Letters Section Editor: Robert M. Golub, MD, Senior Editor.
To the Editor: Dr Fox and colleagues1 documented a multinational improvement in provision of evidence-based care for patients with acute coronary syndromes (ACS), with reduction in mortality and morbidity associated with these treatments. The study reinforces the need to further improve adherence to evidence-based guidelines and demonstrates the clinical benefit that can be achieved with such a strategy.
However, Fox et al did not assess the temporal pattern in outcomes in patients with diabetes. In a study examining the changing patterns in outcome after acute myocardial infarction (AMI) in multiple hospitals in the United Kingdom, we analyzed data from more than 3000 unselected patients sustaining an AMI in either 1995 or 2003 and assessed changes in care and all-cause mortality at 30 days and 18 months.2 Our data support those of Fox et al showing improved quality of care for all patients with AMI. However, patients with diabetes did not demonstrate the improvement in survival seen in patients without diabetes.
Between 1995 and 2003, 18-month mortality in nondiabetic patients fell from 30.1% to 25.7%, an approximately 15% relative reduction (P = .008). However, 18-month mortality in patients with diabetes was not significantly changed over this period (38% in 1995 vs 36.4% in 2003; P = .71).
The reasons for our findings are unclear, although current treatment strategies may fail to address specific aspects of vascular pathophysiology in patients with diabetes. For example, insulin resistance, oxidative stress, and inflammation may be inadequately addressed by current treatments.3 Moreover, cardiologists may not fully adhere to recognized guidelines regarding the optimal management of diabetes.4
The global population of patients with type 2 diabetes is projected to reach 366 million by 2030.5 With the increasing prevalence of diabetes, the results of the efforts to improve outcome post ACS may be abrogated or even reversed. To avoid this, research into the prevention and management of cardiovascular diseases in diabetes must be prioritized.
Financial Disclosures: None reported.
Cubbon RM, Gale CP, Grant PJ, Hall AS, Kearney MT. Lower Rates of Heart Failure and Death in Acute Coronary Syndromes. JAMA. 2007;298(9):969-971. doi:10.1001/jama.298.9.969-a