Timing of Invasive Strategy in Diabetic and Non-Diabetic Patients with Non-St-Segment Elevation Acute Coronary Syndrome

Abstract

INTRODUCTION: Patients with acute coronary syndrome without ST segment elevation are a heterogeneous group with respect to the risk of having a major adverse cardiac event (MACE). A history of diabetes mellitus (DM) is no doubt one of the factors that defi ne a patient as being at a higher risk of having the syndrome. AIM: To compare early invasive strategy with selective invasive strategy indicated for patients with and without DM. PATIENTS AND METHODS: The study enrolled 178 patients with unstable angina or non-ST elevation myocardial infarction (UA/NSTEMI), and of these 52 (29.2%) had DM. Patients were randomly assigned to an early invasive strategy (these were scheduled to undergo coronary arteriography and percutaneous coronary intervention within 24 hours after admission) or to a selective invasive strategy (at fi rst these were medically stabilized, with coronary arteriography required only in case of angina recurrence and/or evidence of inducible myocardial ischemia). The patients were followed up for a mean period of 22.8 ± 14 months. RESULTS: In the follow up the diabetics allocated to an early invasive strategy were found to have a signifi cantly lower angina recurrence incidence (p = 0.005), rehospitalization rate (p = 0.001), fewer arteriographies (p = 0.001) and coronary interventions (p = 0.001) and low cumulative incidence of MACE (p = 0.008) in comparison with the diabetics assigned to selective invasive strategy. We also found, using the Kaplan-Meier curves survival analysis, that the time to MACE in patients assigned to an early invasive strategy was signifi cantly longer than that in the group of selective invasive strategy. In the follow-up of non-diabetics we found no signifi cant difference in MACE rate between the patients allocated to early invasive strategy and those assigned to selective invasive strategy. In the selective invasive strategy group, however, the cardiovascular adverse events tended to occur earlier than in the early invasive strategy group. CONCLUSIONS: Early invasive strategy in diabetic patients with non-ST-segment elevation acute coronary syndrome is associated with a reduced MACE rate compared with the selective invasive strategy used in these patients. Early invasive strategy applied in diabetic patients is also associated with a signifi cantly longer time to MACE. In non-diabetics the advantages of early over selective invasive strategy are not so clearly differentiated.

Chest pain during admission in a reference cardiac emergency unit

“…The significant association between the score assigned to the chest pain and delta t found corroborates other studies that also found the fastest search for service of patients with higher pain intensity (6) . A previous study also showed lower averages of pain for diabetic patients compared with non-diabetic ones, and in other international researchers found bigger complications related to the diabetic group (1,15) . Overweight and obesity were present in frequencies above the Brazilian population, and even not having significant association with pain values, they are important modifiable risk factors for the event (4,11,13) .…”