Opportunity to Improve Care? Under-Recognition and Under-Treatment of Diabetes During Acute MI | Journal Scan
What is the prevalence of underlying diabetes mellitus (DM) that was previously undiagnosed, and its frequency of recognition among patients hospitalized with acute myocardial infarction (AMI)?
This was a post hoc analysis of the TRIUMPH (Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients’ Health Status) study of 4,340 patients with AMI from 24 US hospitals, who were enrolled in TRIUMPH between June 2005 and December 2008. Glycosylated hemoglobin was assessed at a core laboratory; test results were blinded to treating providers. Underlying DM that was previously undiagnosed was defined as the absence of known DM and a core laboratory glycosylated hemoglobin of ≥6.5% or, if the patient did not consent to the laboratory substudy, by a chart glycosylated hemoglobin of ≥6.5%. DM that was previously undiagnosed was considered recognized under the following conditions: patient received DM education, discharged on glucose-lowering medication, or had a qualifying primary or secondary discharge diagnosis code.
Among 2,854 AMI patients without known DM on admission, 287 patients (10%) met criteria for previously undiagnosed DM. Among these patients, 65% (186 patients) went unrecognized by treating providers (i.e., without provision of DM education or glucose-lowering medication or supporting documentation at discharge). Furthermore, only 4.8% of these patients with undiagnosed DM had been initiated on glucose lowering 6 months following discharge.
The authors concluded that 1 in 10 patients with AMI and without previously diagnosed DM actually have first detected DM. In almost three-quarters of patients, DM is unrecognized (without provision of appropriate treatment or education).
This is an important analysis, albeit with limitations, that draws attention to the potential (and likely) under-diagnosis and under-recognition of previously undetected DM in patients with AMI. While treatment of DM may be relegated to the outpatient setting (and not addressed specifically during a hospitalization for AMI), there may be value to incorporating screening, recognition, and treatment of DM during the hospital stay. As the authors point out, the recognition of DM in the inpatient setting may have implications for cardiac care (e.g., revascularization strategy for multivessel disease). Although the current analysis does not establish whether earlier recognition of DM during the AMI hospitalization may favorably impact macrovascular and microvascular outcomes, it certainly seems appropriate to consider incorporating universal screening for DM into routine AMI care.
Keywords: Acute Coronary Syndrome, Acute Disease, Diabetes Mellitus, Documentation, Glucose, Health Status, Hemoglobin A, Glycosylated, Hospitalization, Inpatients, Metabolic Syndrome X, Myocardial Infarction, Patient Discharge, Prevalence, Primary Prevention, Quality of Health Care, Translational Medical Research
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