Underuse of evidence-based treatment partly explains the worse clinical outcome in diabetic patients with acute coronary syndromes

Raymond T. Yan, Andrew T. Yan, Mary Tan, Darren K McGuire, Lawrence Leiter, David H. Fitchett, Claude Lauzon, Kevin Lai, Chi Ming Chow, Anatoly Langer, Shaun G. Goodman

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Abstract

Background: Diabetes-related differences in treatment and clinical outcome of patients across the entire spectrum of acute coronary syndromes (ACSs) have potential clinical implications but have not been well studied. Methods: The multicenter, prospective, Canadian ACS Registry enrolled 4578 patients hospitalized for ACS between 1999 and 2001 across 9 provinces in Canada. We compared baseline characteristics, in-hospital and post-discharge treatments, and clinical outcome of diabetic and non-diabetic patients. The impact of diabetes on use of thrombolytic therapy and coronary revascularization; and the independent association between diabetes, treatments, and diabetes-treatment interactions on outcome were examined. Results: Diabetic patients with ACS had more cardiovascular risk factors and higher-risk clinical presentation. They paradoxically received less evidence-based medications in-hospital, at discharge, and at 1-year. Although diabetes independently predicted higher 1-year mortality (OR 1.47, 95% CI 1.15-1.87; P = .002) after adjustment for validated prognosticators, it was also an independent predictor of not receiving thrombolytic therapy (OR 0.72, 95% CI 0.54-0.95; P = .021) and coronary revascularization (OR 0.69, 95% CI 0.59-0.82; P < .001). These underused therapies were all independently associated with reduced 1-year mortality, with no significant diabetes-related treatment-outcome heterogeneity. Importantly, diabetes remained an independent adverse prognosticator even after further adjustment for these differences in treatment. Conclusions: Evidence-based therapies are underused in the contemporary management of diabetic patients with ACS, which partly explains their worse outcome. Diabetes should be considered a high-risk feature in ACS risk stratification that encourages more intensive treatments. Continued efforts to promote adherence to existing proven therapies and to develop novel treatment strategies targeting diabetes-specific cardiovascular pathophysiology are imperative to improve their adverse prognosis.

Original languageEnglish (US)
Pages (from-to)676-683
Number of pages8
JournalAmerican Heart Journal
Volume152
Issue number4
DOIs
StatePublished - Oct 2006

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Acute Coronary Syndrome
Thrombolytic Therapy
Therapeutics
Mortality
Canada
Registries

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

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Underuse of evidence-based treatment partly explains the worse clinical outcome in diabetic patients with acute coronary syndromes. / Yan, Raymond T.; Yan, Andrew T.; Tan, Mary; McGuire, Darren K; Leiter, Lawrence; Fitchett, David H.; Lauzon, Claude; Lai, Kevin; Chow, Chi Ming; Langer, Anatoly; Goodman, Shaun G.

In: American Heart Journal, Vol. 152, No. 4, 10.2006, p. 676-683.

Research output: Contribution to journalArticle

Yan, RT, Yan, AT, Tan, M, McGuire, DK, Leiter, L, Fitchett, DH, Lauzon, C, Lai, K, Chow, CM, Langer, A & Goodman, SG 2006, 'Underuse of evidence-based treatment partly explains the worse clinical outcome in diabetic patients with acute coronary syndromes', American Heart Journal, vol. 152, no. 4, pp. 676-683. https://doi.org/10.1016/j.ahj.2006.04.002
Yan, Raymond T. ; Yan, Andrew T. ; Tan, Mary ; McGuire, Darren K ; Leiter, Lawrence ; Fitchett, David H. ; Lauzon, Claude ; Lai, Kevin ; Chow, Chi Ming ; Langer, Anatoly ; Goodman, Shaun G. / Underuse of evidence-based treatment partly explains the worse clinical outcome in diabetic patients with acute coronary syndromes. In: American Heart Journal. 2006 ; Vol. 152, No. 4. pp. 676-683.
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abstract = "Background: Diabetes-related differences in treatment and clinical outcome of patients across the entire spectrum of acute coronary syndromes (ACSs) have potential clinical implications but have not been well studied. Methods: The multicenter, prospective, Canadian ACS Registry enrolled 4578 patients hospitalized for ACS between 1999 and 2001 across 9 provinces in Canada. We compared baseline characteristics, in-hospital and post-discharge treatments, and clinical outcome of diabetic and non-diabetic patients. The impact of diabetes on use of thrombolytic therapy and coronary revascularization; and the independent association between diabetes, treatments, and diabetes-treatment interactions on outcome were examined. Results: Diabetic patients with ACS had more cardiovascular risk factors and higher-risk clinical presentation. They paradoxically received less evidence-based medications in-hospital, at discharge, and at 1-year. Although diabetes independently predicted higher 1-year mortality (OR 1.47, 95{\%} CI 1.15-1.87; P = .002) after adjustment for validated prognosticators, it was also an independent predictor of not receiving thrombolytic therapy (OR 0.72, 95{\%} CI 0.54-0.95; P = .021) and coronary revascularization (OR 0.69, 95{\%} CI 0.59-0.82; P < .001). These underused therapies were all independently associated with reduced 1-year mortality, with no significant diabetes-related treatment-outcome heterogeneity. Importantly, diabetes remained an independent adverse prognosticator even after further adjustment for these differences in treatment. Conclusions: Evidence-based therapies are underused in the contemporary management of diabetic patients with ACS, which partly explains their worse outcome. Diabetes should be considered a high-risk feature in ACS risk stratification that encourages more intensive treatments. Continued efforts to promote adherence to existing proven therapies and to develop novel treatment strategies targeting diabetes-specific cardiovascular pathophysiology are imperative to improve their adverse prognosis.",
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T1 - Underuse of evidence-based treatment partly explains the worse clinical outcome in diabetic patients with acute coronary syndromes

AU - Yan, Raymond T.

AU - Yan, Andrew T.

AU - Tan, Mary

AU - McGuire, Darren K

AU - Leiter, Lawrence

AU - Fitchett, David H.

AU - Lauzon, Claude

AU - Lai, Kevin

AU - Chow, Chi Ming

AU - Langer, Anatoly

AU - Goodman, Shaun G.

PY - 2006/10

Y1 - 2006/10

N2 - Background: Diabetes-related differences in treatment and clinical outcome of patients across the entire spectrum of acute coronary syndromes (ACSs) have potential clinical implications but have not been well studied. Methods: The multicenter, prospective, Canadian ACS Registry enrolled 4578 patients hospitalized for ACS between 1999 and 2001 across 9 provinces in Canada. We compared baseline characteristics, in-hospital and post-discharge treatments, and clinical outcome of diabetic and non-diabetic patients. The impact of diabetes on use of thrombolytic therapy and coronary revascularization; and the independent association between diabetes, treatments, and diabetes-treatment interactions on outcome were examined. Results: Diabetic patients with ACS had more cardiovascular risk factors and higher-risk clinical presentation. They paradoxically received less evidence-based medications in-hospital, at discharge, and at 1-year. Although diabetes independently predicted higher 1-year mortality (OR 1.47, 95% CI 1.15-1.87; P = .002) after adjustment for validated prognosticators, it was also an independent predictor of not receiving thrombolytic therapy (OR 0.72, 95% CI 0.54-0.95; P = .021) and coronary revascularization (OR 0.69, 95% CI 0.59-0.82; P < .001). These underused therapies were all independently associated with reduced 1-year mortality, with no significant diabetes-related treatment-outcome heterogeneity. Importantly, diabetes remained an independent adverse prognosticator even after further adjustment for these differences in treatment. Conclusions: Evidence-based therapies are underused in the contemporary management of diabetic patients with ACS, which partly explains their worse outcome. Diabetes should be considered a high-risk feature in ACS risk stratification that encourages more intensive treatments. Continued efforts to promote adherence to existing proven therapies and to develop novel treatment strategies targeting diabetes-specific cardiovascular pathophysiology are imperative to improve their adverse prognosis.

AB - Background: Diabetes-related differences in treatment and clinical outcome of patients across the entire spectrum of acute coronary syndromes (ACSs) have potential clinical implications but have not been well studied. Methods: The multicenter, prospective, Canadian ACS Registry enrolled 4578 patients hospitalized for ACS between 1999 and 2001 across 9 provinces in Canada. We compared baseline characteristics, in-hospital and post-discharge treatments, and clinical outcome of diabetic and non-diabetic patients. The impact of diabetes on use of thrombolytic therapy and coronary revascularization; and the independent association between diabetes, treatments, and diabetes-treatment interactions on outcome were examined. Results: Diabetic patients with ACS had more cardiovascular risk factors and higher-risk clinical presentation. They paradoxically received less evidence-based medications in-hospital, at discharge, and at 1-year. Although diabetes independently predicted higher 1-year mortality (OR 1.47, 95% CI 1.15-1.87; P = .002) after adjustment for validated prognosticators, it was also an independent predictor of not receiving thrombolytic therapy (OR 0.72, 95% CI 0.54-0.95; P = .021) and coronary revascularization (OR 0.69, 95% CI 0.59-0.82; P < .001). These underused therapies were all independently associated with reduced 1-year mortality, with no significant diabetes-related treatment-outcome heterogeneity. Importantly, diabetes remained an independent adverse prognosticator even after further adjustment for these differences in treatment. Conclusions: Evidence-based therapies are underused in the contemporary management of diabetic patients with ACS, which partly explains their worse outcome. Diabetes should be considered a high-risk feature in ACS risk stratification that encourages more intensive treatments. Continued efforts to promote adherence to existing proven therapies and to develop novel treatment strategies targeting diabetes-specific cardiovascular pathophysiology are imperative to improve their adverse prognosis.

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