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Impact of Diabetes on Mortality in Patients With Myocardial Infarction and Left Ventricular Dysfunction
Alvaro M. Murcia, MD;
Charles H. Hennekens, MD, DrPH;
Gervasio A. Lamas, MD;
Manuel Jiménez-Navarro, MD;
Jean L. Rouleau, MD;
Greg C. Flaker, MD;
Steven Goldman, MD, DrPH;
Hicham Skali, MD;
Eugene Braunwald, MD;
Marc A. Pfeffer, MD, PhD
Arch Intern Med. 2004;164:2273-2279.
Background Diabetes is a major risk factor for developing coronary heart disease. In patients with diabetes who survived myocardial infarction (MI), less is known about subsequent morbidity and mortality. We evaluated the effects of diabetes in post-MI patients with left ventricular dysfunction on cardiovascular events and death.
Methods The Survival and Ventricular Enlargement, a randomized, double-blind, placebo-controlled multicenter trial, evaluated the efficacy of captopril vs placebo in 2231 patients following acute MI with left ventricular dysfunction defined as an ejection fraction less than or equal to 40%. Patients were randomly assigned to captopril or placebo 3 to 16 days following MI and were followed up for 2 to 5 years (mean, 3.5 years).
Results Among the 2231, 496 (22.2%) were patients with a history of diabetes, of which 168 (33.9%) were treated with insulin. Patients with diabetes were significantly older; more likely to be women; have a history of prior MI or hypertension; be obese or manifest Killip class II or greater; and have higher systolic blood pressure, pulse pressure, and heart rate, as well as lower ejection fraction. During follow-up, 31.3% of patients with diabetes and 20.1% of nondiabetic patients died (P<.001). Furthermore, 50% of the patients with diabetes had at least 1 major cardiovascular event compared with 32.3% among the nondiabetic patients (P<.001). In multivariate analysis that adjusted for all significant differences in baseline characteristics, patients with diabetes had a 39% higher total mortality (P = .001) and 49% more cardiovascular events (P = .001). Among the patients with diabetes, baseline insulin treatment was associated with a greater risk of death (41.1% vs 26.2%; P = .001) and cardiovascular events (58.3% vs 45.7%; P = .008).
Conclusions In patients who survived MI with left ventricular dysfunction, diabetes increased risk of death from all causes even after controlling for differences in other risk factors. Patients with diabetes treated with insulin have a particularly higher mortality risk. Patients with diabetes who survived MI with left ventricular dysfunction, in particular those receiving insulin, are at high risk of subsequent mortality and cardiovascular events and thus require intensive risk factor modification, as well as evaluation for novel therapies.
Author Affiliations: Mount Sinai Medical Center & Miami Heart Institute (Drs Murcia and Lamas) and Agatston Research Institute (Dr Hennekens), Miami Beach, Fla; University of Miami School of Medicine, Miami, Fla (Drs Hennekens and Lamas); Hospital Clínico Universitario Virgen de la Victoria, Málaga, Spain (Dr Jiménez-Navarro); Toronto General Hospital, Toronto, Ontario (Dr Rouleau); University of Missouri Hospital and Clinics, Columbia (Dr Flaker); Tucson VA Hospital, Tucson, Ariz (Dr Goldman); and Brigham and Women’s Hospital and Harvard Medical School, Boston, Mass (Drs Skali, Braunwald, and Pfeffer).
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