Marso Steven P, Miller Todd, Rutherford Barry D, Gibbons Raymond J, Qureshi Mansoor, Kalynych Anna, Turco Mark, Schultheiss Heinz P, Mehran Roxana, Krucoff Mitchell W, Lansky Alexandra J, Stone Gregg W
The Mid America Heart Institute, Saint Luke's Hospital, Kansas City, Missouri, USA.
Am J Cardiol. 2007 Jul 15;100(2):206-10. doi: 10.1016/j.amjcard.2007.02.080. Epub 2007 Jun 4.
Diabetes mellitus is strongly associated with increased cardiovascular morbidity and mortality in patients with ST-segment elevation myocardial infarction. It is unknown whether myocardial perfusion is decreased in diabetic compared with nondiabetic patients after primary percutaneous coronary intervention (PCI), which may contribute to their worse prognosis. We compared myocardial perfusion and infarct sizes between diabetic and nondiabetic patients undergoing PCI for acute ST-segment elevation myocardial infarction in the EMERALD trial. EMERALD was a prospective, randomized, multicenter study evaluating distal embolic protection during primary PCI in ST-segment elevation myocardial infarction. End points included final myocardial blush grade, complete ST-segment resolution (STR) 30 minutes after PCI, and final infarct size as determined by technetium-99m single proton emission computed tomography measured between days 5 and 14. Of 501 patients, 62 (12%) had diabetes mellitus. Diabetic patients had impaired myocardial perfusion after PCI as measured by myocardial blush grade 0/1 (34% vs 16%, p = 0.002) and lower rates of complete 30-minute STR (45% vs 65%, p = 0.005). Infarct size (median 20% vs 11%, p = 0.005), development of new onset severe congestive heart failure (12% vs 4%, p = 0.016), and 30-day mortality (10% vs 1%, p <0.0001) were also greater in diabetic patients. After multivariate adjustment, diabetes remained associated with lack of complete STR and mortality at 6 months. Use of distal protection devices did not improve outcomes in diabetic or nondiabetic patients. In conclusion, in patients with ST-segment elevation myocardial infarction undergoing primary PCI, diabetes is independently associated with decreased myocardial reperfusion, larger infarct, development of congestive heart failure, and decreased survival.
糖尿病与ST段抬高型心肌梗死患者心血管发病率和死亡率增加密切相关。目前尚不清楚与非糖尿病患者相比，糖尿病患者在接受直接经皮冠状动脉介入治疗（PCI）后心肌灌注是否降低，这可能导致其预后更差。在EMERALD试验中，我们比较了接受PCI治疗急性ST段抬高型心肌梗死的糖尿病患者和非糖尿病患者之间的心肌灌注和梗死面积。EMERALD是一项前瞻性、随机、多中心研究，评估ST段抬高型心肌梗死直接PCI期间的远端栓塞保护。终点包括最终心肌 blush 分级、PCI后30分钟完全ST段回落（STR）以及通过99m锝单光子发射计算机断层扫描在第5天至第14天之间测定的最终梗死面积。在501例患者中，62例（12%）患有糖尿病。通过心肌 blush 分级0/1测量，糖尿病患者PCI后心肌灌注受损（34%对16%，p = 0.002），30分钟完全STR发生率较低（45%对65%，p = 0.005）。糖尿病患者的梗死面积（中位数20%对11%，p = 0.005）、新发严重充血性心力衰竭的发生率（12%对4%，p = 0.016）和30天死亡率（10%对1%，p <0.0001）也更高。多变量调整后，糖尿病仍与6个月时缺乏完全STR和死亡率相关。使用远端保护装置并未改善糖尿病或非糖尿病患者的预后。总之，在接受直接PCI的ST段抬高型心肌梗死患者中，糖尿病独立与心肌再灌注减少、梗死面积增大、充血性心力衰竭的发生以及生存率降低相关。
