| BACKGROUND:Primary percutaneous coronary intervention (PCI) is now considered the optimal approach to management of ST-segment elevation myocardial infarction (STEMI). Since, diabetes and dyslipidemia are established risk factors of Coronary Artery Disease and independent predictors of outcome after Primary PCI, clear understanding of these risk factors is one of the crucial elements in the management of patients before and after STEMI.OBJECTIVE:The aim of this study is to assess the characteristics of diabetes and dyslipidemia as cardiovascular risk factors and to analyze some possible factors predictive of in-hospital outcome in STEMI patients who underwent Primary PCI.METHODS:The study included 613 STEMI patients out of 675 Acute Coronary Syndrome(ACS) patients admitted to Zhongshan Hospital for Primary PCI from January 2005 to December 2008. Clinical, biochemical and angiographic data were abstracted from detailed chart reviews and retrospectively analyzed using SPSS 13.0 product for windows. The differences in categorical variables were analyzed using the x2-analysis, and the differences in continuous variables were analyzed by the unpaired two-tailed t-test. Relationships were determined using Multivariate Logistic stepwise regression analysis and factors predictive of in-hospital mortality were evaluated.RESULTS:(1) Out of a total of 675 ACS patients, consisting of 542 men (80.3%) and 133 women (19.7%) with mean age 64.1±11.4 years,613(90.8%) were ST-elevation ACS(STE-ACS) patients-495(80.8%) men,118(19.2%) women, mean age 64.0±11.2 years. Comparing the STE-ACS and Non-STE-ACS group, there were more diabetic patients in STE-ACS group (19.7% vs.7.6%, p=0.025), Systolic Blood pressure(BP) was lower in the STE-ACS group (121.5±21.6 vs.129.3±22.8 mmHg); while Admission Fasting Plasma glucose (7.5±3.1 vs.6.7±18.1 mmol/L, p=0.031), Admission cTnT (8.8±8.1 vs.1.6±2.5 ng/ml, p= 0.000), Admission CK-MB (259.5±243.7 vs.71.2±107.6 U/L, p=0.000) were higher in STE-ACS group. From STE-ACS group, Pre-procedural TIMI-0 was found in 455(74.2%), Post-procedural TIMI-3 flow was achieved in 583(95.1%), in-hospital mortality was 24(3.9%) and mean pre-discharge Ejection Fraction was 58.5±10.4%.(2) Out of the 613 STEMI patients,481(78.5%) had Total Cholesterol<5.2mmol/L,460(75.0%) with Triglycerides(TG)<1.69 mmol/L, 310(50.6%) with LDL-C<2.6 mmol/L,48(7.8%) with HDL-C＞1.55 mmol/L, 492(80.2%) with Lp(a)<300 mg/L,92(15%) with Apo(b)<0.6 g/L. Cross-classification revealed 419(68.4%) with HDL-C<1.55 mmol/L and TG<1.69 mmol/L; 1(0.2%) with HDL-C＞1.55 mmol/L and TG>5.65 mmol/L. We also observed 286(46.6%) with HDL-C<1.55 mmol/L and LDL-C<2.6 mmol/L; and no patients with HDL-C＞1.55 mmol/L and LDL-C＞4.9 mmol/L. On comparing HDL-C<1.55 mmol/L and HDL-C＞1.55 mmol/L groups, we found that higher HDL-C (>1.55 mmol/L) was more common in women (17.5% vs.39.6%, p=0.000) and low HDL-C (<.155 mmol/L) was associated with smoking (51.9% vs.27.1%, p=0.001).(3) Comparing the Diabetes Mellitus(DM) (n=121,19.7%) and non-DM (n=492, 80.3%) group, Diabetics with STEMI were older (65.8±10.9 vs.63.5±11.3 days, p=0.042), more often women (28.1% vs.17.1%, p=0.006), more hypertensive (57.9% vs.41.9%, p=0.002) and more hyperlipidemic (10.7% vs.5.1%, p=0.021), had higher Systolic BP (128.8±21.6 vs.119.8±21.3 mmHg, p=0.000), higher Diastolic BP (71.9±13.8 vs.69.0±14.1 mmHg, p=0.040), higher TG level (1.7±2.1 vs.1.3±0.9 mmol/L, p=0.001), higher Fasting plasma glucose level (10.2±3.7 vs. 6.9±2.5 mmol/L, p=0.000) but lower Serum Uric Acid (311.3±98.5 vs. 347.5±103.1μmol/L, p=0.001).(4) From the STEMI group, number of in-hospital deaths were 24(3.9%). Compared with those who did not die in-hospital, patients who died in hospital had higher Admission heart-rate (93.9±21.9 vs.83.0±15.1 beats/min, p=0.001), higher Admission Fasting plasma glucose (9.1±4.9 vs.7.5±3.0 mmol/L, p=0.009), higher Blood Urea Nitrogen (7.6±2.0 vs.6.2±2.4 mmol/L, p=0.007), higher peak cTnT (15.7±9.2 vs.11.2±7.8 ng/ml, p=0.007), higher Peak CK-MB (605.8±619.4 vs. 321.6±259.9 U/L, p=0.000) but lower TIMI-3 flow (70.8% vs.96.1%; p=0.000). Multivariate Logistic Regression analysis revealed heart-rate (OR=1.035; 95% CI[1.008-1.063]; p=0.012) and Fasting Plasma Glucose (OR=1.149; 95% CI[1.017-1.299]; p=0.026) on admission as independent predictors of in-hospital mortality and post-procedural TIMI-3 flow (OR=0.103; 95%CI[0.031-0.341]; p=0.000) as a predictor of in-hospital survival.CONCLUSIONS:Diabetes is commonly encountered in STEMI patients and these patients are usually older, mostly women and more often hypertensive and hyperlipidemic and they usually present with higher blood pressure and higher blood glucose level on admission. In addition, since higher fasting plasma glucose and higher heart-rate on admission, as well as post-procedural TIMI＜3 flow have been found to be strong predictors of in-hospital mortality, a stricter management strategy is warranted to control these parameters in order to improve outcome.We need to go beyond LDL-C measurement lowering therapy for the optimal management of Coronary Heart Disease risk. Due to the link between low HDL-C level and STEMI, raising plasma HDL-C seems to be a legitimate therapeutic target for the optimal prevention of Coronary Artery Disease in a large proportion of high risk patients, especially in smokers and men.
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