1. Diabetes mellitus (DM) is associated with worse clinical and angiographic outcomes even in acute myocardial Infarction (AMI) patients.

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1 Midterm Clinical Outcomes of Insulin Requiring Diabetes Mellitus versus Non-insulin Dependent Diabetes Mellitus in Acute Myocardial Infarction Patients in Drug Eluting Stent Era : Insight from Korea Acute Myocardial Infarction Registry (KAMIR) Sureshkumar Ramasamy,Seung-Woon Rha*, Kanhaiya L. Poddar, Ji Young Park, Kang-Yin Chen, Cheol Ung Choi, Chang Gyu Park, Hong Seog Seo, Dong Joo Oh, Myung Ho Jeong* Korea University Guro Hospital, Seoul, Korea * Chonnam National University Hospital, Gwangju, Korea

2 Abstract Objectives: Diabetes mellitus (DM) is associated with worse clinical and angiographic outcomes even in acute myocardial Infarction (AMI) patients. However, there are limited data regarding the prognosis of insulinrequiring DM (IRDM) pts as compared with non-insulin dependent DM (NIDDM) pts presenting with AMI in the drug-eluting stent (DES) era. Methods: The study population consisted of 1188 consecutive STEMI and NSTEMI pts enrolled in the Korea Acute Myocardial Infarction Registry (KAMIR) from November 2005 to June We compared the clinical outcomes of AMI pts requiring insulin for the management DM (IRDM group, n=492, 41.4%) as compared with only oral hypoglycemic agents requiring DM pts (NIDDM group, n=696, 58.6%) who underwent percutaneous coronary intervention (PCI) with DES. Results: The baseline clinical and procedural characteristics were balanced between IRDM group and NIDDM group except more dyslipidemia, current smokers, elderly pts, higher Killip class 3 and low left ventricular Ejection Fraction were noted in IRDM group. Pts with IRDM group showed higher in hospital cardiac death, cardiogenic shock, higher cumulative cardiac death and total major cardiac events (MACE) in the multivariate analysis (Table). Conclusion: Pts with IRDM group showed not only the worse baseline characteristics but also showed worse midterm clinical outcomes as compared with those of NIDDM in Asian population. Intensive medical and procedural interventions should be exercised at the earliest to achieve better clinical outcomes in IRDM pts presenting AMI.

3 Background 1. Diabetes mellitus (DM) is associated with worse clinical and angiographic outcomes even in acute myocardial Infarction (AMI) patients. 2. However, there are limited data regarding the prognosis of insulin-requiring DM (IRDM) pts as compared with non-insulin dependent DM (NIDDM) pts presenting with AMI in the drugeluting stent (DES) era

4 Purpose To evaluate the midterm clinical outcomes of insulin-requiring DM (IRDM) pts as compared with non-insulin dependent DM (NIDDM) pts presenting with AMI in the drug-eluting stent (DES) era

5 Methods 1. Study Population ; The study population consisted of 1188 consecutive STEMI and NSTEMI pts enrolled in the Korea Acute Myocardial Infarction Registry (KAMIR) from November 2005 to June Study Groups ; We compared the clinical outcomes of AMI pts requiring insulin for the management of DM (IRDM group, n=492 pts, 41.4%) as compared with only oral hypoglycemic agents requiring DM pts (NIDDM group, n=696 pts, 58.6%) who underwent percutaneous coronary intervention (PCI) with DES.

6 Methods 3. Antiplatelet therapy 1) All pts received Aspirin; 100 mg orally, indefinitely 2) All pts received Clopidogrel (Plavix ) preloaded mg before PCI, followed by daily administration of 75 mg and encouraged to continue at least for 1 year. 3) In case of suspicious higher risk of stent thrombosis ; Routine triple antiplatelets (Aspirin, Clopidogrel and Cilostazol) for one month, then changed to dual antiplatelets

7 Methods 4. Antithrombotic therapy 1) Enoxaparin (Clexane ); 60mg bid before PCI and after PCI during the hospital stay (within 7 days). 2) Unfractionated Heparin; a bolus of 50 U/kg prior to PCI for 1 st one hour 3) GP IIbIIIa blocker (Reopro ); depend on physician s discretion

8 Methods 5. Percutaneous Coronary Intervention (PCI) Procedure 1) A variety of atheroablative devices were not utilized and mostly simple predilation or was performed to get an adequate luminal diameter which was necessary to accommodate the unexpanded DES or BMS and their delivery system. 2) Thrombus aspiration was done using Thrombuster II catheter or Export catheter if there were significant angiographic visible thrombi in the target lesion before stenting. 6. Study End Points ; Individual major clinical hard enpoints including mortality, repeat revascularization, re-ami and total major adverse cardiac events (MACE) at 12 months were evaluated.

9 Statistics 1. All statistical analyses were performed using SPSS Continuous variables were expressed as means ± standard deviation and were compared using Student s t-test. 3. Categorical data were expressed as percentages and were compared using chi-square statistics or Fisher s exact test. 4. Multivariate analysis was used to test the association of Total occlusion of IRA with 12 month MACE 5. A P-value of 0.05 was considered statistically significant.

10 Results

11 Results 1. Baseline Characteristics ; The baseline clinical and procedural characteristics were balanced between IRDM group and NIDDM group except more dyslipidemia, current smokers, elderly pts, higher Killip class 3 and low left ventricular Ejection Fraction were noted in IRDM group. 2. Midterm Clinical Outcomes ; Pts with IRDM group showed higher in hospital cardiac death, cardiogenic shock, higher cumulative cardiac death and total major cardiac events (MACE) in the multivariate analysis (Table).

12 Twelve-Month Clinical outcomes (on Multivariate analysis) Variables, N (%) IRDM Group (n= 492 pts) NIDDM Group (n=696 pts) P value Cardiogenic Shock 29 (5.9) 12 (1.7) 0.003* In Hospital Cardiac Death 18 (3.7) 4 (0.6) 0.002* In Hospital Mortality 25 (5.1) 8 (1.1) 0.001* Total deaths 47 (9.6) 21 (3.0) 0.001* Cardiac Deaths 32 (6.5) 13 (1.9) Any MI 12 (2.4) 11 (1.6) Repeat Revascularization 23 (4.7) 42 (6.0) TLR-PCI 9 (1.8) 13 (1.9) TVR-PCI 10 (2.0) 21 (3.0) Total MACE 83 (16.9) 77 (11.1) 0.025*

13 Conclusion 1. Pts with IRDM group showed not only the worse baseline characteristics but also showed worse midterm clinical outcomes as compared with those of NIDDM in Asian population. 2. Intensive medical and procedural interventions should be exercised at the earliest to achieve better clinical outcomes in IRDM pts presenting AMI.