Age-dependent differences in diabetes and acute hyperglycemia between men and women with ST-elevation myocardial infarction: a cohort study

BACKGROUND: Both acute hyperglycemia as diabetes results in an impaired prognosis in ST-elevation myocardial infarction (STEMI) patients. It is unknown whether there is a different prevalence of diabetes and acute hyperglycemia in men and women within age-groups. METHODS: Between 2004 and 2010, 4640 consecutive patients (28% women) with STEMI, were referred for primary PCI. Patients were stratified into two age groups, < 65 years (2447 patients) and ≥65 years (2193 patients). Separate analyses were performed in 3901 patients without diabetes. Diabetes was defined as known diabetes or HbA1c ≥6.5 mmol/l at admission. RESULTS: The prevalence of diabetes was comparable between women and men in the younger age group (14% vs 12%, p = 0.52), whereas in the older age group diabetes was more prevalent in women (25% vs 17% p < 0.001). In patients without diabetes, admission glucose was comparable between both genders in younger patients (8.1 ± 2.0 mmol/l vs 8.0 ± 2.2 mmol/l p = 0.36), but in older patients admission glucose was higher in women than in men (8.7 ± 2.1 mmol/l vs 8.4 ± 2.1 mmol/l p = 0.028). After multivariable analyses, the occurrence of increased admission glucose was comparable between men and women in the younger age group (OR 1.1, 95%CI 0.9-1.5), but increased in women in the older age group (OR 1.3, 95% CI 1.1-1.7). Both diabetes and hyperglycemia were associated with a higher one-year mortality in both men and women. CONCLUSIONS: The differences between men and women in hyperglycemia and diabetes in patients with STEMI are age dependent and can only be observed in older patients. This may have implications for medical treatment and should be investigated further

Minimal starting time of data reconstruction for qualitative myocardial perfusion rubidium-82 positron emission tomography imaging

Objective Qualitative positron emission tomography (PET) myocardial perfusion imaging (MPI) scans are reconstructed with a delay after an injection of rubidium-82 (82 Rb) to ensure blood pool clearance and sufficient left ventricle to myocardium contrast. Our aim was to derive the minimal starting time of data reconstruction (STDR) after an injection of 82 Rb for which the diagnostic value and image quality remained unaffected. Materials and methods We retrospectively included 23 patients who underwent rest-stress 82 Rb PET MPI using 740 MBq. Patients fulfilling one of the two criteria indicating a slow blood pool clearance (ejection fraction <50% and/or cardiac output <3 l/min) were included in a consecutive manner. PET images using five different STDRs (1:15-2:15 min) were reconstructed and compared with reference images (STDR of 2:30 min). Differences in the summed rest score greater than or equal to 3 and total perfusion deficit greater than 3% were considered to significantly influence the diagnostic value. In addition, image quality was scored by two experts as not interpretable, inferior, adequate, or excellent. Results The summed rest score differed greater than or equal to 3 from the reference in seven or more patients (≥30%) using STDR less than or equal to 2:00 min (P<0.02). STDR less than or equal to 1:30 min resulted in six or more patients (≥26%) with a total perfusion deficit difference greater than 3% (P<0.03). In addition, STDR less than or equal to 2:00 min resulted in a lower image quality (P<0.002) and STDR less than or equal to 2:15 min resulted in greater than or equal to two scans with noninterpretable image quality. Conclusion STDR less than or equal to 2:15 min resulted in lower diagnostic value or insufficient image quality for qualitative PET MPI using 740 MBq 82 Rb. An STDR of 2:30 min can be considered for clinical adoption

Impact of image processing in the detection of ischaemia using CZT-SPECT/CT

Background:\ud The new multipinhole cardiac single photon emission computed tomography/computed tomography (SPECT/CT) cameras with cadmium–zinc–telluride (CZT) detectors are highly sensitive and produce images of high quality but rely on complex dedicated reconstruction algorithms. The aim of this study was to determine the impact of various processing steps on image formation and in the detection of ischaemia in CZT-SPECT/CT both with and without attenuation correction (AC).\ud \ud Materials and methods:\ud Data on 20 consecutive patients who underwent a 1-day protocol stress–rest SPECT/CT using 99mTc-tetrofosmin were processed twice by three experienced operators, yielding 120 AC and 120 noncorrected (NC) data sets. Processing steps included selection and determination of myocardial axes, manual SPECT/CT coregistration for AC and myocardial masking. Using the 17-segment cardiac model, differences between stress and rest segmental uptake (%) were calculated for NC and AC image sets. Both interoperator and intraoperator variations were considered significant for the diagnosis of ischaemia when greater than 5%.\ud \ud Results:\ud The mean interoperator variations were 2.4±1.4% (NC) and 3.8±1.9% (AC) (P<0.01). In 6% (NC) and 23% (AC) of the 120 processed cases, operator variation was larger than 5% and therefore potentially clinically interfering with the diagnosis of ischaemia. Differences between interoperator and intraoperator variations were nonsignificant.\ud \ud Conclusion:\ud Operator variations in the processing of myocardial perfusion image data using CZT-SPECT/CT are significant and may influence the diagnosis of ischaemia, especially when AC is applied. Clearer guidelines for image processing are necessary to improve the reproducibility of the studies and to obtain a more reliable diagnosis of ischaemia

Minimizing rubidium-82 tracer activity for relative PET myocardial perfusion imaging

Objectives: Recommended rubidium-82 activities for relative myocardial perfusion imaging (MPI) using present-generation PET scanners may be unnecessarily high. Our aim was to derive the minimum activity for a reliable relative PET MPI assessment. Materials and methods: We analyzed 140 scans from 28 consecutive patients who underwent rest-stress MPI-PET (Ingenuity TF). Scans of 852, 682, 511, and 341 MBq were simulated from list-mode data and compared with a reference scan using 1023 MBq. Differences in the summed rest score, total perfusion deficit, and image quality were obtained between the reference and each of the simulated rest scans. Combined stress-rest scans obtained at a selected activity of 682 MBq were diagnostically interpreted by experts and outcome was compared with the reference scan interpretation. Results: Differences in summed rest score more than or equal to 3 were found using 682, 511, and 341 MBq in two (7%), four (14%), and five (18%) patients, respectively. Differences in total perfusion deficit more than 7% were only found at 341 MBq in one patient. Image quality deteriorated significantly only for the 341 MBq scans (P<0.001). Interpretation of stress-rest scans did not differ between 682 and 1023 MBq scans. Conclusion: A significant reduction in administered Rb-82 activity is feasible in relative MPI. An activity of 682 MBq resulted in reliable diagnostic outcomes and image quality, and can therefore be considered for clinical adoption

Design of the ZWOT-CASE study : An observational study on the effectiveness of an integrated programme for cardiovascular risk management compared to usual care in general practice

Background: Cardiovascular diseases (CVD) contribute considerably to mortality and morbidity. Prevention of CVD by lifestyle change and medication is important and needs full attention. In the Netherlands an integrated programme for cardiovascular risk management (CVRM), based on the Chronic Care Model (CCM), has been introduced in primary care in many regions in recent years, but its effects are unknown. In the ZWOT-CASE study we will assess the effect of integrated care for CVRM in the region of Zwolle on two major cardiovascular risk factors: systolic blood pressure (SBP) and low-density lipoprotein cholesterol (LDL-cholesterol) in patients with or at high risk of CVD. Methods: This study is a pragmatic observational study comparing integrated care for CVRM with usual care among patients aged 40-80 years with CVD (n = 370) or with a high CVD risk (n = 370) within 26 general practices. After 1 yr follow-up, primary outcomes (SBP and LDL-cholesterol level) are measured. Secondary outcomes include lifestyle habits (smoking, dietary habits, alcohol use, physical activity), risk factor awareness, 10-year risk of cardiovascular morbidity or mortality, health care consumption, patient satisfaction and quality of life. Conclusion: The ZWOT-CASE study will provide insight in the effects of integrated care for CVRM in general practice in patients with CVD or at high CVD risk. Trial registration: The ZWOlle Transmural Integrated Care for CArdiovaScular Risk Management Study; ClinicalTrials.gov; Identifier: NCT03428061; date of registration: 09-02-2018; This study has been retrospectively registered

Primary percutaneous coronary intervention compared with fibrinolysis for myocardial infarction in diabetes mellitus - Results from the primary coronary angioplasty vs thrombolysis-2 trial

Background: There is growing evidence for a clinical benefit of primary percutaneous coronary intervention (PCI) compared with fibrinolysis; however, whether the treatment effect is consistent among patients with diabetes mellitus is unclear. We compared PCI with fibrinolysis for treatment of ST-segment elevation myocardial infarction in patients with diabetes mellitus. Methods: A pooled analysis of individual patient data from 19 trials comparing primary PCI with fibrinolysis for treatment of ST-segment elevation myocardial infarction was performed. Trials that enrolled at least 50 patients with ST-segment elevation myocardial infarction and randomized patients to receive either primary PCI or fibrinolysis were considered for inclusion in our study. Clinical end points were total deaths, recurrent infarction, death or nonfatal recurrent infarction, and stroke, measured 30 days after randomization. Results: Of 6315 patients, 877 (14%) had diabetes. Thirty-day mortality (9.4% vs 5.9%; P <.001) was higher in patients with diabetes. Mortality was lower after primary PCI compared with fibrinolysis in both patients with diabetes (unadjusted odds ratio, 0.49; 95% confidence interval, 0.31-0.79; P = .004) and without diabetes (unadjusted odds ratio, 0.69; 95% confidence interval, 0.54-0.86, P = .001), with no evidence of heterogeneity of treatment effect (P = .24 for interaction). Recurrent infarction and stroke were also reduced after primary PCI in both patient groups. After multivariable analysis, primary PCI was associated with decreased 30-day mortality in patients with and without diabetes, with a point estimate of greater benefit in diabetic patients. Conclusions: Diabetic patients with ST-segment elevation myocardial infarction treated with reperfusion therapy have increased mortality compared with patients without diabetes. The beneficial effects of primary PCI compared with fibrinolysis in diabetic patients are consistent with effects in nondiabetic patients

Primary percutaneous coronary intervention compared with fibrinolysis for myocardial infarction in diabetes mellitus - Results from the primary coronary angioplasty vs thrombolysis-2 trial

Background: There is growing evidence for a clinical benefit of primary percutaneous coronary intervention (PCI) compared with fibrinolysis; however, whether the treatment effect is consistent among patients with diabetes mellitus is unclear. We compared PCI with fibrinolysis for treatment of ST-segment elevation myocardial infarction in patients with diabetes mellitus. Methods: A pooled analysis of individual patient data from 19 trials comparing primary PCI with fibrinolysis for treatment of ST-segment elevation myocardial infarction was performed. Trials that enrolled at least 50 patients with ST-segment elevation myocardial infarction and randomized patients to receive either primary PCI or fibrinolysis were considered for inclusion in our study. Clinical end points were total deaths, recurrent infarction, death or nonfatal recurrent infarction, and stroke, measured 30 days after randomization. Results: Of 6315 patients, 877 (14%) had diabetes. Thirty-day mortality (9.4% vs 5.9%; P <.001) was higher in patients with diabetes. Mortality was lower after primary PCI compared with fibrinolysis in both patients with diabetes (unadjusted odds ratio, 0.49; 95% confidence interval, 0.31-0.79; P = .004) and without diabetes (unadjusted odds ratio, 0.69; 95% confidence interval, 0.54-0.86, P = .001), with no evidence of heterogeneity of treatment effect (P = .24 for interaction). Recurrent infarction and stroke were also reduced after primary PCI in both patient groups. After multivariable analysis, primary PCI was associated with decreased 30-day mortality in patients with and without diabetes, with a point estimate of greater benefit in diabetic patients. Conclusions: Diabetic patients with ST-segment elevation myocardial infarction treated with reperfusion therapy have increased mortality compared with patients without diabetes. The beneficial effects of primary PCI compared with fibrinolysis in diabetic patients are consistent with effects in nondiabetic patients