|Year : 2020 | Volume
| Issue : 2 | Page : 148-152
Does angiographic profile and outcome of diabetic patients among Asian Indians correlate with presenting glycated hemoglobin during acute ST-elevation myocardial infarction? DECIPHER study
Vishal Sharma1, Kamal Sharma1, Zeeshan Mansuri1, Sharad Jain1, Sanjeev Bhatia1, Krutika Patel2
1 Department of Cardiology, U. N. Mehta Institute of Cardiology and Research Centre, Civil Hospital Campus, Ahmedabad, Gujarat, India
2 Department of Research, U. N. Mehta Institute of Cardiology and Research Centre, Civil Hospital Campus, Ahmedabad, Gujarat, India
|Date of Submission||29-Jun-2020|
|Date of Decision||21-Apr-2020|
|Date of Acceptance||21-Apr-2020|
|Date of Web Publication||27-Aug-2020|
Dr. Kamal Sharma
Department of Cardiology, U. N. Mehta Institute of Cardiology and Research Centre, Civil Hospital Campus, Asarwa, Ahmedabad - 380 016, Gujarat
Source of Support: None, Conflict of Interest: None
Background: The risk of myocardial infarction (MI) is high in patients with diabetes mellitus. The study aimed to evaluate the risk factors focusing on presenting glycated hemoglobin (HBA1C) and the angiographic profile of diabetic patients with ST elevation myocardial infarction (STEMI) and in-hospital 3-point major adverse cardiac event (MACE). Materials and Methods: Two hundred consecutive diabetic patients presenting with STEMI were enrolled for prospective observational study. Each patient underwent investigations including HbA1C, electrocardiogram, echocardiography, and coronary angiography with SYNTAX 1 SCORE (SS1) with intent to early revascularization. Continuous variables were compared using the unpaired Student's t-test. A receiver operator characteristic analysis was performed to determine a cutoff point for HbA1c value for predicting disease severity and prognosticate in-hospital 3-point MACE using multivariate analysis after normalizing the confounders. Results: Of the total 200 patients, 70 (35%) had single-vessel disease, 58 (29%) had the double-vessel disease, while 72 (36%) had triple-vessel disease. Among these patients, left main coronary artery was involved in 22 (11%) of patients. Hypertension (73.8% vs. 60%), obesity (35.4% vs. 18.4%), and left ventricular (LV) dysfunction (13.7% vs. 2.9%) were risk factors associated with disease severity with an odds ratio of 1.88 (95% confidence interval [CI]: 1.01–3.49; P = 0.04), 2.4 (95% CI: 1.19–4.84; P = 0.01), and 5.46 (95% CI: 1.23–24.29; P = 0.03), respectively. Receiver operating characteristic analysis of HbA1c with respect to 3P-MACE of in-hospital death, recurrent MI, and CV stroke revealed HBA1C <8.9 g% as cutoff for lower MACE as compared to those with >8.9 g% (95% CI: 0.66–0.79; P = 0.0004) with 65% sensitivity and 76.7% specificity. HbA1c >7.9 g% were more likely to have multivessel disease and SS1 >33. Patients with surgical site infection >33 were more likely to be hypertensive and had severe LV dysfunction and higher 3P MACE. Conclusion: Diabetic Asian Indian patients with STEMI with HbA1c >7.9 g% were more likely to have a multivessel disease and SYNTAX 1 Score >33. There was a significant association between presenting HbA1c >7.9 g% and disease severity and higher 3-P MACE among presenting with HbA1c >8.9 g%.
Keywords: Glycated hemoglobin A, major adverse cardiac event, ST-elevation myocardial infarction, SYNTAX score
|How to cite this article:|
Sharma V, Sharma K, Mansuri Z, Jain S, Bhatia S, Patel K. Does angiographic profile and outcome of diabetic patients among Asian Indians correlate with presenting glycated hemoglobin during acute ST-elevation myocardial infarction? DECIPHER study. J Pract Cardiovasc Sci 2020;6:148-52
|How to cite this URL:|
Sharma V, Sharma K, Mansuri Z, Jain S, Bhatia S, Patel K. Does angiographic profile and outcome of diabetic patients among Asian Indians correlate with presenting glycated hemoglobin during acute ST-elevation myocardial infarction? DECIPHER study. J Pract Cardiovasc Sci [serial online] 2020 [cited 2020 Oct 31];6:148-52. Available from: https://www.j-pcs.org/text.asp?2020/6/2/148/293594
| Introduction|| |
Patients with both clinical cardiovascular disease and diabetes are classified as extreme-risk groups for ST-segment elevation myocardial infarction (STEMI) and non-STEMI in the latest guidelines published by the American Association of Clinical Endocrinologists and the American College of Endocrinology. The Indian Council of Medical Research India Diabetes Study showed that India had 62.4 million people with diabetes in 2011. These numbers are projected to increase to 101.2 million by 2030.
According to the world diabetes Atlas More Details, India has the second-highest prevalence of diabetes among adults at 9.1% in the southeast Asian region, and the newly diagnosed diabetic was very high (35%) in western India. However, among Asian Indians, information is lacking regarding presenting glycated hemoglobin (HbA1C) of patients with STEMI and its potential prognostic impact on the in-hospital outcomes of these patients and its correlation if any with an angiographic profile.
Involvement of left main coronary artery is significantly high and severity of stenosis, and total occlusion of vessels is more commonly seen in diabetic patients. Although the incidence of triple-vessel or multivessel disease is significantly higher with the duration of diabetes. Patients with poor glycemic control with elevated levels of HbA1c had a diffuse pattern of atherosclerotic disease and high levels of HbA1c correlated with patients undergoing coronary artery bypass (CABG) in some studies., In this study, we aim to analyze the angiographic profile of diabetic patients presenting with STEMI and try to find cutoff if any for prognostic value for in-hospital 3-P major adverse cardiac event (MACE) and disease severity of presenting HBA1C.
| Materials and Methods|| |
A total of 200 consecutive Asian Indian diabetic patients who presented with STEMI were enrolled in this single-center, prospective, observational study conducted at a tertiary care cardiac hospital between periods of November 2015 to March 2017. The study was approved by the institutional ethics committee. The meeting was conducted on the date of March 24, 2015, with reference number UNMICRC/CARDIO/2015/64.
Patients who were known case of diabetes mellitus (DM) on treatment and had newly diagnosed ST-elevation myocardial infarction (MI) <48 h of duration were included in this study. Written inform consent was a must for inclusion in this study. Patients who had congenital heart disease, valvular abnormalities or sub-aortic stenosis, and myocarditis were excluded from the study.
Apart from demographics, each patient underwent investigations, including HbA1c, electrocardiogram, echocardiography, and color Doppler study and coronary angiography with SYNTAX 1 SCORE (SS1). Coronary angiography was performed according to the standard protocols with intent to revascularization. Seventy percent or more of diameter stenosis in any major coronary artery or its major branch (>2.5 mm) was considered as significant. The same sitting percutaneous transluminal coronary angioplasty (PTCA) was performed whenever necessary for culprit-vessel revascularization.
All statistical analyses were performed using SPSS (Statistical Program for Social Sciences) version 20.0 (Chicago, IL, USA). Continuous variables were reported as mean ± standard deviation. Categorical variables were expressed as numbers and percentages. Continuous variables were compared using the unpaired Student's t-test or one-way analysis of variance. A receiver operator characteristic analysis was performed to determine a cutoff point for HbA1c value for predicting disease severity and prognosis in-hospital 3-point MACE using multivariate analysis after normalizing the confounds. The cutoff value of P < 0.05 was considered for the statistical significance. Whenever appropriate, 95% confidence intervals (CIs) were calculated.
| Results|| |
Among 200 patients, 108 (54%) males and 92 (42%) females, 144 (72%) presented with typical angina, whereas 24 (12%) presented with dyspnea and 32 (16%) presented with other symptoms, namely giddiness, nausea, vomiting, and perspiration. Hypertension, history of coronary artery disease (CAD), and tobacco intake were the more prevalent risk factors. Hypertension was the most common risk factor found in 138 (69%) patients, Tobacco intake was found in 64 (32%) and history of CAD in 42 (21%) patients. One hundred and thirty-eight (69%) patients were on anti-hypertensive drugs, 82 (41%) patients were on angiotensin-converting enzyme inhibitors, and 42 (21%) was on anti-platelet and statins both. One hundred and twelve (56%) patients were on oral hypoglycemic agents, 40 (20%) patients were on insulin, while 48 (24%) patients were on both insulin and oral hypoglycemic. One hundred and twenty-two (61%) had an anterior wall myocardial infarction (AWMI), while 78 (39%) patients had an inferior wall myocardial infarction (IWMI).
Of total 200 patients, 130 diabetic patients had multivessel disease, 72 (55.4%) were male, while 58 (44.6%) were female. One hundred (55.4%) patients were more than 50 years of age. There was a trend for increased disease severity (as defined by SYNTAX 1 score >33) amongst males and age >50 years, though this was not statistically significant probably due to small sample size. The presence of risk factors hypertension (73.8% vs. 60%), obesity (35.4% vs. 18.4%), and severe left ventricular (LV) dysfunction (13.7% vs. 2.9%) was statistically significant for disease severity (SYNTAX 1 score >33) with odds ratio of 1.88 (95% CI: 1.01–3.49; P = 0.04), 2.4 (95% CI: 1.19–4.84; P = 0.01), and 5.46 (95% CI: 1.23–24.29; P = 0.03), respectively, as shown in [Table 1].
|Table 1: Risk factors associated with disease severity between syntax 1 score <33 and >33|
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A receiver operating characteristic (ROC) analysis was performed after normalizing the confounds to determine a cutoff for HbA1c value for predicting disease severity as assessed by SYNTAX 1 Score >33 as compared to those with SS1 <33 and yielded a value of HbA1c >7.9 g% with 85.4% sensitivity and 75.7% specificity (95% CI: 0.749–0.862 P < 0.0001) shows in [Figure 1]. One hundred and twenty-eight patients had HbA1c >7.9 g% and 72 patients had <7.9 g%. There was a significant association between high HBA1C (>7.9 g %) with disease severity (SYNTAX 1 Score >33), as shown in [Table 2]. ROC analysis of HbA1c with respect to 3P-MACE of in-hospital death, recurrent MI, and CV stroke revealed HBA1C <8.9 g% (n = 180) as cutoff for lower MACE as compared to those with >8.9 g% (n = 20) with 65% sensitivity and 76.7% specificity (95% CI: 0.66–0.79; P = 0.0004) shows in [Figure 2].
|Figure 1: Receiver operating characteristic curve (ROC) showed patients with >7.9 gm% of HbA1c was significantly associated with disease severity.|
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|Table 2: Risk factors associated with presenting glycated hemoglobin <7.9 and >7.9 mg%|
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|Figure 2: ROC curve showed patients with >8.9 gm% of HbA1c was significantly associated with 3P-MAC.|
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We also analyzed for correlation, if any, between HbA1c (<7.9 mg% and >7.9 mg%) and traditional risk factors, as shown in [Table 2]. Hypertension (74.2% vs. 59.7% and 75.6% vs 57.5%) and 3-P MACE (14.1% vs. 2.8% and 14.2% vs. 2.7%) with an odds ratio of 1.94 (95% CI: 1.05–3.59; P = 0.03) and 5.73 (95% CI: 1.29–25.45; P = 0.02) were higher in patients with HbA1c >7.9 mg% group. We also analyzed the duration of diabetes (<5 years and >5 years) and its impact on the angiographic profile and MACE. The mean duration of DM-II was 6.68 ± 3.39 years. Hypertension and 3P MACE had an odds ratio of 2.29 (95% CI: 1.23–4.23; P = 0.009) and 5.72 (95% CI: 1.29–25.45; P = 0.02), respectively, for patients with DM-II duration more than 5 years, as shown in [Table 3]. The single-vessel disease (SVD) was more common in a shorter duration of diabetes (<5 years) and triple vessel disease (TVD) was more common in longer duration (>5 years). Logistic linear regression analysis showed that duration of diabetes > 5 years and HbA1C >7.9 mg% both are associated with 3-P MACE.
Of 200, 16 (8%) patients had <30% ejection fraction (EF) (severe left ventricle dysfunction [LVD]), 123 (61.5%) had moderate LV dysfunction LVEF (30%–50%), and 61 (30.5%) had >50% with normal EF. Severe LV dysfunction statistically significant in patients with SS 1 >33 (P = 0.03) but did not correlate with HbA1c (P = 0.89) or duration of DM-II (P = 0.21). The same may be due to the smaller sample size in our study. Of 122 (61%) patients diagnosed with AWMI in 12 (9.8%) had severe LVD. Seventy-eight (39%) patient were IWMI, with 4 (5.1%) patients had Severe LVD.
As shown in [Table 4], there was no significant difference between those with HBA1C <7.9 mg % versus those with HBA1C >7.9 mg% with regard to the occurrence of anterior or IWMI. However, those with higher HBA1C >7.9 mg% were more likely to have higher 3P MACE, CABG as a mode of revascularization as compared to percutaneous coronary intervention (PCI) and had a longer duration of DM of 8.31 ± 2.63 years as compared to 3.78 ± 2.54 if HBA1C was <7.9 mg% (P < 0.0001).
| Discussion|| |
Asian Indians have one of the highest incidences of heart disease in the world. The disease also tends to be more aggressive and manifests at a younger age. However, the present study shows the mean age of presentation was 57.1 ± 9.1 years with the maximum number of patients 96 (48%) in 50–60 years of age group, while the mean age at CREATE study was 57.5 ± 12.1 years.
DM is well known to have an adverse influence on the prognosis of patients with acute MI. The presence of hypertension, obesity, and severe LV dysfunction was statistically significant for disease severity. Granger et al. and Meisinger et al.'s studies also show similar findings in our study., Body mass index (BMI) of 29.5% patients in this study population was above (30 kg/m2). Diercks et al.'s study found that most (30%) of the CRUSADE patients were classified as obese (obesity BMI ≥30.0).
Hypertension was found in 69% of patients of our study population, while smokers were 21% of the patients. In our study, dyslipidemia, as a risk factor, was found in 55% of the patients, whereas in the CREATE study, it was found that 37.7% were hypertensive, 40.2% were smokers, and 37.7% had dyslipidemia.
Suixty-one percent STEMI patients had AWMI, while 39% of STEMI patients had an IWMI, whereas in a study done by Meisinger et al., 56% of the patients had an anterior wall STEMI. Our angiographic findings show that of the total 200 diabetic patients, 35% had SVD, 29% patients had double-vessel disease, while 36% patients had TVD, which was comparable to study done by Gui et al. who found that diabetic patients had SVD (28.8%) less frequent and with a higher prevalence of TVD (35.2%).
DM remains an independent predictor of adverse outcomes after PCI or CABG. In the present study, 64% of the patients underwent PTCA, while 36% of the patients underwent CABG. HbA1c reflects the metabolic and glycemic control over the last few weeks. A study done by Mani et al. showed that 96.2% TVD had values of HbA1c >7 g% with a statistically significant difference between the clinical presentation, complications, and disease severity in diabetic patients with STEMI. The present study showed a strong correlation between a higher HbA1c (>7.9 g%) and a higher SYNTAX 1 Score on the angiographic profile as well as a worse 3P MACE (>8.9 g%) even after normalizing for the confounders.
3P-MACE in the form of death, recurrent MI, and stroke occurred in 20 (10%) patients with a multivessel disease which was statistically significant; similar to results observed in a smaller randomized trial of Veterans (Veterans Affairs Coronary Artery Revascularization in Diabetes Study) with diabetes and multivessel CAD. Diabetic patients with high HbA1c values indicate poorer glycemic control just prior to their infarction. A recent study done by Russel et al. had suggested an elevated admission glucose level (sugar >8.5 mmol) predicted in-hospital mortality with not very strong predictability. Our study suggests that 3-P MACE is higher in the subgroup with HbA1c >8.9 g% (95% CI: 0.66–0.79; P = 0.0004), with 65% sensitivity and 76.7% specificity. This probably reflects a stronger association of HBA1C with MACE rather than just presenting blood sugar levels.
To the best of our knowledge, this is the first ever study among Asian Indians to identify presenting HBA1C cutoffs to predict outcomes and lesion complexity amongst diabetics presenting with acute coronary syndrome (ACS).
| Conclusion|| |
In our study, diabetic Asian Indian patients with STEMI with HbA1c >7.9 g% were more likely to have multivessel disease. There was a significant association between presenting HbA1c >7.9 g% and disease severity as defined by SYNTAX 1 score >33. Higher 3-P MACE, which was composite of death, recurrent MI, and stroke was higher with HbA1c >8.9 g%.
A possible hypothesis is that HBA1c may be elevated in ACS without established diabetes, and hence, its elevation as an inflammatory marker remains a possibility. We have not analyzed other inflammatory markers in the study, and hence, the results may be confounded for the impact of ACS on HBA1C, if any.
The authors are grateful to the Director, Dr. R. K. Patel, and other interventional cardiologist authors for their valuable support in the completion of this project.
The study has been approved by the institutional ethics committee (UNMICRC/CARDIO/2015/64) and has been performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.
Financial support and sponsorship
This work was supported by the U. N. Mehta Institute of Cardiology and Research Centre itself and received no specific grant from any funding agency, commercial sector, or not-for-profit sector.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, et al
. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The etTask Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2018;39:119-77.
Anjana RM, Pradeepa R, Deepa M, Datta M, Sudha V, Unnikrishnan R, et al
. Prevalence of diabetes and prediabetes (impaired fasting glucose and/or impaired glucose tolerance) in urban and rural India: Phase I results of the Indian Council of Medical Research-INdia DIABetes (ICMR-INDIAB) study. Diabetologia 2011;54:3022-7.
Atlas D. IDF Diabetes Atlas. 7th
ed. Brussels, Belgium: Diabetes Res Clin Pract, International Diabetes Federation; 2015.
Singh PS, Sharma H, Zafar KS, Singh PK, Yadav SK, Gautam RK, et al
. Prevalence of type 2 diabetes mellitus in rural population of India-a study from Western Uttar Pradesh. Int J Res Med Sci 2017;5:1363-7.
Farkouh ME, Domanski M, Sleeper LA, Siami FS, Dangas G, Mack M, et al
. Strategies for multivessel revascularization in patients with diabetes. N
Engl J Med 2012;367:2375-84.
Verhagen SN, Wassink AM, van der Graaf Y, Gorter PM, Visseren FL; SMART Study Group. Insulin resistance increases the occurrence of new cardiovascular events in patients with manifest arterial disease without known diabetes. The SMART study. Cardiovasc Diabetol 2011;10:100.
Malthesh MK, Sakib TM, Mallesh P. Coronary artery involvement in diabetic and non-diabetic patients with acute coronary syndrome. Int J Sci Study 2016;3:295-8.
Zheng J, Cheng J, Wang T, Zhang Q, Xiao X. Does HbA1c level have clinical implications in diabetic patients undergoing coronary artery bypass grafting? A systematic review and meta-analysis. Int J Endocrinol 2017;1-8.
Sharma R, Bhairappa S, Prasad SR, Manjunath CN. Clinical characteristics, angiographic profile and in hospital mortality in acute coronary syndrome patients in South Indian population. Heart India 2014;2:65.
Xavier D, Pais P, Devereaux PJ, Xie C, Prabhakaran D, Reddy KS, et al
. Treatment and outcomes of acute coronary syndromes in India (CREATE): A prospective analysis of registry data. Lancet 2008;371:1435-42.
Ahmed M, Rubaiyat KA, Saleh MA, Chowdhury AW, Khuda CK, Ferdous KA, et al
. Clinical characteristics and angiographic profile of acute coronary syndrome patients in a tertiary hospital of Bangladesh. Bangladesh Heart J 2018;33:10-5.
Granger CB, Califf RM, Young S, Candela R, Samara J, Worley S, et al
. Outcome of patients with diabetes mellitus and acute myocardial infarction treated with thrombolytic agents. J Am Coll Cardiol 1993;21:920-5.
Meisinger C, Heier M, von Scheidt W, Kirchberger I, Hörmann A, Kuch B. Gender-Specific short and long-term mortality in diabetic versus nondiabetic patients with incident acute myocardial infarction in the reperfusion era (the MONICA/KORA Myocardial Infarction Registry). Am J Cardiol 2010;106:1680-4.
Diercks DB, Roe MT, Mulgund J, Pollack CV Jr., Kirk JD, Gibler WB, et al
. The obesity paradox in non-ST-segment elevation acute coronary syndromes: results from the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association Guidelines Quality Improvement Initiative. Am Heart J 2006;152:140-8.
Gui MH, Qin GY, Ning G, Hong J, Li XY, Lu AK, et al
. The comparison of coronary angiographic profiles between diabetic and non-diabetic patients with coronary artery disease in a Chinese population. Diabetes Res Clin Pract 2009;85:213-9.
Mani VE, John M, Calton R. Impact of HbA1c on acute cardiac states. J Assoc Phys India 2011;59:1-3.
Kamalesh M, Sharp TG, Tang XC, Shunk K, Ward HB, Walsh J, et al
. Percutaneous coronary intervention versus coronary bypass surgery in United States veterans with diabetes. J Am Coll Cardiol 2013;61:808-16.
Russel RI, Ranjith N, Sartorius B. Admission blood glucose as a prognostic indicator in patients with acute myocardial infarction: Admission in blood glucose. SA Heart 2019;16:118-26.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]