‘Stark disparities’ exist in non-STEMI management for adults with vs. without diabetes
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Key takeaways:
- Patients with diabetes had greater mortality risk up to 10 years after hospitalization for MI compared with those without diabetes.
- High-quality inpatient care was associated with lower mortality risk.
Individuals with diabetes who were hospitalized for non-ST elevation myocardial infarction had significantly higher risk for long-term mortality compared with individuals without diabetes, according to new research.
However, the study, published in Diabetologia, also showed higher-quality inpatient care reduced mortality risk across all patients with diabetes.
Diabetes is a well-established risk factor for acute MI and non-STEMI. Recent smaller studies suggest that novel interventions for the treatment of diabetes may have decreased acute MI mortality risk in this population, but larger-scale long-term studies have yet to confirm this.
Moreover, “there has been emerging evidence within the literature that these mortality trends may not just be directly caused by the pathophysiology of diabetes on coronary artery disease but rather a reflection of suboptimal care during their inpatient stay,” Andrew Cole, BSc, MRCP, National Institute for Health and Care Research academic clinical fellow in cardiology at the SpR Keele Cardiovascular Research Group at Keele University in Staffordshire, U.K., told Healio.
Researchers performed a nationwide cohort study to assess how diabetes status impacts mortality risk after hospital care for non-STEMI, as well as the quality of hospital care these patients received.
Using data from the Myocardial Ischaemia National Audit Project (MINAP) registry and the Office for National Statistics, the researchers evaluated outcomes for 456,376 adults who were hospitalized in the U.K. for non-STEMI between 2005 and March 2019. Of them, 112,576 (25%) had diabetes.
The primary endpoint of all-cause mortality was measured at 30 days, 1 year, 5 years and 10 years from hospital admittance. Researchers assessed quality of inpatient care using the opportunity-based quality indicator (OBQI) score, which considers the inpatient prescription of specific therapies and referral to cardiac rehabilitation at discharge to determine a score of poor, fair, good or excellent.
Mean follow-up was 1,976 days (standard deviation, 1,560 days).
The most common method of diabetes management in the cohort included oral hypoglycemic medication (52%), followed by insulin (30%) and diet (17%).
Researchers noted that participants with diabetes were older compared with participants without diabetes (median age, 74 years vs. 73 years) and were more likely to be Asian (13% vs. 4%) or Black (2% vs. 1%) but less likely to have undergone revascularization (38% vs. 40%).
“Individuals with diabetes presented, in general, with more adverse features of non-STEMI including pulmonary edema. They would therefore be less likely to tolerate angiography,” Cole told Healio.
The researchers found that, compared with patients without diabetes, patients with diabetes were less likely to receive an invasive coronary angiography within 72 hours (57% vs. 66%, P < .001) but more likely to be started on angiotensin-converting enzyme inhibitors (81% vs. 77%, P < .001) and beta-blockers (77% vs. 74%, P < .001) for moderate to severe left ventricular systolic dysfunction. Overall, patients with diabetes had a greater mean OBQI score (81.5 vs. 79.2; P < .001) compared with patients without diabetes.
Concerning the primary endpoint, Cole and colleagues found that participants with diabetes had a greater unadjusted mortality rate at all time points compared with participants without diabetes, including at 30 days (9% vs. 7%), 1 year (23% vs. 18%), 5 years (52% vs. 38%) and 10 years (73% vs. 56%; P for all < .001).
This association persisted in the multivariate model, which was adjusted for age, sex, ethnicity and comorbid conditions such as hypertension, with patients with diabetes at increased mortality risk at all timepoints compared with patients without diabetes (30 days: HR = 1.19; 95% CI, 1.15-1.23; 1 year: HR = 1.28; 95% CI, 1.26-1.31; 5 years: HR = 1.36; 95% CI, 1.34-1.38; 10 years: HR = 1.39; 95% CI, 1.36-1.42).
Subgroup analyses that compared different diabetes management groups, including diet-treated, tablet-treated and insulin-treated patients, showed that the insulin-treated group had the greatest risk for long-term mortality.
Finally, the researchers found that among patients with diabetes, those who received “good” (HR = 0.74; 95% CI, 0.73-0.76) and “excellent” (HR = 0.69; 95% CI, 0.68-0.71) inpatient care had lower mortality rates compared with those who received “poor” care (P for both < .001).
Specifically, among patients with diabetes, those who treated their diabetes with diet (HR = 0.64; 95% CI, 0.61-0.68) and insulin (HR = 0.69; 95% CI, 0.66-0.72) and received “excellent” hospital care had the lowest mortality rates compared with those who received “poor” care.
The researchers noted several limitations to this study, including a lack of external validation of data inputted into the MINAP registry and their inability to determine GLP-1 receptor agonist use among individuals in the cohort.
Overall, the researchers said this study reveals “stark disparities” in the management of MI among patients with diabetes.
“We believe this article highlights the importance for clinicians to provide the best possible care to individuals with diabetes hospitalized with NSTEMI,” Cold told Healio. “We show that within this cohort excellent inpatient care, including adherence to local guideline-directed medical therapy and timely angioplasty, can significantly improve their longer-term mortality outcomes.”
For more information:
Andrew Cole, BSc, MRCP, can be reached at andrew.cole165@gmail.com; X (Twitter), @DrAndrewCole.
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