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CLINICAL STUDIES

Diabetes mellitus and outcome after primary coronary angioplasty for acute myocardial infarction: lessons from the GUSTO-IIb angioplasty substudy

David Hasdai, MD^a, Christopher B. Granger, MD, FACC^*, S. Sanjay Srivatsa, MBBChir, FACC, Douglas A. Criger, MS^*, Stephen G. Ellis, MD, FACC, Robert M. Califf, MD, FACC^*, Eric J. Topol, MD, FACC and David R. Holmes, Jr., MD, FACC

^a Rabin Medical Center, Petah Tikva, Israel
^* Duke Clinical Research Institute, Durham, North Carolina, USA
Mayo Clinic, Rochester, Minnesota, USA
Cleveland Clinic Foundation, Cleveland, Ohio, USA

Manuscript received March 6, 1999; revised manuscript received November 9, 1999, accepted January 13, 2000.

Reprint requests and correspondence: Dr. David R. Holmes, Jr., Division of Internal Medicine and Cardiovascular Diseases, Mayo Clinic, 200 First St. Southwest, Rochester, Minnesota 55905
holmes.david{at}mayo.edu

OBJECTIVES

We sought to compare the efficacy of primary angioplasty in diabetics versus nondiabetics and to evaluate the relative benefits of angioplasty over thrombolytic therapy among diabetics.

BACKGROUND

Primary angioplasty for myocardial infarction is at least as effective as thrombolytic therapy in the general population. However, the influence of diabetic status on outcome after primary angioplasty versus thrombolysis remains unknown.

METHODS

Patients in the Global Use of Strategies To Open Occluded Arteries in Acute Coronary Syndromes (GUSTO-IIb) Angioplasty Substudy were randomized to receive either primary angioplasty or accelerated alteplase. The interaction of diabetic status (diabetics n = 177, nondiabetics n = 961) and treatment strategy with the occurrence of the primary end point (death, nonfatal reinfarction or nonfatal, disabling stroke at 30 days) was analyzed (power to detect a 40% relative reduction in the primary end point with alpha = 0.05 and beta = 0.20). Among patients who were randomized to and underwent primary angioplasty, procedural success (defined as residual stenosis <50% and TIMI grade 3 flow) was assessed based on diabetic status.

RESULTS

Compared with nondiabetics, diabetics had worse baseline clinical and angiographic profiles. Despite more severe stenosis and poorer flow in the culprit artery, procedural success with angioplasty was similar for diabetics (n = 81; 70.4%) and nondiabetics (n = 391; 72.4%). Outcome at 30 days was better for nondiabetics randomized to angioplasty versus alteplase (adjusted odds ratio, 0.62; 95% confidence interval, 0.41–0.96) with a similar trend for diabetics (0.70, [0.29–1.72]). We noted no interaction between diabetic status and treatment strategy on outcome (p = 0.88).

CONCLUSIONS

Primary angioplasty was similarly successful in diabetics and nondiabetics and appeared to be more effective than thrombolytic therapy among diabetics with acute infarction.

Abbreviations and Acronyms   ACT = activated clotting time   AMI = acute myocardial infarction   aPTT = activated partial thromboplastin time   GUSTO-IIb = Global Use of Strategies To Open Occluded Arteries in Acute Coronary Syndromes (trial)-IIb   TIMI = Thrombolysis In Myocardial Infarction

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