Clinical characteristics,GRACE score,TIMI score and prognosis of patients with type 2 diabetes mellitus complicated with acute coronary syndrome

Zhuo-Ya Yao,Bing-Wei Bao,Shao-Huan Qian,Miao-Nan Li ,Hong-Ju Wang

Department of Cardiovascular Disease,The First Affiliated Hospital of Bengbu Medical College,Bengbu 233000,China

Keywords:Acute coronary syndrome Type 2 diabetes Global registry of acute coronary events risk score Thrombolysis in myocardial infarction score Major adverse cardiovascular events Clinical prognosis

ABSTRACT Objective:To analyze the clinical characteristics of patients with type 2 diabetes mellitus(T2DM) with acute coronary syndrome (ACS),the global registry of acute coronary events(GRACE)score,the thrombolysis in myocardial infarction (TIMI) score and clinical prognosis.Method:The study was a retrospective one-center observational study,continuous inclusion of 600 ACS patients diagnosed by coronary angiography in our hospital from October 2018 to July 2019.Collect general clinical data,laboratory examination results,imaging data and interventional treatment data of all patients.Were divided into:T2DM with ACS group (group DA) and non-T2DM with ACS (group NDA) according to whether or not they were associated with T2DM.According to the GRACE、TIMI score,the two groups were divided into high risk group,middle risk group and low risk group.All patients underwent coronary angiography to calculate the number of vascular lesions and Gensini scores.Design questionnaire,after discharge to 2 groups of patients by telephone or outpatient follow-up average of 10 months,statistics of the occurrence of MACE events.Result:Among the 600 patients included in the study,362 were male (60.3%) and 238 were female (39.7%) with mean age (64.7±10.3) years.The baseline data showed that the G、TG、UA、CR levels were higher in the DA group than in the NDA group;the proportion of men was lower than in the NDA group.The results of coronary angiography showed that the Gensini score of DA group was higher than that of NDA group,and the proportion of single lesion was lower than that of NDA group.The binary Logistic regression analysis suggested that age and CRP were independent risk factors for MACE events in patients with T2DM.GRACE risk stratification showed that the proportion of high risk group in DA group was significantly higher than that in NDA group,and there was no significant difference between low and middle risk group.TIMI risk stratification showed that the proportion of high risk group in DA group was significantly higher than that in NDA group,while the proportion of low and middle risk group was lower than that in NDA group.The ROC curve shows that the area (AUC) below the ROC curve that GRACE、TIMI score predicted the occurrence of MACE events in patients with T2DM and ACS was 0.707 and 0.586.Conclusion:Patients with T2DM and ACS had higher clinical risk stratification than without T2DM.GRACE score compared with the TIMI score had better predictive value for the occurrence of MACE events after discharge of T2DM with ACS patients.

1.Introduction

Coronary atherosclerotic plaque deposits on the surface of the coronary vascular endothelium,which leads to complete or incomplete vascular occlusion,which is the pathological basis of acute coronary syndromes (ACS).As a serious type of coronary heart disease,the incidence of ACS has continued to rise in recent years,posing an important threat to people's lives and health.Type 2 diabetes is an equal-risk disease of coronary heart disease.Epidemiological investigations and studies have found that the proportion of patients with ACS is on the rise in the whole society[1].Therefore,how to conduct a more effective risk assessment for patients with type 2 diabetes and ACS is an important clinical issue that needs to be studied in depth.The global registry of acute coronary events (GRACE) score and The clinical trial of thrombolysis in myocardial infarction (TIMI) score are currently commonly used clinical evaluation methods for patients with ACS.The evaluation has important reference significance.At the same time,in terms of patient prognosis,studies have shown that GRACE and TIMI scores have high predictive value for the occurrence of major adverse cardiac events (MACE) in patients with acute coronary syndromes [2].However,at this stage,less attention has been paid to the value and comparison of GRACE and TIMI scores in evaluating the poor prognosis of patients with type 2 diabetes and ACS.Therefore,the purpose of this study is to understand the clinical characteristics of patients with common type 2 diabetes and ACS,and to explore the evaluation value and related comparison of GRACE and TIMI scores in the occurrence of major cardiovascular adverse events (MACE) in such patients after PCI.

2.Materials and methods

2.1 Research object

A total of 600 cases of ACS patients who underwent coronary angiography and confirmed diagnosis from October 2018 to July 2019 in the Department of Cardiovascular Medicine of our hospital were divided into type 2 diabetes group (DA group,n=155) and non-diabetics according to whether they had type 2 diabetes.Type 2 diabetes group (NDA group,n=445).Diagnostic criteria:ACS includes 1.Unstable angina (UAP);2.Non ST segment elevation myocardial infarction (NSTEMI);3.ST elevation myocardial infarction (ST segment elevation myocardial infarction,STEMI)[3,4].The diagnosis of type 2 diabetes adopts the current international WHO (1999) diagnostic criteria [5].Exclusion criteria include:(1)patients with other types of diabetes except type II diabetes;(2)patients with other heart diseases such as congenital heart disease,severe heart valve disease,cardiomyopathy;(3) iodine or iodine contrast agent allergy Patients;(4) Concurrent or short-term severe liver and kidney dysfunction,acute infectious diseases and other wasting diseases,etc.;(5) Patients with incomplete medical history data collection.This study was reviewed by the hospital's ethics committee,and all the included patients had informed consent.

2.2 Research methods

After admission,all subjects completed general clinical data such as age,gender,history of underlying diseases,and history of medical surgical treatment.Blood pressure,electrocardiogram,heart color Doppler ultrasound and other examinations.In the morning the next day after admission,venous blood was drawn from the patients and sent to the laboratory of our hospital for blood routine,biochemical routine,liver and kidney function,myocardial injury markers and other items to be checked,and their blood uric acid,blood creatinine,blood lipids,and troponin I were recorded.And other laboratory indicators.Coronary angiography was performed by a cardiologist from the First Affiliated Hospital of Bengbu Medical College.The diagnostic criteria of the American ACC/AHA guidelines[6]were used to determine the results,and the vascular lesions were quantitatively calculated based on the Gensini score[7] combined with the patient’s coronary angiography results The degree of narrowness.

2.3 GRACE and TIMI scoring system

According to the subject’s age,heart rate,systolic blood pressure,creatinine,Killip classification level and risk factors to complete the GRACE score of all subjects[8];based on the subject’s age,risk factors,coronary angiography results,angina pectoris,ECG ST Segment changes and myocardial injury marker levels completed the TIMI score of all subjects[9,10].

Risk stratification according to GRACE scoring system[11]:lowrisk group (88≤points),intermediate-risk group (89≤GRACE ≤118 points) and high-risk group (>118 points);according to TIMI scoring system[12] Stratification:low-risk group (non-ST-segment elevation ACS≤2;ST-segment elevation ACS≤3),intermediaterisk group (3≤ TIMI ≤4 points;4≤ TIMI≤6 points) and high-risk group (≥ 5 points;≥ 7 points).

2.4 Follow-up

All patients were followed up for an average of 10 months by telephone or outpatient after discharge.The end of the follow-up event was the major adverse cardiovascular event (MACE),including recurrence of angina,secondary heart failure,revascularization,acute myocardial infarction,cardiac death,etc.

2.5 Statistical methods

The SPSS25.0 software was used for statistical analysis of data.The measurement data satisfies the normal distribution and the uniformity of variance was compared with the difference between groups by t test,and the t'test was used for the unsatisfactory uniformity of variance.The count data were compared with the χ2test;for the relevant data that did not meet the χ2test conditions,the comparison was made according to the Fisher exact probability method.Binary Logistic regression and ROC curve were used to evaluate the risk factors and predictive value of MACE events in patients with type 2 diabetes and ACS 10 months after discharge.P＜0.05 indicates that the difference is statistically significant.

3.Results

3.1 Comparison of general clinical data

Among the 600 patients,there were 362 males (60.3%) and 238 females (39.7%),with an average age of (64.7±10.3) years.Baseline data showed that the proportion of men in the DA group was lower than that in the NDA group,while the levels of G,TG,UA,and CR were higher than those in the NDA group (P<0.05).There were no statistically significant differences in the age,TC,HDL,LDL,Lp(a),Crp,LVEF,smoking,hypertension,atrial fibrillation,stroke,acute myocardial infarction,and premature coronary heart disease in the two groups (P＞ 0.05).See Table 1.

Table 1 General data()

Table 1 General data()

Table 2 Comparison of Coronary Disease Degree Index()

Table 2 Comparison of Coronary Disease Degree Index()

3.2 The relationship between type 2 diabetes and the severity of coronary artery disease

The Gensini scores of DA group and NDA group were 41.26±31.92 and 33.67±30.50,respectively.The Gensini score of DA group was significantly higher than that of NDA group (P<0.05).In terms of the number of vascular disease,the proportion of single-vessel disease in DA group was significantly lower than that in NDA group (P<0.01),but there was no significant difference in the ratio of double-vessel and three-vessel disease (P>0.05).

3.3 Analysis of risk factors for the prognosis of patients in the DA group

Binary Logistic regression was used to include the gender,age,CRP,lipoprotein a,TC,TG,HDL,LDL,CR,and UA indicators of the DA group into the analysis.The results showed:age (P=0.024)and CRP (P=0.012)) Is an independent risk factor for MACE events in patients with type 2 diabetes and ACS.See Table 3.

Table 3 Dual Logistic Regression Analysis of Factors Affecting MACE Events in Patients with T2DM and ACS

3.4 The risk stratification of GRACE and TIMI scores in the 2 groups and the comparison of the relationship with the risk of MACE events

According to GRACE and TIMI scoring standards,patients were divided into low-risk group,intermediate-risk group and high-risk group.The results showed that in terms of GRACE scores,there was no statistically significant difference in the proportions of lowrisk and intermediate-risk groups in the DA group (P>0.05),while the proportion of high-risk groups was significantly higher than that of the NDA group (P<0.05);in terms of TIMI scores,the DA group was low The proportion of middle-risk group was significantly lower than that of NDA group (P<0.01),while the proportion of high-risk group was higher than that of NDA group (P<0.01).See Table 4.

Table 4 Comparison of risk stratification in GRACE、TIMI score between two group

The area under the ROC curve (AUC) of the GRACE and TIMI risk scores for predicting the incidence of MACE events in patients with type 2 diabetes and ACS in the average 10 months after discharge were 0.707 and 0.586,respectively.The cut-off points were 74.5 and 4.5,and the sensitivity was 0.966 and 0.966,respectively.0.552,specificity was 0.357,0.563,and Youden index were 0.323 and 0.115,respectively.see picture 1.

Figure 1 GRACE、TIMI risk score to predict postoperative MACE of patients with type 2 diabetes mellitus with ACS ROC curve.

4.Discussion

Insulin resistance (IR) is a key factor in the increase of blood sugar in patients with type 2 diabetes.The changes in related biochemical indicators and signal pathways can up-regulate the inflammatory response of the constituent cells of coronary atherosclerotic plaques,leading to coronary atherosclerosis.The formation of hardened plaques accelerates,which in turn increases the severity of coronary artery disease [13].Therefore,compared with patients without type 2 diabetes,the extent of plaque lesions,the degree of inflammation and the level of coronary occlusion in patients with type 2 diabetes are greater than those in normal patients [14].This study found that the DA group had a higher Gensini score and a lower proportion of single coronary artery lesions than the NDA group,which indirectly suggests that the pathogenesis related to type 2 diabetes has an important impact on the development of coronary artery lesions in ACS patients..In recent years,some scholars have found that triglyceride levels are positively correlated with IR in patients with type 2 diabetes,and triglycerides are one of the independent risk factors for cardiogenic death in patients with STEMI after discharge from the hospital [15,16].A study by enrolling 776 type 2 diabetes patients with ACS found that the increase in triglyceride levels of the included subjects is closely related to the occurrence of MACE events after intervention [17].Consistent with the above research results,in this study,the level of triglyceride in the DA group was significantly higher than that in the NDA group,suggesting that the level of triglyceride should be paid more attention to in patients with type 2 diabetes with ACS,and timely through lifestyle and drug interventions.Improve the quality of life of these patients.

Epidemiological investigations and studies at home and abroad have confirmed that the incidence of adverse prognostic events in patients with type 2 diabetes and coronary heart disease has increased significantly [18,19].RussoN et al [20] found from the perspective of the relationship between glucose tolerance and survival rate that patients with abnormal glucose metabolism had a significant decrease in survival rate,suggesting that the status of glucose metabolism is closely related to the prognostic survival status of patients.

Therefore,under the premise of more severe coronary artery disease in patients with type 2 diabetes and ACS,how to conduct more effective risk factor assessment for such patients is an important clinical issue that needs to be studied in depth.This study will conduct a multi-factor analysis of factors that may affect the occurrence of MACE events in patients with type 2 diabetes and ACS in an average of 10 months after surgery.It is found that age and CRP are independent risk factors that affect the occurrence of MACE events in such patients,suggesting that in clinical work we It is necessary to pay more attention to such patients with advanced age and abnormally elevated CRP levels.

GRACE score and TIMI score are considered to be one of the most accurate ways to assess the risk of myocardial infarction and death in ACS patients [21-23].In the context of poor prognosis for some ACS patients,these two prognostic assessment systems are of great significance in assisting the decision-making of clinical treatment directions.At present,although there are literature reports on the prognostic value of the two scores in different types of patients and how clinicians choose,the results are not the same.Simona et al[2] surveyed STEMI patients after interventional therapy and found that GRACE scores have higher value in predicting the mortality of patients 6 to 12 months after discharge than PAMI,ZWOLLE and other scoring systems.At the same time,GRACE score is also a good predictor of 12-month MACE events in AMI patients [24].Studies have confirmed that the TIMI score is also stable in the prediction and evaluation of the primary endpoint event [25].In this study,after an average of about 10 months of follow-up observation and analysis and comparison of the predictive value of GRACE and TIMI scores on the risk of MACE events in patients with type 2 diabetes and ACS,the results showed that the DA group had a higher GRACE and TIMI score high-risk ratio.In terms of predictive value,the GRACE score predicts that the area under the ROC curve of the incidence of MACE events in patients with type 2 diabetes and ACS 10 months after discharge from the hospital is significantly higher than the TIMI score.As a result,the GRACE score can be used to effectively identify high-risk patients with type 2 diabetes and ACS,and then purposefully monitor the vital signs of these patients,and effectively control the incidence of MACE events.

In summary,the GRACE and TIMI risk stratification of type 2 diabetes patients with ACS is higher than that of ACS patients without type 2 diabetes.On the other hand,GRACE score is a commonly used clinical evaluation index for ACS patients at this stage.It is significantly better than TIMI score in predicting MACE events in patients with type 2 diabetes and ACS after discharge.We should pay attention to GRACE score in predicting the clinical prognosis of such patients.Applications.At the same time,the number of cases included in this study is limited,and large-scale multicenter studies are still needed in the future to better confirm the predictive role of GRACE and TIMI scores in the prognosis of ACS patients with type 2 diabetes.