the risk of having a major adverse cardiac event (MACE). A history of diabetes mellitus (DM) is no doubt one of the factors that define a patient as being at a higher risk of having the syndrome.
Aim:
To compare early invasive strategy with selective invasive strategy indicated for patients with and without DM.
Patients And Methods:
The study enrolled 178 patients with unstable angina or non-ST elevation myocardial infarction (UA/NSTEMI), and of these 52 (29.2%) had DM. Patients were randomly assigned to an early invasive strategy (these were scheduled to undergo coronary arteriography and percutaneous coronary intervention within 24 hours after admission) or to a selective invasive strategy (at first these were medically stabilized, with coronary arteriography required only in case of angina recurrence and/or evidence of inducible myocardial ischemia). The patients were followed up for a mean period of 22.8 +/- 14 months.
Results:
In the follow up the diabetics allocated to an early invasive strategy were found to have a significantly lower angina recurrence incidence (p = 0.005), rehospitalization rate (p = 0.001), fewer arteriographies (p = 0.001) and coronary interventions (p = 0.001) and low cumulative incidence of MACE (p = 0.008) in comparison with the diabetics assigned to selective invasive strategy. We also found, using the Kaplan-Meier curves survival analysis, that the time to MACE in patients assigned to an early invasive strategy was significantly longer than that in the group of selective invasive strategy. In the follow-up of non-diabetics we found no significant difference in MACE rate between the patients allocated to early invasive strategy and those assigned to selective invasive strategy. In the selective invasive strategy group, however, the cardiovascular adverse events tended to occur earlier than in the early invasive strategy group.
Conclusions:
Early invasive strategy in diabetic patients with non-ST-segment elevation acute coronary syndrome is associated with a reduced MACE rate compared with the selective invasive strategy used in these patients. Early invasive strategy applied in diabetic patients is also associated with a significantly longer time to MACE. In non-diabetics the advantages of early over selective invasive strategy are not so clearly differentiated.
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