Medical Versus Invasive Management of Non-ST Segment Elevation Myocardial Infarction in Diabetes Mellitus
Alexander B Luizzi1, Austin V Le1, Gauravpal S Gill2
1School of Medicine, Creighton University, Omaha, NE, United States of America.
Insights
Diabetic patients with non ST-segment elevation myocardial infarction (NSTEMI) treated with percutaneous coronary intervention (PCI) had lower mortality than those medically managed. This study suggests PCI may improve survival in this high-risk group.
Area of Science:
- Cardiology
- Diabetology
- Internal Medicine
Background:
- Management guidelines for ST-segment elevation myocardial infarction are clear, but evidence for treating other acute coronary syndromes in diabetic patients is inconclusive.
- Diabetic patients represent a high-risk population for cardiovascular events.
Purpose of the Study:
- To compare the outcomes of conservative medical management versus an invasive approach (percutaneous coronary intervention, PCI) in diabetic patients with non-ST-segment elevation myocardial infarction (NSTEMI).
Main Methods:
- Retrospective analysis of diabetic patients with NSTEMI admitted between 2013-2018.
- Data collected included demographics, treatment strategy (medical vs. PCI), survival, myocardial infarction recurrence, stroke, and revascularization procedures.
- Multivariable analysis using Kaplan-Meier and Cox proportional-hazard models was performed.
Main Results:
- 172 patients were treated medically and 185 with PCI.
- Over five years, 48 medically treated patients died compared to 30 patients treated with PCI.
- No significant differences were observed in stroke or recurrent myocardial infarction rates between groups.
Conclusions:
- Diabetic patients with NSTEMI treated with PCI experienced lower all-cause mortality over a five-year period compared to medical management.
- While trends suggest higher repeat interventions in the PCI group, overall outcomes favored the invasive approach.
- Treatment selection bias is a limitation, and findings should be considered hypothesis-generating.
Introduction:
While management guidelines clearly indicate treatment algorithms for ST-segment elevation myocardial infarction, evidence behind treatment of other forms of acute coronary syndrome among diabetic patients has been inconclusive. This study examines diabetic patients with non ST-segment elevation myocardial infarction (NSTEMI) who were subsequently treated conservatively or with an invasive approach.
Methods:
Diabetic patients admitted to our health network with NSTEMI between January 2013-2018 were identified. Data collected included demographics, treatment, survival, recurrence of myocardial infarction (MI), stroke and additional revascularization procedures. Historical data including comorbid factors present at time of NSTEMI and history of revascularization procedures were also collected.
Results:
A total of 357 patients met exclusion criteria. 172 were treated medically and 185 with PCI. A total of 78 deaths occurred over the five year observation period. 48 patients who were treated medically died while 30 patients treated with PCI died. After initial medical management, nine patients went on to require PCI while 19 patients treated with PCI required additional PCI. Recurrence of MI occurred in 19.8 % in medically managed patients and 18.6 % in patients who underwent PCI. Multivariable analysis was completed with the Kaplan-Meier method to estimate the survival function and Cox proportional-hazard models to investigate association between the variables and survival time.
Conclusions:
In this single center study, diabetic patients treated with PCI had lower rates of all-cause mortality over the five-year study period compared to medical management. There was no difference in stroke events, recurrent MI, or revascularization between the two groups although patients from the PCI group showed a trend towards higher risk for repeat interventions. Treatment selection bias remains the major limitation of this study and thus, the results of the comparison of therapeutic choices should be viewed as hypothesis generating.
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