24.09.2020

Diabetes after acute coronary syndrome

Cardiovascular diseases (CVD) remain the leading cause of mortality. According to the world health organization each year, claiming more than 17 million people. In the structure of CVD leading position continues to occupy coronary heart disease (CHD) [1]. Studies have shown that diabetes mellitus (DM) is an independent risk factor for development and progression of atherosclerosis and significantly increases the risk of development of cardiovascular events [2, 3].

In 2017, the number of patients with diabetes in the world amounted to 425 million people. According to the International diabetes Federation (International Diabetes Federation, IDF) to 2045 population of patients with diabetes may increase one and a half times and reach 629 million people [4]. According to domestic Federal register of diabetic patients at the end of 2016 in Russia was 4.35 million people, of which the number of patients with type 2 diabetes amounted to 4 million [5].

It is known that diabetes is a frequent companion of acute coronary syndrome (ACS). According to international registries of acute coronary syndrome, the proportion of patients with DM among patients with ACS varies from 22% to 34% [6]. It is common to consider diabetes as a factor that increases the risk of coronary events and death in patients with ACS [7, 8].

In patients with ACS DM worsens the prognosis, leading to increase the risk of adverse outcomes (cardiovascular mortality, myocardial infarction (MI), increases in the frequency of revascularization of the myocardium) [9, 10]. In this connection it is believed that patients with diabetes often need to undergo invasive treatment. According to major studies of the SYNTAX and FREEDOM with stable coronary artery disease and diabetes, which often revealed multivessel disease, preference should be given to coronary bypass surgery, but not percutaneous coronary intervention (PCI) or a conservative tactics [11-16].

However, most sightings prove that diabetics who undergo any type of revascularization, have the worst long-term prognosis of the postoperative period compared to patients without disorders of carbohydrate metabolism [11, 17, 18]. Hence the high importance of measures aimed at reduction of cardiovascular events and reduce mortality in patients with diabetes who have suffered an ACS, including after the invasive myocardial revascularization. These activities are carried out in the framework of the comprehensive cardiorehabilitation (CU), which is part of the long-term management of patients after ACS and myocardial revascularization and contributes to the reduction of disability and mortality in the future [19].

To date, the conventional model of the CU is a three-stage system of recovery of patients with ACS and myocardial revascularization: the first stage is stationary, the second – early third, and inpatient rehabilitation – outpatient. Currently, it requires further consideration and clarification of questions of influence of different stages of CR on outcomes in patients with diabetes who have had ACS. All this determined the aim of the study was to examine the effect of the second phase of CD on outcomes in patients with diabetes who have had ACS.

Materials and methods

Type of research – prospective, open, selective. The observation period was 12 months. The study included 115 patients with type 2 diabetes, including 44 men and 71 women, who were hospitalized in the coronary care unit with ACS over the period 2016-2017, the Diagnosis of ACS was established on the basis of complaints, anamnesis, changes in the electrocardiogram and laboratory tests (troponin).

The average age of the subjects was 63.1 ± 7.4 years, duration of diabetes of 7.9 ± 5.3 years, the level of glycated hemoglobin НbA1c and 7.6 ± 2% at the time of admission.

Exclusion criteria from the study were severe disorders of rhythm and conduction, atrial fibrillation, terminal heart failure, severe renal or liver failure and other serious somatic diseases, including autoimmune and cancer.

Management of patients with ACS was carried out in full compliance with the Federal standards and recommendations of the European society of cardiology (European Society of Cardiology, ESC) and the Russian society of cardiology.

Depending on the stages of the CD all patients were divided into two groups: group 1 (n = 52, mean age 62 ± 6.9 years) – patients who have undergone all three stages of CD; group 2 (n = 63, mean age 63,8 ± 7,7 years) – patients discharged after inpatient phase of CU from on outpatient.

Groups were comparable by basic clinical-anamnestic and laboratory parameters (table. 1).

All patients underwent coronary angiography (CAG). Significant stenosis was considered as the presence of stenosis of more than 50% of at least one coronary artery (CA). The defeat was considered multicostatum when there are two or more significant stenosis KA. Performed myocardial revascularization: PCI or coronary artery bypass grafting (CABG) is indicated.

Evaluated short-term prognosis: in-hospital mortality and the number of procedures for revascularization of the myocardium in the acute period.

Evaluated the long-term forecast: frequency of repeated revascularization of the myocardium, and death for 12 months. Contact with patients was carried out during scheduled visits and by phone.

Statistical data processing was performed using programs MS Excel, Biostat 2009. To assess the nature of normality of distribution of data we used the Shapiro–Wilkes. The data obey a normal distribution, are given as M ± SD, M is the average sample value, SD – standard deviation; to evaluate the statistical significance of intergroup differences of quantitative indicators were used bilateral student test. In the absence of normal distribution, data are presented as the median (Me) and 25th and 75th precentile; the statistical significance of intergroup differences of quantitative traits was evaluated according to the criterion U-Mann–Whitney. The statistical significance of intergroup differences in qualitative characteristics were assessed using odds ratios. Differences were considered statistically significant at values of p < 0.05.

Results and discussion

In our study of 115 patients with diabetes in 88 (76,5%) had significant lesions. 58 (66%) of them multicostata defeat. It is known that multicostata lesion is more common in patients with type 2 diabetes and patients with ACS without ST-segment elevation [20, 21]. According to A. Khalid (2012) in DM, and all types of ACS (unstable angina, ST-segment elevation, without ST-segment elevation) multicostata defeat was met in 42% of cases [21]. Results in our study were higher.

Among patients directed to the second stage of the CD, were more likely to be a significant stenosis KA according to the CAG (table. 2). Differences in the characteristics of coronary flow in the groups have been identified.

The choice of strategy Micarta revascularization in coronary artery disease in patients with diabetes, which is more common multicostata defeat, remains an area of intense discussion and debate. Most of the studies concern patients with stable coronary artery disease [22]. In a study of S. Karam (2017) in ACS on the background of diabetes, PCI was carried out at drosoulites lesions in 83% of cases in duhsasana – in 75% of cases, trehsetovom in 35% of cases, CABG was performed at drosoulites lesions in 1% of cases in duhsasana in 11% of cases and tresolution – 42% [23].

In our study, invasive tactics occurred in 55 (48%) patients subjected to PCI of these, 29 patients (53%), CABG and 26 patients (47%). Our data are consistent with the national register RECORD, where 36.8% of patients with type 2 diabetes in ACS were subjected to myocardial revascularization (PCI accounted for 44%, and for CABG 56%) (p = 0.1) [24]. However, according to the international registry GRACE [25] the frequency of myocardial revascularization in the acute phase of ACS in patients with diabetes is 68.8% (n = 2683), which is approximately 1.5 times less than in our study (p < 0.001).

On the second stage of the CU in our work, often went patients with ACS and type 2 diabetes undergoing surgical myocardial revascularization (p = 0.001), including 56% underwent surgery CABG, which accounted for 36.5% of the total number of patients to the second stage CU (tab. 3). This is fully consistent with the data of the international registry for cardiorehabilitation EuroCaReD conducted with the participation of 2095 patients from 13 countries with the most frequent reason for referral to the second phase of the CU Russian patients was surgery CABG, namely 750 of 2095 patients (35,8%) (p = 0,9) [26].

Literature data show that the introduction of integrated programmes CU in patients undergoing OKS, helps to reduce the number of recurrent coronary events and mortality [27]. In our study, when analysing patients who were or were not participating in the second stage, CU was not statistically significant differences in the frequency of surgical myocardial revascularization, and death during 12 months of observation. Data on the effect of the second phase of CD on outcomes in ACS patients with type 2 diabetes are shown in table. 4. The lack of differences in patients with ACS and type 2 diabetes in two – and three-step CU in the predictive parameters can be explained by the high frequency used in the first stage of surgical methods of myocardial revascularization in accordance with current standards of treatment [7, 8].

Insights
  1. At the first stage of cardiorehabilitation of patients with acute coronary syndrome and type 2 diabetes half of the patients subjected to surgical revasculariza that corresponds to the domestic registers of patients with ACS, but 1.5 times less than in the GRACE international registry.
  2. The management of acute coronary syndrome in patients with type 2 diabetes when performing modern standards of treatment, with the use of surgical revascularization does not cause significant differences in the prognostic parameters (frequency of death, myocardial infarction and myocardial revascularization) during 12 months of observation, patients who have undergone two – and three-step cardiac rehabilitation.

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