Future Strategies for Improving Outcomes in Patients with Diabetes and Acute Coronary Syndromes

Abstract

Approximately a third of admissions for acute myocardial infarction (MI) occur in individuals with diabetes mellitus (DM). Admission rates for MI are over sevenfold higher among people with DM than in those without DM, and threefold higher after accounting for differences in age and gender. Diabetes shifts the risk of acute coronary syndrome forward by 15–20 years and abolishes female premenopausal protection. Patients with diabetes and acute coronary syndrome have poorer outcomes than comparable nondiabetic individuals. Diabetes is a predictor of prehospital cardiac arrest, shortand long-term mortality, recurrent MI and the development of heart failure and cardiogenic shock in patients with acute coronary syndromes. Despite advances in acute cardiac care, diabetes confers almost a doubling of shortand long-term mortality [1–6]. Predictors of 1-year mortality in a patient with diabetes and MI include age, female gender [7–9], blood pressure, history of prior MI, blood glucose at the time of hospital admission, duration of diabetes, insulin therapy and urine albumin content [10,11]. Diabetes remains a major risk factor for mortality after adjustment for multiple clinical variables, extent of coronary artery disease and therapy [12]. Multiple factors contribute to poorer outcomes in the diabetic patient and are summarized in Box 1. Despite early reperfusion after MI and similar procedural outcomes from percutaneous coronary intervention, patients with diabetes have an increased mortality from heart failure [13–15] and cardiogenic shock [16]. Yet, prior coronary artery bypass surgery appears to have a protective role in patients with diabetes who sustain an acute MI [17].