IMPACT OF PHARMACOLOGICAL TREATMENT ON MORTALITY AFTER MYOCARDIAL-INFARCTION IN DIABETIC-PATIENTS

Several studies performed before and after the introduction of fibrino lysis as a routine treatment of patients with myocardial infarction (M I) consistently showed that diabetic patients have a higher mortality in-hospital and after discharge. Women with insulin-dependent diabetes (IDD) appear to have a particularly ominous prognosis. So far, very f ew randomized prospective studies evaluated the effect of pharmacologi cal treatments on prognosis of diabetic patients during acute MI: most of the information on the effect of commonly used cardiovascular drug s in diabetic patients with acute MI (AMI) has been obtained only from retrospective subgroup analyses of some of the large trials or as non randomized comparisons. The overview of fibrinolytic trials in acute M I found that fibrinolytic treatment was associated with a 35 days mort ality of 13.6% versus 17.3% in diabetics (-21.7%) and 8.7% versus 10.2 % in nondiabetics (-14.3%). Data from trials with aspirin suggest that the beneficial effect of this drug is maintained in diabetic patients with acute MI, but the optimal dosage remains undefined. Based on ava ilable evidence, beta blockers appear to be able to reduce mortality p ost-MI in diabetic patients, with an absolute and relative beneficial effect that is, in most cases, larger than that observed in nondiabeti c patients. The pooled data from studies non beta blockers indicate a 37% mortality reduction in diabetic patients, compared to 13% in nondi abetics during the acute phase, and a 48% reduction of mortality compa red to 33% in nondiabetics post-discharge. Data on outcome of diabetic patients in trials evaluating calcium antagonists are lacking, and th ere is a strong need for a reevaluation of data from completed trials to obtain some hints on the possible effect of these agents in this po pulation. The ''long-term'' studies on angiotensin-converting enzyme ( ACE) inhibitors in patients with left ventricular dysfunction some tim e after AMI have shown that the beneficial effect documented in the ov erall population is present also when limiting the analysis to patient s with a history of diabetes, whereas the ''acute'' studies enrolling patients within 24-36 h after the onset of symptoms have shown a marke d beneficial effect of ACE inhibitors in diabetic patients. For exampl e, in the GISSI 3 study, treatment with lisinopril was associated with a decreased 6-week mortality in both IDD (11.8% versus 21.1, p < 0.05 ) and non-IDD (8.0% versus 10.6%, p < 0.05) patients corresponding to a 44.1% and 24.5% reduction, respectively. All these results must be t aken with great caution because in no studies the effect of treatment in diabetic patients was a predefined analysis. They strongly suggest, however, that ACE inhibitors and beta blockers may be particularly be neficial during the acute phase of MI and also post-discharge, offerin g a strong rationale for their widespread use in diabetic patients wit h acute MI. (Journal of Diabetes and (C) Elsevier Science Inc., 1997.