Surprise, surprise

It is well established that CVD is a leading cause of death in diabetics. Certainly, the prevalence of CAD in diabetics is higher than in nondiabetics, as well as the risk of MI, and silent ischemia. Diabetes remains a major independent cardiovascular risk factor even when adjusting for age, hypertension, hypercholesterolemia as well documented in MRFIT. It is also well established that diabetics have worse outcomes in STEMI. Though diabetics having primary angioplasty have better outcomes than those receiving thrombolytics [1], they tend to have worse outcome than nondiabetics regardless of method of reperfusion [2]. In acute MI, diabetics are more often to have pulmonary edema and congestive heart failure despite similar infarct size and ejection fraction. In AIDA STEMI, patients with STEMI undergoing PCI, intracoronary Abciximab as compared to Intravenous Abciximab did not result in a difference in the combined endpoint (death, reinfarction, and CHF). However, it was associated with reduced rates of CHF as an individual outcome. AIDA STEMI further confirmed the safety of intracoronary Abciximab administration. In the CICERO trial, intracoronary Abciximab in STEMI undergoing primary PCI with aspiration, compared to intravenous administration does not improve myocardial reperfusion as assessed by STsegment resolution, it was associated with improved myocardial reperfusion as assessed by myocardial blush grade and a smaller enzymatic infarct size [3]. The data on thrombus aspiration during primary PCI has been conflicting. In some studies, it has been shown to be associated with improved myocardial perfusion and blush grade and ST segment resolution [4]. Furthermore, the improved myocardial blush grade was clearly associated with better clinical outcomes (lower rate of death and MACE) [4]. In other studies, it was not associated with increased myocardial salvage, on the contrary, it might have been associated with larger infarct size [5]. Manual thrombectomy did not reduce 30-day mortality, stent thrombosis, rate of stroke, or recurrent MI according to TASTE trial. INFUSE-AMI, 30-days outcomes showed small but significant reduction in infarct size assessed by cardiac magnetic resonance imaging, using intracoronary abciximab versus no Abciximab in large anterior STEMI, but not with manual aspiration. Post-hoc analysis of INFUSE-AMI data (day 31–1 year), there was decreased CHF and hospitalization with CHF with aspiration. Though INFUSE-AMI was not powered for clinic endpoints, the post-hoc analysis certainly shows intriguing results. In INFUSE-AMI, diabetic patients were older than nondiabetics, had statistically significant larger BMI, more comorbidities (hypertension and hyperlipidemia). They were more likely to present later than nondiabetic from symptoms onset. Diabetics had more extensive disease in the infarct related vessel. Diabetics had similar rates of restoring coronary blood flow (TIMI flow grade, myocardial blush grade) to nondiabetics, as well as similar infarct reperfusion success (infarct size and EF by cMRI). The data might have been off set by the fact that less diabetic versus nondiabetics had cMRI to assess the infarct size and reperfusion compared to nondiabetic (66.6% vs. 86.5%, P 5 0.007). It is unclear as to why diabetics had less cMRI (e.g., severe kidney disease, MRI noncompatible devices such as ICDs suggestive of poor EF and higher risk patient population to start with). We do not know the infarct size in these diabetic patients without cMRI and hence we do not know how the data could have been affected, especially in a sample size. Interestingly, diabetics had more MACCE (death, reinfarction, ischemia-driven TVR, and stroke). This suggests that there is more to MACCE than just reperfusion success. It certainly raises the possibility that the higher risk profile of diabetic patients (i.e., age, higher BMI, HTN, and multiple lesions) could play an important role in outcomes of PCI in STEMI more than just adequate perfusion.