Final benefit of primary percutaneous coronary intervention for ST-elevation myocardial infarction in older patients: long-term results of a randomised trial.

BACKGROUND: Although the short-term benefit of primary percutaneous coronary intervention (PCI) in elderly patients with ST-elevation myocardial infarction (STEMI) has been demonstrated, the final long-term survival benefit is as yet unknown. AIM: To assess the final survival benefit of primary PCI as compared to thrombolytic therapy in patients over 75 years of age. METHODS: Patients > 75 years with STEMI were randomised to either primary PCI or thrombolysis. Long-term data on survival were available for all patients. RESULTS: A total of 46 patients were randomised to primary PCI, 41 to thrombolysis. There were no significant differences in baseline variables. After a maximum of 20 years' follow-up, all patients had passed away. The patients randomised to thrombolysis died after a mean follow-up duration of 5.2 years (SD 4.9) compared to 6.7 years (SD 4.8) in patients randomised to primary PCI (p = 0.15). Thus, the mean final survival benefit of primary PCI was 1.5 years. CONCLUSION: The final survival benefit of primary PCI as compared to thrombolysis in elderly patients with STEMI is 1.5 years and their life expectancy increases by 28.8%.

Instantaneous wave-free ratio and fractional flow reserve in clinical practice.

OBJECTIVES: To compare fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) measurements in an all-comer patient population with moderate coronary artery stenoses. BACKGROUND: Visual assessment of the severity of coronary artery stenoses is often discordant in moderate lesions. FFR allows reliable functional severity assessment in these cases but requires adenosine-induced hyperaemia with associated additional time, costs and side effects. The iFR is a hyperaemia-independent index. METHODS AND RESULTS: Between November 2015 and February 2017, 356 consecutive patients were included in whom 515 coronary stenoses were measured using both iFR and FFR. Mean iFR and FFR were 0.90 ± 0.09 and 0.86 ± 0.08, respectively. iFR correlated well with FFR [r = 0.75; p < 0.001]. Receiver operating characteristic analysis identified an area under the curve of 0.92. An iFR-only strategy with a treatment cut-off ≤0.89 revealed a diagnostic classification agreement with the FFR-only strategy in 420 lesions (82%) with a sensitivity of 87%, a specificity of 80%, a positive predictive value of 56% and a negative predictive value of 96%. CONCLUSIONS: Real-time iFR measurements have good negative predictive value compared to FFR, but moderate diagnostic accuracy (82%). It exposes fewer patients to adenosine, reduces procedure time and costs. Further prospective trials are needed to evaluate specific clinical settings, cut-off values and endpoints.

Contemporary use of arterial and venous conduits in coronary artery bypass grafting: anatomical, functional and clinical aspects.

Although the benefits of using the left internal mammary artery to bypass the left anterior descending artery (LAD) have been extensively ascertained, freedom from major cardiovascular events and survival after coronary artery bypass grafting (CABG) also correlate with the completeness of revascularisation. Hence, careful selection of the second-best graft conduit is crucial for CABG success. The more widespread use of saphenous vein grafts contrasts with the well-known long-term efficacy of multiple arterial grafting, which struggles to emerge as the procedure of choice due to concerns over increased technical difficulties and higher risk of postoperative complications. Conduit choice is at the discretion of the operator instead of being discussed by the heart team, where cardiologists are not usually engaged in such decisions due to a hypothetical lack of technical knowledge. Furthermore, according to the ESC/EACTS guidelines, traditional CABG remains the gold standard for multi-vessel coronary artery disease with complex LAD stenosis, but hybrid procedures using percutaneous coronary intervention for non-LAD targets could combine the best of two worlds. With the aim of raising the cardiologist's awareness of the surgical treatment options, we provide a comprehensive overview of the anatomical, functional and clinical aspects guiding the decision-making process in CABG strategy.

Cardiac shockwave therapy in patients with chronic refractory angina pectoris.

BACKGROUND: Cardiac shockwave therapy (CSWT) might improve symptoms and decrease ischaemia burden by stimulating collateral growth in chronic ischaemic myocardium. This prospective study was performed to evaluate the feasibility and safety of CSWT. METHODS: We included 33 patients (mean age 70 ± 7 years, mean left ventricular ejection fraction 55 ± 12 %) with end-stage coronary artery disease, chronic angina pectoris and reversible ischaemia on myocardial scintigraphy. CSWT was applied to the ischaemic zones (3-7 spots/session, 100 impulses/spot, 0.09 mJ/mm(2)) in an echocardiography-guided and ECG-triggered fashion. The protocol included a total of 9 treatment sessions (3 treatment sessions within 1 week at baseline, and after 1 and 2 months). Clinical assessment was performed using exercise testing, angina score (CCS class), nitrate use, myocardial scintigraphy, and cardiac magnetic resonance (CMR) 1 and 4 months after the last treatment session. RESULTS: One and 4 months after CSWT, sublingual nitrate use decreased from 10/week to 2/week (p < 0.01) and the angina symptoms diminished from CCS class III to CCS class II (p < 0.01). This clinical improvement was accompanied by an improved myocardial uptake on stress myocardial scintigraphy (54.2 ± 7.7 % to 56.4 ± 9.4 %, p = 0.016) and by increased exercise tolerance at 4-month follow-up (from 7.4 ± 2.8 to 8.8 ± 3.6 min p = 0.015). No clinically relevant side effects were observed. CONCLUSION: CSWT improved symptoms and reduced ischaemia burden in patients with end-stage coronary artery disease without relevant side effects. The study provides a solid basis for a randomised multicentre trial to establish CSWT as a new treatment option in end-stage coronary artery disease.

Multivessel revascularisation versus infarct-related artery only revascularisation during the index primary PCI in STEMI patients with multivessel disease: a meta-analysis.

BACKGROUND: There are controversial data regarding infarct-related artery only (IRA-PCI) revascularisation versus multivessel revascularisation (MV-PCI) in ST-elevation myocardial infarction (STEMI) patients with multivessel disease undergoing primary percutaneous coronary intervention (PCI). We performed a meta-analysis comparing outcome in same stage MV-PCI versus IRA-PCI in STEMI patients with multivessel disease. METHODS: Systematic searches of studies comparing MV-PCI with IRA-PCI in the MEDLINE and the Cochrane Database of systematic reviews were conducted. A meta-analysis was performed of all available studies. Primary outcome was all-cause mortality. Secondary endpoints were re-infarction, revascularisation, bleeding and major adverse cardiac events (MACE). RESULTS: A total of 15 studies were identified with a total number of 35,975 patients. Mortality rate was significantly higher in the MV-PCI group compared with the IRA-PCI group, odds ratio (OR): 1.64 (1.46-1.85). Both the incidence of re-infarction and re-PCI were significantly lower in the MV-PCI group compared with the IRA-PCI group: OR 0.54 (0.34-0.88) and OR 0.67 (0.48-0.93), respectively. Bleeding complications occurred more often in the MV-PCI group as compared with the IRA-PCI group: OR 1.24 (1.08-1.42). Rates of MACE were comparable between the two groups. CONCLUSIONS: MV-PCI during the index of primary PCI in STEMI patients is associated with a higher mortality rate, a higher risk of bleeding complications, but lower risk of re-intervention and re-infarction and comparable rates of MACE.

Glucose dysregulation in nondiabetic patients with ST-elevation myocardial infarction: acute and chronic glucose dysregulation in STEMI.

BACKGROUND: Admission hyperglycaemia is associated with an increased risk of mortality after myocardial infarction. Whether long-term glucose dysregulation (assessed by HbA1c) is more important than acute hyperglycaemia is unknown. We evaluated the prognostic value of admission glucose and HbA1c levels in nondiabetic patients with ST-segment elevation acute myocardial infarction (STEMI). METHODS: In 504 unselected, consecutive patients with STEMI, glucose and HbA1c levels were measured on admission. Glucose was categorised as <11.1 mmol/l (n=422) and >or= 11.1 mmol/l (n=82). HbA1c levels were categorised as <6.0% (n=416) and >or=6.0% (n=88). Mean follow-up was 1.6+/-0.6 years. RESULTS: Patients with hyperglycaemia on admission were comparable with those with normoglycaemia. However,patients with HbA1c >or=6.0%, as compared with those with HbA1c <6%, were older, were more often on beta-blockers and more frequently had multivessel disease. Thirty-day mortality in the subsequent glucose categories (<11.1 mmol/l and >or=11.1 mmol/l) was 4% and 19% (p<0.001) and in the subsequent HbA1c categories (<6% and >or=6%) was 5% and 12% (p=0.03). After multivariable analyses, admission glucose (OR 4.91,95% CI 2.03 to 11.9, p< 0.001) but not HbA1c (OR 1.33, 95%CI 0.48 to 3.71, p=0.58) was significantly associated with 30-day mortality. Among 30-day survivors, neither admission glucose nor HbA1c were predictors of long-term mortality. CONCLUSION: Elevated admission glucose is an important predictor of 30-day outcome after STEMI, while prior long-term glucose dysregulation is a covariate of other high-risk clinical characteristics. Among 30-day survivors, neither admission blood glucose nor HbA1c were predictors of long-term outcome.

Electrical storms in Brugada syndrome successfully treated with isoproterenol infusion and quinidine orally.

Brugada syndrome is an inherited cardiac disease and is associated with a peculiar pattern on the electrocardiogram and an increased risk of sudden death. Electrical storm is a malignant but rare phenomenon in symptomatic patients with Brugada syndrome. We describe a patient who presented with repetitive ICD discharges during two episodes of recurrent VF. After the initiation of isoproterenol infusion and oral quinidine, the ventricular tachyarrhythmias were successfully suppressed. (Neth Heart J 2007;15:151-4.).

Troponin T elevation and prognosis after multivessel compared with single-vessel elective percutaneous coronary intervention.

BACKGROUND.: Although techniques for percutaneous coronary intervention (PCI) have improved, patients with PCI of more vessels may still have an increased risk. We performed a prospective observational study evaluating the differences between multivessel and single-vessel procedures according to postprocedural troponin T (TnT) elevation and events during follow-up. METHODS.: The study included 713 patients without elevated TnT (<0.05 ng/ml) before PCI. Primary endpoint was the combined endpoint of death, myocardial infarction, stroke, repeat coronary angiography and readmission for anginal symptoms during the mean follow-up of 10.9 months. RESULTS.: TnT after PCI was elevated in 150 patients (21%) and was significantly associated with an increased incidence of the primary endpoint (RR 1.55, 95% CI 1.01 to 2.38). PCI of more than one vessel was performed in 146 patients (20%). These patients more often had increased TnT levels after the procedure (31.5 vs. 18.3%, p=0.001) and an increased incidence of the primary endpoint during follow-up (28 vs. 19%, p=0.01). After multivariable analysis, multivessel PCI was a statistically significant predictor of postprocedural TnT increase (OR 1.90, 95% CI 1.17 to 3.06). Multivessel PCI was also associated with an increased risk of the primary endpoint (OR 1.73, 95% CI 1.18 to 2.52), but after adjusting for multivessel disease this association was not statistically significant (OR 1.42, 95% CI 0.92 to 2.19). CONCLUSION.: Elective PCI of more vessels in one session is, in comparison with single-vessel PCI, more often associated with postprocedural troponin T rise and a (nonsignificantly) higher incidence of cardiac events during follow-up. Whether staged PCI is associated with less morbidity has to be assessed. (Neth Heart J 2007;15:178-83.).

Circumflex artery-related acute myocardial infarction: limited ECG abnormalities but poor outcome.

BACKGROUND: Circumflex (CX) artery-related myocardial infarction (MI) is less well represented in trials on ST-elevation acute myocardial infarction (STEMI), most often due to the absence of significant ST-segment elevation, and therefore the outcome of these patients is less well known. We aimed to compare the outcome of patients with CX versus right coronary artery (RCA) related STEMI in a large cohort of patients treated with primary angioplasty. METHODS: A total of 1683 consecutive patients with STEMI were studied. Patients who lacked STsegment elevation were also included if they had persistent chest pain with signs of ischaemia or regional wall motion abnormalities on echocardiography. Coronary angioplasty was performed according to standard procedures. After the intervention, all patients received aspirin and clopidogrel or ticlopidine. RESULTS: The infarct-related vessel was the CX in 229 patients (14%) and the RCA in 600 patients (36%). No differences in baseline characteristics were present. Mean extent of ST-segment elevation or deviation was significantly higher in patients with the RCA as infarct-related vessel. Enzymatic infarct size was significantly higher in the CXrelated MI (1338+/-1117 IU/l vs. 1806+/-1498 IU/l, p<0.001). Left ventricular ejection fraction <45% was more often present in patients with CXrelated MI (37 vs. 26%, p<0.01). Both short- and long-term mortality were significantly higher in the CX-related MI. CONCLUSION: This study emphasises the fact that CX-related infarction has a worse prognosis compared with RCA-related infarction. (Neth Heart J 2007;15:286-90.).

Prognostic value of admission glucose and glycosylated haemoglobin levels in acute coronary syndromes.

BACKGROUND: Admission hyperglycaemia is associated with poorer prognosis in patients with an acute coronary syndrome (ACS). Whether hyperglycaemia is more important than prior long-term glucose metabolism, is unknown. AIM: To investigate the prognostic value of admission glucose and HbA(1c) levels in patients with ACS. METHODS: We measured glucose and HbA(1c) at admission in 521 consecutive patients with suspected ACS. Glucose was categorized as <7.8 (n = 305), 7.8-11.0 (n = 138) or > or =11.1 mmol/l (n = 78); HbA(1c) as <6.2% (n = 420) or > or =6.2% (n = 101). Mean follow-up was 1.6 +/- 0.5 years. RESULTS: The diagnosis of ACS was confirmed in 332 patients (64%), leaving 189 (36%) with atypical chest pain. In ACS patients, mortality by glucose category (<7.8, 7.8-11.0 or > or =11.1 mmol) was 9%, 8% and 25%, respectively (p = 0.001); mortality by HbA(1c) category (<6.2% vs. > or =6.2%) was 10% vs. 17%, respectively (p = 0.14). On multivariate analysis, glucose category was significantly associated with mortality (HR 3.0, 95% CI 1.1-8.3), but HbA(1c) category was not (HR 1.5, 95%CI 0.6-4.2). DISCUSSION: Elevated admission glucose appears more important than prior long-term abnormal glucose metabolism in predicting mortality in patients with suspected ACS.

Primary angioplasty: preprocedural pharmacological therapy.

Primary coronary angioplasty has been shown to be an effective reperfusion therapy for patients with acute myocardial infarction, not only for those who present to PTCA centres but also for patients who present to hospitals without angioplasty facilities. With the increasing use of primary angioplasty more patients will be transferred to a (tertiary) PTCA centre. An increase in treatment delay is associated with a worse clinical outcome. The importance of an open infarct-related vessel at acute angiography is becoming clear. Pharmacological pretreatment of patients during transportation to a PTCA centre with the aim to open the infarct-related vessel in advance might be beneficial. Glycoprotein IIb/IIIa receptor blockers seem to be the agents of choice for facilitated PTCA. The safety and (cost) effectiveness of this pretreatment of patients transported to undergo primary angioplasty remain to be evaluated.

Cardioverter defibrillator implantation in a patient with absent right superior vena cava.

Left-sided superior vena cava (LSVC) is the most common venous thoracic anomaly. Absence of the right superior vena cava (RSVC) on the other hand is very rare. We describe a patient with this abnormal venous system, who was admitted to our centre for an implantation of a cardioverter defibrillator (ICD).

Impaired platelet inhibitory effect of a single dose of acetylsalicylic acid in patients with unstable coronary artery syndrome in comparison with healthy volunteers.

BACKGROUND AND AIM: Controversial reports have been published about the efficiency of potent platelet inhibitors in patients with coronary artery syndrome (CAS). We therefore questioned whether a functional change in platelets affects the patient's response to ASA. STUDY DESIGN AND METHODS: Nineteen consecutive patients presenting with unstable coronary syndrome and 15 healthy volunteers were included. No platelet inhibitory drugs or coumarin were used in either group before the study. Platelet aggregation tests were performed on baseline samples and after a single dose of ASA. Afterwards, all patients underwent coronary angiography to exclude non-CAS. RESULTS: In the patient group (n=15 after exclusion) no significant increase in bleeding constant was found after ASA, using a PFA analyser, in contrast to the control group. The maximal velocity and the maximal percentage optical platelet aggregation using ADP was significantly more reduced in the control group. ASA did not significantly reduce the thromboxane B2 production in the patient group. CONCLUSION: ASA has less platelet inhibitory effects in patients with unstable CAS in comparison with healthy volunteers. Platelets, in the hyperactive state of unstable CAS, prove to be less subject to inhibition. This might add to the explanation of the lack of efficiency of platelet inhibitory drugs to prevent thrombotic complications after PTCA and platelet aggregation onto stent surfaces in patients with acute CAS.

Prediction of success and major complications during elective coronary angioplasty.

BACKGROUND: Complications from coronary angioplasty remain a concern despite improvements in technology and operator's skills. Identification of high-risk patients is important with regard to surgical standby and other precautions that have to be taken for such patients. METHODS: Prior to elective coronary angioplasty, the probability of success and the risk of complications were estimated on the basis of angiographic and clinical characteristics. A total of 2365 consecutive elective procedures were evaluated. Estimates for success and complications were classified into three categories: high, intermediate or low probability. RESULTS: Angioplasty success was achieved in 1025 of 1056 (97%) procedures with high success probability; in 833 of 914 (91%) with intermediate success probability and 304 of 395 (77%) with low success probability. Complications occurred in five of 271 (2%) procedures with an anticipated low risk of complications, in 72 of 1973 (4%) procedures with a intermediate risk and in 13 of 121 (11%) procedures with a high risk of complications. Out of a total of 28, 22 (80%) surgical bypass procedures were performed in the intermediate anticipated risk category. CONCLUSIONS: For groups of patients, reliable prediction of success and complications is possible. However, most emergency bypass surgery after failed angioplasty is performed in patients with a predicted intermediate risk of complications. Interventional cardiologists are not able to identify in advance the majority of patients who will need surgery for failed angioplasty.

Angiographic determination of myocardial reperfusion by primary coronary angioplasty for acute myocardial infarction.

BACKGROUND: The primary objective of reperfusion therapies for acute myocardial infarction is not only restoration of blood flow in the epicardial coronary artery but also complete and sustained reperfusion of the infarcted part of the myocardium. METHODS: We studied 777 patients who underwent primary coronary angioplasty during a six-year period and investigated the value of angiographic evidence of myocardial reperfusion (myocardial blush grade) in relation to the extent of ST-segment elevation resolution, enzymatic infarct size, left ventricular function, and long-term mortality. The myocardial blush immediately after the angioplasty procedure was graded by two experienced investigators, who were otherwise blinded to all clinical data: 0: no myocardial blush, 1: minimal myocardial blush, 2: moderate myocardial blush, and 3: normal myocardial blush. RESULTS: The myocardial blush was related to the extent of the early ST-segment elevation resolution on the 12-lead electrocardiogram. Patients with blush grades 3, 2 and 0/1 had enzymatic infarct sizes of 757, 1143 and 1623 (p<0.0001), respectively, and ejection fractions of 0.50, 0.46 and 0.39, respectively (p<0.0001). After a mean±SD follow-up of 1.9±1.7 years, mortality rates of patients with myocardial blush grades 3, 2 and 0/1 were 3%, 6% and 23% (p<0.0001), respectively. Multivariate analysis showed that the myocardial blush grade was a predictor of long-term mortality, independent of Killip class, Thrombolysis In Myocardial Infarction (TIMI) grade flow, left ventricular ejection fraction, and other clinical variables. CONCLUSION: In patients after reperfusion therapy, the myocardial blush grade as seen on the coronary angiogram can be used to describe the effectiveness of myocardial reperfusion, and is an independent predictor of long-term mortality.

Clinical characteristics and outcome of patients with acute myocardial infarction and preinfarction angina.

OBJECTIVES/BACKGROUND: Preinfarction angina is associated with reduced myocardial infarct size in patients treated with thrombolysis. Our objective was to assess the relation between preinfarction angina and infarct size, left ventricular function and clinical outcome in patients treated with primary angioplasty (PTCA) and compare this with patients treated with thrombolysis. METHODS: In the Zwolle Infarction Study, 953 patients were treated for acute myocardial infarction between 1990 and 1996; 761 patients underwent primary PTCA and 192 patients received thrombolysis as reperfusion therapy. RESULTS: Preinfarction angina was present in about 50% of the patients, who were categorised into angina ≤24 hours and angina >24 hours before infarction. Patients in both treatment groups have a longer ischaemic time when preinfarction angina is present. In patients treated with thrombolysis, preinfarction angina ≤24 hours results in a smaller enzymatic infarct. Thrombolysis seems to be more effective when preinfarction angina occurs within the 24 hours prior to myocardial infarction. Collateral filling of the infarct-related artery is more often seen in patients with preinfarction angina. In the primary PTCA group, a longer ischaemic time in patients with preinfarction angina does not result in increased infarct size, and this effect remains after excluding patients with collateral filling. CONCLUSIONS: The protective effect of preinfarction angina is likely to be due to better collateral filling of the infarct-related artery and to ischaemic preconditioning of the myocardium.

Statin therapy and mortalitiy in patients with ST-segment elevation myocardial infarction treated with primary angioplasty.

BACKGROUND: Statin therapy can reduce long-term mortality in several subgroups of patients with coronary artery disease, but the benefits after primary angioplasty for ST-segment elevation myocardial infarction (STEMI) have yet to be established. Thus the aim of the current study was to determine whether statin therapy is associated with a reduction in mortality in patients with STEMI treated with primary angioplasty. METHODS: Our population is represented by a total of 1513 consecutive in-hospital survivors treated with primary angioplasty for STEMI between April 1997 and October 2001. Patients were divided into two groups according to statin therapy (statin group, n=893; control group, n=620) at discharge. Clinical follow-up was performed at one year. Multivariate analysis was performed including a propensity score for statin use. RESULTS: At one-year follow-up statin therapy was associated with a significantly lower mortality (1.2 vs. 71.%, RR [95% CI] 0.16 [0.09-0.32], p<0.0001). Also at multivariate analysis, including the propensity score, statin therapy was associated with a significant mortality reduction (adjusted RR [95% CI] 0.24 [0.12-0.47], p<0.0001). CONCLUSION: Statin therapy at discharge was associated with a significant reduction in one-year mortality after primary angioplasty for STEMI. Therefore, the use of statins after STEMI is highly recommended.

Angiographic determinants of infarct size after successful percutaneous intervention for acute ST-elevation myocardial infarction: the impact of distal embolisation.

BACKGROUND: We investigated the impact of distal embolisation and other angiographic determinants in patients after successful primary angioplasty for acute myocardial infarction. METHODS: Angiographic data were assessed on the coronary angiogram carried out immediately after successful (TIMI 2 or 3) coronary angioplasty in 631 consecutive patients with acute myocardial infarction. Embolisation was defined as a distal filling defect with an abrupt 'cutoff' in ≥1 of the peripheral coronary artery branches of the infarct-related artery, distal to the site of angioplasty. Endpoints were left ventricular ejection fraction (LVEF) and enzymatic infarct size. RESULTS: Left anterior descending artery related myocardial infarction, impaired myocardial blush and distal embolisation were independent determinants of infarct size. Distal embolisation was present in 102 patients (16%) and was associated with a larger enzymatic infarct size (LDH Q48 2250 vs. 1532, p=0.001) and a lower LVEF (41% vs. 44%, p=0.04). There was no difference in the frequency of distal embolisation between patients treated with or without stents. CONCLUSIONS: In successful primary angioplasty, infarct-related artery, impaired myocardial blush and distal embolisation are independent determinants of infarct size. Distal embolisation can be visualised in 16% of the patients and is associated with a larger enzymatic infarct size and lower LVEF. Intracoronary stenting is not associated with an increased risk of distal embolisation during primary angioplasty.

Long-term clinical outcome of ST-segment elevation myocardial infarction patients with and without diabetes mellitus in the Zwolle trial.

OBJECTIVES: We sought to compare long-term survival after ST-segment elevation myocardial infarction (STEMI) in patients with and without diabetes mellitus (DM) treated with primary percutaneous coronary intervention (PCI) or thrombolytic therapy. BACKGROUND: DM is an adverse prognostic factor after STEMI. However, there is only limited information about long-term clinical outcome in STEMI patients with DM treated with PCI or thrombolysis. METHODS: Patients with STEMI (n=395) were randomised to treatment either with intravenous streptokinase or PCI. Mean follow-up was 8±2 years. We studied long-term mortality of patients with DM (n=32) and without DM (n=363) and the interaction with the treatment regimen. RESULTS: After eight years, a total of 17 patients with DM (53%) died compared with 88 (24%) patients without DM (OR 3.5, p<0.001). Reduced left ventricular ejection fraction (LVEF) after STEMI was more often present in patients with DM compared with patients without DM (31% vs. 15%, p=0.01). Multivariate analysis revealed that DM (OR 2.6, 95% CI 1.4-4.7, p=0.002), reduced LVEF (OR 2.4, 95% CI 1.5-3.8, p<0.001) and age ≥60 years (OR 2.4, 95% CI 1.5-3.8, p<0.001) were independent risk factors for long-term mortality. Patients with DM treated with PCI had less LVEF (13% vs. 53%, p=0.01) and lower long-term mortality rates (38% vs. 69%, p=0.08) compared with treatment with thrombolysis. CONCLUSIONS: STEMI patients with DM are a high-risk group with higher long-term mortality rates compared with patients without DM. PCI is the treatment of choice, particularly in DM patients.