Yan Raymond T, Yan Andrew T, Tan Mary, McGuire Darren K, Leiter Lawrence, Fitchett David H, Lauzon Claude, Lai Kevin, Chow Chi-Ming, Langer Anatoly, Goodman Shaun G
Terrence Donnelly Heart Centre, Division of Cardiology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
Am Heart J. 2006 Oct;152(4):676-83. doi: 10.1016/j.ahj.2006.04.002.
Diabetes-related differences in treatment and clinical outcome of patients across the entire spectrum of acute coronary syndromes (ACSs) have potential clinical implications but have not been well studied.
The multicenter, prospective, Canadian ACS Registry enrolled 4578 patients hospitalized for ACS between 1999 and 2001 across 9 provinces in Canada. We compared baseline characteristics, in-hospital and post-discharge treatments, and clinical outcome of diabetic and non-diabetic patients. The impact of diabetes on use of thrombolytic therapy and coronary revascularization; and the independent association between diabetes, treatments, and diabetes-treatment interactions on outcome were examined.
Diabetic patients with ACS had more cardiovascular risk factors and higher-risk clinical presentation. They paradoxically received less evidence-based medications in-hospital, at discharge, and at 1-year. Although diabetes independently predicted higher 1-year mortality (OR 1.47, 95% CI 1.15-1.87; P = .002) after adjustment for validated prognosticators, it was also an independent predictor of not receiving thrombolytic therapy (OR 0.72, 95% CI 0.54-0.95; P = .021) and coronary revascularization (OR 0.69, 95% CI 0.59-0.82; P < .001). These underused therapies were all independently associated with reduced 1-year mortality, with no significant diabetes-related treatment-outcome heterogeneity. Importantly, diabetes remained an independent adverse prognosticator even after further adjustment for these differences in treatment.
Evidence-based therapies are underused in the contemporary management of diabetic patients with ACS, which partly explains their worse outcome. Diabetes should be considered a high-risk feature in ACS risk stratification that encourages more intensive treatments. Continued efforts to promote adherence to existing proven therapies and to develop novel treatment strategies targeting diabetes-specific cardiovascular pathophysiology are imperative to improve their adverse prognosis.
在整个急性冠状动脉综合征（ACS）范围内，患者治疗及临床结局的糖尿病相关差异具有潜在临床意义，但尚未得到充分研究。
多中心、前瞻性的加拿大ACS注册研究纳入了1999年至2001年期间在加拿大9个省份因ACS住院的4578例患者。我们比较了糖尿病患者和非糖尿病患者的基线特征、住院期间及出院后的治疗情况以及临床结局。研究了糖尿病对溶栓治疗和冠状动脉血运重建使用的影响；以及糖尿病、治疗与糖尿病 - 治疗相互作用对结局的独立关联。
患有ACS的糖尿病患者有更多心血管危险因素和更高风险的临床表现。矛盾的是，他们在住院期间、出院时及1年时接受的循证药物较少。尽管在对经过验证的预后因素进行调整后，糖尿病独立预测1年死亡率较高（OR 1.47，95%CI 1.15 - 1.87；P = 0.002），但它也是未接受溶栓治疗（OR 0.72，95%CI 0.54 - 0.95；P = 0.021）和冠状动脉血运重建（OR 0.69，95%CI 0.59 - 0.82；P < 0.001）的独立预测因素。这些未充分使用的治疗方法均与1年死亡率降低独立相关，且不存在显著的糖尿病相关治疗 - 结局异质性。重要的是，即使在对这些治疗差异进行进一步调整后，糖尿病仍然是一个独立的不良预后因素。
在当代糖尿病合并ACS患者的管理中，循证治疗未得到充分应用，这部分解释了他们较差的结局。在ACS风险分层中，糖尿病应被视为一个高危特征，鼓励进行更强化的治疗。持续努力促进对现有已证实疗法的依从性，并开发针对糖尿病特异性心血管病理生理学的新型治疗策略，对于改善其不良预后至关重要。
