Late-onset heart failure as a mechanism for adverse long-term outcome in diabetic patients undergoing revascularization (A 13-year report from the Lady Davis Carmel Medical Center registry)

The adverse long-term prognosis following myocardial revascularization in d iabetic patients has been ascribed to accelerated coronary disease, a highe r incidence of late coronary restenosis after revascularization, and myocar dial dysfunction. To examine the development of heart failure and its progn ostic implications in diabetic patients, we analyzed the long-term (13-year ) follow-up data of 363 patients-193 percutaneous transluminal coronary ang ioplasties and 170 coronary artery bypass operations-revascularized in a si ngle cardiovascular center from 1984 to 1986. Baseline characteristics (age , previous infarction, baseline ventricular function) were similar in the 8 0 diabetic and 283 nondiabetic patients; multivessel disease and hypertensi on were marginally more common in diabetics (p = NS). Cumulative incidence of hospitalization for heart failure was high in the diabetic cohort (25% v s 11%, p = 0.001), with a rapidly increasing incidence after 5 years. Survi val after first hospitalization for heart failure was markedly reduced in d iabetics (11 of 20 [55%] vs 25 of 31 [81%] at 3 years; p = 0.04), as was su rvival free of further hospitalization for heart failure (5 of 20 [25%] vs 20 of 30 [63%]; p < 0.005). Long-term 13-year survival (43% vs 78%, p < 0.0 001) and survival free of heart failure (33% vs 71%, p < 0.0001) were decre ased in diabetics, especially those with reduced ventricular function at ba seline (17% vs 42%, p = 0.07). Multivariate analysis showed diabetes to be the strongest independent predictor of decreased survival (odds ratio 3.6, 95% confidence interval 2.0 to 6.2; p < 0.0001) and survival free of heart failure (odds ratio 4.0, 95% confidence interval 2.2 to 7.1; p < 0.0001) in patients undergoing revascularization. In summary, late-onset heart failur e was frequent in diabetic patients after percutaneous transluminal coronar y angioplasty or coronary artery bypass grafting, and once present heralded an unrelenting progressive downhill clinical course. (C) 2000 by Excerpta Medico, Inc.