The Role of Diabetes and Age in Early Coronary Revascularization Among 'Stable' Patients with Non-ST-Segment Elevation Acute Coronary Syndromes

Medicine Cardiovascular System
coronary revascularization diabetes non-ST-segment elevation acute coronary syndrome elderly patients clinical outcomes

Academic Background

Non-ST-segment elevation acute coronary syndrome (NSTE-ACS) is a common cardiovascular disease, particularly among diabetic patients, whose incidence and mortality rates are significantly higher than those of non-diabetic patients. Although current clinical guidelines recommend early (within 24 hours) coronary revascularization for all NSTE-ACS patients, the benefits of this strategy for patients who are clinically stable at admission, especially the elderly and diabetic patients, remain unclear. Therefore, this study aims to explore the clinical outcomes of early revascularization versus initial conservative treatment strategies in stable NSTE-ACS patients, with a particular focus on the impact of diabetes and age on treatment efficacy.

Source of the Paper

This paper was authored by Natalia Fabin and her research team from the University of Bologna, Italy, in collaboration with institutions such as Google Cloud Space in the United States and Hospital Clinic de Barcelona in Spain, among others from several European countries. The paper was published in 2024 in the journal Cardiovascular Research, with the DOI 10.1093/cvr/cvae190.

Research Process

Study Design and Sample

This study was based on the International Survey of Acute Coronary Syndromes (ISACS-TC) database, including 7,589 NSTE-ACS patients from seven European countries between October 2010 and July 2023. Patients with cardiac arrest, hemodynamic instability, or severe ventricular arrhythmias at admission were excluded. The final sample consisted of 2,343 diabetic patients and 5,246 non-diabetic patients.

Research Methods

The study used the Inverse Probability of Treatment Weighting (IPTW) model to adjust for between-group differences, with the primary outcome being 30-day all-cause mortality. Patients were divided into an early revascularization group (revascularization within 24 hours) and an initial conservative treatment group. Multivariate logistic regression analysis was employed to investigate the impact of diabetes and age on treatment outcomes.

Research Findings

  1. Overall Results: The study showed that elderly patients (≥65 years) had a significantly lower mortality rate after early revascularization. Among diabetic patients, the mortality rate in the early revascularization group was 3.3%, compared to 6.7% in the initial conservative treatment group (risk ratio RR: 0.48; 95% CI: 0.28–0.80). Among non-diabetic patients, the mortality rate in the early revascularization group was 2.7%, compared to 4.7% in the initial conservative treatment group (RR: 0.57; 95% CI: 0.36–0.90).

  2. Interaction Between Diabetes and Age: Multivariate analysis revealed that diabetes was an independent predictor of mortality in elderly patients (OR: 1.43; 95% CI: 1.03–1.99), but it had no significant impact on younger patients (OR: 1.04; 95% CI: 0.53–2.06).

  3. Safety Analysis: Early revascularization did not increase the risk of major bleeding or PCI complications. Among diabetic patients, the incidence of major bleeding was 0.8% in the early revascularization group, compared to 2.8% in the initial conservative treatment group (RR: 0.26; 95% CI: 0.12–0.57).

Conclusion

Early coronary revascularization significantly reduced 30-day mortality in elderly NSTE-ACS patients, particularly among diabetic patients. However, in younger patients, early revascularization did not provide significant survival benefits. Therefore, the early revascularization strategy should be prioritized for elderly patients, especially those with diabetes.

Research Highlights

  1. Personalized Treatment Strategy for Stable NSTE-ACS Patients: This study is the first to explore the benefits of early revascularization in stable NSTE-ACS patients, proposing a personalized treatment strategy based on age and diabetes.

  2. Interaction Between Diabetes and Age: The study found that diabetes significantly increased the risk of mortality in elderly patients, and early revascularization could significantly reduce this risk, providing important evidence for clinical decision-making.

  3. Safety Assessment: The study confirmed that early revascularization did not increase the risk of major bleeding or PCI complications, further supporting its safety in elderly patients.

Research Significance

This study offers a new perspective on the treatment of NSTE-ACS patients, emphasizing the need for personalized treatment strategies based on age and diabetes status in stable patients. The findings suggest that early revascularization should be prioritized for elderly patients, especially those with diabetes, while younger patients may be more suitable for initial conservative treatment. This discovery not only helps optimize clinical decision-making but also provides important references for future randomized controlled trials.

Other Valuable Information

The study also found that early revascularization significantly reduced hospital stays, further supporting its potential value in resource optimization. Additionally, the IPTW model used in the study provides an effective method for addressing confounding factors in observational data, offering methodological references for similar studies.

Through this study, we have gained a better understanding of the treatment needs of NSTE-ACS patients and provided important insights for future clinical practice and research directions.