Norhammar Anna, Malmberg Klas, Diderholm Erik, Lagerqvist Bo, Lindahl Bertil, Rydén Lars, Wallentin Lars
Department of Cardiology, Karolinska Hospital, Stockholm, Sweden.
J Am Coll Cardiol. 2004 Feb 18;43(4):585-91. doi: 10.1016/j.jacc.2003.08.050.
This study was designed to study the influence of diabetes on the outcome of unstable coronary artery disease (CAD).
Diabetes mellitus is a major contributor to CAD. Despite improvement in the management of patients with unstable coronary syndromes, this condition is still linked to a substantially increased mortality and morbidity among diabetic patients. Recent evidence advocates early revascularization in unstable coronary syndromes. Diabetic patients subjected to coronary interventions under stable conditions have a higher risk for complications and a more dismal prognosis than nondiabetic subjects. Accordingly, it is of considerable interest to obtain further information regarding the best possible management of diabetic patients with unstable CAD.
A total of 2158 patients without and 299 with diabetes mellitus were randomized to an early invasive or a noninvasive strategy. The severity of CAD was expressed as the number and extent of vessel involvement.
Three-vessel disease was diagnosed in 42% of diabetic and 31% of nondiabetic patients (p = 0.006). The percentages of patients with ST-depression and troponin-T >0.03 microg/l at admission were comparable among diabetic and nondiabetic patients. Mortality and reinfarction after 12 months were more frequent among diabetic than nondiabetic patients in both treatment groups. Diabetes remained a strong independent predictor for death and myocardial infarction in multivariable analysis. The invasive strategy reduced event rate in nondiabetic patients from 12.0% to 8.9% (odds ratio [OR] = 0.72; confidence interval [CI] 0.54 to 0.95; p = 0.019) and in diabetic patients from 29.9% to 20.6% (OR 0.61; CI 0.36 to 1.04; p = 0.066). In a multivariate analysis including the extent of CAD, diabetes remained a strong independent predictor of the combined end point (relative risk [RR] 2.40; CI 1.47 to 3.91; p = 0.0001) and of mortality (RR 5.43; CI 2.09 to 14.12; p = 0.001).
An invasive strategy improved outcome for both diabetic and nondiabetic patients with unstable CAD. However, diabetes mellitus remained an independent and important risk factor for death and myocardial infarction in the invasive group. Thus, factors beyond the extent of flow-limiting coronary lesions are of considerable importance for outcome in diabetic subjects with unstable coronary syndromes.
本研究旨在探讨糖尿病对不稳定型冠状动脉疾病（CAD）预后的影响。
糖尿病是CAD的主要促成因素。尽管不稳定型冠状动脉综合征患者的管理有所改善，但这种情况在糖尿病患者中仍与死亡率和发病率的大幅增加相关。最近的证据支持在不稳定型冠状动脉综合征中尽早进行血运重建。与非糖尿病患者相比，在稳定条件下接受冠状动脉介入治疗的糖尿病患者发生并发症的风险更高，预后更差。因此，获取有关不稳定型CAD糖尿病患者最佳管理的更多信息具有重要意义。
将2158例非糖尿病患者和299例糖尿病患者随机分为早期侵入性策略组或非侵入性策略组。CAD的严重程度用血管受累的数量和范围表示。
42%的糖尿病患者和31%的非糖尿病患者被诊断为三支血管病变（p = 0.006）。糖尿病患者和非糖尿病患者入院时ST段压低和肌钙蛋白-T>0.03μg/l的患者百分比相当。在两个治疗组中，糖尿病患者12个月后的死亡率和再梗死发生率均高于非糖尿病患者。在多变量分析中，糖尿病仍然是死亡和心肌梗死的强有力独立预测因素。侵入性策略使非糖尿病患者的事件发生率从12.0%降至8.9%（优势比[OR]=0.72；置信区间[CI]0.54至0.95；p = 0.019），糖尿病患者从29.9%降至20.6%（OR 0.61；CI 0.36至1.04；p = 0.066）。在包括CAD范围的多变量分析中，糖尿病仍然是联合终点（相对风险[RR]2.40；CI 1.47至3.91；p = 0.0001）和死亡率（RR 5.43；CI 2.09至14.12；p = 0.001）的强有力独立预测因素。
侵入性策略改善了不稳定型CAD糖尿病患者和非糖尿病患者的预后。然而，糖尿病在侵入性治疗组中仍然是死亡和心肌梗死的独立且重要的危险因素。因此，除了限流性冠状动脉病变范围之外的因素对不稳定型冠状动脉综合征糖尿病患者的预后也非常重要。
