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Table of Contents
ORIGINAL ARTICLE
Year : 2013  |  Volume : 14  |  Issue : 1  |  Page : 1-4  

The management of elderly diabetic Saudi patients with acute coronary syndrome


1 Department of Cardiology, King Saud Bin Abdulaziz University for Health Sciences, King Abdul Aziz Medical City, Jeddah, Saudi Arabia
2 Department of Cardiology, Arrayan Hospital, Dr. Sulaiman Al Habib Medical Group, Riyadh, Saudi Arabia

Date of Web Publication13-Feb-2013

Correspondence Address:
Abdulhalim J Kinsara
Department of Cardiology, King Saud Bin Abdulaziz University for Health Sciences, COM. King Abdul Aziz Medical City, P.O. Box 9515, Jeddah 21423
Saudi Arabia
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DOI: 10.4103/1995-705X.107112

PMID: 23580917

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   Abstract 

Background and Purpose: Elderly Diabetics (DM) who present with Acute Coronary Syndrome (ACS) constitute a very high risk group. We present the pattern of management of elderly patients (>65 years) in the Kingdom of Saudi Arabia (KSA) in comparison to the international data extrapolated from a Multicenter International Diabetes-Acute Coronary Syndromes (MIDAS).
Materials and Methods: DM patients presenting with unstable angina or non-ST-segment elevation myocardial infarction (MI) at the time of admission to the hospital were collectively enrolled into the MIDAS study. A total of 3624 patients were enrolled; 142 were from Saudi Arabia. Primary clinical outcome measure was in-hospital death or MI. We present the data of KSA based on the age of the patients in comparison to the international registry.
Results: Baseline characteristics were typical for DM presenting with ACS, with mean age of 67 ± 15 years, males, constituted 36% of patients while 94% of patients were DM type 2. There was marked underutilization of glycoprotein IIb/IIIa inhibitors in those aged over 65 years with a decrease from 22.5 to 12.7 in KSA (Odds ratio 0.56) patients. The percentage of early coronary angiography approach in KSA was less than that of the international data with further reduction of the percentage in Saudi elderly population (from 49.3% to 25.5% with Odds ratio 0.52).
Conclusions: In elderly Saudi diabetic patients admitted with ACS, there is tendency for underutilization of GP IIb/IIIa, early coronary angiography, and revascularization that needs to be addressed.

Keywords: Acute Coronary Syndrome, diabetics, elderly, GP IIb/IIIa, Multicenter International Diabetes-Acute Coronary Syndromes, NSTEMI, Saudi


How to cite this article:
Kinsara AJ, Hasanin AM. The management of elderly diabetic Saudi patients with acute coronary syndrome. Heart Views 2013;14:1-4

How to cite this URL:
Kinsara AJ, Hasanin AM. The management of elderly diabetic Saudi patients with acute coronary syndrome. Heart Views [serial online] 2013 [cited 2014 Jul 26];14:1-4. Available from: http://www.heartviews.org/text.asp?2013/14/1/1/107112


   Background and Purpose Top


Both age and diabetes mellitus (DM) are independent prognostic predictors of hospital mortality in Acute Coronary Syndrome (ACS). [1] An analysis on the in-hospital events and 6 months outcomes in elderly patients with ACS who were included in the GRACE registry showed that the more elderly, the higher risk are the patients, the less frequently coronary angiography, and revascularization are used in spite of an increasing GRACE risk score. [2] There is paucity of data in Kingdom of Saudi Arabia (KSA) despite the high percentage of elderly diabetic patients and the high prevalence of DM.

Multicenter International Diabetes - Acute Coronary Syndromes (MIDAS) study aimed to monitor the adherence to evidence-based therapy of diabetic patients with ACS and to describe the in-hospital outcomes of diabetic patients in the setting of ACS. [3],[4] We present the characteristic risk profile and points of concern in the management of elderly patients in the KSA in comparison to the international data.


   Design Top


MIDAS is an observational registry and diagnostic, monitoring, or therapeutic procedures were not applied to the patients. DM patients presenting with Non ST Elevation - Acute Coronary Syndrome were enrolled into the study at the time of admission to the emergency room or the coronary care unit in five hospitals in KSA. A total of 3624 patients were enrolled; 142 were from Saudi Arabia. Primary clinical outcome measure was in-hospital death or myocardial infarction (MI). MIDAS did not interfere with the medical care of the patients, which was done according to local practice.


   Results Top


Baseline characteristics for MIDAS participants were typical of diabetics with ACS. The mean age was 67 ± 15 years and there was female predominance (64%). DM type 2 constitutes 94% of the patients [Table 1].
Table 1: Baseline characteristics for multicenter international diabetes - acute coronary syndromes patients

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The utilization of glycoprotein IIb/IIIa inhibitors in international MIDAS was 37.4%, predominantly Tirofiban, in comparison to 18.3% in KSA ( P = 0.046). There was marked underutilization of glycoprotein IIb/IIIa inhibitors in KSA in those ≥65 years (12.7%) in comparison to 22.5% in those <65 years (Odds ratio 0.56). Meanwhile, the utilization of GP IIb/IIIa in international MIDAS elderly population decreased from 40.8% in those aged <65 years to 35.7% in those aged ≥65 years with Odds ratio 0.87 [Figure 1].
Figure 1: GP IIb/IIIa utilization based on age group

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On the contrary, the utilization of clopedogril/ticlopidine in KSA was 96.8% exceeding the international figure of 74.7% ( P < 0.0001). Surprisingly, the utilization of clopedogril/ticlopidine in KSA in those aged ≥65 years (98.2%) was higher than those aged <65 years (95.8%) [Figure 2].

The percentage of early coronary angiography approach in KSA was less than that of the international data with further drop of the percentage in Saudi elderly population (25.5% in those aged over 65 years) in comparison to 49.3% in those aged <65 years with Odds ratio 0.52. Meanwhile, there was mild drop in the international figure (42.5% in those aged ≥65 years in comparison to 53.4% in those aged <65 years with Odds ratio 0.80) [Figure 3].

In contrast, the percentage of Per Cutaneuos coronary Intervention procedures in Saudi elderly patients (23.6% in those aged ≥65 years) was very close to those aged <65 years (25.4%), but much less than the international elderly (≥65 years), who had percutaneous coronary intervention (PCI) in 42.5% [Figure 4].
Figure 2: Clopedogril utilization based on age group

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Figure 3: Percentage of early coronary angiography approach based on age group

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Figure 4: Percentage of PCI based on age group

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The percentage of patients who had Coronary Artery Bypass Graft in elderly KSA (≥65years) was 7.3% in comparison to 12.7% in those aged <65 years. The international figure in those aged ≥ 65 years (8.9%) did not show remarkable difference in comparison with those aged <65 years (9.4%) [Figure 5].
Figure 5: Percentage of CABG based on age group

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   Discussion Top


One study in Saudi subjects showed that, in those aged over 60 years, the prevalence of Non Insulin Dependant Diabetic Mellitus was 28.82% in males and 24.92% in females. Furthermore, DM was the most prevalent risk factor for coronary artery disease, present in 56% of patients. [5] However, data regarding the adherence to evidence-based therapy in this group of patients are lacking.

Elderly are at the risk of being under-treated both medically and by interventions as supported by recent registries and statements; [1],[2] however, the available data from KSA are few.

The mean age of MIDAS patients (65 years) was similar to that of GRACE registry (66 years) and NCDR ACTION registry (64 years). [6],[7] Data from MIDAS showed, in general, satisfactory use of evidence-based therapies. However, there were significant differences in utilization of different lines of treatment based on age.

Elderly patients were under-treated in the invasive arm in term of coronary angiography, PCI, and coronary artery bypass graft (CABG). This was more marked in elderly Saudi patients. Despite the current strong recommendations for their use in diabetics presenting with ACS, there was marked underutilization of GP IIb/IIIa inhibitors in elderly Saudi MIDAS patients as well as those aged under 65 years. This underutilization was obviously due to fear of bleeding, taking into consideration that recent reports and guidelines showed more concern about the increased risk of bleeding upon using double or triple antiplatelet therapy in combination with heparin.

In contrast, the use of clopedogril/ticlopidine in KSA was in total compliance and it exceeded the international data and the 86% achieved by the top 10% performing hospitals in ACTION registry. This observation might have been related to the use of clopedogril in patients who did not receive GP IIb/IIIa inhibitors due to the fear of bleeding.

Although coronary angiography approach in KSA was matching in those aged less than 65 years, there was significant difference in the Saudi elderly population, probably due to fear of complications. This differential treatment needs to be addressed.

In contrast, the percentage of PCI procedures in Saudi elderly patients was very close to those aged less than 65 years. This might be explained by the bad coronary anatomy of Saudi diabetic patients, who are noted to have high glycosylated hemoglobin (Hb a1c ).

Underutilization of CABG was noted in Saudi elderly. This percentage was close to that of patients who had CABG in the setting of acute coronary event in The Saudi Project for Assessment of Coronary Events (SPACE) registry (9%); [8] whereas in the SPACE registry, the percentage of early coronary angiography (60%) and PCI (39%) exceeds that of the Saudi MIDAS population. This also might be related to the difference in the number of the centers that have cardiac catheterization laboratories in each study.

One of the restriction on these data is the selective involvement of certain cardiac centers, however, this will invite for further studies in this group.


   Conclusions Top


Elderly KSA patients tend to have less use of utilization of GP IIb/IIIa and early coronary angiography and CABG but not clopedogril/ticlopidine. This concern needs further attention by health authority, since elderly patients represent a very high-risk group that may benefit the most from intensive medical therapy and early coronary angiography.

 
   References Top

1.Alexander KP, Newby LK, Cannon CP, Armstrong PW, Gibler WB, Rich MW, et al. Acute coronary care in the elderly, part I: Non-ST-segment-elevation acute coronary syndromes: A scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: In collaboration with the Society of Geriatric Cardiology. Circulation 2007;115:2549-69.  Back to cited text no. 1
[PUBMED]    
2.Malmberg K, Yusuf S, Gerstein HC, Brown J, Zhao F, Hunt D, et al. Impact of diabetes on long-term prognosis in patients with unstable angina and non-Q-wave myocardial infarction: Results of the OASIS (Organization to Assess Strategies for Ischemic Syndromes) Registry. Circulation 2000;102:1014-9.  Back to cited text no. 2
[PUBMED]    
3.Roffi M. Presentation of the preliminary results of the MIDAS Registry. Argentina: World Congress of Cardiology, Buenos Aires; 2008.  Back to cited text no. 3
    
4.O'Neil T. MIDAS, preliminary results of an international registry of diabetics with ACS. Available from: http://www.theheart.org/documents/sponsorededucation/educationalprograms/872527/Focus On MIDAS.  Back to cited text no. 4
    
5.Devlin G, Gore JM, Elliott J, Wijesinghe N, Eagle KA, Avezum A, et al. Management and 6-month outcomes in elderly and very elderly patients with high-risk non-ST-elevation acute coronary syndromes: The Global Registry of Acute Coronary Events. Eur Heart J 2008;29:1275-82.  Back to cited text no. 5
[PUBMED]    
6.Granger CB, Goldberg RJ, Dabbous O, Pieper KS, Eagle KA, Cannon CP, et al. Predictors of hospital mortality in the global registry of acute coronary events. Arch Intern Med 2003;163:2345-53.  Back to cited text no. 6
[PUBMED]    
7.Peterson ED, Roe MT, Chen AY, Fonarow GC, Lytle BL, Cannon CP, et al. The NCDR ACTION Registry-GWTG: Transforming contemporary acute myocardial infarction clinical care. Heart 2010;96:1798-802.  Back to cited text no. 7
[PUBMED]    
8.AlHabib KF, Hersi A, AlFaleh H, Kurdi M, Arafah M, Youssef M, et al. The Saudi Project for Assessment of Coronary Events (SPACE) registry: Design and results of a phase I pilot study. Can J Cardiol 2009;25:e255-8.  Back to cited text no. 8
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
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