Akuter Myokardinfarkt bei Patienten mit Diabetes mellitus

S. Szabo; H. M. Hoffmeister

doi:10.1055/s-0037-1619521

Hämostaseologie, Table of Contents

Hamostaseologie 2001; 21(04): 176-185
DOI: 10.1055/s-0037-1619521

Original article

Schattauer GmbH

Akuter Myokardinfarkt bei Patienten mit Diabetes mellitus

Pathophysiologie, Diagnostik und therapeutische AspekteAcute myocardial infarction in patients with diabetes mellitusPathophysiology, diagnosis and therapeutic aspects

Authors

S. Szabo

¹Medizinische Klinik, Abteilung Innere Medizin III, Eberhard-Karls-Universität, Tübingen
H. M. Hoffmeister

²Städtisches Klinikum, Abteilung für Kardiologie und Allgemeine Innere Medizin, Solingen

Abstract

Zusammenfassung

Kardiovaskuläre Erkrankungen stellen bei Patienten mit Diabetes mellitus die wesentliche Ursache für Morbidität und Mortalität dar. Haupttodesursache bei Diabetikern ist der akute Myokardinfarkt. Auch nach diesem Ereignis bestehen erhöhte Mortalitätsraten und eine höhere Inzidenz für die Entwicklung einer Herzinsuffizienz versus Patienten ohne Diabetes.

Pathophysiologische Besonderheiten ergeben sich im Hinblick auf die Auswirkung des Diabetes auf die koronare Herzerkrankung mit einer myokardialen und einer vaskulären Komponente. Darüber hinaus bestehen bei Diabetikern häufig weitere Erkrankungen wie die arterielle Hypertonie, Veränderungen der Hämostase, der Fibrinolyse, korpuskulärer Blutbestandteile und der Inflammation. Nicht alle klassischen diagnostischen Kriterien des Myokardinfarkts können bei Diabetikern aufgrund der Begleiterkrankungen uneingeschränkt angewandt werden. Die Therapie hat die rasche und permanente Reperfusion der verschlossenen Koronararterie zum Ziel; dabei kommen verschiedene pharmakologische Thrombolyse-Regime und die perkutane transluminale Koronarangioplastie in Frage. Weitere Studien müssen abgewartet werden, um ein optimales Vorgehen zur Prognoseverbesserung dieser Patientenpopulation zu finden.

Summary

The main cause for morbidity and mortality in patients with diabetes mellitus are cardiovascular diseases. Acute myocardial infarction in this group has a poorer outcome (death and development of heart failure) versus patients without diabetes. Preexisting myocardial, vascular, prothrombotic, antifibrinolytic alterations as well as an inflammatory state occur frequently in diabetic patients. Classical symptoms of acute myocardial infarction are often not present in patients with diabetes making the diagnosis more difficult. The aim of the therapy is to restore a prompt and permanent blood flow in the occluded coronary artery in order to preserve as much viable myocardium as possible. Different thrombolytic regimen are used nowadays, another option is the percutaneous coronary angioplasty. Further prospective studies are required to define optimal therapeutic strategies in this high risk population.

Schlüsselwörter

Diabetes mellitus - akuter Myokardinfarkt

Keywords

Diabetes mellitus - acute myocardial infarction

Full Text

References

Literatur
1 American Diabetes Association. Consensus statement. Role of cardiovascular risk factors in prevention and treatment of macrovascular disease in diabetes. Diabetes Care 1993; 16 (Suppl): 72-8.
2 Antiplatelet Trialists’ Collaboration. Collaborative overview of randomised trials of antiplatelet therapy – 1: Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. Br Med J 1994; 308: 81-106.
3 BARI Investigators. Comparison of coronary bypass surgery with angioplasty in patients with multivessel disease. N Engl J Med 1996; 335: 217-25.
4 Benzuly KH, Davidson CJ, Gubernikoff G, Eckman LJ, Saoud J, Faxon DP. Clinical Outcomes of Direct PTCA Performed On-Call. Circulation 102 (Suppl. 02) II-385.
5 Braunwald E, Kloner RA. The stunned myocardium: prolonged, postischemic ventricular dysfunction. Circulation 1982; 66: 1146-9.
6 Butler R, MacDonald TM, Struthers AD, Morris AD. The clinical implications of diabetic heart disease. Eur Heart J 1998; 19: 1617-27.
7 Califf RM, Lee KL, Granger CB, Ohman EM. Predictors of outcome of reperfusion therapy. Eur Heart J 1997; 18: 728-35.
8 Carter AM, Grant PJ. Vascular homeostasis, adhesion molecules, and macrovascular disease in non-insulin-dependent diabetes mellitus. Diabet Med 1997; 14: 423-32.
9 Celentano A, Vaccaro O, Tammaro P, Galderisi M, Crivro M, Oliviero M, Imperatore G, Palmieri V, Iovino V, Riccardi G, deDivitiis O. Early abnormalities of cardiac function in non-insulin-dependent diabetes mellitus and impaired glucose tolerance. Am J Cardiol 1995; 76: 1173-6.
10 Fisher BM, Frier BM. Evidence for a specific heart disease of diabetes in humans. Diab Med 1990; 7: 478-89.
11 Gray RP, Yudkin JS, Patterson DL. Plasminogen activator inhibitor: a risk factor for myocardial infarction in diabetic patients. B Heart J 1993; 69: 228-32.
12 Grundy SM, Benjamin IJ, Burke GL. et al. Diabetes and Cardiovascular Disease: A Statement for Healthcare Professionals From the American Heart Association. Circulation 1999; 100: 1134-46.
13 Gundersen T, Kjekshus J. Timolol treatment after myocardial infarction in diabetic patients. Diabetes Care 1983; 6: 285-90.
14 Gwilt DJ, Petri M, Lewis PW, Nattrass M, Pentecost BL. Myocardial infarct size and mortality in diabetic patients. Br Heart J 1985; 54: 466-72.
15 Hamby RI, Sherman L, Mehta J, Aintablain A. Reappraisal of the role of the diabetic state in coronary artery disease. Chest 1976; 70: 251-7.
16 Harris MI. Undiagnosed NIDDM: clinical and public health issues. Diabetes Care 1993; 16: 642-52.
17 Hasadi D, Granger CB, Srivatsa SS, Criger DA, Ellis SG, Califf RM, Topol EJ, Holmes Jr DR. Diabetes Mellitus and Outcome After Primary Coronary Angioplasty for Acute Myocardial Infarction: Lessons from the GUSTO-IIb Angioplasty Substudy. JACC 200 35: 1502-12.
18 Herlitz J, Malmberg K, Karlson BW, Ståhl L, Rydén L, Hjalmarson Å. Mortality and morbidity during a five-year follow-up in diabetics with myocardial infarction. Acta Med Scand 1988; 224: 31-8.
19 Hoffmeister HM, Mauser M, Schaper W. Repeated short periods of regional myocardial ischemia: effect on local function and high energy phosphate levels. Basic Res Cardiol 1986; 81: 361-72.
20 Hoffmeister HM, Jur M, Ruf-Lehmann M, Helber U, Heller W, Seipel L. Endothelial tissue-type plasminogen activator release in coronary heart disease. J Am Coll Cardiol 1998; 31: 547-51.
21 Hoffmeister HM, Szabo S, Kastner C, Beyer ME, Helber U, Kazmaier S, Wendel HP, Heller W, Seipel L. Thrombolytic therapy in acute myocardial infarction: comparison of procoagulant effects of streptokinase and alteplase regimen with focus on the kallikrein system and plasmin. Circulation 1998; 98: 2527-33.
22 Jacoby RM, Nesto RW. Acute myocardial infarction in the diabetic patient: pathophysiology, clinical course and prognosis. J Am Coll Cardiol 1992; 20: 736-44.
23 Jain SK, Nagi DK, Slavin BM, Lumb PJ, Yudkin JS. Insulin therapy in type two diabetic subjects suppresses plasminogen activator (PAI-1) activity and proinsulin like molecules independently of glycaemic control. Diab Med 1993; 10: 27-33.
24 Jilma B, Fasching P, Ruthner C, Rumplmayr A, Ruzicka S, Kapiotis S, Wagner OF, Eichler HG. Elevated circulating P-selectin in insulin dependent diabetes mellitus. Thromb Haemost 1996; 76: 328-32.
25 Kannel WB, McGee DL. Diabetes and cardiovascular disease: the Framingham Study. JAMA 1979; 241: 2035-8.
26 Kendall MJ, Lynch KP, Hjalmarson Å, Kjekshus J. B-blockers and sudden cardiac death. Ann Int Med 1995; 123: 358-67.
27 Kjekshus J, Pedersen TR. Reducing the risk of coronary events: evidence from the Scandinavian Simvastatin Survival Study (4S). Am J Cardiol 1995; 76: 64C-68C.
28 Krolewski AJ, Kosinski EJ, Warram JH, Leland OS, Busick EJ, Asmal AC, Rand LI, Christlieb RA, Bradley RF, Kahn CR. Magnitude and determinants of coronary artery disease in juvenile-onset, insulin-dependent diabetes mellitus. Am J Cardiol 1987; 59: 750-5.
29 Lew AS, Hod H, Cercek B, Shah P, Ganz W. Mortality and morbidity rates of patients older and younger than 75 years with acute myocardial infarction treated with intravenous streptokinase. Am J Cardiol 1987; 59: 1-5.
30 Malmberg K, Herlitz J, Hjalmarson Å, Rydén L. Effects of metoprolol on mortality and late infarction in diabetics with suspected acute myocardial infarction. Retrospective data from two large scale studies. Eur Heart J 1989; 10: 423-8.
31 Malmberg K, Rydén L. Myocardial infarction in patients with diabetes mellitus. Eur Heart J 1988; 9: 259-64.
32 Malmberg K, Rydén L, Efendic S, Herlitz J, Nicol P, Waldenström A, Wedel H, Welin L. on Behalf of the DIGAMI Study Group. Randomized Trial of Insulin-Glucose Infusion Followed by Subcutaneous Insulin Treatment in Diabetic Patients With Acute Myocardial Infarction (DIGAMI Study): Effects on Mortality at 1 Year. JACC 1995; 26: 57-65.
33 Malmberg K, Yusuf S, Hertzel CG, Brown J, Zhao F, Hunt D, Piegas L, Calvin J, Keltai M. Budaj A for the OASIS Registry Investigators. Impact of Diabetes on Long-Term Prognosis in Patients With Unstable Angina and Non-Q-Wave Myocardial Infarction. Circulation 2000; 102: 1014-9.
34 Rahimtoola SH. The hibernating myocardium. Am Heart J 1989; 117: 211-21.
35 Reimer KA, Hill ML, Jennings RB. Prolonged depletion of ATP and of the adenine nucleotide pool due to delayed resynthesis of adenine nucleotides following reversible myocardial ischemic injury in dogs. J Mol Cell Cardiol 1981; 13: 229-39.
36 Robertson WB, Strong JP. Atherosclerosis in persons with hypertension and diabetes mellitus. Lab Invest 1968; 18: 538-51.
37 Sacks FM, Pfeffer MA, Moye LA, Rouleau JL, Rutherford JD, Cole TG, Brown L, Warnica JW, Arnold JMO, Wun CC, Davis BR, Braunwald E. The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. N Engl J Med 1996; 335: 1001-9.
38 Salge D, Nienaber CA, Spielmann RP, Bleifeld W. Non-Q wave and Q wave myocardial infarct: correlation with regional myocardial perfusion, wall function and prognosis within 1 year. Z Kardiol 1990; 79: 261-7.
39 Schaper W. The current status of experimental heart infarct research. Z Kardiol 1990; 79: 811-8.
40 Silva JA, Ramee SR, White CJ, Collins TJ, Jenkins JS, Nunez E, Zhang S, Jain SP. Primary stenting in acute myocardial infarction: Influence of diabetes mellitus in angiographic results and clinical outcome. Am Heart J 199 138: 446-55.
41 Simes RJ, Topol EJ, Holmes Jr DR. et al. Link between the angiographic substudy and mortality outcomes in a large randomized trial of myocardial reperfusion. Importance of early and complete infarct artery reperfusion: GUSTO-I Investigators. Circulation 1995; 91: 1923-8.
42 Stein B, Weintraub WS, Gebhart S, Cohen-Bernstein CL, Grosswald R, Liberman HA, Douglas JS, Morris DC, King SBIII. Influence of diabetes mellitus on early and late outcome after percutaneous transluminal coronary angioplasty. Circulation 1995; 91: 979-89.
43 Stone GW, Grines CL, Cox DA, Stuckey T, Carroll JD, Guagliumi G, Rutherford BD, Essente P, Lansky AJ, Tcheng JE, Griffin J, Garcia E. A Prospective, Randomized Trial Comparing Primary Balloon Angioplasty with or without Abciximab to Primary Stenting with or without Abciximab in Acute Myocardial Infarction – Primary Endpoint Analysis from the Cadillac Trial. Circulation 2000; 102 (Suppl. 02) I-664.
44 Strandberg LE, Ericsson CG, O’Konor ML, Bergstrand L, Lundin P, Rehnquist N, Tornvall P. Diabetes mellitus is a strong negative prognostic factor in patients with myocardial infarction treated with thrombolytic therapy. J Int Med 2000; 248: 119-25.
45 Strano A, Davi G, Patrono C. In vivo platelet activation in diabetes mellitus (Review). Semin Thromb Hemost 1991; 17: 422-5.
46 The Joint European Society of Cardiology/American College of Cardiology Committee. Myocardial infarction redefined – A consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the Redefinition of Myocardial Infarction. Eur Heart J 2000; 21: 1502-13.
47 Topol EJ, Ohman EM, Armstrong PW, Wilcox R, Skene AM, Aylward P, Simes J, Dalby A, Betriu A, Bode C, White HD, Hochman JS, Emanuelson H, Vahanian A, Sapp S, Stebbins A, Moliterno DJ, Califf RM. Survival outcomes 1 year after reperfusion therapy with either alteplase or reteplase for acute myocardial infarction: results from the global utilization of streptokinase and t-PA for occluded coronary arteries (GUSTO) III trial. Circulation 2000; 102: 1761-5.
48 Tschoepe D. The activated megakaryocyteplatelet-system in vascular disease: focus on diabetes. Semin Thromb Hemost 1995; 21: 152-60.
49 Tschoepe D, Roesen P, Kaufmann L, Schauseil S, Kehrel B, Ostermann H, Gries FA. Evidence for abnormal platelet glycoprotein expression in diabetes mellitus. Eur J Clin Invest 1990; 20: 166-70.
50 Van de Werf F, Adgey J. The Assessment of the Safety and Efficacy of a New Thrombolytic (ASSENT-2) Investigators. Single-bolus tenecteplase compared with front-loaded alteplase in acute myocardial infarction: the ASSENT-2 double-blind randomised trial. Lancet 1999; 354: 716-22.
51 Ward H, Yudkin JS. Thrombolysis in patients with diabetes. Br Med J 1995; 310: 3-4.
52 Woodfield SL, Lundergan CF, Reiner JS, Greenhouse SW, Thompson MA, Rohrbeck SC, Deychak Y, Simoons ML, Califf RM, Topol EJ, Ross AM. for the GUSTO-I Angiographic Investigators. Angiographic Findings and Outcome in Diabetic Patients Treated With Thrombolytic Therapy for Acute Myocardial Infarction: The GUSTO-I Experience. JACC 1996; 28: 1661-9.
53 Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med 2000; 342: 145-53.