1 Translational Laboratory for Cardiovascular Imaging and Therapy, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Spain.
2 CIBER de Enfermedades CardioVasculares, Spain.
Eur Heart J Acute Cardiovasc Care. 2019 Apr;8(3):231-241. doi: 10.1177/2048872618803701. Epub 2018 Sep 27.
Diabetes is associated with poor cardiovascular outcomes, and insulin-treated patients usually have a worse prognosis than non-insulin-treated subjects. The relationship between insulin treatment and outcomes in high-risk myocardial infarction patients has not been described in a large dataset.
To investigate the association between insulin-treated diabetes and long-term cardiovascular outcomes in patients with high-risk myocardial infarction, we used adjusted Cox models to compare cardiovascular mortality and hospitalisation among 28,771 patients grouped by diabetes status and insulin treatment from four randomised clinical trials (VALIANT, EPHESUS, OPTIMAAL, CAPRICORN) of acute myocardial infarction complicated by heart failure and/or left ventricular systolic dysfunction.
After an approximately 2-year follow-up, patients with no diabetes (21,386 subjects, 74.3%), non-insulin-treated diabetes (4977 patients, 17.3%) and insulin-treated diabetes (2409 subjects, 8.4%) had an incremental yearly mortality risk (15.8%, 21.3% and 28.1%, respectively). Insulin-treated diabetes patients presented with a higher cardiovascular burden and comorbidities. After adjustment for 18 baseline covariates, patients with non-insulin-treated and insulin-treated diabetes were at higher risk of cardiovascular death (hazard ratio (HR) 1.25, 95% confidence interval (CI) 1.13-1.38 and HR 1.49, 95% CI 1.31-1.69, respectively; P for comparison of non-insulin-treated vs. insulin-treated diabetes =0.016) and cardiovascular hospitalisation (HR 1.33, 95% CI 1.25-1.41 and HR 1.16, 95% CI 1.11-1.22, respectively) compared to patients without diabetes. These results remained consistent after further adjustment for medications and left ventricular ejection fraction.
Insulin-treated diabetes patients had higher event rates than diabetes patients taking oral treatments and patients without diabetes. However, insulin-treated diabetes patients had more comorbidities and atherosclerotic disease, precluding any causality suggestion between insulin treatment and outcomes. This high-risk population may require specific and/or more intense cardiovascular protective therapies.
糖尿病与心血管不良结局相关，且接受胰岛素治疗的患者通常预后较未接受胰岛素治疗的患者差。在大型数据集中心肌梗死高危患者中，胰岛素治疗与结局的关系尚未得到描述。
为了研究高风险心肌梗死患者中胰岛素治疗糖尿病与长期心血管结局的关系，我们使用校正的 Cox 模型比较了 4 项随机临床试验（VALIANT、EPHESUS、OPTIMAL、CAPRICORN）中因心力衰竭和/或左心室收缩功能障碍而并发急性心肌梗死后，根据糖尿病状态和胰岛素治疗将 28771 例患者分为两组的心血管死亡率和住院率：无糖尿病（21386 例，74.3%）、未接受胰岛素治疗的糖尿病（4977 例，17.3%）和接受胰岛素治疗的糖尿病（2409 例，8.4%）。
大约 2 年的随访后，无糖尿病（21386 例，74.3%）、未接受胰岛素治疗的糖尿病（4977 例，17.3%）和接受胰岛素治疗的糖尿病（2409 例，8.4%）患者的年死亡率分别为 15.8%、21.3%和 28.1%。接受胰岛素治疗的糖尿病患者心血管负担和合并症更高。在调整了 18 项基线协变量后，未接受胰岛素治疗的糖尿病和接受胰岛素治疗的糖尿病患者的心血管死亡风险更高（风险比（HR）分别为 1.25、95%置信区间（CI）为 1.13-1.38 和 HR 为 1.49、95%CI 为 1.31-1.69；非胰岛素治疗组与胰岛素治疗组相比，P=0.016）和心血管住院（HR 分别为 1.33、95%CI 为 1.25-1.41 和 HR 为 1.16、95%CI 为 1.11-1.22）。在进一步调整药物和左心室射血分数后，这些结果仍然一致。
与接受口服治疗的糖尿病患者和无糖尿病患者相比，接受胰岛素治疗的糖尿病患者的事件发生率更高。然而，接受胰岛素治疗的糖尿病患者有更多的合并症和动脉粥样硬化疾病，排除了胰岛素治疗与结局之间的任何因果关系。这种高危人群可能需要特定的和/或更强化的心血管保护治疗。
