Invasive strategy in patients with advanced diabetes and non-ST-segment elevation acute coronary syndrome.: Angiographic findings and clinical follow-up.: PREDICAR study results

Introduction and objectives. Advanced diabetes can be associated with diffuse coronary artery disease that is difficult to treat by revascularization. We studied angiographic findings and disease progression in patients with advanced diabetes (either insulin-dependent or taking antidiabetic drugs for > 5 years) and non-ST-elevation acute coronary syndrome who were being treated using an invasive strategy. Methods. The study included 141 patients. The extent of the coronary artery disease was quantified using a score derived from a 29-segment coronary angiogram. The composite endpoint was death, myocardial infarction, or readmission for unstable angina within one year of follow-up. Results. The extent of coronary disease was associated with Killip class > 1 at admission (P=.02), previous coronary surgery (P=.003), ST-segment depression (P=.01), and a poor ejection fraction (P=.0001). The more of these factors present (i.e., 0, 1, 2 or 3 factors), the greater the extent of the coronary disease (i.e., 12 [7], 15 [7], 21 [6] and 23 [7] points, respectively; P=.0001). There was a significant difference between patients with >= 2 factors and those with < 2 factors. Eighty-five patients (60%) underwent revascularization during hospital admission and 39 (28%) experienced endpoint events during follow-up. Revascularization was the only factor related to outcome (hazard ratio [HR] =0.43; 95% confidence interval [CI], 0.20-0.90; P=.02), even after adjustment using a revascularization propensity score (C-index 0.80). Conclusions. In patients with non-ST-elevation acute coronary syndrome and advanced diabetes being managed using an invasive strategy, a history of coronary surgery, ST-segment depression and poor left ventricular function were all associated with the presence of diffuse coronary artery disease. Clinical follow-up indicated that revascularization during hospital admission improved prognosis.