Fifteen-Year Trends of Cardiogenic Shock and Mortality in Patients with Diabetes and Acute Coronary Syndromes



      Our study was intended to examine time trends of management and mortality of acute coronary syndrome patients with associated diabetes mellitus.


      We analyzed data from 5 nationwide registries established between 2001 and 2014, including consecutive acute coronary syndrome patients admitted to the Italian Intensive Cardiac Care Units.


      Of 28,225 participants, 8521 (30.2%) had diabetes: as compared with patients without diabetes, they were older and had significantly higher rates of prior myocardial infarction and comorbidities (all P < .0001). Prevalence of diabetes and comorbidities increased over time (P for trend < .0001). Cardiogenic shock rates were higher in patients with diabetes, as compared with those without diabetes (7.8% vs 2.8%, P < .0001), and decreased significantly over time only in patients without diabetes (P = .007). Revascularization rates increased over time in patients both with and without diabetes (both P for trend < .0001), although with persistingly lower rates in patients with diabetes. All-cause in-hospital mortality was higher in patients with diabetes (5.4 vs 2.5%, respectively, P < .0001) and decreased more consistently in patients without diabetes (P for trend = .007 and < .0001, respectively). At multivariable analysis, diabetes remains an independent predictor of both cardiogenic shock (odds ratio 2.03; 95% confidence interval, 1.77-2.32; P < .0001) and mortality (odds ratio 1.95; 95% confidence interval, 1.69-2.26; P < .0001).


      Despite significant mortality reductions observed over 15 years in acute coronary syndromes, patients with diabetes continue to show threefold higher rates of cardiogenic shock and lower revascularization rates as compared with patients without diabetes. These findings may explain the persistingly higher mortality of patients with diabetes and acute coronary syndromes.


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        • Bauters C.
        • Lemesle G.
        • de Groote P.
        • Lamblin N.
        A systematic review and meta-regression of temporal trends in the excess mortality associated with diabetes mellitus after myocardial infarction.
        Int J Cardiol. 2016; 217: 109-121
        • De Luca L.
        • Olivari Z.
        • Bolognese L.
        • et al.
        A decade of changes in clinical characteristics and management of elderly patients with non-ST-elevation myocardial infarction admitted in Italian cardiac care units.
        Open Heart. 2014; 1e000148
      1. De Luca L, Marini M, Gonzini L, et al. Contemporary trends and age-specific sex differences in management and outcome for patients with ST-segment elevation myocardial infarction. J Am Heart Assoc. 2016;5(12). pii: e004202

        • De Luca L.
        • Olivari Z.
        • Farina A.
        • et al.
        Temporal trends in the epidemiology, management and outcome of patients with cardiogenic shock complicating acute coronary syndromes.
        Eur J Heart Fail. 2015; 17: 1124-1132
        • De Luca L.
        • Casella G.
        • Rubboli A.
        • et al.
        Recent trends in management and outcome of patients with acute coronary syndromes and atrial fibrillation.
        Int J Cardiol. 2017; 248: 369-375
        • De Luca L.
        • Di Pasquale G.
        • Gonzini L.
        • et al.
        Trends in management and outcome of patients with non-ST elevation acute coronary syndromes and peripheral arterial disease.
        Eur J Intern Med. 2019; 59: 70-76
        • Di Chiara A.
        • Chiarella F.
        • Savonitto S.
        et al; BLITZ Investigators. Epidemiology of acute myocardial infarction in the Italian CCU network: the BLITZ study.
        Eur Heart J. 2003; 24: 1616-1629
        • Rizzello V.
        • Lucci D.
        • Maggioni A.P.
        et al; IN-ACS Outcome Investigators. Clinical epidemiology, management and outcome of acute coronary syndromes in the Italian network on acute coronary syndromes (IN-ACS Outcome study).
        Acute Card Care. 2012; 14: 71-80
        • Casella G.
        • Di Pasquale G.
        • Oltrona Visconti L.
        • et al.
        Management of patients with acute coronary syndromes in real-world practice in Italy: an outcome research study focused on the use of ANTithRombotic Agents: the MANTRA registry.
        Eur Heart J Acute Cardiovasc Care. 2013; 2: 27-34
        • Olivari Z.
        • Steffenino G.
        • Savonitto S.
        • et al.
        The management of acute myocardial infarction in the cardiological intensive care units in Italy: the 'BLITZ 4 Qualità' campaign for performance measurement and quality improvement.
        Eur Heart J Acute Cardiovasc Care. 2012; 1: 143-152
        • De Luca L.
        • Leonardi S.
        Cavallini C, et al.
        EYESHOT Investigators Contemporary antithrombotic strategies in patients with acute coronary syndromes admitted to cardiac care units in Italy: the EYESHOT study Eur Heart J Acute Cardiovasc Care. 2015; 4: 441-452
        • Stevens L.A.
        • Coresh J.
        • Greene T.
        • Levey A.S.
        Assessing kidney function--measured and estimated glomerular filtration rate.
        N Engl J Med. 2006; 354: 2473-2483
        • Donahoe S.M.
        • Stewart G.C.
        • McCabe C.H.
        • et al.
        Diabetes and mortality following acute coronary syndromes.
        JAMA. 2007; 298: 765-775
        • Ryden L.
        • Grant P.J.
        • Anker S.D.
        • et al.
        ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD–summary.
        Eur Heart J. 2013; 34: 3035-3087
        • Danaei G.
        • Finucane M.M.
        • Lu Y.
        et al; Global Burden of Metabolic Risk Factors of Chronic Diseases Collaborating Group. National, regional, and global trends in fasting plasma glucose and diabetes prevalence since 1980: systematic analysis of health examination surveys and epidemiological studies with 370 country-years and 2.7 million participants.
        Lancet. 2011; 378: 31-40
        • Preis S.R.
        • Hwang S.J.
        • Coady S.
        • et al.
        Trends in all-cause and cardiovascular disease mortality among women and men with and without diabetes mellitus in the Framingham Heart Study, 1950 to 2005.
        Circulation. 2009; 119: 1728-1735
        • Thiele H.
        • Akin I.
        • Sandri M.
        et al; on behalf of the CULPRIT-SHOCK Investigators. Multivessel PCI in cardiogenic shock complicating acute myocardial infarction.
        N Engl J Med. 2017; 377: 2419-2432
        • Bell D.S.
        Heart failure: the frequent, forgotten, and often fatal complication of diabetes.
        Diabetes Care. 2003; 26: 2433-2441
        • Boudina S.
        • Abel E.D.
        Diabetic cardiomyopathy revisited.
        Circulation. 2007; 115: 3213-3223
        • Savonitto S.
        • Morici N.
        • Nozza A.
        • et al.
        Predictors of mortality in hospital survivors with type-two diabetes mellitus and acute coronary syndromes.
        Diab Vasc Dis Res. 2018; 15: 14-23
        • Gaede P.
        • Lund-Andersen H.
        • Parving H.H.
        • Pedersen O.
        Effect of a multifactorial intervention on mortality in type 2 diabetes.
        N Engl J Med. 2008; 358: 580-591
        • Standl E.
        • Schnell O.
        • McGuire D.K.
        • Ceriello A.
        • Rydén L.
        Integration of recent evidence into management of patients with atherosclerotic cardiovascular disease and type 2 diabetes.
        Lancet Diabetes Endocrinol. 2017; 5: 391-402