Clinical Features and Prognosis of Type 2 Myocardial Infarction in Acutely Decompensated Diabetic Patients



      After the introduction of the universal definition of myocardial infarction, the incidence and diagnosis of type 2 myocardial infarction have risen dramatically, yet there are no clear guidelines on clinical management. Diabetic patients are at high risk for developing type 2 myocardial infarction when admitted in a decompensated state, and they are also at high risk for future cardiovascular events.


      We performed a retrospective analysis of 1058 patients admitted with diabetic ketoacidosis or hyperosmolar hyperglycemic state between 2011 and 2016. Patients were included if they had cardiac troponin I measured within 24 hours of admission, were older than 18 years of age, and had no evidence of acute coronary syndrome on admission. Baseline characteristics, admission laboratory test results, major adverse cardiovascular events, cardiac stress testing, and coronary angiography data up to 1 year after admission were reviewed. Patients were categorized into 2 groups: those with and those without type 2 myocardial infarction. The study had 2 endpoints: mortality and major adverse cardiac events (MACE) at 1 year and an abnormal result on stress test or coronary angiography at 1 year.


      Of the 845 patients who met the inclusion criteria, 133 patients (15%) had type 2 myocardial infarction on admission. Patients with type 2 myocardial infarction were at a significantly higher risk for mortality and MACE at 1 year than those without. Patients with type 2 myocardial infarction were also at higher risk for developing an abnormal result on stress test or coronary angiography within 1 year of admission as compared with those without type 2 myocardial infarction (40% vs 24%; odds ratio 2; P = .0699).


      Acutely decompensated diabetic patients with type 2 myocardial infarction are at increased risk for death and MACE. These patients may also be at risk for undiagnosed coronary artery disease.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The American Journal of Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Umpierrez G.
        • Korytkowski M.
        Diabetic emergencies—ketoacidosis, hyperglycaemic hyperosmolar state and hypoglycaemia.
        Nat Rev Endocrinol. 2016; 12: 222-232
        • Thygesen K.
        • Alpert J.S.
        • Jaffe A.S.
        • et al.
        Third universal definition of myocardial infarction.
        Circulation. 2012; 126: 2020-2035
        • Geddes J.
        • Deans K.A.
        • Cormack A.
        • et al.
        Cardiac troponin I concentrations in people presenting with diabetic ketoacidosis.
        Ann Clin Biochem. 2007; 44: 391-393
        • Al-Mallah M.
        • Zuberi O.
        • Arida M.
        • Kim H.E.
        Positive troponin in diabetic ketoacidosis without evident acute coronary syndrome predicts adverse cardiac events.
        Clin Cardiol. 2008; 31: 67-71
        • Eubanks A.
        • Raza F.
        • Alkhouli M.
        • et al.
        Clinical significance of troponin elevations in acute decompensated diabetes without clinical acute coronary syndrome.
        Cardiovasc Diabetol. 2012; 11: 154
        • Thygesen K.
        • Alpert J.S.
        • White H.D.
        • Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction
        Universal definition of myocardial infarction.
        J Am Coll Cardiol. 2007; 50: 2173-2195
        • Nestelberger T.
        • Boeddinghaus J.
        • Badertscher P.
        • et al.
        Effect of definition on incidence and prognosis of type 2 myocardial infarction.
        J Am Coll Cardiol. 2017; 70: 1558-1568
        • Amsterdam E.A.
        • Wenger N.K.
        • Brindis R.G.
        • et al.
        2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
        J Am Coll Cardiol. 2014; 64 (Erratum in: J Am Coll Cardiol. 2014;64(24):2713-2714. Dosage error in article text): e139-e228
        • O'Gara P.T.
        • Kushner F.G.
        • Ascheim D.D.
        • et al.
        2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines: developed in collaboration with the American College of Emergency Physicians and Society for Cardiovascular Angiography and Interventions.
        Catheter Cardiovasc Interv. 2013; 82: E1-E27
        • Kitabchi A.E.
        • Umpierrez G.E.
        • Miles J.M.
        • Fisher J.N.
        Hyperglycemic crises in adult patients with diabetes.
        Diabetes Care. 2009; 32: 1335-1343
        • Kitabchi A.E.
        • Umpierrez G.E.
        • Murphy M.B.
        • et al.
        Management of hyperglycemic crises in patients with diabetes.
        Diabetes Care. 2001; 24: 131-153
        • Centers for Disease Control and Prevention
        National Diabetes Statistics Report, 2017.
        (Published July 17, 2017; Available at)
        • Molina P.E.
        Endocrine Physiology.
        McGraw-Hill Medical, New York2013
        • Sandoval Y.
        • Smith S.W.
        • Thordsen S.E.
        • Apple F.S.
        Supply/demand type 2 myocardial infarction: should we be paying more attention?.
        J Am Coll Cardiol. 2014; 63: 2079-2087
        • Braunwald E.
        50th anniversary historical article. Myocardial oxygen consumption: the quest for its determinants and some clinical fallout.
        J Am Coll Cardiol. 1999; 34: 1365-1368
        • Chiariello M.
        • Indolfi C.
        Silent myocardial ischemia in patients with diabetes mellitus.
        Circulation. 1996; 93: 2089-2091
        • Alpert J.S.
        • Thygesen K.A.
        • White H.D.
        • Jaffe A.S.
        Diagnostic and therapeutic implications of type 2 myocardial infarction: review and commentary.
        Am J Med. 2014; 127: 105-108
        • Saaby L.
        • Poulsen T.S.
        • Hosbond S.
        • et al.
        Classification of myocardial infarction: frequency and features of type 2 myocardial infarction.
        Am J Med. 2013; 126: 789-797
        • Roche
        Breakthrough development for Americans with suspected heart attack—next generation troponin T test from Roche cleared by FDA.
        (Published January 19, 2017; Available at)