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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 12  |  Issue : 2  |  Page : 61-64

Acute coronary syndrome among diabetic patients in invasive versus noninvasive hospitals


1 Department of cardiology, King Saud Bin Abdulaziz University for Health Sciences, COM, King Abdul Aziz Medical City-WR, King Faisal Cardiac Center, Jeddah, Saudi Arabia
2 Department of cardiology, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
3 King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
4 Department of Epidemiology and Medical Statistics, COM, University of Ibadan, Ibadan, Nigeria

Date of Web Publication30-Jul-2015

Correspondence Address:
Abdulhalim J Kinsara
King Saud Bin Abdulaziz University for Health Sciences, COM, King Abdul Aziz Medical City-WR, King Faisal Cardiac Center, Mail Code 6599, P.O. Box 9515, Jeddah 21423
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0189-7969.152006

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  Abstract 

Background: Risk stratification is an important step in proper management of acute coronary syndromes (ACS). This should be carried in every hospital as it might improve the outcome even in hospitals with no coronary angiogram facility but are following the guideline of management.
Objective: We present the characterization based on thrombolysis in myocardial infarction (TIMI) risk profile of unstable angina (UA)/non-ST-segment elevation (NSTEMI) myocardial infarction - ACS in diabetic patients in King Abdulaziz Medical City National Guard Hospital (KAMC) in Jeddah, a noninvasive facility and compared with 4 other hospitals in the Kingdom of Saudi Arabia with cardiac catheterization facilities. These hospitals were involved in multicenter international diabetes-ACS study. In addition, we compared the characterization of two therapeutic modalities used in management of such cases: Glycoprotein (GP) IIb/IIIa inhibitors and coronary angiogram.
Materials and Methods: The characterization of the risk profile of 35 diabetic patients from KAMC, noninvasive hospital were compared with 142 patients from four hospitals in KSA, and 3,624 patients from the international hospitals who had cardiac catheterization facility admitted with UA/NSTEMI, ACS.
Results: The distributions of TIMI scores were similar among the three groups. The odds ratios were also comparable across the three groups. When GP IIb/IIIa inhibitors usages were compared, the usage for a particular group was not different. The high risk factors were similar in patients who underwent coronary angiogram in the centers of KSA who had cardiac catheterization in comparison to those international centers.
Conclusions: The nonavailability of catheterization facilities does not cause referral bias, with risk factors being similar and treatment approach was matching. Immediate triage and risk stratification, e.g. TIMI score will affect the outcome of cardiovascular mortality and might explain some similarity in the outcome between invasive and noninvasive hospitals.

Keywords: Acute coronary syndromes, cardiac catheterization, clopidogrel/ticlopidine, coronary angiogram, diabetics, glycoprotein IIb/IIIa, Jeddah, multicenter international diabetes-acute coronary syndromes, non-ST-segment elevation, Saudi


How to cite this article:
Kinsara AJ, Batwa WA, Alzain IO, Almansouri ZS, Yusuf OB. Acute coronary syndrome among diabetic patients in invasive versus noninvasive hospitals. Nig J Cardiol 2015;12:61-4

How to cite this URL:
Kinsara AJ, Batwa WA, Alzain IO, Almansouri ZS, Yusuf OB. Acute coronary syndrome among diabetic patients in invasive versus noninvasive hospitals. Nig J Cardiol [serial online] 2015 [cited 2019 Jul 16];12:61-4. Available from: http://www.nigjcardiol.org/text.asp?2015/12/2/61/152006


  Introduction Top


The current guidelines recommend that patients with unstable angina/non-ST-segment elevation, acute coronary syndromes (UA/NSTEMI-ACS) be transferred to centers with cardiac catheterization facilities very early on if the risk profile is high. This recommendation is more important to adhere in diabetes mellitus (DM). Although the outcome is distinctly different, whether the patient's characteristics or referral bias to invasive hospital, influences the outcome, is an issue that needs to be looked at.s

Currently, there is no accurate method to determine which patients with stable angina will stabilize on medical therapy and who will develop NSTEMI-ACS. There is even less data for DM, despite its higher associated mortality. [1],[2]

We assessed the thrombolysis in myocardial infarction (TIMI) scores in NSTEMI-ACS in diabetic patients at the King Abdulaziz Medical City (KAMC) Jeddah, a noninvasive facility with four other hospitals in Saudi Arabia and compared it with the international data for patients treated with aggressive antiplatelet therapy glycoprotein (GP) IIb/IIIa inhibitors or coronary angiogram in multicenter international diabetes-ACS study. [3],[4]


  Materials and methods Top


Diabetic patients presenting with UA or NSTEMI myocardial infarction collectively, what clinical practice guidelines refer to as UA/NSTEMI-ACS, were enrolled in the study at the time of admission to the Emergency/Coronary Care Department. The sample size was 35 from KAMC, Jeddah, 142 from other four hospitals with catheterization lab facility and 3642 from the international hospitals involved in the study.

Odd ratio for the different risk profiles was assessed among the three groups studied.


  Results Top


Majority (52%) of KAMC patients had TIMI score 3, compared with 29% and 21% in KSA and the international centers, respectively. 26% of the international centers had TIMI score of 4, while only less than 10% were TIMI score 6 and 7 [Figure 1] of the international centers had TIMI score of 4, while only less than 10% were TIMI score 6 and 7 [Figure 1].
Figure 1: The distribution of thrombolysis in myocardial infarction score among three groups

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When GP IIb/IIIa inhibitors usage was compared, the usage for the three groups was slightly different for the different variables considered. Patients aged ≥ 65 years were 44% less likely to receive GP IIb/IIIa inhibitors in KAMC (odds ratio = 0.56) and the international centers (OR = 0.87) while in the other four hospitals, they were less Likely to receive the treatment (OR = 1.86).

The development of new UA/NSTEMI-ACS in the group of patients with prior aspirin use, had lead the three groups to use GP IIb/IIIa inhibitors with OR = 0.59, 0.57, 0.93. In addition, the group of patients with document coronary artery disease was more likely to be treated aggressively with GP IIb/IIIa inhibitors; odds within the three groups were 0.45, 0.85, and 0.93 in KAMC, four hospitals and the international centers, respectively. While all other TIMI indicators such as the presence of at least 3 risk factors for CHD, at least two anginal episodes prior the 24 h, presence of ST segment deviation on ECG, elevated serum cardiac biomarkers, were not associated with the decision to initiate GP IIb/IIIa inhibitors, contrary to what is expected.

Keeping in mind, that the study population were only diabetes patients; OR = 10 in all three groups [Figure 2].
Figure 2: Glycoprotein IIb/IIIa inhibitors usage among three groups for the different variables of thrombolysis in myocardial infarction score

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Similarly high-risk factors related to coronary angiography were compared in four centers of KSA having cardiac catheterization in comparison to international centers, Age ≥ 65 years, presence of ST segment deviation on ECG, elevated serum cardiac biomarkers, prior coronary stenosis of ≥ 50% were driven factors to proceed for coronary angiogram in both groups.

While the presence of at least three risk factors for CHD, use of aspirin in the prior 7 days, TIMI > 3 were leading to initiate coronary angiogram in four invasive KSA hospitals but not in the international [Figure 3].
Figure 3: The utilization of coronary angiogram among three groups for the different variables of thrombolysis in myocardial infarction score

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  Discussion Top


The TIMI risk score is based upon data from TIMI 11B and ESSENCE in which seven variables at presentation, were assessed in terms of their independently predictive outcome in patients with a NSTEMI ACS; a value of one was assigned when a factor was present and 0 when it was absent: Age ≥ 65 years, presence of at least three risk factors for CHD, use of aspirin in the prior 7 days, at least two anginal episodes in prior the 24 h, presence of ST segment deviation on ECG, elevated serum cardiac biomarkers, prior coronary stenosis of ≥50%. [5]

A higher TIMI risk score correlated with increased numbers of events at 2 weeks: Score of 1 - lead to 5% event rate while Score of 6/7 - was associated with 41% event rate.

Diabetes mellitus increases the risk of recurrent ACS and diabetic patients derive the greatest benefit from aggressive antithrombotic therapy. The odd ratio of utilization of GP IIb/IIIa, among particular risk was not different and this is what is defined as conservative approach, since it reduces the catheter procedure but might lengthen the patient's stay.

Our results demonstrate that a cardiac service with a guideline based therapy will have similar flow of patients with more equipped one. As we are discussing in the following section, the noninvasive approach with aggressive antiplatelet in the carefully selected patients is a reasonable option for treatment of ACS. Similarly, a score to identify patient who benefits from coronary angiogram needs to be in place.

Our data suggest also that TIMI score might be less helpful in risk stratification in DM, when compared to the published data among non-DM patients.

Early invasive therapy involves prompt catheterization of all patients with UA or NSTEMI after the initiation of medical therapy, usually 4-48 h from admission.

The benefits of different trials were not consistent when applied to all UA or NSTEMI. ICTUS trial: Showed no benefit from an early invasive strategy with the incidence of the primary endpoint of 22.7 versus 21.2% in the selective strategy. [6] RITA 3 trial: Invasive strategy was associated with a lower rate of the combined endpoint of death, nonfatal MI, or refractory angina (9.6 vs. 14.5%, OR = 0.66, 95% confidence interval: 0.51-0.85) at 4 months, but did not persist at 1 year. [7] TACTICS-TIMI 18 trial: The primary endpoint (death, MI, re-hospitalization for an ACS) was significantly lower with an invasive strategy but there was no mortality benefit. [8] FRISC II, The rate of death or MI was significantly lower in the invasive group but the difference in mortality was not significant at 1 year. [9] VANQWISH trial did not show a superiority of the invasive arm. [10] TIMI IIIB trial: There was no significant difference in the rates of death and nonfatal MI between the two approaches at 6 weeks (7.5 vs. 8.2%) or 1 year (10.8 vs. 12.2%). [11]

The comparison highlights that Risk stratification is an important step in proper management of UA/NSTEMI-ACS.

We could conclude that the facility with cardiac catheterization facility does not cause referral bias with patients presented had similar risk and receive aggressive noninvasive treatment. Immediate triage and risk stratification, e.g. TIMI score, will affect the outcome and might explain some similarities in the outcome in some studies between invasive and noninvasive hospitals.

 
  References Top

1.
Jneid H, Anderson JL, Wright RS, Adams CD, Bridges CR, Casey DE Jr, et al. 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non-ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2012;60:645-81.  Back to cited text no. 1
    
2.
O′Donoghue ML, Vaidya A, Afsal R, Alfredsson J, Boden WE, Braunwald E, et al. An invasive or conservative strategy in patients with diabetes mellitus and non-ST-segment elevation acute coronary syndromes: A collaborative meta-analysis of randomized trials. J Am Coll Cardiol 2012;60:106-11.  Back to cited text no. 2
    
3.
O′Neil T. MIDAS, preliminary results of an international registry of diabetics with ACS. Available from: http://www.readbag.com/theheart-documents-sponsorededucation-educationalprograms-872527-focuson-midas-v3. [Last accessed on 2014 Oct 5].  Back to cited text no. 3
    
4.
Kinsara AJ, Hasanin AM. The management of elderly diabetic saudi patients with acute coronary syndrome. Heart Views 2013;14:1-4.  Back to cited text no. 4
[PUBMED]  Medknow Journal  
5.
Antman EM, Cohen M, Bernink PJ, McCabe CH, Horacek T, Papuchis G, et al. The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making. JAMA 2000;284:835-42.  Back to cited text no. 5
    
6.
Damman P, Hirsch A, Windhausen F, Tijssen JG, de Winter RJ; ICTUS Investigators. 5-year clinical outcomes in the ICTUS (Invasive versus Conservative Treatment in Unstable Coronary Syndromes) trial, a randomized comparison of an early invasive versus selective invasive management in patients with non-ST-segment elevation acute coronary syndrome. J Am Coll Cardiol 2010;55:858-64.  Back to cited text no. 6
    
7.
Fox KA, Poole-Wilson PA, Henderson RA, Clayton TC, Chamberlain DA, Shaw TR, et al. Interventional versus conservative treatment for patients with unstable angina or non-ST-elevation myocardial infarction: The British heart foundation RITA 3 randomised trial. Randomized Intervention Trial of unstable Angina. Lancet 2002;360:743-51.  Back to cited text no. 7
    
8.
Cannon CP, Weintraub WS, Demopoulos LA, Vicari R, Frey MJ, Lakkis N, et al. Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med 2001;344:1879-87.  Back to cited text no. 8
    
9.
Invasive compared with non-invasive treatment in unstable coronary-artery disease: FRISC II prospective randomised multicentre study. FRagmin and Fast Revascularisation during InStability in coronary artery disease investigators. Lancet 1999;354:708-15.  Back to cited text no. 9
[PUBMED]    
10.
Boden WE, O′Rourke RA, Crawford MH, Blaustein AS, Deedwania PC, Zoble RG, et al. Outcomes in patients with acute non-Q-wave myocardial infarction randomly assigned to an invasive as compared with a conservative management strategy. Veterans Affairs Non-Q-Wave Infarction Strategies in Hospital (VANQWISH) Trial Investigators. N Engl J Med 1998;338:1785-92.  Back to cited text no. 10
    
11.
Effects of tissue plasminogen activator and a comparison of early invasive and conservative strategies in unstable angina and non-Q-wave myocardial infarction. Results of the TIMI IIIB Trial. Thrombolysis in Myocardial Ischemia. Circulation 1994;89:1545-56.  Back to cited text no. 11
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