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PUBLIC "-//NLM//DTD JATS (Z39.96) Journal Archiving and Interchange DTD with MathML3 v1.3 20210610//EN" "JATS-archivearticle1-3-mathml3.dtd">
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<article xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink" dtd-version="1.3" xml:lang="en" article-type="research-article"><?properties open_access?><processing-meta base-tagset="archiving" mathml-version="3.0" table-model="xhtml" tagset-family="jats"><restricted-by>pmc</restricted-by></processing-meta><front><journal-meta><journal-id journal-id-type="nlm-ta">Intern Med</journal-id><journal-id journal-id-type="iso-abbrev">Intern Med</journal-id><journal-title-group><journal-title>Internal Medicine</journal-title></journal-title-group><issn pub-type="ppub">0918-2918</issn><issn pub-type="epub">1349-7235</issn><publisher><publisher-name>The Japanese Society of Internal Medicine</publisher-name></publisher></journal-meta>
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<article-meta><article-id pub-id-type="pmid">38403771</article-id><article-id pub-id-type="pmc">11518611</article-id>
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<article-id pub-id-type="doi">10.2169/internalmedicine.2987-23</article-id><article-categories><subj-group subj-group-type="heading"><subject>Original Article</subject></subj-group></article-categories><title-group><article-title>An In-depth Single-center Retrospective Assessment of In-hospital Outcomes in Acute Myocardial Infarction Patients with and without Diabetes</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Hitomi</surname><given-names>Sho</given-names></name><xref rid="aff1" ref-type="aff">1</xref></contrib><contrib contrib-type="author"><name><surname>Koeda</surname><given-names>Yorihiko</given-names></name><xref rid="aff1" ref-type="aff">1</xref></contrib><contrib contrib-type="author"><name><surname>Tosaka</surname><given-names>Kengo</given-names></name><xref rid="aff1" ref-type="aff">1</xref></contrib><contrib contrib-type="author"><name><surname>Kanehama</surname><given-names>Nozomu</given-names></name><xref rid="aff1" ref-type="aff">1</xref></contrib><contrib contrib-type="author"><name><surname>Niiyama</surname><given-names>Masanobu</given-names></name><xref rid="aff2" ref-type="aff">2</xref></contrib><contrib contrib-type="author"><name><surname>Ishida</surname><given-names>Masaru</given-names></name><xref rid="aff1" ref-type="aff">1</xref></contrib><contrib contrib-type="author"><name><surname>Itoh</surname><given-names>Tomonori</given-names></name><xref rid="aff1" ref-type="aff">1</xref></contrib><contrib contrib-type="author"><name><surname>Morino</surname><given-names>Yoshihiro</given-names></name><xref rid="aff1" ref-type="aff">1</xref></contrib><aff id="aff1">
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<label>1</label>Division of Cardiology, Department of Internal Medicine, Iwate Medical University, Japan</aff><aff id="aff2">
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<label>2</label>Department of Cardiology, Japanese Red Cross Hachinohe Hospital, Japan</aff></contrib-group><author-notes><fn><p>Correspondence to Dr.　Yoshihiro Morino, <email>ymorino@iwate-med.ac.jp</email></p></fn></author-notes><pub-date pub-type="epub"><day>26</day><month>2</month><year>2024</year></pub-date><pub-date pub-type="ppub"><day>1</day><month>10</month><year>2024</year></pub-date><volume>63</volume><issue>19</issue><fpage>2595</fpage><lpage>2603</lpage><history><date date-type="received"><day>2</day><month>10</month><year>2023</year></date><date date-type="accepted"><day>25</day><month>12</month><year>2023</year></date></history><permissions><copyright-statement>Copyright © 2024 by The Japanese Society of Internal Medicine</copyright-statement><license><ali:license_ref xmlns:ali="http://www.niso.org/schemas/ali/1.0/" specific-use="textmining" content-type="ccbyncndlicense">https://creativecommons.org/licenses/by-nc-nd/4.0/</ali:license_ref><license-p>The Internal Medicine is an Open Access journal distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. To view the details of this license, please visit (<ext-link xlink:href="https://creativecommons.org/licenses/by-nc-nd/4.0/" ext-link-type="uri">https://creativecommons.org/licenses/by-nc-nd/4.0/</ext-link>).</license-p></license></permissions><abstract><sec><title>Objective</title><p>This study examined variations in in-hospital mortality causes and identified independent mortality predictors among patients with acute myocardial infarction (AMI) with and without diabetes mellitus (DM).</p></sec><sec><title>Methods</title><p>We examined factors influencing in-hospital mortality in a single-center retrospective observational study. Separate multivariate analyses were conducted for both groups to identify independent predictors of in-hospital mortality.</p></sec><sec><title>Patients</title><p>This study included consecutive patients admitted to Iwate Medical University Hospital between January 2012 and December 2017 with a diagnosis of AMI.</p></sec><sec><title>Results</title><p>Of 1,140 patients meeting the AMI criteria (average age: 68.2±12.8 years old, 75% men), 408 (35.8%) had diabetes. The DM group had a 1.87-times higher 30-day mortality rate, a lower prevalence of ST-elevated MI (56.6% vs. 65.3% in non-DM, p=0.004), and more frequent non-cardiac causes of death (32% vs. 14% in non-DM, p=0.046) than the non-DM group. Independent predictors of in-hospital mortality in both groups were cardiogenic shock (CS) [DM: hazard ratio (HR) 6.59, 95% confidence interval (CI) 2.90-14.95; non-DM: HR 4.42, 95% CI 1.99-9.77] and renal dysfunction (DM: HR 5.64, 95% CI 1.59-20.04; non-DM: HR 5.92, 95% CI 1.79-19.53). Among patients with DM, a history of stroke was an additional independent predictor of in-hospital mortality (HR 2.59, 95% CI 1.07-6.31).</p></sec><sec><title>Conclusion</title><p>Notable disparities were identified in the causes of death and predictive factors of mortality between these two groups of patients with AMI. To further improve AMI outcomes, individualized management and prioritizing non-cardiac comorbidities during hospitalization may be crucial, particularly in patients with DM.</p></sec></abstract><kwd-group kwd-group-type="author"><kwd>diabetes mellitus</kwd><kwd>acute myocardial infarction</kwd><kwd>cause of death</kwd><kwd>mortality</kwd></kwd-group></article-meta></front><body><sec><title>Introduction</title><p>Diabetes mellitus (DM) is widely recognized as being associated with poor clinical scenarios across various facets of ischemic heart disease. Indeed, it is a significant risk factor for coronary disease. Furthermore, atherosclerotic changes in coronary arteries tend to exhibit a more extensive distribution in individuals with DM than in those without DM. Following revascularization, a higher occurrence of restenosis or major adverse clinical events is expected in patients with DM than in those without DM during the follow-up period. Drug-eluting stents have also been employed in such cases (<xref rid="B1" ref-type="bibr">1</xref>).</p><p>Acute myocardial infarction (AMI) has remained a significant contributor to mortality worldwide. Based on an observational multicenter registry in Japan, 36.4% of AMI patients were found to have DM as a comorbidity (<xref rid="B2" ref-type="bibr">2</xref>).</p><p>With the widespread adoption of primary coronary intervention (PCI), AMI mortality has substantially declined. The current nationwide registry database in Japan has indicated that the mortality rate could be reduced to less than 3% if AMI patients were to receive primary PCI (<xref rid="B3" ref-type="bibr">3</xref>). However, a German study that compared outcomes between 2005 and 2021 highlighted that the rates of in-hospital death remained significantly higher in myocardial infarction (MI) patients with DM than in those without DM, despite an overall reduction in in-hospital mortality (<xref rid="B4" ref-type="bibr">4</xref>). Even with the contemporary utilization of primary PCI, patients with DM still experience higher in-hospital mortality than those without DM (<xref rid="B5" ref-type="bibr">5</xref>), and the long-term prognosis has also been observed to be worse within this population (<xref rid="B6" ref-type="bibr">6</xref>).</p><p>While the overall association between AMI and DM has been confirmed, a comprehensive evaluation, including a precise determination of the direct cause of death, is lacking. Accordingly, the present study aimed to elucidate specific variations in the direct causes of in-hospital mortality between patients with and without DM in order to identify the independent factors that predict mortality, considering each patient group separately.</p><p>Our study endeavored to achieve a comprehensive understanding of the differences in the causes of death associated with AMI in patients with and without DM and to identify distinct predictors of mortality within these two patient groups.</p></sec><sec><title>Materials and Methods</title><sec><title>Study population</title><p>The study population comprised patients admitted to Iwate Medical University Hospital between January 2012 and December 2017 due to AMI, specifically those who met the criteria outlined in the 3rd universal definition of MI (<xref rid="B7" ref-type="bibr">7</xref>).</p><p>AMI was diagnosed based on the evidence of myocardial necrosis in patients with acute myocardial ischemia in a clinical setting. The criteria for detection included the presence of a rise and/or fall in cardiac biomarker values, with at least one value exceeding the 99th percentile upper reference limit. In addition, at least one of the following conditions had to be met: 1) symptoms of ischemia; 2) new or presumed new significant ST-segment-T wave changes or new left bundle branch block; 3) development of a pathological Q wave on an electrocardiogram (ECG); 4) imaging evidence of new loss of viable myocardium or new regional wall motion abnormality; and 5) identification of an intracoronary thrombus by angiography or autopsy. Furthermore, in accordance with the classification of MI (types 1 to 5) as defined by the 3rd universal definition (<xref rid="B7" ref-type="bibr">7</xref>), the patients were classified as either type 1, spontaneous MI; type 2, MI secondary to an ischemia imbalance; or MI resulting in death when biomarker values were unavailable.</p><p>The exclusion criteria for the study subjects were as follows: 1) patients with AMI classified into two categories [type 4, including MI related to PCI or stent thrombosis; and type 5, including MI related to coronary artery bypass grafting (CABG)]; 2) patients transported after an unexplained cardiac arrest who died without resuscitation or admission, making the involvement of myocardial ischemia unclear; and 3) patients who declined to participate in the study via an opt-out mechanism.</p><p>The study was conducted in accordance with the ethical provisions of the Helsinki Declaration (2013 Brazil revision) and approved by the Ethics Committee of Iwate Medical University (MH2023-013). In this retrospective observational study, eligible patients were provided an opportunity to opt out (https://iwate-heart.jp/public_information/).</p></sec><sec><title>Definition</title><p>The definition of each parameter used in this study was established by referring to previous studies that are widely regarded as representative in the field. Hypertension was defined (in accordance with the ACC/AHA Stage 2 hypertension guidelines) as a systolic blood pressure of ≥140 mmHg, a diastolic blood pressure of ≥90 mmHg upon admission, or the use of antihypertensive medication (<xref rid="B8" ref-type="bibr">8</xref>). Diabetes was defined as a blood sugar level ≥200 mg/dL upon admission, an HbA1c level of ≥6.5%, or the administration of diabetes medication (<xref rid="B9" ref-type="bibr">9</xref>). For cases that did not meet this definition, fasting blood sugar, daily blood sugar fluctuation, and glucose tolerance tests were not conducted. Dyslipidemia was defined in line with the guidelines in Japan as low-density lipoprotein (LDL)-cholesterol ≥140 mg/dL or high-density lipoprotein (HDL)-cholesterol <40 mg/dL (<xref rid="B10" ref-type="bibr">10</xref>) and included a total cholesterol level of ≥240 mg/dL or the administration of lipid-lowering drugs. A history of ischemic heart disease was defined as a history of AMI or revascularization (PCI or CABG). A current smoking habit was defined as smoking within the year prior to admission. A history of stroke was defined as any past stroke that required hospitalization, including cerebral infarction and intracranial hemorrhaging. Consequently, incidental asymptomatic lacunar infarctions identified on imaging were excluded. Atrial fibrillation was defined as any history of treatment, regardless of whether it was chronic or paroxysmal, or any evidence of atrial fibrillation found on previous Holter monitoring or a 12-lead ECG. Cases of transient paroxysmal atrial fibrillation observed during hospitalization without a previous record were not included. However, those with consistent atrial fibrillation waveforms upon admission, even without prior records, were included. Obesity was defined as a body mass index (BMI) ≥25.0 kg/m<sup>2</sup> or higher upon admission (<xref rid="B11" ref-type="bibr">11</xref>). Renal dysfunction was defined as an estimated glomerular filtration rate (eGFR) of <60 mL/min/1.73 m<sup>2</sup> upon admission (<xref rid="B12" ref-type="bibr">12</xref>) or dialysis.</p></sec><sec><title>Study endpoints</title><p>The primary outcome measure was in-hospital mortality, and a thorough examination of the underlying causes of death was conducted. Secondary outcome measures included acute-phase complications that occurred during hospitalization, such as heart failure, shock, arrhythmias, bleeding, mechanical complications, and infections.</p></sec><sec><title>Statistical analyses</title><p>All statistical analyses were performed using the SPSS<sup>Ⓡ</sup> 28.0 software program for Windows (IBM, Chicago, USA). The patients were divided into two groups based on the presence or absence of DM, and the analyses were conducted accordingly. For comparisons between the two groups, the chi-squared and Mann-Whitney U tests were employed. The Kaplan-Meier method was used to calculate the cumulative event occurrence rate. The hazard ratio (HR) for event occurrence was assessed using a Cox proportional hazards model. Statistical significance was set at p<0.05.</p></sec></sec><sec><title>Results</title><sec><title>Patient and clinical characteristics</title><p>A total of 1,140 patients with AMI met the enrollment criteria, and 408 patients (35.8%) were categorized as having DM. The mean age of the patients was 68.2±12.8 years old, and 75% were men.</p><p>The participants were stratified into two groups based on the presence of DM. <xref rid="t001" ref-type="table">Table 1</xref> shows a comparison of the baseline clinical characteristics between the DM and non-DM groups. The DM group had a significantly higher BMI and a higher prevalence of hyperlipidemia than the non-DM group. In contrast, a current smoking habit and hypertension were significantly more prevalent in the non-DM group than in the DM group. Regarding the history of major vascular diseases, a history of coronary artery disease or stroke was significantly more frequent in the DM group than in the non-DM group. Importantly, the frequency of cardiac arrest on admission was significantly higher in the DM group than in the non-DM group, despite no apparent differences in systolic and diastolic blood pressure values on admission between the two groups.</p><table-wrap position="float" id="t001"><label>Table 1.</label><caption><p>A Comparison of Baseline Clinical Characteristics between the DM or Non-DM Groups.</p></caption><table frame="hsides" rules="groups"><thead style="border-top:solid thin; border-bottom:solid thin;"><tr><th valign="middle" align="center" rowspan="1" colspan="1">Variables</th><th style="width:1em" rowspan="1" colspan="1"/><th valign="middle" align="center" rowspan="1" colspan="1">Total (n=1140)</th><th style="width:1em" rowspan="1" colspan="1"/><th valign="middle" align="center" rowspan="1" colspan="1">DM (n=408)</th><th style="width:1em" rowspan="1" colspan="1"/><th valign="middle" align="center" rowspan="1" colspan="1">Non-DM (n=732)</th><th style="width:1em" rowspan="1" colspan="1"/><th valign="middle" align="center" rowspan="1" colspan="1">p value</th></tr></thead><tbody style="border-top:solid thin; border-bottom:solid thin;"><tr><td valign="top" rowspan="1" colspan="1">
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<bold>Age (years)</bold>
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</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">68.2±12.8</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">68.3±12.1</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">68.0±13.1</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.977</td></tr><tr><td valign="top" rowspan="1" colspan="1">
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<bold>Sex (male)</bold>
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</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">76.0%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">74.8%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">76.6%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.475</td></tr><tr><td valign="top" rowspan="1" colspan="1">
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<bold>BMI (kg/m<sup>2</sup>)</bold>
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</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">24.4±4.0</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">25.0±4.2</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">24.0±3.8</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1"><0.001</td></tr><tr><td valign="top" rowspan="1" colspan="1">
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<bold>Obesity (BMI≥25)</bold>
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</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">38.1%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">45.6%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">34.6%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1"><0.001</td></tr><tr><td valign="top" rowspan="1" colspan="1">
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<bold>DM</bold>
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</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">35.8%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">100%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1"/></tr><tr><td valign="top" rowspan="1" colspan="1">
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<bold>Hypertension</bold>
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</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">69.9%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">78.7%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">64.9%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1"><0.001</td></tr><tr><td valign="top" rowspan="1" colspan="1">
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<bold>Dyslipidemia</bold>
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</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">51.3%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">62.8%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">44.8%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1"><0.001</td></tr><tr><td valign="top" rowspan="1" colspan="1">
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<bold>Current smoker</bold>
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</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">34.9%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">34.4%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">35.2%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.784</td></tr><tr><td valign="top" rowspan="1" colspan="1">
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<bold>History of CAD</bold>
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</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">13.5%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">21.4%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">9.0%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1"><0.001</td></tr><tr><td valign="top" rowspan="1" colspan="1">
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<bold>History of stroke</bold>
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</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">11.5%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">15.3%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">9.4%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.005</td></tr><tr><td valign="top" rowspan="1" colspan="1">
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<bold>History of atrial fibrillation</bold>
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</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">7.9%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">9.1%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">7.2%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.266</td></tr><tr><td valign="top" rowspan="1" colspan="1">
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<bold>CPA on admission</bold>
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</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">5.3%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">7.2%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">4.2%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.029</td></tr><tr><td valign="top" rowspan="1" colspan="1">
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<bold>Systolic BP on admission (mmHg)</bold>
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</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">145±34</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">144±34</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">145±34</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.517</td></tr><tr><td valign="top" rowspan="1" colspan="1">
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<bold>Diastolic BP on admission (mmHg)</bold>
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</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">85±21</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">83±21</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">86±22</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.027</td></tr><tr><td valign="top" rowspan="1" colspan="1">
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<bold>HR on admission (bpm)</bold>
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</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">81±19</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">82±20</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">81±19</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.105</td></tr><tr><td valign="top" rowspan="1" colspan="1">
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<bold>STEMI</bold>
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</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">62.2%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">56.6%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">65.3%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.004</td></tr><tr><td valign="top" rowspan="1" colspan="1">
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<bold>Killip I-IV (%)</bold>
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</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">71.6/14.3/5.5/8.6</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">64.2/16.3/7.9/11.6</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">75.8/13.1/4.1/6.9</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1"><0.001</td></tr><tr><td valign="top" rowspan="1" colspan="1">
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<bold>LVEF (%)</bold>
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</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">51.4±19.7</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">49.6±28.9</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">52.3±11.6</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1"><0.001</td></tr><tr><td valign="top" rowspan="1" colspan="1">
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<bold>Serum creatinine (mg/dL)</bold>
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</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">1.24±1.65</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">1.57±2.12</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">1.06±1.29</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.008</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>eGFR (mL/min/1.73 m<sup>2</sup>)</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">68.0±28.5</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">64.3±33.0</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">70.1±25.5</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.003</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>Renal dysfuncti on (eGFR<60)</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">36.9%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">44.4%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">32.8%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1"><0.001</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>Hemodialysis or CAPD</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">4.4%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">8.1%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">2.3%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1"><0.001</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>Blood glucose (mg/dL)</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">163±78</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">207±97</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">140±50</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1"><0.001</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>Hemoglobin A1c (%)</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">6.1±1.5</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">7.1±1.5</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">5.6±0.5</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1"><0.001</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>Triglyceride (mg/dL)</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">127±111</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">138±146</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">120±84</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.002</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>Total cholesterol (mg/dL)</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">186±45</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">179±49</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">189±42</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1"><0.001</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>LDL-cholesterol (mg/dL)</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">115±37</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">109±37</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">119±37</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1"><0.001</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>HDL-cholesterol (mg/dL)</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">47±14</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">45±15</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">48±14</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1"><0.001</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>L/H ratio</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">2.6±1.0</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">2.5±1.0</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">2.6±1.0</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.144</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>Brain natriuretic peptide (pg/mL)</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">381±800</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">511±975</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">308±673</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.001</td></tr></tbody></table><table-wrap-foot><fn><p>DM: diabetes mellitus, BMI: body mass index, CAD: coronary artery disease, CPA: cardiopulmonary arrest, BP: blood pressure, HR: heart rate, STEMI: ST elevation myocardial infarction, LVEF: left ventricular ejection fraction, eGFR: estimated glomerular filtration rate, CAPD: continuous ambulatory peritoneal dialysis, LDL: low density lipoprotein, HDL: high density lipoprotein</p></fn></table-wrap-foot></table-wrap><p>The prevalence of ST-elevated MI was significantly lower in the DM group than in the non-DM group. Significant differences were observed between the two groups in terms of the ejection fraction on admission, serum creatinine level, eGFR, serum B-type natriuretic peptide (BNP) level, and Killip status. A blood examination of serum lipid profiles revealed a significantly higher triglyceride level and a significantly lower LDL-cholesterol level in the DM group than in the non-DM group.</p></sec><sec><title>Patient management and overall in-hospital outcomes</title><p>A detailed comparison of the patient management strategies is presented in <xref rid="t002" ref-type="table">Table 2</xref>. In the DM group, emergent coronary angiography and PCI were performed significantly less frequently than in the non-DM group. In addition, the prevalence of lesions involving the left main coronary artery was significantly higher in the DM group than in the non-DM group. Furthermore, patients in the DM group underwent CABG significantly more frequently than in the non-DM group.</p><table-wrap position="float" id="t002"><label>Table 2.</label><caption><p>A Comparison of Patient Management between the Two Groups.</p></caption><table frame="hsides" rules="groups"><thead style="border-top:solid thin; border-bottom:solid thin;"><tr><th valign="middle" align="center" rowspan="1" colspan="1">Variables</th><th style="width:1em" rowspan="1" colspan="1"/><th valign="middle" align="center" rowspan="1" colspan="1">Total (n=1,140)</th><th style="width:1em" rowspan="1" colspan="1"/><th valign="middle" align="center" rowspan="1" colspan="1">DM (n=408)</th><th style="width:1em" rowspan="1" colspan="1"/><th valign="middle" align="center" rowspan="1" colspan="1">Non-DM (n=732)</th><th style="width:1em" rowspan="1" colspan="1"/><th valign="middle" align="center" rowspan="1" colspan="1">p value</th></tr></thead><tbody style="border-top:solid thin; border-bottom:solid thin;"><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>Emergency coronary angiography</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">87.8%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">84.2%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">89.7%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.007</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>Lesion of left main trunk</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">9.7%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">13.9%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">7.3%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.001</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>Multivessel coronary artery disease</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">59.6%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">71.4%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">53.0%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1"><0.001</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>Emergency PCI</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">78.4%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">73.8%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">81.0%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.004</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>Slow-flow or no-reflow post PCI</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">14.2%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">16.1%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">13.1%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.203</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>Coronary artery bypass grafting</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">9.2%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">12.3%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">7.5%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.008</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>Respirator</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">10.5%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">14.2%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">8.5%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.004</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>Intra-aortic balloon pumping</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">11.4%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">16.7%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">8.4%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1"><0.001</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>VA-ECMO</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">2.0%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">3.3%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">1.3%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.023</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>Peak creatine kinase (IU/L)</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">2,198±2,758</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">2,073±2,850</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">2,269±2,705</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.003</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>Hospitalization days</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">19±48</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">20±22</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">18±57</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.002</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>In-hospital mortality</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">6.6%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">9.3%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">5.1%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.005</td></tr></tbody></table><table-wrap-foot><fn><p>DM: diabetes mellitus, PCI: percutaneous coronary intervention, VA-ECMO: venoarterial extracorporeal membrane oxygenation</p></fn></table-wrap-foot></table-wrap><p>Regarding mechanical support, patients in the DM group received significantly more frequent treatments with mechanical ventilation, intra-aortic balloon pump, and veno-atrial extracorporeal membrane oxygenation than in the non-DM group. As a result, in-hospital mortality was significantly higher and the length of hospital stay significantly longer in the DM group than in the non-DM group. The Kaplan-Meier survival curve of in-hospital mortality (within 30 days after admission), illustrated in <xref rid="g001" ref-type="fig">Fig. 1</xref>, shows a significant difference between the two groups. The HR for in-hospital mortality in the DM group was 1.87 (95% confidence interval: 1.19-2.93, p=0.007).</p><fig position="float" id="g001"><label>Figure 1.</label><caption><p>Thirty-day cumulative survival rates in patients with acute myocardial infarction, stratified by DM status. Patients with DM (shown in red) had a significantly lower survival rate than those without DM (shown in blue).</p></caption><graphic xlink:href="1349-7235-63-2595-g001" position="float"/></fig></sec><sec><title>An in-depth analysis of the causes of in-hospital deaths and predictive factors</title><p>The in-hospital mortality rate of the 1,140 patients included in this study was 6.6%. A comparison of the causes of in-hospital death between the two groups is shown in <xref rid="g002" ref-type="fig">Fig. 2</xref>. Nearly half of the causes were attributed to cardiogenic shock (CS) in both groups. However, the remaining causes of death appeared to differ between the two groups, particularly in terms of mechanical complications, infection, and malignant disease. When comparing the causes of death, a higher proportion of non-cardiac deaths (including infections, malignancies, strokes, and multiple organ failures) were observed in the DM group than in the non-DM group (32% vs. 14%, p=0.046, respectively). Deaths due to mechanical complications were more frequent in the non-DM group than in the DM group; however, the difference was not statistically significant (DM: 16% vs. non-DM: 32%, p=0.119). When examining the relationship between the timing of death and its causes, it was found that, for both groups, the majority of deaths until the third clinical day were predominantly due to CS or mechanical complications. However, regarding the causes of death after the tenth clinical day, in the DM group, the proportion of deaths attributed to CS or mechanical complications was <30%, with a greater number of patients dying from other causes, such as lethal arrhythmias, cerebral infarction, infections, and malignancies. In contrast, in the non-DM group, the proportion of patients dying from CS or mechanical complications remained high (65%).</p><fig position="float" id="g002"><label>Figure 2.</label><caption><p>Pie charts illustrating the causes of death in each group reveal differences. In the DM group, a higher percentage of non-cardiac deaths, such as infections, malignancies, strokes, and multiple organ failures, was observed than in the non-DM group (32% vs. 14%, respectively), with a statistically significant difference (p=0.046). Among the six cases of mechanical complications in patients who died in the DM group, there were two cases of ventricular septal rupture (VSR) and four cases of free-wall rupture (FWR). In the non-DM group, out of the 12 cases of mechanical complications in deceased patients, there were 4 cases of VSR, 7 of FMR, and 1 of papillary muscle rupture (PMR).</p></caption><graphic xlink:href="1349-7235-63-2595-g002" position="float"/></fig><p>Factors potentially associated with in-hospital mortality were individually compared between those who survived and those who died in both the DM and non-DM groups (<xref rid="t003" ref-type="table">Table 3</xref>). In the DM group, statistically significant differences were observed in the age, hypertension, current smoking habit, history of stroke, Killip status, ejection fraction on admission, renal dysfunction (eGFR <60 mL/min/1.73 m<sup>2</sup>), and serum BNP levels between the survival and in-hospital death subgroups. However, these factors showed slight variation in the non-DM group. Interestingly, the sex, history of atrial fibrillation, and ST elevation were also found to be significantly different factors in the non-DM group. Notably, in the non-DM group, a history of stroke no longer had a significant impact on in-hospital death when comparing the surviving and deceased patients.</p><table-wrap position="float" id="t003"><label>Table 3.</label><caption><p>Comparisons of Clinical Characteristics between AMI Patients Who Survived and Those Who Died from Both the DM and Non-DM Groups.</p></caption><table frame="hsides" rules="groups"><thead style="border-top:solid thin; border-bottom:solid thin;"><tr><th rowspan="2" valign="middle" align="center" colspan="1">Variables</th><th rowspan="2" style="width:1em" colspan="1"/><th colspan="5" valign="middle" align="center" style="border-bottom:solid thin;" rowspan="1">DM (n=408)</th><th rowspan="2" valign="middle" style="width:1em" colspan="1"/><th colspan="5" valign="middle" align="center" style="border-bottom:solid thin;" rowspan="1">Non-DM (n=732)</th></tr><tr><th valign="middle" align="center" rowspan="1" colspan="1">Survivors <break/>(n=370)</th><th style="width:1em" rowspan="1" colspan="1"/><th valign="middle" align="center" rowspan="1" colspan="1">In-hospital death <break/>(n=38)</th><th style="width:1em" rowspan="1" colspan="1"/><th valign="middle" align="center" rowspan="1" colspan="1">p value</th><th valign="middle" align="center" rowspan="1" colspan="1">Survivors <break/>(n=695)</th><th style="width:1em" rowspan="1" colspan="1"/><th valign="middle" align="center" rowspan="1" colspan="1">In-hospital death <break/>(n=37)</th><th style="width:1em" rowspan="1" colspan="1"/><th valign="middle" align="center" rowspan="1" colspan="1">p value</th></tr></thead><tbody style="border-top:solid thin; border-bottom:solid thin;"><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>Age (years)</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">67.9±12.3</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">72.8±9.6</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.025</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">67.6±13.0</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">75.7±12.7</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1"><0.001</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>Sex (male)</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">74.3%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">78.9%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.532</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">77.6%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">59.5%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.011</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>Obesity (BMI≥25)</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">46.1%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">40.5%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.520</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">35.1%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">24.2%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.199</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>Hypertension</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">80.3%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">63.2%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.014</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">64.0%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">82.9%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.022</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>Dyslipidemia</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">63.3%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">57.9%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.510</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">45.1%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">40.0%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.556</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>Current smoker</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">35.9%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">14.3%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.020</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">36.1%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">14.3%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.018</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>History of CAD</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">21.9%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">16.2%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.422</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">8.7%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">14.3%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.263</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>History of stroke</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">13.8%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">28.6%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.022</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">9.7%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">3.2%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.227</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>History of atrial fibrillation</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">8.4%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">15.8%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.130</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">6.1%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">27.8%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1"><0.001</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>Cardiogenic shock (Killip IV)</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">6.5%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">62.2%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1"><0.001</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">4.5%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">52.8%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1"><0.001</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>STEMI</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">55.4%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">68.4%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.123</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">64.2%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">86.1%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.007</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>LVEF (%)</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">49.5±12.0</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">50.8±89.3</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1"><0.001</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">52.7±11.4</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">44.2±13.8</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1"><0.001</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>Blood glucose (mg/dL)</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">200±88</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">282±149</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.001</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">128±27</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">133±47</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.252</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>Renal dysfunction (eGFR<60)</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">40.5%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">81.6%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1"><0.001</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">39.6%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">84.8%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1"><0.001</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>Brain natriuretic peptide (pg/mL)</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">463.6±935.3</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">972.4±1225.5</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1"><0.001</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">279.8±625.9</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">834.9±1146.0</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1"><0.001</td></tr><tr><td valign="top" rowspan="1" colspan="1"><bold>Revascularization</bold>
|
|
<break/><bold>(emergency PCI or CABG)</bold></td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">82.7%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">73.7%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.169</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">86.3%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">62.2%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1"><0.001</td></tr><tr><td valign="top" style="padding-left:1em;" rowspan="1" colspan="1">
|
|
<bold>- Emergency PCI</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">74.1%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">71.1%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.689</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">82.4%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">54.1%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1"><0.001</td></tr><tr><td valign="top" style="padding-left:1em;" rowspan="1" colspan="1">
|
|
<bold>- CABG</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">13.2%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">2.6%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.057</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">7.3%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">10.8%</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.435</td></tr></tbody></table><table-wrap-foot><fn><p>DM: diabetes mellitus, BMI: body mass index, CAD: coronary artery disease, STEMI: ST-elevation myocardial infarction, LVEF: left ventricular ejection fraction, eGFR: estimated glomerular filtration rate, PCI: percutaneous coronary intervention, CABG: coronary artery bypass grafting</p></fn></table-wrap-foot></table-wrap><p>The predictors of in-hospital mortality for both the DM and non-DM groups were analyzed separately using univariate analyses, and the results are shown in <xref rid="t004" ref-type="table">Table 4</xref>. Any factors found to be statistically significant in the univariate analyses in either group were included in the Cox's proportional hazards model to identify independent predictors of in-hospital death, as shown in <xref rid="t005" ref-type="table">Table 5</xref>. Consequently, CS, renal dysfunction, and a history of stroke independently predicted in-hospital mortality in the DM group. Conversely, CS and renal dysfunction were independent predictors of in-hospital mortality in the non-DM group. Furthermore, in the non-DM group, patients who underwent revascularization (emergency PCI or CABG) had a lower risk of in-hospital mortality than those who did not, but this difference was not statistically significant in the DM group. An interaction test for in-hospital death using a two-way analysis of variance showed that there was an interaction between “DM” and “a history of stroke” (p=0.006).</p><table-wrap position="float" id="t004"><label>Table 4.</label><caption><p>Univariate Analyses for In-hospital Death.</p></caption><table frame="hsides" rules="groups"><thead style="border-top:solid thin; border-bottom:solid thin;"><tr><th rowspan="2" valign="middle" align="center" colspan="1">Variables</th><th rowspan="2" style="width:1em" colspan="1"/><th colspan="5" valign="middle" align="center" style="border-bottom:solid thin;" rowspan="1">DM (n=408)</th><th rowspan="2" valign="middle" style="width:1em" colspan="1"/><th colspan="5" valign="middle" align="center" style="border-bottom:solid thin;" rowspan="1">Non-DM (n=732)</th></tr><tr><th valign="middle" align="center" rowspan="1" colspan="1">HR</th><th style="width:1em" rowspan="1" colspan="1"/><th valign="middle" align="center" rowspan="1" colspan="1">95%CI</th><th style="width:1em" rowspan="1" colspan="1"/><th valign="middle" align="center" rowspan="1" colspan="1">p value</th><th valign="middle" align="center" rowspan="1" colspan="1">HR</th><th style="width:1em" rowspan="1" colspan="1"/><th valign="middle" align="center" rowspan="1" colspan="1">95%CI</th><th style="width:1em" rowspan="1" colspan="1"/><th valign="middle" align="center" rowspan="1" colspan="1">p value</th></tr></thead><tbody style="border-top:solid thin; border-bottom:solid thin;"><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>Age (years)</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">1.03</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(0.99-1.06)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.061</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">1.05</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(1.02-1.08)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.002</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>Sex (female)</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.77</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(0.35-1.69)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.517</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">2.10</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(1.09-4.06)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.028</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>Hypertension</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.45</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(0.23-0.87)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.017</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">2.45</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(1.02-5.91)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.046</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>History of stroke</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">1.90</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(0.91-3.97)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.087</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.26</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(0.36-1.93)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.263</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>History of atrial fibrillation</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">1.90</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(0.79-4.58)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.15</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">4.07</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(1.93-8.55)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1"><0.001</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>Cardiogenic shock (Killip IV)</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">8.84</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(4.49-17.41)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1"><0.001</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">10.82</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(5.48-21.38)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1"><0.001</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>STEMI</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">1.79</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(0.90-3.57)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.098</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">2.96</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(1.15-7.63)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.025</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>LVEF (%)</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">1.00</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(0.99-1.01)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.19</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.96</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(0.94-0.99)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.002</td></tr><tr><td valign="top" rowspan="1" colspan="1">
|
|
<bold>Renal dysfunction (eGFR<60)</bold>
|
|
</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">4.30</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(1.89-9.86)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1"><0.001</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">11.32</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(4.39-29.20)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1"><0.001</td></tr><tr><td valign="top" rowspan="1" colspan="1"><bold>Revascularization</bold>
|
|
<break/><bold>(emergency PCI or CABG)</bold></td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.61</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(0.30-1.25)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.178</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.23</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(0.12-0.45)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1"><0.001</td></tr></tbody></table><table-wrap-foot><fn><p>DM: diabetes mellitus, HR: hazard ratio, CI: confidence interval, STEMI: ST-elevation myocardial infarction, LVEF: left ventricular ejection fraction, eGFR: estimated glomerular filtration rate, PCI: percutaneous coronary intervention, CABG: coronary artery bypass grafting</p></fn></table-wrap-foot></table-wrap><table-wrap position="float" id="t005"><label>Table 5.</label><caption><p>Multivariate Analyses for In-hospital Death.</p></caption><table frame="hsides" rules="groups"><thead style="border-top:solid thin; border-bottom:solid thin;"><tr><th rowspan="2" valign="middle" align="center" colspan="1">Variables</th><th rowspan="2" style="width:1em" colspan="1"/><th colspan="5" valign="middle" align="center" style="border-bottom:solid thin;" rowspan="1">DM (n=408)</th><th rowspan="2" valign="middle" style="width:1em" colspan="1"/><th colspan="5" valign="middle" align="center" style="border-bottom:solid thin;" rowspan="1">Non-DM (n=732)</th></tr><tr><th valign="middle" align="center" rowspan="1" colspan="1">HR</th><th style="width:1em" rowspan="1" colspan="1"/><th valign="middle" align="center" rowspan="1" colspan="1">95%CI</th><th style="width:1em" rowspan="1" colspan="1"/><th valign="middle" align="center" rowspan="1" colspan="1">p value</th><th valign="middle" align="center" rowspan="1" colspan="1">HR</th><th style="width:1em" rowspan="1" colspan="1"/><th valign="middle" align="center" rowspan="1" colspan="1">95%CI</th><th style="width:1em" rowspan="1" colspan="1"/><th valign="middle" align="center" rowspan="1" colspan="1">p value</th></tr></thead><tbody style="border-top:solid thin; border-bottom:solid thin;"><tr><td valign="top" rowspan="1" colspan="1">
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<bold>Age (years)</bold>
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</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.99</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(0.95-1.03)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.497</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">1.01</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(0.96-1.04)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.980</td></tr><tr><td valign="top" rowspan="1" colspan="1">
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<bold>Sex (female)</bold>
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</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.78</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(0.26-2.38)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.668</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">1.40</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(0.63-3.01)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.406</td></tr><tr><td valign="top" rowspan="1" colspan="1">
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<bold>Hypertension</bold>
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</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.81</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(0.34-1.93)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.634</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">1.38</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(0.53-3.58)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.506</td></tr><tr><td valign="top" rowspan="1" colspan="1">
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<bold>History of stroke</bold>
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</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">2.59</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(1.07-6.31)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.036</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.34</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(0.045-2.61)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.302</td></tr><tr><td valign="top" rowspan="1" colspan="1">
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<bold>History of atrial fibrillation</bold>
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</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">1.60</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(0.54-4.76)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.396</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">2.07</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(0.83-5.19)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.119</td></tr><tr><td valign="top" rowspan="1" colspan="1">
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<bold>Cardiogenic shock (Killip IV)</bold>
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</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">6.59</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(2.90-14.95)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1"><0.001</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">4.42</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(1.99-9.77)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1"><0.001</td></tr><tr><td valign="top" rowspan="1" colspan="1">
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<bold>STEMI</bold>
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</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">1.85</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(0.71-4.80)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.206</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">2.46</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(0.89-6.71)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.080</td></tr><tr><td valign="top" rowspan="1" colspan="1">
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<bold>LVEF (%)</bold>
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</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.98</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(0.95-1.01)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.160</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.99</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(0.96-1.02)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.354</td></tr><tr><td valign="top" rowspan="1" colspan="1">
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<bold>Renal dysfunction (eGFR<60)</bold>
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</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">5.64</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(1.59-20.04)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.008</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">5.92</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(1.79-19.53)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.004</td></tr><tr><td valign="top" rowspan="1" colspan="1"><bold>Revascularization</bold>
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<break/><bold>(emergency PCI or CABG)</bold></td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.66</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(0.28-1.58)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.350</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">0.24</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1">(0.10-0.56)</td><td valign="top" rowspan="1" colspan="1"/><td valign="top" align="center" rowspan="1" colspan="1"><0.001</td></tr></tbody></table><table-wrap-foot><fn><p>DM: diabetes mellitus, HR: hazard ratio, CI: confidence interval, STEMI: ST-elevation myocardial infarction, LVEF: left ventricular ejection fraction, eGFR: estimated glomerular filtration rate, PCI: percutaneous coronary intervention, CABG: coronary artery bypass grafting</p></fn></table-wrap-foot></table-wrap><p>In addition, we focused on patients with CS (n=97) and compared in-hospital mortality between patients with DM (n=47) and those without DM (n=50). In-hospital deaths were observed in 23 CS cases in the DM group (48.9%) and 19 CS cases in the non-DM group (38.0%). The DM group had a higher mortality rate; however, these differences were not statistically significant (p=0.277).</p></sec></sec><sec><title>Discussion</title><p>The results of this study are summarized here. First, the dominant coronary risk factors and proportion of these risk factors varied between individuals with and without DM. Second, the DM group showed a higher prevalence of non-ST-elevation MI than in non-DM group. Third, among patients with AMI, those with DM had a worse short-term prognosis than those without DM. Indeed, the risk of mortality within 30 days after experiencing an AMI was 1.87 times higher in the DM group than in the non-DM group. Fourth, there were distinct differences in the direct causes of mortality between the two groups. Non-cardiac causes were more prevalent in patients with DM than in those without DM, despite CS being a significant factor in almost half of the cases in both groups. Fifth, the presence of CS on admission and renal dysfunction were identified as independent risk factors for in-hospital mortality in both groups. Furthermore, among patients with DM, a history of stroke was also recognized as an independent factor that could worsen the in-hospital prognosis. The effect of revascularization procedures on in-hospital mortality differed between the DM and non-DM groups. Finally, there was no significant difference in the in-hospital mortality of patients with CS between the DM and non-DM groups.</p><p>In Japan, there is a limited amount of research regarding predictors of in-hospital mortality for AMI based on the presence or absence of DM or differences in the specific causes of death. Although we have conducted large-scale studies related to AMI in Japan, such as the JROAD registry (<xref rid="B13" ref-type="bibr">13</xref>) and the J-PCI Registry (<xref rid="B3" ref-type="bibr">3</xref>), these registry surveys are limited in terms of available parameters, and it is speculated that they may not be suitable for in-depth research analyses.</p><p>However, our institution (Iwate Medical University) maintains a detailed database of AMI patients that adheres to the latest definitions, encompassing registrations of over 1,000 individuals. Comprehensive retrospective investigations can be conducted with access to the medical records. Utilizing this database, we can explore predictors of in-hospital mortality in AMI patients based on their DM status, delve into the specific causes of death, and thoroughly examine other related factors.</p><p>In terms of differences in clinical presentation, there was a higher prevalence of non-ST-elevation myocardial infarction (NSTEMI) in the DM group than in the non-DM group. To some extent, this may be attributed to the presence of pre-existing collateral circulation due to advanced plaque progression in this population.</p><p>Although previous studies have documented an adverse prognosis in AMI patients with comorbid diabetes mellitus (<xref rid="B5" ref-type="bibr">5</xref>,<xref rid="B14" ref-type="bibr">14</xref>,<xref rid="B15" ref-type="bibr">15</xref>), our study adds clarity by demonstrating a substantial impact on mortality. Notably, we identified an HR of 1.87 for mortality, even in a cohort in which nearly 85% of the patients underwent invasive strategies. Cardiovascular deaths (including those due to CS, mechanical complications, and lethal arrhythmias) accounted for nearly 85% of in-hospital fatalities in the non-DM group. Conversely, they constituted only 68% of in-hospital deaths in the DM group, signifying a higher prevalence of noncardiovascular causes of mortality in this population. Infections, strokes, and malignancies have emerged as direct causes of death in this subgroup. Considering the systemic nature of disorders in patients with DM, these results are not surprising, but they underscore the importance of comprehensive care or systemic management for this population to further improve survival rates.</p><p>The higher prevalence of stroke as the direct cause of death in the DM group than the non-DM group can be explained as follows: Patients with DM typically exhibit a higher prevalence of diseased aortic walls or a prothrombotic state as well as an increased need for mechanical cardiac support during the perioperative period than those without DM. These additional factors may increase the rate of embolic stroke, which can be induced by catheterization procedures or mechanical support devices as well as by thrombi within the aneurysmal left ventricle. Furthermore, the greater requirement for anticoagulant agents to address these problems may be associated with an elevated risk of hemorrhagic stroke.</p><p>In the DM group, we observed a higher prevalence of an advanced Killip status upon admission and a greater frequency of mechanical cardiac support devices than in the non-DM group. Consequently, the patients' conditions tended to deteriorate further from the time of admission than in the non-DM group. Nevertheless, the DM group exhibited lower actual rates of both coronary angiography and revascularization than the non-DM group, similar to a previous report (<xref rid="B16" ref-type="bibr">16</xref>). The lower frequency of ST-elevation MI and an increased possibility of asymptomatic patients, concerns related to an impaired renal function, as well as the use of contrast agents may partially explain the lower rate of emergent angiography. The higher frequency of left main coronary artery involvement in the DM group than in the non-DM group led to the reduced use of PCI and increased use of CABG. These factors are hypothesized to not only influence the lower frequency of revascularization procedures but also explain the divergent prognostic outcomes of these procedures between the DM and non-DM groups.</p><p>CS continues to be a significant factor influencing mortality in patients with AMI, as supported by numerous previous studies (<xref rid="B17" ref-type="bibr">17</xref>-<xref rid="B19" ref-type="bibr">19</xref>). However, our findings revealed that there was no marked difference in the in-hospital mortality between DM and non-DM patients with CS, consistent with a previous study (<xref rid="B20" ref-type="bibr">20</xref>). Because the management of CS remains a paramount concern in both groups, alternative approaches, such as the utilization of left ventricle unloading devices (<xref rid="B21" ref-type="bibr">21</xref>,<xref rid="B22" ref-type="bibr">22</xref>) or intracoronary supersaturated oxygen therapy (<xref rid="B23" ref-type="bibr">23</xref>), should be explored to enhance the outcomes of patients experiencing CS.</p><p>While both groups shared common predictors of in-hospital mortality, such as CS and renal dysfunction, a history of stroke was identified as an independent predictor of in-hospital mortality solely within the DM group. The reasons for this cannot be explained easily. One possible explanation may be that systemic atherosclerosis is more advanced in diabetic patients than in those without DM. Another potential explanation may be that patients with a history of stroke may be frailer than those without such a history. We are currently investigating the mechanisms underlying these results. However, it is essential to pay careful attention to patients with AMI with such a history throughout their hospitalization, especially among patients with DM.</p><sec><title>Study limitations</title><p>Several limitations associated with the present study warrant mention. In this study, diabetes was defined according to criteria established from prior AMI research and existing literature. Intraday glucose variability and oral glucose tolerance tests were not performed, potentially leading to some cases of diabetes or impaired glucose tolerance being categorized as nondiabetic. This limitation was inherent to this study. Furthermore, despite the availability of the latest 4th version of the universal definition (<xref rid="B24" ref-type="bibr">24</xref>), we chose to apply the 3rd version of the universal definition (<xref rid="B7" ref-type="bibr">7</xref>) in this study. This decision was made because the 3rd definition was used during the recruitment period. However, it is important to acknowledge that the composition of the enrolled patient population may not have substantially differed; therefore, we employed the 3rd universal definition (<xref rid="B25" ref-type="bibr">25</xref>). Finally, the door-to-balloon time is a well-established mortality parameter in AMI patients (<xref rid="B26" ref-type="bibr">26</xref>). However, our study had a substantial proportion of NSTEMI patients (approximately 40%); therefore, we did not include this parameter in our analysis.</p></sec></sec><sec><title>Conclusion</title><p>Among patients with AMI, the 30-day mortality rate was 1.87 times higher in the DM group than in the non-DM group. Patients with DM had a higher occurrence of non-cardiac causes of death than those without DM, with CS being responsible for almost half of the mortality cases in both groups. Independent predictors of in-hospital mortality were CS and renal dysfunction in both patient groups, while a history of stroke was identified as an additional predictor in the DM group. To further improve outcomes for patients with AMI, personalized management that prioritizes addressing non-cardiac comorbidities during hospitalization may be crucial, particularly in patients with DM.</p></sec><sec sec-type="COI-statement"><p>
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<bold>Author's disclosure of potential Conflicts of Interest (COI).</bold>
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