Lack of association of diabetes with increased postoperative mortality and cardiac morbidity: results of 6565 major vascular operations.

HYPOTHESIS: A number of preoperative factors, including diabetes mellitus (DM), have been cited as increasing risk in patients undergoing major vascular operations. In smaller studies at our institution we have not found this to be apparent. This study reviewed all major vascular operations to confirm our bias that DM is not associated with increased mortality or cardiac morbidity. DESIGN: Case series retrospectively reviewed from a vascular registry established in 1990. SETTING: Tertiary care center. PATIENTS: Consecutive sample of 6565 patients who underwent lower extremity revascularization or carotid or aortic procedures, grouped by presence or absence of DM. MAIN OUTCOME MEASURES: Postoperative mortality, congestive heart failure, or myocardial infarction. RESULTS: Patients with DM made up 62.3% of the population, and those without diabetes, 37.7%. Average age of the DM group was 67.1 years, with 61.3% male and 38.7% female. Average age of the non-DM group was 70.6 years, with 61.8% male and 38.2% female. The rates of overall postoperative mortality, myocardial infarction, and congestive heart failure were 1.14%, 1.59%, and 1.13%, respectively. Comparing the DM with the non-DM group, these rates were 0.96% vs 1.46%, 1.77% vs 1.30%, and 1.13% vs 1.14%, respectively. Using multivariate analysis, the DM group had an inverse relationship to perioperative death, with an odds ratio of 0.53 (P =.01). The factors that were associated with increased mortality were hemodialysis and history of congestive heart failure. Previous myocardial infarction was the only factor that predicted postoperative myocardial infarction. Kaplan-Meier survival curves showed a significantly decreased survival in the DM group during the next 5 years (P<.001). CONCLUSIONS: Diabetes alone does not confer a higher mortality or cardiac morbidity rate with major vascular procedures. However, long-term survival is significantly worse in this group of patients.

Utility of a genomic-based, personalized medicine test in patients presenting with symptoms suggesting coronary artery disease.

PURPOSE: Better methods are needed to assess patients presenting with symptoms suggestive of obstructive coronary artery disease (CAD). We hypothesized that the use of a gene expression score (GES) would lead to a change in the diagnostic evaluation. METHODS: The Primary Care Providers Use of a Gene Expression Test in Coronary Artery Disease Diagnosis (IMPACT-PCP) trial (clinical trial identifier NCT01594411, clinicaltrials.gov) was a prospective study of stable, nonacute, nondiabetic patients presenting with chest pain and related symptoms at 4 primary care practices. All patients underwent GES testing, with clinicians documenting their planned diagnostic strategy both before and after GES. The GES was derived from a peripheral blood draw measuring expression of 23 genes and has been shown to have a 96% negative predictive value for excluding the diagnosis of obstructive CAD. RESULTS: Of the 251 study patients, 140 were women (56%); the participants had a mean age of 56 years (standard deviation, 13.0) and a mean body mass index of 30 mg/kg(2) (standard deviation, 6.7). The mean GES was 16 (range, 1-38), and 127 patients (51%) had a low GES ([ltqeu]15). A change in the diagnostic testing pattern before and after GES testing was noted in 145 of 251 patients (58% observed vs. 10% predefined expected change; P < .001). CONCLUSIONS: Incorporation of the GES into the diagnostic workup showed clinical utility above and beyond conventional clinical factors by optimizing the patient's diagnostic evaluation.