Absence of Clinical Triggering in Diabetic Patients with ST-Segment Elevation Myocardial Infarction Predicts Multiple Vessel Coronary Disease and is Associated with Increased Mortality

Background - Multiple physical, emotional, and extrinsic triggers have been attributed to acute coronary syndrome (ACS). Diabetic patients often experience ACS with atypical presentation. We assessed the prognostic value of identifiable triggers among diabetic STEMI patients treated with primary percutaneous coronary intervention (PCI).

Methods and Results - We conducted a retrospective, single-center observational study including 284 consecutive diabetic patients with STEMI undergoing PCI. Acute physical and emotional triggers were identified and recorded from patients’ historical data. The predictive value of clinical triggering was determined by multivariate logistic regression and cox regression analysis. A potential trigger was identified in 30% of patients. Physical exertion was the most dominant trigger (62%) followed by psychological stress (15%) and acute illness (15%). Patients with non-triggered STEMI were older (66±11y vs 60±11y) and presented higher prevalence of multivessel CAD, compared to triggered-STEMI patients (76% vs 39%, respectively, p<0.001). In a multivariate logistic regression model, non-trigged STEMI emerged as a strong, independent predictor of multivessel CAD (OR 4.35, 95% CI 2.48-7.62, p<0.001). In univariate Cox regression analysis (follow-up 55 ± 25 months) non-triggered STEMI was associated with decreased long term survival (OR 2.653, 95% CI 1.186 – 5.935, p=0.018).

Conclusions - Symptom onset without a recognizable trigger among diabetic STEMI patients predicts multivessel CAD and is associated with reduced long term survival.