Impact of type 2 diabetes mellitus on in-hospital outcomes in patients with ST-elevation myocardial infarction: A nationwide study in Germany.

<i>Circulation: Cardiovascular Interventions</i> Editors’ Picks

BACKGROUND AND OBJECTIVESGender associations with acute coronary syndrome (ACS), remain inconsistent. Gender-specific data in the Saudi Project for Assessment of Coronary Events registry, launched in December 2005 and currently with 17 participating hospitals, were explored.DESIGN AND SETTINGSA prospective multicenter study of patient with ACS in secondary and tertiary care centers in Saudi Arabia were included in this analysis.PATIENTS AND METHODSPatients enrolled from December 2005 until December 2007 included those presented to participating hospitals or transferred from non-registry hospitals. Summarized data were analyzed.RESULTSOf 5061 patients, 1142 (23%) were women. Women were more frequently diagnosed with non ST-segment elevation myocardial infarction (NSTEMI [43%]) than unstable angina (UA [29%]) or ST-segment elevation myocardial infarction (STEMI [29%]). More men had STEMI (42%) than NSTEMI (37%) or UA (22%). Men were younger than women (57 vs 63 years) who had more diabetes, hypertension, and hyperlipidemia. More men had a history of coronary artery disease. More women received angiotensin receptor blockers (ARB) and fewer had percutaneous coronary intervention (PCI). Gender differences in the subset of STEMI patients were similar to those in the entire cohort. However, gender differences in the subset of STEMI showed fewer women given β-blockers, and an insignificant PCI difference between genders. Thrombolysis rates between genders were similar. Overall, in-hospital mortality was significantly worse for women and, by ACS type, was significantly greater in women for STEMI and NSTEMI. However, after age adjustment there was no difference in mortality between men and women in patients with NSTEMI. The multivariate-adjusted (age, risk factors, treatments, door-to-needle time) STEMI gender mortality difference was not significant (OR=2.0, CI: 0.7–5.5; P=.14).CONCLUSIONThese data are similar to other reported data. However, differences exist, and their explanation should be pursued to provide a valuable insight into understanding ACS and improving its management.

Background: Morphine is commonly used for analgesia in the setting of chest discomfort associated with acute coronary syndromes (ACS). However, a retrospective analysis in non-ST elevation acute coronary syndrome (NSTE-ACS) patients suggesting increased mortality with morphine administration and further studies suggesting morphine may delay and inhibit the absorption of the oral anti-platelet agents has placed its utility in ACS under closer scrutiny. In a large single center retrospective study, we analyzed the association between morphine and in-hospital outcomes in ST elevation myocardial infarction (STEMI) and NST-ACS patients undergoing coronary angiogram +/- percutaneous coronary intervention (PCI). Methods: All STEMI and NSTE-ACS patients undergoing PCI between January 2009 and July 2016 in Massachusetts General Hospital were included in our study. Following institutional board review approval, baseline patient characteristics (demographics, risk factors and medical history) was obtained. In-hospital outcomes included mortality, post-procedure cardiogenic shock, length of hospital stay and infarct size as measured by troponin level. Results: Overall, 3027 patients were examined. Of those, 1287/3027 (42.52%) had STEMI, of which 359/1287 patients received morphine (27.89%). STEMI patients who received morphine were younger, had a higher prevalence of prior MI, PCI, and angina, were more likely to be on oxygen therapy, and had a longer time to PCI. 1740/3027 (57.48%) of study patients had NST-ACS, of which 424 (24.37%) received morphine. NSTE-ACS patients who received morphine were younger, had a higher prevalence of cerebrovascular disease, peripheral vascular disease, prior PCI, MI, congestive heart failure and valvular surgery. In unadjusted outcomes, STEMI patients who received morphine had a lower in-hospital mortality [4.18% versus 7.54%, odds ratio (OR): 0.53, p=0.03] and smaller infarct size (mean troponin level 0.75 ng/ml versus 1.29 ng/ml, p=0.02). There was no significant difference in post procedure cardiogenic shock or length of hospital stay (p= 0.26 and p=0.29 respectively). After adjusting for basic characteristics no outcomes remained significant in the STEMI cohort. In the NST-ACS cohort, patients who received morphine had a longer hospital stay (mean 6.58 days versus 4.78 days, p&lt;0.0001) and larger infarct size (mean troponin 1.16 ng/ml versus 0.90 ng/ml, p= 0.05). There was no statistical difference in in-hospital mortality or cardiogenic shock (p=0.17 and p=0.80 respectively). After adjusting for basic characteristics, length of hospital stay (p &lt;0.0001) and infarct size (p=0.02) remained significant. Conclusion: In a large retrospective study, morphine was associated with larger infarct size and a longer hospital admission in NSTE-ACS patients but had no effect on outcomes in STEMI patients.

BackgroundType 2 diabetes mellitus (T2DM) is associated with acute coronary syndrome, and elevated blood glucose levels on hospital admission may influence outcomes in patients with ST-elevated myocardial infarction (STEMI). We conducted this study to determine the prognostic outcome of hyperglycemia at admission on in-hospital outcomes of STEMI patients with and without T2DM.MethodsThis prospective study was conducted from June 13, 2018, to October 12, 2019, and included patients older than 18 years diagnosed with STEMI. For our purposes, hyperglycemia was defined as blood glucose levels >140 mg/dl. Hypertension was considered as systolic blood pressure >140 mmHg or diastolic pressure > 90 mmHg. The predictive value of glycemia on admission for outcomes was assessed via patient mortality following thrombolysis or percutaneous coronary intervention (PCI).ResultsOur study included 256 patients (196 men, 76.5%; 60 women, 23.5%) with a mean age of 55 ± 11 years. A total of 92 patients (35.9%) were admitted with known T2DM diagnoses: 72 of them had hyperglycemia and 20 patients had euglycemia (p = 0.0001). Post-PCI mortality was six (18.8%) in the hyperglycemic group and one (2.2%) in the euglycemic group (p = 0.03). In-hospital mortality was higher in the hyperglycemic group (n = 12, 12.5%) compared to the euglycemic group (n = 6, 3.7%; p = 0.015). Significant risk factors of mortality for STEMI patients with hyperglycemia on admission were age 60 years or older (odds ratio [OR], 5.63 [1.54-20.58]; p = 0.007), heart failure on admission (OR, 6.84 [1.85-25.22)]; p = 0.003), T2DM (OR, 4.14 [0.50-33.96]; p = 0.05), and presenting with renal failure (OR, 6.78 [1.74-26.42]; p = 0.009).ConclusionThrombolysis and PCI are effective and safe treatments in STEMI patients. Hyperglycemia has a great adverse impact on hospital outcomes in patients with or without T2DM. STEMI patients with hyperglycemia on hospital admission have higher mortality rates.

The following articles are being highlighted as part of Circulation's Topic Review series. This series will summarize the most important manuscripts, as selected by the editors, published in Circulation and the Circulation subspecialty journals. The studies included in this article represent the most read manuscripts published on the topic of cardiovascular quality and outcomes within the last year.

Objectives: This study aimed to investigate the relationship between post-percutaneous coronary intervention (PCI) hemoglobin levels and in-hospital outcomes in patients with ST-elevation myocardial infarction (STEMI). Methodology: A retrospective cohort study was conducted on 120 STEMI patients undergoing primary PCI at Hayatabad Medical Complex, Peshawar, from January to December 2023. Patients were stratified into three groups based on post-PCI hemoglobin levels: normal, mildly anemic, and severely anemic. Inclusion criteria included STEMI patients aged ≥18 years with complete medical records, while those with active post-procedural bleeding were excluded. Data collected encompassed pre- and post-PCI hemoglobin levels, comorbidities (chronic kidney disease, diabetes, hypertension), anemia treatment details, and in-hospital outcomes. Multivariate regression analysis was performed to identify independent predictors of outcomes. Results: Lower post-PCI hemoglobin levels were significantly associated with increased in-hospital mortality and major adverse cardiac events (MACE). Mortality rates were 4.0%, 10.0%, and 20.0% in the normal, mildly anemic, and severely anemic groups, respectively (p=0.02). MACE occurred in 6.0%, 17.5%, and 30.0% of these groups (p=0.01). Severe anemia was an independent predictor of mortality (odds ratio [OR] 2.5, 95% confidence interval [CI] 1.1–5.7, p=0.03) and MACE (OR 3.2, 95% CI 1.4–7.2, p=0.01). Comorbid conditions, including chronic kidney disease, diabetes, and hypertension, further amplified these risks. Conclusion: Post-PCI hemoglobin levels play a pivotal role in determining in-hospital outcomes in STEMI patients. Addressing anemia and associated comorbidities is crucial for improving prognosis. Implementation of comprehensive anemia management strategies is essential to optimize patient care and enhance survival rates.

Objective To investigate the clinical characteristics and risk factors of non-premature STEMI patients underwentprimaryPCI with multivessel disease. Methods Data of clinic and coronary angiographic features were retrospectively compared between group of 371 younger STEMI patients (male age <55 years, female <65 years)and group of 662 older STEMI patients. All patients were admitted to hospital from January 2005 to January 2015 and treated with primary PCI. The patients’ gender, smoking history, family history of coronary heart disease (CHD), hypertension, type 2 diabetes mellitus, previous myocardial infarction and revascularization, stroke history, serum uric acid, lipids etc. were documented. The comparison of coronary artery disease characteristics and the incidence of adverse events during hospitalization were also carried out between two groups. Results (1) Prevalence of males(88.4% vs.76.9%), smokers(74.9% vs.51.5%), family history of CHD(21.0% vs.9.7%)and levels of diastolic blood pressure, total cholesterol, low density lipoprotein cholesterol (LDL-c), triglycerides, and low cholesterol were significantly higher in the non-prematuregroup than in the premature group (all P<0.01), while high density lipoprotein cholesterol (HDL-c)was lower in non-prematuregroup (P<0.01). (2) The incidence of in-hospital events in both groups were low. There was less ventricular tachycardia in the non-premature group (1.5% vs.0.3%)(P<0.05). (3) There were no statistically significant differences in the number of infarct vessels, site ofinfarctbetween two groups.(4) Logistic regression analysis showed that smoking(OR=2.22, 95%CI: 1.588-3.108)(P<0.05), family history of CHD(OR=2.12, 95%CI: 1.431-3.140)(P<0.05), triglyceride concentration(OR=1.971, 95%CI: 1.475-2.635)(P<0.05), LDL-c(OR=1.193, 95%CI: 1.008-1.413)(P=0.04)were independent risk factors fornon-premature STEMI withmultivessel disease. Conclusion Smoking, family history of CHD, triglyceride concentration, LDL are main risk factors of younger age STEMI patients with multiple vessel disease; Compared with younger age patients, older age patients during hospitalization are more likely to occur ventricular tachycardia. Regardless of age difference, the characteristics of coronary artery lesions show no significant difference. Key words: ST-segment elevation myocardial infarction; Multivessel disease; Non-premature; Risk factors; Clinical features; Primary percutaneous coronaryintervention; Smoking; Family history; Dyslipidemia

A Multidisciplinary Approach to Reducing Door-to-Balloon Time in a Community Hospital

Chronic low-grade inflammation has emerged as a hallmark of type 2 diabetes mellitus (T2DM), contributing significantly to the pathogenesis of various cardiovascular diseases, notably ST-elevated myocardial infarction (STEMI). The intricate interplay between inflammation and cardiovascular health in the context of T2DM has been a subject of intensive research in recent years. In particular, the development of various markers of inflammation has provided valuable tools for better understanding the complex relationship between low-grade inflammation and cardiovascular disease in T2DM. Elevated levels of these markers have been consistently associated with increased cardiovascular risk in patients with T2DM, indicating their potential as prognostic indicators. The aim of the study was to investigate the potential association between type 2 diabetes mellitus and low-grade inflammation markers in patients with ST-elevated myocardial infarction through a comparative analysis of systemic immune-inflammation indices, fibronectin, and soluble suppression of tumorogenesis-2 (sST2) levels in ST-elevated myocardial infarction patients with and without type 2 diabetes mellitus. We enrolled 158 patients diagnosed with STEMI who were admitted to the Ivano-Frankivsk Regional Clinical Cardiological Center. The study population was divided into three groups: 1 – consisting of 45 patients with both STEMI and T2DM, and the 2 – consisting of 34 patients with STEMI only, T2DM only group – 69 patients, Control group – 10 healthy patients. In summary, the findings from the study provide compelling evidence to support the notion that patients who suffer from both STEM and T2DM exhibit a more robust inflammatory response and higher platelet count, compared to those with STEMI alone. These results suggest that the presence of T2DM may exacerbate the pro-inflammatory and pro-thrombotic state that is typically associated with STEMI, thereby emphasizing the critical need for early intervention to prevent or mitigate inflammation and platelet activation in this particular patient population. Type 2 diabetes mellitus patients with ST-segment elevation myocardial infarction show higher levels of inflammation markers and fibronectin, indicating greater low-grade inflammation. Elevated levels of soluble suppression of tumorigenicity 2 suggest myocardial remodeling. Targeting low-grade inflammation could be a potential therapy for STEMI in T2DM patients.

This study aimed to determine whether convertase subtilisin/kexin type 9 (PCSK9)-associated cardiovascular risk is modulated by triglyceride-glucose (TyG) in ST-segment elevation myocardial infarction (STEMI) patients with primary percutaneous coronary disease (PCI). A total of 1541 patients with STEMI (aged ≥18 years) undergoing primary PCI were consecutively enrolled between March 2017 and March 2019. When stratifying the overall population according to TyG indices less than or greater than the median (TyG median = 9.07) as well as according to quartiles of PCSK9 levels, higher TyG index levels were significantly associated with all-cause mortality only when TyG levels were 9.07 or higher (ie, relative to quartile 1 [Q1], the adjusted HR for all-cause mortality was 3.20 [95% CI, 0.54-18.80] for Q2, p = 0.199; 7.89 [95% CI, 1.56-40.89] for Q3, p = 0.013; and 5.61 [95% CI, 1.04-30.30] for Q4, p = 0.045. During a median follow-up period of 1.96 years, the HR for all-cause mortality was higher in the subset of patients with TyG ≥median and PCSK9 ≥median (p for trend = 0.023) among those with type 2 diabetes mellitus (T2DM). However, there were no statistically significant differences among the subgroups. Among T2DM patients with a TyG index greater than the median, the Kaplan-Meier curve showed that patients with the highest PCSK9 levels had an increased risk of all-cause mortality (log-rank p = 0.017) and cardiac-cause mortality (log-rank p = 0.037) compared with lower PCSK9 quartile levels. Elevated PCSK9 levels are related to all-cause mortality and cardiac-related mortality when TyG levels are greater than the median, but not when levels are less than the median. This suggests a potential benefit of lowering circulating PCSK9 levels in STEMI patients with insulin resistance.

The recent study by Shah and colleagues, "Association of Hemoglobin Level with In-Hospital Outcomes in Patients with STEMI Treated with Primary Percutaneous Coronary Intervention," brings renewed attention to the clinical impact of anemia in patients presenting with ST-elevation myocardial infarction (STEMI) [1]. Conducted at the Hayatabad Medical Complex in Pakistan, this retrospective study highlights a compelling association: lower hemoglobin levels at presentation correlate with higher rates of major adverse cardiac events (MACE) and in-hospital mortality. These findings underscore the need to reevaluate the role of hemoglobin as a prognostic marker—and potentially, a modifiable factor—in acute cardiac care. Despite significant advances in reperfusion strategies and emergency care, STEMI remains a leading cause of morbidity and mortality worldwide [2]. Among the modifiable risk factors that often go unrecognized in this context is anemia, typically defined as a hemoglobin level below 13 g/dL in men and 12 g/dL in women [3]. Anemia is prevalent in patients with acute coronary syndromes and may exacerbate myocardial ischemia by impairing oxygen delivery to already compromised tissue [4]. In Shah et al.'s cohort, mortality ranged from approximately 4% in patients with normal hemoglobin to nearly 20% in those with severe anemia. MACE—including heart failure, arrhythmias, and cardiogenic shock—was also significantly more common among anemic individuals. Notably, the statistical analysis demonstrated that severe anemia was an independent predictor of in-hospital mortality, with the risk of death more than doubling in this group. These findings have practical implications for clinical decision-making. While early reperfusion remains the cornerstone of STEMI management, the initial evaluation should not overlook hemoglobin levels, which may offer valuable prognostic information. Current transfusion guidelines advocate for a restrictive strategy, generally recommending transfusion only when hemoglobin drops below 7–8 g/dL or when symptoms of anemia emerge. Yet this study suggests that even moderate anemia may carry prognostic weight. This raises important questions about whether clinical thresholds for intervention should be reconsidered, or at least more individualized. Rather than defaulting to transfusion—which carries its own risks—clinicians might consider broader strategies: optimizing hemodynamics, minimizing procedural blood loss, and addressing reversible causes of anemia such as iron deficiency or chronic disease. Early detection of anemia could enable timely and targeted interventions, potentially improving outcomes without relying solely on transfusion-based strategies. Nevertheless, the study has important limitations. Its retrospective nature precludes causal inference, and its single-center setting in Pakistan may limit generalizability to other healthcare systems or populations. Larger prospective, multicenter trials are needed to validate these findings and guide evidence-based protocols. Future research should explore optimal hemoglobin thresholds for intervention, the timing and volume of transfusion when warranted, and the utility of adjunctive therapies such as iron supplementation or erythropoietin. An additional opportunity lies in better understanding how anemia interacts with common STEMI comorbidities like diabetes and chronic kidney disease. These interactions may demand a more personalized approach to risk stratification and management. Beyond the clinical sphere, this study also carries public health implications. In countries where nutritional deficiencies and chronic diseases are prevalent, population-level anemia screening and prevention strategies could play a pivotal role in reducing the burden of cardiovascular events. Integrating early hemoglobin assessment into STEMI protocols and educating frontline providers on its importance could enhance both patient care and system-level efficiency. The association between anemia and poor in-hospital outcomes in STEMI patients undergoing PCI, as demonstrated by Shah et al., invites renewed attention to a potentially modifiable risk factor in acute cardiac care. Their findings reinforce the need for routine hemoglobin evaluation at presentation and support the integration of anemia management into comprehensive STEMI care pathways. As the field moves toward increasingly personalized and precise cardiovascular medicine, even modest adjustments—like addressing anemia early—could make a significant difference in patient outcomes. References Shah SK, Danish N, Akhtar S, Khalil MSUD, Ali N, Amin QNU. Association of Hemoglobin Level with In-Hospital Outcomes in Patients with STEMI Treated with Primary Percutaneous Coronary Intervention. Pak Heart J. 2025;58(02):252-7. DOI: 10.47144/phj.v58i2.2786 Vernon ST, Coffey S, D'Souza M, Chow CK, Kilian J, Hyun K, et al. ST-Segment-Elevation Myocardial Infarction (STEMI) Patients Without Standard Modifiable Cardiovascular Risk Factors-How Common Are They, and What Are Their Outcomes? J Am Heart Assoc. 2019;8(21):e013296. DOI: 10.1161/JAHA.119.01329. Prabhakar SK, Abbott JD. Factors influencing the outcomes of percutaneous coronary intervention in the stent era. Interv Cardiol. 2012;4(5):557-68. DOI:10.2217/ica.12.59 Rhodes CE, Denault D, Varacallo MA. Physiology, oxygen transport [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan– [updated 2022 Nov 14; cited 2025 Jun 5]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538336/

P5476Usefulness of haemoglobin level combined with CAMI-STEMI score for predicting MACCE in patients with acute ST-elevation myocardial infarction after PCI

Low serum albumin levels and in-hospital outcomes in patients with ST segment elevation myocardial infarction

Background: Previous studies have highlighted the impact of sex differences on the outcomes of patients admitted for ST-elevation myocardial infarction (STEMI). However, there is limited evidence as to whether there is a difference in the outcomes between females and male STEMI patients who have a concomitant diagnosis of chronic kidney disease (CKD) and end-stage renal disease (ESRD). Research Question: Does sex affect the outcomes for STEMI patients with concomitant CKD and ESRD? Methods: This is a retrospective population-based cohort study that uses the National Inpatient Sample database. CKD patients in the United States hospitalized for STEMI were identified using the International Classification of Diseases, Ninth and Tenth Revision (ICD-9 and 10) codes. Inclusion criteria were adult patients who were hospitalized from 2012 to 2020. A subset of patients with ESRD were also identified. Multivariate regression analysis was performed, with the model adjusted for age and comorbidities. The primary outcome of interest was in-hospital mortality. Secondary outcomes evaluated included ischemic stroke, major bleeding complications, pressor requirement, permanent pacemaker implantation, percutaneous coronary intervention, coronary artery bypass grafting, surgery, pericardiocentesis, mechanical circulatory support, and mechanical ventilation. Results: A total of 1,283,255 STEMI patients without CKD, 158,715 STEMI patients with CKD, and 22,690 STEMI patients with ESRD were identified and analyzed. Among patients with STEMI and CKD, females demonstrated higher in-hospital mortality compared to male counterparts (16.7% vs 12.7%, aOR=1.13, 95% CI: 1.05-1.21, p&lt;0.01). Females were also more likely to develop ischemic stroke (4.0% vs 3.0%, aOR=1.16, 95% CI: 1.01-1.34, p=0.04). While there was no sex difference in the in-hospital mortality and most secondary outcomes among STEMI patients with ESRD, female patients in this group were less likely to receive coronary artery bypass grafting (5.0% vs 8.7%, aOR=0.54, 95% CI: 0.42-0.70, p&lt;0.001) and mechanical circulatory support (12.8% vs 17.8%, aOR=0.69, 95% CI: 0.58-0.83, p&lt;0.001). Conclusion: Increased in-hospital mortality rates were shown for females admitted for STEMI with CKD. However, for STEMI patients with ESRD, there was no significant difference between males and females with respect to mortality rates. Further research needs to be conducted to better explain this said difference in outcomes.

Background: Our study aims to compare in-hospital management and outcomes in patients with cardiogenic shock due to ST-segment elevation myocardial infarction (STEMI) versus non-ST-segment elevation myocardial infarction (NSTEMI). Methods: We conducted a retrospective cohort study using the National Inpatient Sample database between 2016-2019, including patients with STEMI/NSTEMI complicated by cardiogenic shock. An inverse probability treatment weighting analysis was performed to compare in-hospital management and outcomes between patients with STEMI and NSTEMI. Adjusted relative risks (aRR) with their 95% confidence intervals (CIs) were estimated. Results: A total of 150,395 patients with cardiogenic shock due to acute myocardial infarction were included, of whom 52.8% had STEMI. The median age was 68 years (60-77) and 35% were female. Percutaneous coronary intervention, intra-aortic balloon counterpulsation, percutaneous ventricular assist device, extracorporeal membrane oxygenation, and mechanical ventilation use were significantly higher in the STEMI group compared to NSTEMI. Coronary artery bypass grafting, renal replacement therapy, length of hospital stay, and total costs were lower in the STEMI group. Pulmonary arterial catheterization and cardiac transplantation were similar between both groups. Inverse probability treatment weighting analysis showed that in-hospital mortality was significantly higher in the STEMI group compared to NSTEMI (34.2% vs. 28.8%, aRR 1.19, 95% CI 1.14-1.23) and also major bleeding. Conclusion: In conclusion, patients with cardiogenic shock due to STEMI had worse prognosis, higher use of percutaneous coronary intervention/mechanical circulatory support, and major bleeding than the NSTEMI group. In contrast, patients with NSTEMI had greater use of coronary artery bypass grafting and hospital resources.