Treatment disparities in the care of patients with and without diabetes presenting with non-ST-segment elevation acute coronary syndromes.
OBJECTIVE
The objective of this study was to characterize treatment patterns among patients with diabetes presenting with non-ST-segment elevation (NSTE) acute coronary syndromes (ACSs).


METHODS
We compared adherence to treatment recommendations from the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for NSTE ACS among 46,410 patients from 413 U.S. hospitals that were included in the Can Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines (CRUSADE) quality improvement initiative. Patients were stratified as nondiabetic, non-insulin-dependent diabetic (type 2 diabetic), and insulin-treated diabetic.


RESULTS
Insulin-treated diabetic patients were less likely than nondiabetic patients to receive aspirin (adjusted odds ratio 0.83 [95% CI 0.74-0.93]), beta-blockers (0.89 [0.83-0.96]), heparin (0.90 [0.83-0.98]), and glycoprotein IIb/IIIa inhibitors (0.86 [0.79-0.93]). Type 2 diabetic patients were treated similarly to nondiabetic patients. After adjustment for differences in clinical characteristics, insulin-treated diabetic patients were significantly less likely than nondiabetic patients to receive cardiac catheterization within 48 h of presentation (0.80 [0.74-0.86]) or percutaneous coronary intervention (0.87 [0.82-0.94]). Compared with nondiabetic patients, insulin-treated diabetic and type 2 diabetic patients were more likely to undergo coronary artery bypass grafting (1.34 [1.21-1.49] and 1.35 [1.26-1.44]). In-hospital mortality rates were higher in insulin-treated diabetic (6.8%) and type 2 diabetic (5.4%) than in nondiabetic (4.4%) patients.


CONCLUSIONS
Diabetic patients have a higher risk of mortality than nondiabetic patients, yet physicians adhere to the ACC/AHA NSTE ACS guidelines less often when treating diabetic patients, particularly insulin-treated diabetic patients. Increased use of guideline-recommended therapies and early invasive management strategies in diabetic patients may improve their outcomes.
Brogan
Gerard X
GX
Department of Emergency Medicine, New York University School of Medicine/North Shore Long Island Jewish Health System, Plainview, New York 11803, USA. gbrogan@nshs.edu
Peterson
Eric D
ED
Mulgund
Jyotsna
J
Bhatt
Deepak L
DL
Ohman
E Magnus
EM
Gibler
W Brian
WB
Pollack
Charles V
CV
Farkouh
Michael E
ME
Roe
Matthew T
MT
D000208:Acute Disease; D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D000328:Adult; D001241:Aspirin / Q000627:therapeutic use; D006328:Cardiac Catheterization; D000077144:Clopidogrel; D001026:Coronary Artery Bypass; D003327:Coronary Disease / Q000188:drug therapy / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D003922:Diabetes Mellitus, Type 1; D003924:Diabetes Mellitus, Type 2; D003925:Diabetic Angiopathies / Q000601:surgery / Q000628:therapy*; D005260:Female; D006493:Heparin / Q000627:therapeutic use; D006801:Humans; D008297:Male; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D012008:Recurrence; D016019:Survival Analysis; D013988:Ticlopidine / Q000031:analogs & derivatives / Q000627:therapeutic use
D000319:Adrenergic beta-Antagonists; D010975:Platelet Aggregation Inhibitors; D006493:Heparin; D000077144:Clopidogrel; D013988:Ticlopidine; D001241:Aspirin