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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 10  |  Issue : 1  |  Page : 31-34

Clinical study of burden of type 2 diabetes mellitus in acute coronary syndromes and their complications


Department of General Medicine, Geetha Nursing Home, Tenali, Andhra Pradesh, India

Date of Submission10-Dec-2020
Date of Acceptance14-Dec-2020
Date of Web Publication4-Mar-2021

Correspondence Address:
P Dakshina Murthy
Consultant Physician, Geetha Nursing Home, Kothapet, Tenali 522201, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcsr.jcsr_104_20

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  Abstract 


Background: Sparse published data are available regarding the burden of Type 2 diabetes mellitus (T2DM) in patients presenting with acute coronary syndrome (ACS) in a health-care setting managed by physicians.
Methods: The present study was conducted to assess the burden of T2DM, amongst persons admitted with ACS, and study the complications during their hospital stay.
Results: During November 2016 and May 2017, 167 persons with ACS were admitted in the intensive care unit of a 15-bedded hospital managed by physicians. Of these, 66 (39.5%) were found to have T2DM (57 were known to have T2DM, T2DM was freshly detected in 9). Of the 66 patients with T2DM and ACS, 44 (67%) had ST-elevation myocardial infarction (MI) (25 persons had anterior wall MI and 19 had inferior wall MI) and 22 (33%) had non-ST-elevation MI/unstable angina. Ten (15%) patients died during hospital stay (9 died due to cardiac arrest and one patient died on the way to another centre). Other complications included acute left ventricular failure (n = 4). Two of these recovered with treatment and two others were shifted to another centre. One patient had developed cardiogenic shock and recovered with treatment. One person with post-infarction angina was referred to another centre for angiogram.
Conclusions: Early recognition of diabetes mellitus in patients presenting with ACS is essential to save life and prevent complications.

Keywords: Acute coronary syndrome, complications, diabetes mellitus


How to cite this article:
Murthy P D, Gopal P V. Clinical study of burden of type 2 diabetes mellitus in acute coronary syndromes and their complications. J Clin Sci Res 2021;10:31-4

How to cite this URL:
Murthy P D, Gopal P V. Clinical study of burden of type 2 diabetes mellitus in acute coronary syndromes and their complications. J Clin Sci Res [serial online] 2021 [cited 2021 Aug 3];10:31-4. Available from: https://www.jcsr.co.in/text.asp?2021/10/1/31/310761




  Introduction Top


Type 2 diabetes mellitus (T2DM) has reached epidemic proportions globally, particularly in developing countries. According to the International Diabetes Federation estimates in 2019, around 463 million people are living with T2DM and this number is expected to rise to 700 million by 2045.[1]

The estimated number of individuals with T2DM in India in 2019 was 77 million.[2] Subjects with T2DM are known to have 2–4 times increased risk of coronary artery disease (CAD) than people without diabetes. CAD has been reported to occur two to three decades earlier in diabetics as compared to their non-diabetic counterparts. CVD accounts for 65%–75% of deaths in people with diabetes.[3]

Persons with T2DM tend to have more diffuse CAD, more congestive heart failure and worse cardiovascular profile. In the Chennai Urban Population Study No. 5, the prevalence rates of CAD were 9.1%, 14.9% and 21.4% in those with normal glucose tolerance, impaired glucose tolerance and diabetes, respectively.[4]

In spite of lower body mass index, South Asian Indians have more abdominal fat (thin fat Indian), more insulin resistance and hyperinsulinaemia, higher levels of C-reactive protein, low levels of adenopectin and characteristic dyslipidaemia (lower high-density lipoprotein levels, higher triglycerides and high levels of small-dense low-density lipoprotein). All these factors increase the susceptibility to T2DM and CAD. Clustering of the above metabolic factors along with physical inactivity and increased stress is a contributory factor for the high prevalence of metabolic syndrome in Indians and the term 'cardiometabolic syndrome' has been used for this entity.[5]


  Material and Methods Top


Persons with acute coronary syndrome (ACS) comprising acute ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (non-STEMI) and unstable angina, admitted in a 15-bedded hospital managed by physicians in Tenali, a major town in Guntur District of Andhra Pradesh state, during the period of November 2016 to May 2017, were studied.

All persons admitted with chest pain underwent electrocardiogram (ECG) within 10 Min of arrival to the hospital. ACS was clinically diagnosed on the basis of history of prolonged chest pain lasting more than 20 Min, radiating to the left upper limb or both upper limbs, neck, jaw and back of the chest associated with sweating, weakness, nausea, vomiting, anxiety and a sense of impending doom, confirmed by ECG evidence of ST-elevation in at least two contiguous leads with ST-elevation of more than 2 mm in V1, V2 and V3 and ST-elevation of more than 1 mm in LI, aVL or LII and LIII. Cardiac enzyme studies were not done routinely due to cost factor.

Non-STEMI/unstable angina was diagnosed clinically by ECG evidence of ST-segment depression and/or T-wave inversion and sometimes ST-elevation in aVR. All subjects admitted with ACS were studied clinically with respect to the burden of T2DM and the complications encountered. All the admitted subjects underwent estimation of fasting blood glucose and serum cholesterol levels.

Anterior and inferior wall STEMI subjects were treated by reperfusion therapy with streptokinase after considering contraindications.[6] Soluble aspirin and clopidogrel 300 mg were given orally soon after confirmation of the diagnosis. Non-STEMI/unstable angina subjects were treated with beta-blockers, anticoagulants and a loading dose of aspirin and clopidogrel.[7],[8] High-risk persons with ACS were referred to a cardiologist for coronary angiogram and further management. All the patients with ACS were followed up during their hospital stay till their discharge from the hospital. Diabetes mellitus was diagnosed if fasting blood glucose was >126 mg/dL or 2 h postprandial blood glucose was >200 mg/dL or the person was on antidiabetic drugs as per the American Diabetic Association guidelines.[9]

In all the study patients, the clinical course and occurrence of complications and in-hospital outcome were recorded.

Statistical analysis

Data were recorded in a structured pro forma. Descriptive statistics were reported as proportions.


  Results Top


Out of the 167 persons with ACS admitted during the study period, 110 were male (66%). Sixty-six (39 males; 59%) patients were found to have T2DM. Of the 66 patients with T2DM, 44 (67%) had presented with STEMI and 22 (33%) suffered with non-STEMI/unstable angina [Figure 1]. Among the 44 patients with STEMI, 28 (64%) had received thrombolytic therapy (with streptokinase) and 16 (36%) did not receive thrombolytic therapy due to delayed arrival (>12 h after the onset of chest pain) to the hospital.
Figure 1: Burden of T2DM in patients with acute coronary syndrome ACS = acute coronary syndrome; T2DM = type 2 diabetes mellitus; STEMI = ST-elevation myocardial infarction

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Among the 66 patients with T2DM who presented with ACS, the duration of T2DM was less than 5 years in 19 patients. The duration of T2DM was between 5 and 10 years in 19 patients; 10–15 years in 13 patients and 15–20 years and >20 years in 3 patients each. T2DM was newly diagnosed in 9 patients (13.6%).

Out of the 66 T2DM patients who presented with ACS, ten (15%) died (nine died due to cardiac arrest in hospital and one patient died on the way to another centre). Other complications included acute left ventricular failure (n = 4). Two of these recovered with treatment and two others were shifted to another centre. One patient had developed cardiogenic shock and recovered with treatment. One patient with post-infarction angina was referred to another centre for angiogram.


  Discussion Top


Cardiovascular disease is the leading cause of death worldwide, accounting for 21.9% of the total deaths.[10] People with diabetes have 2- to 4-fold higher risk of developing CAD than people without diabetes, and CAD accounts for 65%–75% of deaths in people with diabetes. Patients with diabetes mellitus have more diffuse and multivessel disease on angiogram.[11] Type 2 diabetes is considered more of a vascular disease than a metabolic disease.[12]

Patients with both cardiovascular disease and diabetes mellitus have been classified as 'extreme-risk groups'.[13] The recent treatment guidelines for STEMI and non-STEMI have also categorised patients with ACS and diabetes mellitus as a special population in consideration of their extremely high risk.[14],[15],[16],[17] However, sparse data are available regarding the burden of diabetes mellitus in patients presenting with ACS and therefore, the present study was designed.

In a study from China,[18] 37.6% of the patients presenting with ACS had diabetes mellitus/possible diabetes mellitus. In the present study, 39.5% of the patients with ACS were found to have T2DM, suggesting that T2DM is a major risk factor for these patients. The fact that 13.6% of patients with T2DM remain undetected until presentation with ACS, further reiterates the need for focussed risk factor assessment in patients presenting with ACS.

Although primary percutaneous transluminal coronary angioplasty is considered the reperfusion strategy of choice, thrombolytic therapy in STEMI is lifesaving and the advantage offered by these interventions is time dependent. In the present study, 16/44 (36%) T2DM patients with STEMI did not receive thrombolytic therapy due to delayed arrival (>12 H after the onset of chest pain) to the hospital. Because of atypical symptoms, patients with T2DM often present to hospital very late and are likely to develop severe complications.[19] In T2DM patients with ACS, chest pain is not severe. More atypical symptoms such as painless infarction, sweating, hypotension and weakness are to be kept in mind. Early recognition of ACS is important to save life and prevent complications.

In India, all patients with ACS do not have access to cardiology care and are cared for by physicians. The present study documents the real-time experience in field level regarding the management of ACS in an intensive care unit by physicians. Therefore, primary angioplasty was not one of the therapeutic options that was extended to patients in the present study. In the present study, of the 66 T2DM patients who presented with ACS, ten (15%) died. Published data suggest that during hospitalisation, ACS patients with diabetes mellitus are more likely to develop complications compared with those without diabetes mellitus.[20],[21]

Despite various therapeutic advances, cardiovascular disease is rampant in patients with T2DM throughout the globe including India. Because of the increasing prevalence of both diabetes mellitus and CAD, which have common causative factors, lifestyle modifications are essential to lessen their burden. Our observations suggest that focussed evaluation of diabetes mellitus in patients presenting with ACS can be life saving.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Diabetes Facts & Figures. Last Update: 12/02/2020. Available from: https://idf.org/aboutdiabetes/what-is-diabetes/facts-figures.html. [Last accessed on 2020 Aug 12].  Back to cited text no. 1
    
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Jellinger PS, Handelsman Y, Rosenblit PD, Bloomgarden ZT, Fonseca VA, Garber AJ, et al. American Association of Clinical Endocrinologists and American College of Endocrinology Guidelines for Management of dyslipidemia and prevention of cardiovascular disease. Endocr Pract 2017;23 Supplement 2:1-87.  Back to cited text no. 13
    
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Zhou M, Liu J, Hao Y, Liu J, Huo Y, Smith SC Jr., et al. CCC-ACS investigators. Prevalence and in-hospital outcomes of diabetes among patients with acute coronary syndrome in china: Findings from the improving care for cardiovascular disease in china-acute coronary syndrome project. Cardiovasc Diabetol 2018;17:147.  Back to cited text no. 18
    
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21.
Subherwal S, Bach RG, Chen AY, Gage BF, Rao SV, Newby LK, et al. Baseline risk of major bleeding in non-ST-segment-elevation myocardial infarction: The CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA Guidelines) bleeding score. Circulation 2009;119:1873-82.  Back to cited text no. 21
    


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