Outcome of acute ST-segment elevation myocardial infarction in diabetics treated with fibrinolytic or combination reduced fibrinolytic therapy and platelet glycoprotein IIb/IIIa inhibition lessons from the GUSTO V trial

• Published in: Journal of the American College of Cardiology 2004-02, Vol.43 (4), p.542-548
• Main Authors: GURM, Hitinder S, LINCOFF, A. Michael, GUETTA, Victor, WILCOX, Robert, TOPOL, Eric J, LEE, David, TANG, W. H, GANG JIA, BOOTH, Joan E, CALIFF, Robert M, OHMAN, E. M, VAN DE WERF, Frans, ARMSTRONG, Paul W
• Format: Article
• Language: English
• Subjects: Antibodies, Monoclonal - administration & dosage; Antibodies, Monoclonal - therapeutic use; Aspirin; Biological and medical sciences; Blood platelets; Blood pressure; Cardiology; Cardiology. Vascular system; Cardiovascular disease; Case-Control Studies; Confidence intervals; Coronary heart disease; Diabetes; Diabetes Complications; Drug Therapy, Combination; Electrocardiography; Enzymes; Family medical history; Female; Fibrinolytic Agents - administration & dosage; Fibrinolytic Agents - therapeutic use; Heart; Heart attacks; Heart rate; Humans; Hypertension; Immunoglobulin Fab Fragments - administration & dosage; Immunoglobulin Fab Fragments - therapeutic use; Ischemia; Male; Medical sciences; Middle Aged; Mortality; Myocardial Infarction - complications; Myocardial Infarction - drug therapy; Myocardial Infarction - mortality; Myocarditis. Cardiomyopathies; Platelet Aggregation Inhibitors - administration & dosage; Platelet Aggregation Inhibitors - therapeutic use; Platelet Glycoprotein GPIIb-IIIa Complex - antagonists & inhibitors; Population; Recombinant Proteins - administration & dosage; Recombinant Proteins - therapeutic use; Retrospective Studies; Tissue Plasminogen Activator - administration & dosage; Tissue Plasminogen Activator - therapeutic use
• ISSN: 0735-1097; 1558-3597
• DOI: 10.1016/j.jacc.2003.09.038

We studied the outcome of diabetics enrolled in the Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO) V trial to assess whether the combination of half-dose reteplase and abciximab provides any propitious benefits over standard fibrinolytic therapy in diabetic patients. Diabetics with acute ST-segment elevation myocardial infarction (MI) have a worse outcome compared with nondiabetics. Higher-risk patients are usually more likely to benefit from advances in medical therapy. We analyzed diabetic patients enrolled in the GUSTO V trial to assess the outcome of those randomized to the combination of half-dose reteplase and abciximab versus those randomized to reteplase. We also evaluated whether any differences existed in presentation and outcome of MI among the diabetics versus the nondiabetics enrolled in the study. The trial enrolled 13782 nondiabetics and 2633 diabetics. Compared to nondiabetics, diabetics had a significantly higher mortality at 30 days (8.5% vs. 5.1%, p < 0.001) and at 1 year (12.7% vs. 7.5%, p < 0.001). Among the diabetic subset, no significant difference existed in the incidence of 30-day (8.8% vs. 8.2%, p = 0.52) or 1-year mortality (13.0% vs. 12.4%, p = 0.62) among patients randomized to reteplase compared to those receiving combination of abciximab and reteplase. The incidence of reinfarction (2.5% vs. 4.3%, p = 0.013), recurrent ischemia (11.8% vs. 14.9%, p = 0.017), and urgent revascularization (10.9% vs. 13.3%, p = 0.055) at seven days was lower in diabetics treated with the combination therapy. Compared to nondiabetics, diabetics continue to have a worse outcome with MI. Although combination therapy did not provide a survival benefit, nonfatal ischemic outcomes, including reinfarction, recurrent ischemia, and urgent revascularization, were substantially reduced.