Paradoxical care delivery for patients with diabetes mellitus presenting with non–ST-Segment elevation acute coronary syndromes: Results from the CRUSADE quality improvement initiative

Abstract

Study objectives: Patients with diabetes and presenting with acute coronary syndromes (ACS) are at increased risk of adverse cardiovascular outcomes. Methods: We evaluated 46,410 patients from 413 US hospitals presenting with non–ST-segment elevation (NSTE) ACS (positive cardiac markers or ischemic ST-segment changes) from the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines) Initiative to determine how treatment patterns and outcomes differ in patients with and without diabetes. Patients were categorized as nondiabetic (ND), non–insulin-dependent diabetic (NIDDM), and insulin-dependent diabetic (IDDM). Adherence to treatment recommendations from the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for NSTE ACS was compared among groups. Results: Diabetic patients had more signs of heart failure on presentation (ND 18% versus NIDDM 28% versus IDDM 36%) and renal insufficiency (ND 9% versus NIDDM 18% versus IDDM 32%). Although NIDDM and IDDM patients experienced more short-term death and myocardial infarction than ND patients, their rates of early catheterization and adjunctive pharmacologic therapies were lower, especially for IDDM patients (Table). Conclusion: Adherence to the ACC/AHA NSTE ACS guidelines is suboptimal in patients with diabetes. Increased use of guidelines-recommended therapies and early invasive management strategies in patients with NIDDM and IDDM may improve the outcomes of these patients.Table, abstract 236ND, % (n=31,049)NIDDM, % (n=9,773)IDDM, % (n=5,588)Adjusted OR^∗ (95% CI)Adjusted OR^† (95% CI)Acute treatmentsβ-Blocker77.878.775.31.01 (0.95–1.08)0.89 (0.83–0.96)GP IIb/IIIa inhibitor37.432.225.10.99 (0.94–1.06)0.86 (0.79–0.93)Cath <48 h49.342.431.80.98 (0.93–1.04)0.80 (0.74–0.86)PCI39.133.426.40.97 (0.92–1.02)0.87 (0.82–0.94)PCI/CABG49.745.835.80.89 (0.85–0.93)0.64 (0.60–0.68)OutcomesDeath4.45.46.81.14 (1.02–1.29)1.29 (1.12–1.49)Death/MI7.08.19.61.09 (0.99–1.19)1.16 (1.04–1.30)<b>OR,</b> Odds ratio; <b>GP,</b> glycoprotein; <b>PCI,</b> percutaneous coronary intervention; <b>CABG,</b> coronary artery bypass grafting; <b>MI,</b> myocardial infarction.∗NIDDM versus ND.†IDDM versus ND.