Zuanetti G, Latini R, Maggioni A P, Santoro L, Franzosi M G
Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy.
J Am Coll Cardiol. 1993 Dec;22(7):1788-94. doi: 10.1016/0735-1097(93)90758-s.
This study was conducted to determine the role of insulin-dependent and noninsulin-dependent diabetes in the prognosis of patients after myocardial infarction and treatment with fibrinolytic agents.
Several studies have shown that diabetic patients have a high mortality rate after acute myocardial infarction. However, the impact of diabetes on survival in patients treated with fibrinolytic agents is still undefined. It is also not known whether the type of diabetes or gender affects prognosis.
We analyzed prevalence and prognostic significance of a history of diabetes in patients enrolled in the GISSI-2 study, all of whom received fibrinolytic agents. The incidence of deaths in the hospital and at 6 months after study entry was computed for patients without diabetes and for insulin-dependent and noninsulin-dependent diabetic patients; relative risks were evaluated by univariate and multivariate analysis.
Information on diabetic status was available for 11,667 patients, 94.2% of those randomized in the GISSI-2 study. The prevalence of diabetes was higher in women than in men (8.75% vs. 1.85%, p < 0.01 for insulin-dependent and 23.7% vs. 13.8%, p < 0.01 for noninsulin-dependent diabetic patients). The type of fibrinolytic agent did not affect mortality rates; the increase in in-hospital mortality of diabetic patients was moderate and similar for men with insulin- and noninsulin-dependent diabetes (8.7% and 10.1%, respectively, vs. 5.8% in nondiabetic patients); in women, mortality was markedly higher for insulin-dependent and only slightly higher for noninsulin-dependent diabetic patients (24.0% and 15.8%, respectively, vs. 13.9% for nondiabetic patients). The adjusted relative risks were 1.9 (95% confidence interval 1.2 to 2.9) for insulin-dependent diabetic women and 1.4 (95% confidence interval 1.1 to 1.8) for noninsulin-dependent diabetic men. The mortality rate after discharge showed a similar gender difference, and in insulin-dependent diabetic women, prognosis was ominous even in the absence of left ventricular damage before discharge.
A history of diabetes is associated with a worse prognosis after myocardial infarction, even in patients treated with fibrinolytic agents. Gender and type of diabetes appear to be critical in affecting survival. In men, both insulin-dependent and noninsulin-dependent diabetes are associated with a moderately higher mortality rate; in women, insulin-dependent diabetes is, in itself, a strong risk factor for death after myocardial infarction.
本研究旨在确定胰岛素依赖型糖尿病和非胰岛素依赖型糖尿病在心肌梗死后接受纤溶药物治疗患者的预后中所起的作用。
多项研究表明，糖尿病患者急性心肌梗死后死亡率较高。然而，糖尿病对接受纤溶药物治疗患者生存的影响仍不明确。糖尿病类型或性别是否影响预后也尚不清楚。
我们分析了GISSI - 2研究中所有接受纤溶药物治疗患者的糖尿病病史的患病率及其预后意义。计算了无糖尿病患者、胰岛素依赖型糖尿病患者和非胰岛素依赖型糖尿病患者在住院期间及研究入组后6个月的死亡发生率；通过单因素和多因素分析评估相对风险。
11667例患者（占GISSI - 2研究随机分组患者的94.2%）有糖尿病状态信息。糖尿病患病率女性高于男性（胰岛素依赖型糖尿病患者中分别为8.75%和1.85%，p < 0.01；非胰岛素依赖型糖尿病患者中分别为23.7%和13.8%，p < 0.01）。纤溶药物类型不影响死亡率；糖尿病患者住院死亡率的增加幅度适中，胰岛素依赖型和非胰岛素依赖型糖尿病男性患者相似（分别为8.7%和10.1%，而非糖尿病患者为5.8%）；在女性中，胰岛素依赖型糖尿病患者死亡率显著更高，非胰岛素依赖型糖尿病患者仅略高（分别为24.0%和15.8%，而非糖尿病患者为13.9%）。胰岛素依赖型糖尿病女性的校正相对风险为1.9（95%置信区间1.2至2.9），非胰岛素依赖型糖尿病男性为1.4（95%置信区间1.1至1.8）。出院后死亡率也呈现类似的性别差异，且在胰岛素依赖型糖尿病女性中，即使出院前无左心室损害，预后也不佳。
糖尿病病史与心肌梗死后预后较差相关，即使是接受纤溶药物治疗的患者。性别和糖尿病类型似乎对生存有至关重要的影响。在男性中，胰岛素依赖型和非胰岛素依赖型糖尿病均与死亡率适度升高相关；在女性中，胰岛素依赖型糖尿病本身就是心肌梗死后死亡的一个强危险因素。
