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Young Researcher Contest DOES TYPE 2 DIABETES MELLITUS INFLUENCE CHARACTERS OF PATIENTS WITH ST ELEVATION MYOCARDIAL INFARCTION Tuan Ho Anh, Tien Hoang Anh Hue University Hospital... 1

Young Researcher Contest

DOES TYPE 2 DIABETES MELLITUS INFLUENCE

CHARACTERS OF PATIENTS WITH ST ELEVATION MYOCARDIAL INFARCTION

Tuan Ho Anh, Tien Hoang Anh Hue University Hospital

[1] Đại học Y Hà Nội (2012), Bài giảng bệnh học nội khoa, Tập 1, NXB Y học, Hà Nội, tr 185

[2] Kushner F.G., Hand M., smith S.C et al (2009), "2009 Focused updates: ACC/AHA guidelines for the management of patients with ST-Elevation myocardial infarction and

ACC/AHA/SCAI guidelines on percutaneous coronary intervention", Circulation 2009, Vol 120, pp 2271-2306

[1] Central Endocrinology hos;ital (2012), “Kết quả hoạt động điều tra bản đồ dịch tễ học bệnh Đái tháo đường toàn quốc năm 2012 và xây dựng bộ công cụ đánh giá mức độ

nguy cơ mắc bệnh đái tháo đường dành cho người Việt Nam”, Hội nghị khoa học về nội tiết và chuyển hóa toàn quốc lần thứ VII, tr 23

4

• The more expansive International

Diabetes Foundation (IDF) Atlas defnition—which, in addition to

fasting plasma glucose (FPG) as in the GBD study, includes oral

glucose tolerance and HbA1c tests—found that 366 million people

had diabetes in 2011 By 2030, the number of people with diabetes is expected to increase

to 522 million

522 mil/2030

6

BACKGROUND GLUCOSE LOWERING AND VASCULAR BENEFITS

of tight glycemic control

on T2DM patients:

- ACCORD

- ADVANCE

- VADT

8

?

with and without diabetes mellitus

2 Evaluate several characters that are valuable for mortality prognosis within 07 days

since hospitalization

BACKGROUND

- Diagnosed STEMI (using

Third Universal consensus

2012

- Patient profiles recorded

in hospital: on admission and 7 days thereafter

1/2015 1/2013

SUBJECTS AND METHODS

10

SUBJECTS AND METHODS

- Diagnosed DM and on treatment

- Freshly diagnosed: (ADA 2013):

+ HbA1c ≥6.5% + FPG ≥7mmol/l

+ 2hPG ≥11,1mmol/l + random PG≥11.1mmol/l + classical symptoms

1

2

3

Can’t obtain sufficient data

Got psychiatric disorders

Inconsent to participate study

EXCLUSION CRITERIA

12

• T-student : compare 2 normal-distributed variables

• Mann-Whitney: compare 2 non normal-distributed variables of 2 independent groups

• Logistic regression has been used to search for variables that have independent correlation to death occurring within 07 days since admission Variables have been chosen if p<0.2 in single

regression analysis, p < 0.05 in multivariable regression analysis

• P < 0.05 was considered significant test

Age Mean Min Max

Vinh Ngo Hang et al.(2011), Viet Nam [1] 61.99±10.20 60.00±13.43

Richman P.B et al (1999), America [2] 64.00±13.00 60.00±14.00

Pavlovic J (2013) et al., Serbia [3] 66.34±9.34 64.29±11.48

Lopez de A et al (2013), Spain [4] 67.26±13.95 71.38±11.18

[1] Ngô Hàng Vinh, Phạm Nguyễn Vinh, Phạm Hòa Bình và cs (2011), "Khảo sát các yếu tố nguy cơ tim mạch, tổn thương động mạch vành ở bệnh nhân

có tuổi bị nhồi máu cơ tim cấp, có hoặc không có đái tháo đường", Tạp chí Y học TP Hồ Chí Minh Tập 15(1), tr 200-206

[2] Richman P.B, Brogan G.X, Nashed A.N et al (1999), "Clinical characteristics of diabetic vs nondiabetic patients who "rule-in" for acute myocardial

infarction", Academic Emergency Medicine, Vol 6(7), pp 719-723

[3] Pavlovid J., Đin đic B., Pavlovic A et al (2013), "The influence of diabetes mellitus on morbidity and mortality in patients with acute myocardial

infarction in Jablanica district", Acta Medica Medianae, Vol 52(3), pp 5-11

[4] Lopez-de-Andres A., Garcia R.J., Barrera V.H et al (2014), "National trends over one decade in hospitalzation for acute myocardial infarction among

Spanish adults with type 2 diabetes: Cumulative incidence, outcomes and use of percutaneous coronary intervention", Plos one, Vol 9(1), pp 1-7

RESULTS AND DISCUSSION

chart 1 gender – specified distribution

Female Male

Total DM no DM GENERAL CHARACTERS

Binh Pham Hoa (2010): Male: 77,1% [1

Vinh Ngo Hang (2011): Male: 72,77%

[1] Phạm Hòa Bình, Nguyễn Văn Tân, Nguyễn Ngọc Tú và cs (2010), “Some comments on STEMI AMI treatment at Thong Nhat Hospital",

Tạp chí Y học TP Hồ Chí Minh Tập 14(1), tr 76-82

P > 0.05 RESULTS AND DISCUSSION

(1.07 – 1.95)

Smoking n (%) 15 (61.29) 57 (66.25) 72 (64.86) < 0.05 1.47

(0.98 – 2.17)

Pavlovíc J (2013) Richman P.B (1999)

16

RESULTS AND DISCUSSION

Vinh Ngo Hang et al (2011), HCM City medical journal, 15(1), 200-206;

Total N=111

(%) 10 (32.26) 1 (1.25) 11 (9.91) < 0.01 25.81 (3.45-193.25) < Binh P.H: 14.6%*

< Masood A 20%^

RESULTS AND DISCUSSION

*Binh Pham Hoa et al (2010) several remarks on STEMI treatment at Thong Nhat hos,14(1),76-82;

^Masood A et al (2009),”In-hospital outcome of AMI in correlation with TIMI risk score”, J Ayub Med Coll Abbottabad, Vol 21(4), 24-27; sampling selection, following up timing, treatment method

#Timmer J.R et al (2004), "Long-term, cause-specific mortality after MI in diabetes", ESC,Vol 25, 926-931

54.84%

80.00%

Timmer J.R.: EF< 40% in DM group > non DM (27% vs 15%, p=0.02) [1]

[1] Timmer J.R., Ottervangera J.P., Thomasa K et al (2004), "Long-term, cause-specific mortality after myocardial infarction in diabetes", European society of cardiology,

Vol 25, pp 926-931

18

GENERAL CHARACTERS

RESULTS AND DISCUSSION

DM Non DM

Chart 3 prevalence of DM

72.07%

27.93%

Table 4 HbA1c level of patients

RESULTS AND DISCUSSION

Author No Angina (%)

Kentsh M et al (2003), Germany (n = 18828) [1] 16.90 15.00

[1] Kentsch M., Rodemerk U., Gitt A.K et al (2003), "Angina intensity is not different in diabetic and non-diabetic patients with acute myocardial infarction", Z Kardiol.,

Vol 92(10), pp 817-824

[2] Gradišer M., Dilber D., Cmrecnjak et al (2015), "Comparison of the hospital arrival time and differences in pain quality between Diabetic and Non-Diabetic

STEMI patients", International Journal of Environmental Research and Public Health, vol 12, pp 1387-1396

CLINICAL FEATURES RESULTS AND DISCUSSION

[1] Kentsch M., Rodemerk U., Gitt A.K et al (2003), "Angina intensity is not different in diabetic and non-diabetic patients with acute myocardial infarction",Z Kardiol., Vol 92(10),

pp 817-824

[2] Richman P.B, Brogan G.X, Nashed A.N et al (1999), "Clinical characteristics of diabetic vs nondiabetic patients who "rule-in" for acute myocardial infarction",Academic

Emergency Medicine, Vol 6(7), pp 719-723

24

RESULTS AND DISCUSSION

GENERAL FEATURES

0 20 40 60 80 100

Killip I, II Killip III, IV

ĐTĐ Không ĐTĐ

Chart 2 Killip classification of study groups

Pavlovíc J [1]; Timmer J.R [2]: Killip 1 classification were more prevalent among Diabetic

[1] Pavlovid J., Đin đic B., Pavlovic A et al (2013), "The influence of diabetes mellitus on morbidity and mortality in patients with acute myocardial infarction in Jablanica district",

Acta Medica Medianae, Vol 52(3), pp 5-11

[2] Timmer J.R., Ottervangera J.P., Thomasa K et al (2004), "Long-term, cause-specific mortality after myocardial infarction in diabetes", European society of cardiology,

Vol 25, pp 926-931

RESULTS AND DISCUSSION

Chart 5 Site of myocardial infarcction on ECG

Analogous to Abass F [1], Iqbal M.J [2]

Hung Phạm Văn [3]: LAD 46.3%, RCA 35.9%

[1] Abass F., Mufti T.A., Hafizullah M et al (1999), "Effect of diabetic status on morbidity and mortality following acute myocardial infarction", Journal of Postgraduate

Medical Institute, Vol 13(1), pp 125-131

[2] Iqbal M.J., Rauf M.A., Faheem M et al (2008), "Study on ST-Segment elevation acute myocardial infarction in diabetic and non diabetic patients", Pak J Med Sci.,

Vol 24(6), pp 786-791

[3] Phạm Văn Hùng, Hồ Văn Phước, Nguyễn Quốc Việt và cs (2014), "Đánh giá kết quả chụp và can thiệp động mạch vành qua da tại bệnh viện Đà Nẵng",Tạp chí

Tim mạch học Việt Nam, Số 68, tr 117-122

26

RESULTS AND DISCUSSION

Table 6 Cardiac enzymes concentration by study groups

Quartile

Upper Quartile

CK

(U/L)

DM 1242.19 636.00 1376.59 230.00 1430.75 Non DM 1933.83 1125.5 2300.8 272.00 2512.00

CKMB

(ng/mL)

DM 63.54 26.42 88.75 6.62 79.60 Non DM 131.36 59.75 145.75 8.99 218.50

RESULTS

Table 8 correlation between clinical and laboratory factors and

death within 7 days since admission

RESULTS

Table 9 logistic regression analysis for death prediction that

occurred within 7 days since admission

Diabetes mellitus 3.46 <0.01 31.7 2.77 – 363.9 Systolic blood pressure -0.04 <0.001 0.96 0.95 – 0.98

High Killip classification

(class III, IV)

2.52 <0.05 12.4 1.16 – 132.9

30

RESULTS AND DISCUSSION

[1] The GUSTO Investigators (1993), "An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction", The New

England Journal of Medicine, Vol 329, pp 673-682

[2] The GUSTO III Investigators (1997), "A comparision of reteplase with Alteplase for acute myocardial infarction", The New England Journal ofMedicine,

Vol 337, pp 1118-1123

[3] Reynolds H.R and Hochman J.S (2008), "Cardiogenic shock: current concepts and improving outcomes", Circulation 2008, Vol 117, pp 686-697

[4] Hasdai D., Califf R.M., Thompson T.D et al (1999), "Predictors of cardiogenic shock after thrombolytic therapy for acute myocardial infarction", Journal of

the American College of Cardiology, Vol 35(1), pp 136-143

[5] Wu A.H., Parsons L., Every N.R et al (2002), "Hospital outcomes in patients presenting with congestive heart failure complicating acute myocardial

infarction: A report from the Second National Registry of Myocardial Infarction (NRMI-2)", Journal of American College of Cardiology, Vol 40(8), pp 1389-1394

RESULTS AND DISCUSSION

DISCUSSION

32

were higher than that in non Diabetic pts

• Timmer J.R et al: post STEMI mortality rates among Diabetes were

[1] Ngô Hàng Vinh, Phạm Nguyễn Vinh, Phạm Hòa Bình và cs (2011), "Khảo sát các yếu tố nguy cơ tim mạch, tổn thương động mạch vành ở bệnh nhân có tuổi bị nhồi máu

cơ tim cấp, có hoặc không có đái tháo đường", Tạp chí Y học TP Hồ Chí Minh Tập 15(1), tr 200-206

[2] Timmer J.R., Ottervangera J.P., Thomasa K et al (2004), "Long-term, cause-specific mortality after myocardial infarction in diabetes", European society of cardiology,

Vol 25, pp 926-931

RESULTS AND DISCUSSION

DISCUSSION RESULTS AND DISCUSSION

DISCUSSION

34

On average DM doubles CVD risk

Emerging risk factor collaboration

RESULTS AND DISCUSSION

DISCUSSION

- Lopez-de-Andres A.: DM patients with AMI had higher

in-hospital mortality (OR: 1.14; KTC 95%: 1.05 – 1.17) [1]

- Koo B.K.: DM patients without angina had CAD proportion

similar to that of non DM with angina [2]

- Haffner S.M.: DM patients without previous MI had high risk of

MI as non DM patients with old MI [3]

[1] Lopez-de-Andres A., Garcia R.J., Barrera V.H et al (2014), "National trends over one decade in hospitalzation for acute myocardial infarction

among Spanish adults with type 2 diabetes: Cumulative incidence, outcomes and use of percutaneous coronary intervention", Plos one, Vol 9(1),

pp 1-7

[2] Koo B.K., Kim Y.G., Park K.S et al (2013), "Asymptomatic subjects with diabetes have a comparable risk of coronary artery disease to non-diabetic

subjects presenting chest pain: a 4-year community-based prospective study", BMC Cardiovascular Disorders, Vol 13, pp 87-94

[3] Haffner S.M., Lehto S., Ronnecmaa T et al (1998), "Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects

with and without prior myocardial infarction", The New england Journal of Medicine, Vol 339(4), pp 229-234

RESULTS AND DISCUSSION

DISCUSSION

36

Glycemic continuum and Cardiovascular disease

European Heart Journal (2013) 34, 3035–3087 RESULTS AND DISCUSSION

CONCLUSION

patients with RR=1.8 (95% CI: 1.2 – 2.8)

Clinical symptoms : chest pain, dyspnea…

Do not differ between pts with and without T2DM

2

3 Severe Killip classification on admission among T2DM patients were higher than those without T2DM with RR=6 (95% CI: 1.7 – 21.8)

Low LVEF (< 40%) in T2DM patients was higher than that

in patients without T2DM with RR=2.26 (95% CI: 1.26 – 4.05)

CONCLUSIONS

Diabetes Mellitus, Systolic BP and severe Killip class (class III, IV) were

independent predictors of mortality within 07 days from admission

1

Prognostic mortality rate were with OR 31.7 (95% CI: 2.77 –

363.9) among STEMI patients with T2DM

STEMI patients with severe Killip class (class III, IV) had times higher mortality rate with OR 12.4

(95% CI: 1.16 – 132.9) than lighter Killip class

PROPOSAL

In practice, one needs to evaluate clinical features including:

- Blood pressure measurements

- Killip class

- screening diabetes mellitus

For prognostic mortality among STEMI patients

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