To the Editor: Dr Fox and colleagues1 documented a multinational improvement in provision of evidence-based care for patients with acute coronary syndromes (ACS), with reduction in mortality and morbidity associated with these treatments. The study reinforces the need to further improve adherence to evidence-based guidelines and demonstrates the clinical benefit that can be achieved with such a strategy.
However, Fox et al did not assess the temporal pattern in outcomes in patients with diabetes. In a study examining the changing patterns in outcome after acute myocardial infarction (AMI) in multiple hospitals in the United Kingdom, we analyzed data from more than 3000 unselected patients sustaining an AMI in either 1995 or 2003 and assessed changes in care and all-cause mortality at 30 days and 18 months.2 Our data support those of Fox et al showing improved quality of care for all patients with AMI. However, patients with diabetes did not demonstrate the improvement in survival seen in patients without diabetes.
Between 1995 and 2003, 18-month mortality in nondiabetic patients fell from 30.1% to 25.7%, an approximately 15% relative reduction (P = .008). However, 18-month mortality in patients with diabetes was not significantly changed over this period (38% in 1995 vs 36.4% in 2003; P = .71).
The reasons for our findings are unclear, although current treatment strategies may fail to address specific aspects of vascular pathophysiology in patients with diabetes. For example, insulin resistance, oxidative stress, and inflammation may be inadequately addressed by current treatments.3 Moreover, cardiologists may not fully adhere to recognized guidelines regarding the optimal management of diabetes.4
The global population of patients with type 2 diabetes is projected to reach 366 million by 2030.5 With the increasing prevalence of diabetes, the results of the efforts to improve outcome post ACS may be abrogated or even reversed. To avoid this, research into the prevention and management of cardiovascular diseases in diabetes must be prioritized.
Financial Disclosures: None reported.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
Instructions
Comments are moderated and will appear on the site at the discretion of the Journal of American Medical Association editors. Comments should not exceed 500 words of text and 10 references.
Do not submit personal medical questions or information that could identify a specific patient, questions about a particular case, or general inquiries to an author. Only content that has not been published, posted, or submitted elsewhere should be submitted. By submitting this Comment, you and any coauthors transfer copyright to the journal if your Comment is posted.
* = Required Field
Disclosure of Any Conflicts of Interest* Indicate all relevant conflicts of interest of each author below, including all relevant financial interests, activities, and relationships within the past 3 years including, but not limited to, employment, affiliation, grants or funding, consultancies, honoraria or payment, speakers’ bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. If all authors have none, check "No potential conflicts or relevant financial interests" in the box below. Please also indicate any funding received in support of this work. The information will be posted with your response.
Register and get free email Table of Contents alerts, saved searches, PowerPoint downloads, CME quizzes, and more
Subscribe for full-text access to content from 1998 forward and a host of useful features
Activate your current subscription (AMA members and current subscribers)
Some tools below are only available to our subscribers or users with an online account.
Download citation file:
Customize your page view by dragging & repositioning the boxes below.
and access these and other features:
Register Now
Enter your username and email address. We'll send you a reminder to the email address on record.
Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.