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J Am Coll Cardiol, 2000; 36:1097-1103
© 2000 by the American College of Cardiology Foundation
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CLINICAL STUDY

Diabetes mellitus in cardiogenic shock complicating acute myocardial infarction: a report from the SHOCK Trial Registry

Daniel M. Shindler, MD, FACC*, Sebastian T. Palmeri, MD, FACC*, Tracy A. Antonelli, MPH{dagger}, Lynn A. Sleeper, ScD{dagger}, Jean Boland, MD{ddagger}, Thomas P. Cocke, MD, FACC§, Judith S. Hochman, MD, FACC|| for the SHOCK Investigators

* UMDNJ-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
{dagger} New England Research Institutes, Watertown, Massachusetts, USA
{ddagger} Centre Hospitalier de la Citadelle, Liège, Belgium
§ Mt. Sinai Medical Center, New York, New York, USA
|| St. Luke’s–Roosevelt Hospital, New York, New York, USA

Manuscript received February 16, 2000; revised manuscript received June 2, 2000, accepted June 7, 2000.

Reprint requests and correspondence: Dr. Daniel M. Shindler, 1 Gloucester Court, East Brunswick, New Jersey 08816
shindler{at}umdnj.edu


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 References
 
OBJECTIVES

We sought to examine the role of diabetes mellitus in cardiogenic shock (CS) complicating acute myocardial infarction (AMI) in the SHOCK Trial Registry.

BACKGROUND

The characteristics, outcomes and optimal treatment of diabetic patients with CS complicating AMI have not been well described.

METHODS

Baseline characteristics, clinical and hemodynamic measures, treatment variables, shock etiologies and comorbid conditions were compared for 379 diabetic and 784 nondiabetic patients. Logistic regression was used to examine the association between diabetes and in-hospital mortality, after adjustment for baseline differences.

RESULTS

Diabetics were less likely than nondiabetics to undergo thrombolysis (28% vs. 37%; p = 0.002) or attempted revascularization (40% vs. 49%; p = 0.008). The survival benefit for diabetics selected for percutaneous or surgical revascularization (55% vs. 19% without revascularization) was similar to that for nondiabetics (59% vs. 25%). Overall unadjusted in-hospital mortality was significantly higher for diabetics (67% vs. 58%; p = 0.007), but diabetes was only a borderline predictor of mortality after adjustment for baseline and treatment differences (odds ratio for death, 1.36; 95% confidence interval, 1.00 to 1.84; p = 0.051).

CONCLUSIONS

Diabetics with CS complicating AMI have a higher-risk profile at baseline, but after adjustment, diabetics have an in-hospital survival rate that is only marginally lower than that of nondiabetics. Diabetics who undergo revascularization derive a survival benefit similar to that of nondiabetics.

Abbreviations and Acronyms
  AMI = acute myocardial infarction
  BARI = Bypass Angioplasty Revascularization Investigation
  BUN = blood urea nitrogen
  CK(-MB) = creatine kinase (-MB)
  CS = cardiogenic shock
  GUSTO-I = Global Utilization of Streptokinase and TPA (alteplase) for Occluded coronary arteries (trial)
  LV = left ventricular, left ventricle
  MR = mitral regurgitation
  RV = right ventricular
  SHOCK = SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK? (trial)

Cardiogenic shock (CS) is the leading cause of in-hospital mortality after acute myocardial infarction (AMI) (1,2). Nonrandomized series have described better outcomes for MI patients in shock who are selected for early revascularization, whether alone (3–6) or after thrombolysis (7). More recently, the international, prospective, randomized SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK? (SHOCK) Trial (8–10) has shown that early revascularization, with angioplasty or bypass surgery, is an effective treatment strategy for these patients. Whether this benefit extends to the population of patients with diabetes and CS who were not involved in the randomized trial but were included in the SHOCK Trial Registry is the subject of this article.

Diabetes has been shown to be an independent risk factor for short-term mortality after thrombolysis for AMI, but not after primary angioplasty (11), in the presence or absence of CS (12,13). In two registries of elective angioplasty, diabetes was an independent predictor of long-term adverse events (14,15). Nonetheless, in subgroup analyses of randomized trials, diabetics with MI have been shown to derive a clinical benefit, similar to that of patients without diabetes, from either thrombolysis or primary angioplasty and a similar relative early advantage from primary angioplasty versus thrombolysis (13,16). The conflicting results seen in the randomized and registry portions of the Bypass Angioplasty Revascularization Investigation (BARI) (17,18) may reflect selection bias and differences in patient characteristics (including the degree of glycemic control) among diabetics with multivessel disease who undergo bypass versus angioplasty. Thus, the optimal revascularization method for diabetics remains unknown.

This analysis describes the characteristics, outcomes and treatment of diabetic patients with CS complicating AMI who were prospectively enrolled in the SHOCK Trial Registry (8). Logistic regression was used to examine the association between diabetes and in-hospital mortality, after adjustment for baseline and treatment differences.


   Methods
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 Abstract
 Methods
Results
 Discussion
 References
 
The SHOCK Trial Registry.   The design of the SHOCK Trial and SHOCK Trial Registry has been reported (8,9). In brief, patients with suspected CS complicating AMI were registered prospectively at 36 centers, from April 1993 through August 1997. Patients who did not meet all trial inclusion criteria, and patients who met any single exclusion criterion, were included in the SHOCK Trial Registry. This includes patients with other etiologies for CS, including those with acute, severe mitral regurgitation (MR), ventricular septal rupture (VSR), isolated right ventricular (RV) failure, cardiac tamponade or rupture, prior severe valvular heart disease, dilated cardiomyopathy, or hemorrhage. In all, 1,190 patients were included in the Registry. Twenty-seven patients had unknown diabetes status. The remaining 1,163 are the subject of this article. For comparison, the outcome of diabetics in the randomized SHOCK Trial is reported here as well (10).

Data collection.   Study coordinators abstracted data from medical records and recorded them on standardized case-report forms. The forms captured patient and infarct characteristics, hemodynamic measures, procedure-use data and vital status at discharge. Angiographic reports were sent to the Clinical Coordinating Center for abstraction of data and central completion of a standardized form (19). Height, weight, blood urea nitrogen (BUN), creatinine, left ventricular (LV) ejection fraction and presence of peripheral vascular disease and of hyperlipidemia were collected on approximately two thirds of patients.

Definitions.   Patients were classified as diabetic if this condition was checked on the case report form. The subtype of diabetes was not routinely collected. The etiology of shock was identified as isolated RV failure; acute, severe MR; VSR; tamponade or LV rupture; prior severe valvular heart disease; or predominant LV failure (if other major shock categories did not apply) or iatrogenic shock. Recurrent ischemia was defined as rest angina or ischemic symptoms ≥5 min with ST-segment depression, T-wave inversion, or both with no cardiac enzyme elevation. Reinfarction was defined as: 1) recurrent chest pain or ischemic symptoms ≥30 min and recurrent ST-segment elevation, new Q waves or new left bundle-branch block; 2) total creatine kinase (CK) at least twice the upper limit of normal and >25% or 200 U/mL over the previous value, with an elevated CK-MB level; or 3) a rise in CK-MB above the upper limit of normal after it had reverted to the normal range. Only in-hospital survival was assessed.

Statistics.   Baseline characteristics, clinical and hemodynamic measures, shock etiologies and treatment variables were summarized (for diabetics and nondiabetics) as means and standard deviations for continuous variables and as percentages for categorical variables. Skewed continuous variables were presented as medians and interquartile ranges. Groups were compared using the Fisher exact test for categorical variables, the Mantel-Haenszel test for linear trend for number of diseased vessels, and the Student t-test or Wilcoxon rank-sum test for continuous variables. We examined the independent association between diabetes and in-hospital mortality with three logistic-regression models, which were constructed by including all variables with a univariate p-value for group comparison of ≤0.20. The first model adjusted for patient characteristics only, while the second model included both patient and treatment variables. We also explored the possibility of an interactive effect between diabetes and angioplasty or bypass surgery on in-hospital mortality. The third model added the BUN level at baseline. We did not include this variable in initial modeling, because it was collected for only 673 of the 1,163 patients. The same is true for coronary anatomy because coronary angiography was not performed in all patients; data were available in only 692 patients. All variables with a final p-value of ≤0.05 were retained in the multivariable models. All analyses were conducted using SAS software (SAS Institute, version 6.12, Cary, North Carolina).


   Results
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 Abstract
 Methods
 Results
Discussion
 References
 
Baseline characteristics.   Diabetes status was recorded in 1,163 of the 1,190 Registry patients; 379 (33%) patients had diabetes and 784 patients did not (Table 1). Age, height and weight did not differ by diabetic status; neither did the prevalence of prior bypass surgery, prior angioplasty, current smoking or hyperlipidemia. Diabetics were significantly less likely to be white and significantly more likely to be female or Hispanic and to have a history of MI, congestive heart failure, hypertension or peripheral vascular disease. Renal insufficiency was present in a significantly greater proportion of diabetics; both the median BUN and median serum creatinine were higher in this group.


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  		Table 1 Baseline Demographic and Clinical Characteristics of AMI Patients With CS

 
Clinical findings.   Table 2 shows differences in infarct-related findings. Diabetics were significantly less likely to have Q waves in two or more leads. The median highest total CK was significantly lower in diabetics. There were no significant differences in MI location by ECG, but new left bundle-branch block was significantly more common in diabetics. The time from onset of MI to development of CS did not differ significantly between groups.


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  		Table 2 Characteristics of the Index MI in Patients With CS

 
There was no significant difference in the rate of chest pain between diabetics and nondiabetics. Diabetics underwent coronary angiography less often than nondiabetics (56% vs. 65%, p = 0.006). There was no significant difference in culprit coronary artery, or in the rate of left main stenosis that was ≥50% (Table 2). Diabetics had significantly more two-vessel and three-vessel coronary artery disease (p < 0.001). Left ventricular ejection fraction (total n = 459) was significantly lower in diabetics (p = 0.006).

Of the shock-related clinical variables measured (Table 3 ), aortic stenosis, other significant valvular disease and other causes for shock were significantly more frequent in diabetics (p < 0.05). The rates of severe hemorrhage, mechanical complications, isolated RV CS, dilated cardiomyopathy and anoxic brain damage were not significantly different in the two groups. The hemodynamic variables measured closest to shock likewise did not vary significantly between diabetics and nondiabetics, with the exception of diastolic blood pressure (BP); but the 1 mm Hg difference is not clinically significant.


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  		Table 3 Etiology, Complications and Hemodynamic Measures of CS in AMI

 
Treatment.   Diabetics were less likely to receive thrombolytic agents (p = 0.002) (Table 4). When the rates of attempted angioplasty and bypass surgery were assessed separately, they did not differ by diabetic status; but when the rates were combined, the rate of attempted revascularization was significantly lower in diabetics (40% vs. 49%, p = 0.008). Diabetics received mechanical ventilation more often (p < 0.001). The rates of balloon-pump use and right-heart catheterization were not significantly different.


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  		Table 4 In-hospital Treatment of AMI Patients With CS

 
In-hospital mortality.   Unadjusted in-hospital mortality was 67% in the diabetics versus 58% in the nondiabetics (p = 0.007). In a logistic regression model that adjusted for significant baseline differences (diastolic BP at shock onset, Hispanic race, severe systemic illness), diabetes mellitus remained an independent risk factor for in-hospital mortality (odds ratio [OR], 1.47; 95% confidence interval [CI], 1.10 to 1.96; p = 0.009). For patients who underwent angioplasty only (n = 318), in-hospital survival rates were 48% in diabetics vs. 56% in nondiabetics (p = 0.217). For patients who underwent bypass surgery (n = 216, which includes 36 patients who underwent both angioplasty and bypass surgery), survival rates were 65% in diabetics and 64% in nondiabetics (p = 0.875). In a second model that adjusted for significant differences in patient and treatment characteristics (diastolic blood pressure at shock onset, severe systemic illness, thrombolysis, and angioplasty or bypass surgery), diabetes remained a borderline independent predictor of in-hospital mortality (OR, 1.36; 95% CI, 1.00 to 1.84; p = 0.051). When baseline BUN (collected on only 673 patients) was added to the model that included patient and treatment variables, diabetes was no longer a significant, independent predictor of in-hospital mortality (OR, 1.23; 95% CI, 0.85 to 1.78; p = 0.268).

The survival benefit in diabetics selected for revascularization (55% vs. 19% for nonrevascularized patients) was similar to that of nondiabetics (59% vs. 25%; test for interaction, p = 0.303) (Fig. 1). In the randomized SHOCK Trial, diabetics and nondiabetics derived similar benefit from emergency early revascularization (Table 5).



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  		Figure 1 Survival benefit in diabetics (black bars) and nondiabetics (white bars), overall and by selection for revascularization by angioplasty or bypass surgery. *Includes 36 patients who underwent both angioplasty and bypass surgery.

 

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  		Table 5 SHOCK Trial Mortality of AMI Patients With CS

 

   Discussion
Top
 Abstract
 Methods
 Results
 Discussion
References
 
Diabetics comprise a significant portion of patients (about 25%) both in MI trials that have assessed the incidence of CS (20) and in a large observational study of CS (21,22). Small series of revascularization attempts in CS have not specified the number of diabetics (23–25), precluding meta-analysis for the significance of diabetes. The large number of diabetics in the SHOCK Trial Registry shows that the unadjusted in-hospital mortality of diabetics with CS is significantly higher than that of nondiabetics—but much less so after adjustment for baseline and treatment differences. More importantly, diabetic patients appeared to derive a benefit from revascularization similar to that of shock patients without diabetes, consistent with the overall results of the SHOCK Trial (10).

Prognostic implications.   The poorer prognosis of AMI in diabetics is not explained by a larger infarct size (26). Diabetics were significantly less likely to have Q waves in two or more leads on the index MI ECG or to have ST-segment elevation after the index MI. The median highest total CK was significantly lower in diabetics. The higher rate of many baseline cardiovascular abnormalities in the SHOCK Trial Registry diabetics, including prior MI and congestive heart failure, and the presence of more extensive coronary artery disease and poorer LV ejection fraction, may explain the poorer prognosis. Another possible explanation for the higher mortality of diabetics is that they were less likely to undergo thrombolysis or to undergo attempted revascularization with angioplasty, bypass surgery, or both. However, diabetic status remained marginally significant after adjusting for baseline and treatment differences.

An intriguing possible explanation for the poorer outcomes of diabetic patients may be metabolic abnormalities related to the degree and method of glycemic control both before and after AMI. The Diabetes mellitus, Insulin-Glucose infusion in Acute Myocardial Infarction (DIGAMI) study showed that the admission blood-glucose level was an independent predictor of mortality over an average 3.4-year follow-up period and that intensive insulin treatment reduced long-term mortality even among patients with hyperglycemia at baseline (27).

Reperfusion strategies.   Studies of revascularization in CS have included diabetics, but the number of patients has been too small to comment on the significance of diabetes in CS (4,28–30). Large trials show that a history of diabetes is associated with a poorer prognosis after MI in patients treated with thrombolytic agents (12,31,32). This implies a greater potential for absolute benefit from thrombolysis for AMI in diabetics. Yet, diabetics may be less likely to receive thrombolytic therapy (33). In subgroup analyses of randomized trials, diabetics with MI have been shown to derive a clinical benefit from either thrombolysis or primary angioplasty similar to that of patients without diabetes, and a similar early relative advantage from primary angioplasty versus thrombolysis (13,16). Some physicians may be reluctant to give thrombolytic agents to diabetics, because of concern about ocular hemorrhage in those with diabetic retinopathy, but this concern has been shown to be unjustified (34).

In the randomized BARI trial (17), diabetics with multivessel disease randomized to bypass surgery had significantly better five-year outcomes than did those randomized to angioplasty. Of note, no such treatment difference was seen in the BARI Registry, in which the type of revascularization procedure was determined by the attending physician (18). This difference may reflect selection bias rather than true differences in treatment effect. Although these findings cannot be extrapolated to the SHOCK Trial Registry diabetics, those who underwent angioplasty, bypass surgery, or both, derived a survival benefit similar to that of the SHOCK Trial Registry nondiabetics who underwent these revascularization procedures. This beneficial in-hospital effect of revascularization in the large Registry population of diabetics supports the randomized Trial finding that diabetics and nondiabetics derived similar survival benefit from early revascularization at six-month and one-year follow-up.

Study limitations.   This subgroup analysis of an observational Registry database carries the inherent dangers of selection bias and small sample sizes. However, it does reflect the treatment of these patients in everyday practice.

Renal insufficiency was present in a significantly greater proportion of diabetics. The third logistic regression model attempted to address this by including baseline BUN. This was possible in only 673 of 1,163 patients. In this subset of patients, diabetes was not significantly associated with in-hospital mortality.

The lower ejection fraction, lower incidence of single-vessel disease, and higher incidence of two- and three-vessel disease may well affect survival, but many patients in this study did not undergo angiography.

Conclusions.   Diabetics with CS complicating AMI had a higher-risk profile than nondiabetics. However, their in-hospital survival was only marginally lower than that of nondiabetics after adjustment for these risk factors. Moreover, diabetics appeared to derive a benefit from revascularization similar to that of nondiabetics with CS in both the SHOCK Trial Registry and the randomized SHOCK Trial. Despite their higher-risk profile, diabetics should be strongly considered for early revascularization for CS complicating AMI.


   Footnotes
 
Supported by RO1 grants HL50020, HL49970, 1994-99, from the National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland.


   References
Top
 Abstract
 Methods
 Results
 Discussion
 References
 

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