Impact of Hyperinsulinemia on Long-Term Clinical Outcomes of Percutaneous Coronary Intervention in Patients without Diabetes Who Have Acute Myocardial Syndrome

Figures & data

Table 1 Comparison of Clinical and Angiographic Characteristics According to FINS Status

	Low Insulin (n =157)	Medium Insulin (n =154)	High Insulin (n=157)	F or χ^2	P value
Age	62.59 ± 8.83	62.01 ±9.15	59.21 ± 10.51	0.255	0.775
Gender (M/F)	104/53	104/50	118/39	3.444	0.179
Current smoker	77 (49.04%)	77 (50%)	76 (48.41%)	0.08	0.961
Family history	58 (36.94%)	54 (35.06%)	54 (34.39%)	0.239	0.887
Hypertension	102 (64.86%)	95 (61.68%)	101 (64.33%)	0.406	0.816
Prior MI	18 (11.46%)	11 (7.14%)	14 (8.91%)	1.761	0.415
Clinical presentation				4.337	0.362
STEMI	17	14	24
Non-STEMI	25	30	31
Unstable angina	115	110	102
Grace score	74.44± 21.36	75.05± 19.23	75.21 ± 19.01	0.047	0.954
TC (mmol/L)	4.45± 1.03	4.46± 2.22	4.26 ± 1.05	0.785	0.457
TG (mmol/L)	1.72± 1.20	1.89± 1.98	2.16 ± 1.22*	2.848	0.059
LDL-C (mmol/L)	2.48 ± 0.81	2.46± 0.91	2.34 ± 0.81	1.161	0.314
HDL-C (mmol/L)	1.12± 0.24	1.06± 0.23	1.04 ± 0.22*	4.514	0.012
Glucose (mmol/L)	5.46 ± 0.78	5.42 ± 0.76	5.51 ± 0.90	0.405	0.667
HbA1c (%)	5.82 ± 0.75	5.86 ± 0.48	5.87± 0.41	0.096	0.909
Insulin (uIU/mL)	6.14± 1.41	10.68 ± 1.71**	17.69 ± 3.77**^##	835.16	0
HOMA-IR	1.31± 0.60	2.14± 1.06**	3.62 ± 1.93**^##	121.732	0
Creatinine (μmol/L)	67.89 ± 14.59	67.24 ± 15.55	75.13± 68.69	1.471	0.231
Troponin I (ng/mL) M (IQR)	0.34 (0.03–20.84)	0.35 (0.036–22.42)	0.33 (0.05–16.45)	1.198	0.549
BNP (ng/mL) M (IQR)	54.1 (22.32–145.09)	80.17 (31.5–234)	56.0 (21.07–255.4)	3.193	0.203
HCY (mmol/L)	15.84 ± 8.93	17.64 ± 9.27	16.14± 8.82	1.188	0.306
Urine (mmol/L)	332.04 ± 84.97	336.78 ± 94.19	370.56 ± 101.70*^#	6.511	0.002
BMI	24.31 ± 2.82	26.25 ± 2.72**	27.84 ± 3.41**^##	53.53	0
Waistline (cm)	88.61 ± 11.33	92.66 ± 8.12*	94.33± 8.52**	5.811	0.003
LVD (mm)	48.93 ± 4.62	49.15 ± 4.36	49.72 ± 4.76	0.971	0.38
LAD (mm)	37.77 ± 5.49	38.25 ±4.51	39.21 ± 7.38	1.898	0.151
LVEF (%)	65.53 ± 7.32	65.11 ± 7.13	64.19 ± 8.88	0.979	0.388
Target artery
Left main artery	8 (5.09%)	6 (3.89%)	7 (4.45%)	0.261	0.877
Left anterior descending	95 (60.51%)	84 (54.54%)	90 (57.32%)	1.134	0.567
Left circumflex artery	22 (14.01%)	25 (16.23%)	23 (14.64%)	0.319	0.853
Right coronary artery	31 (19.76%)	31 (20.12%)	37 (23.56%)	2.626	0.269
Bifurcation	29 (18.47%)	33 (21.42%)	45 (28.66%)*	4.891	0.087
Multivessel disease	117 (74.52%)	119 (77.27%)	124 (78.98%)	0.895	0.639
Target lesion
Reference diameter (mm)	2.91 ± 0.43	2.93 ± 0.49	3.01 ± 0.58	2.55	0.079
Lesion length (mm)	19.60 ±8.54	20.36 ± 8.28	22.52 ± 9.39*	4.69	0.01
Diameter stenosis (%)	89.19± 10.76	90.70 ± 7.72	91.75 ± 0.63*	3.24	0.04
Syntax Score	10.81±4.21	10.73±3.97	12.79±5.03*^#	10.727	0
Characteristics of DES
Diameter (mm)	2.91 ± 0.41	2.98 ± 0.42	3.01±0.41	2.121	0.146
Length (mm)	24.26± 14.71	25.71 ± 13.09	28.87±12.24*	4.561	0.011

Notes: *P<0.05 compared with low insulin group; **P<0.01 compared with low insulin group; ^# P<0.05 compared with medium insulin group; ^## P<0.01 compared with medium insulin group.

Abbreviations: FINS, fasting insulin; LVEF, left ventricular ejection fraction; LVD, left ventricular diameter; LA, left atrial diameter; STEMI, ST-segment elevation myocardial infarction; NSTEMI, non-ST segment elevation myocardial infarction; TC, cholesterol; TG, Triglyceride; LDL-C, low density lipoprotein-cholesterol; HDL-C, high-density lipoprotein cholesterol; BNP, B-type natriuretic peptide.; BMI, body mass index; HCY, Homocysteine; HOMA-IR, homeostasis model assessment for insulin resistance; DES, drug-eluting stent.

Table 2 Clinical and Angiographic Characteristics of MACE and Non-MACE Group

	MACE Group (n =86)	Non-MACE (n =382)	F or χ ^2	P value
Age	62.04 ± 9.44	61.14 ±9.64	0.733	0.464
Gender (M/F)	24/62	62/320	0.017	0.896
Current smoker	46 (53.48%)	184 (48.16%)	2.830	0.093
Family history	25 (29.06%)	141 (36.91%)	0.239	0.887
Hypertension	54 (62.79%)	250 (65.44%)	0.278	0.598
Prior MI	19 (22.09)	24 (6.28%)	21.03	0.000
Clinical presentation			0.780	0.677
STEMI	11	44
Non-STEMI	13	73
Unstable angina	62	265
Grace score	74.11± 14.78	76.84± 14.24	0.047	0.954
TC (mmol/L)	4.18± 0.95	4.43± 1.61	1.230	0.219
TG (mmol/L)	1.90± 1.02	1.93± 1.59	0.139	0.890
LDL-C (mmol/L)	2.37 ± 0.73	2.43± 0.86	0.616	0.539
HDL-C (mmol/L)	1.05± 0.18	1.08± 0.24	1.146	0.253
Glucose (mmol/L)	5.52 ± 0.66	5.45 ± 0.84	0.635	0.526
HbA1c (%)	5.77 ± 0.52	5.86 ± 0.58	0.096	0.909
Insulin (uIU/mL)	13.21± 4.15	11.09 ± 5.10	3.305	0.001
HOMA-IR	2.61± 0.95	2.30± 1.05	2.458	0.014
Creatinine (μmol/L)	81.59 ± 11.59	67.57 ± 15.24	2.607	0.009
Troponin I (ng/mL) M (IQR)	0.42 (0.06–33.30)	0.34 (0.03–30)	1.346	0.178
BNP (ng/mL) M (IQR)	78.01 (22.10–258.14)	46.39 (22.77–145.09)	1.405	0.160
HCY (mmol/L)	18.11 ± 11.33	16.15 ± 8.41	1.476	0.141
Urine (mmol/L)	344.81 ± 106.27	346.43 ± 92.47	0.129	0.898
BMI	26.42 ± 4.15	25.98 ± 3.25	2.520	0.012
Waistline (cm)	85.10 ±10.69	79.01 ± 13.36	5.811	0.003
LVD (mm)	49.74 ± 4.91	49.16 ± 4.51	0.932	0.352
LAD (mm)	37.41 ±3.84	38.58 ±6.20	1.438	0.151
LVEF (%)	63.59 ± 9.28	65.25 ± 7.43	0.979	0.388
Target artery
Left main artery	7 (8.13%)	14 (3.66%)	3.279	0.070
Left anterior descending	54 (62.79%)	215 (56.28%)	1.216	0.270
Left circumflex artery	11 (11.62%)	59 (15.44%)	0.389	0.533
Right coronary artery	14 (16.27%)	93 (24.34%)	2.590	0.108
Bifurcation	35 (40.69%)	72 (18.84%)	19.002	0.000
Multivessel disease	68 (79.06%)	294 (76.96%)	0.178	0.673
Target lesion
Reference diameter (mm)	2.82 ± 0.41	2.94 ± 0.45	2.608	0.009
Lesion length (mm)	24.31 ±9.06	20.06 ± 8.60	4.070	0.000
Diameter stenosis (%)	92.68± 6.07	90.07 ± 9.43	2.457	0.014
Small vessel (diameter<2.75mm)	47 (54.65%)	59 (15.44%)	56.591	0.000
Syntax Score	14.11±4.78	10.84±4.24	6.292	0.000
The characteristics of DES
Diameter (mm)	2.93 ± 0.39	2.97 ± 0.42	2.455	0.015
Length (mm)	31.15± 12.33	25.24 ± 13.46	3.666	0.000

Abbreviations: MACE, major adverse cardiac events; LVEF, left ventricular ejection fraction; LVD, left ventricular diameter; LA, left atrial diameter; STEMI, ST-segment elevation myocardial infarction; NSTEMI, non-ST segment elevation myocardial infarction; TC, cholesterol; TG, Triglyceride; LDL-C, low density lipoprotein-cholesterol; HDL-C, high-density lipoprotein cholesterol; BNP, B-type natriuretic peptide; BMI, body mass index; HCY, Homocysteine; HOMA-IR, homeostasis model assessment for insulin resistance DES, drug-eluting stent.

Table 3 Comparison of Clinical Outcomes After Primary PCI During 24-Month Follow-Up According to FINS Status

	Low Insulin n=157	Medium Insulin n=154	High Insulin n=157	χ ^2	P
Primary endpoint
All-cause MACE	23 (22.29%)	24 (23.37%)	39 (34.39%)*^#	6.935	0.031
Death	8 (5.09%)	7 (4.54%)	7 (4.45%)	1.134	0.567
Non-fatal MI	7 (4.45%)	9 (5.84%)	10 (6.36%)	0.319	0.853
TVR	8 (5.09%)	8 (5.19%)	22 (14.01%)*^#	10.999	0.004
Second endpoint
Angina-hospitalization	13 (8.28%)	12 (7.79%)	25 (15.92%)*^#	6.177	0.046

Notes: *Compared with low-insulin group, P<0.05. ^#Compared with medium-insulin group, P<0.05.

Abbreviations: FINS, fasting insulin; MACE, major adverse cardiac events; MI, myocardial infarction; TVR, target vessel revascularization.

Figure 1 Comparison of MACE-free survival among different insulin groups.

Figure 2 Comparison of angina-hospitalization among different insulin groups.

Table 4 Cox Proportional Hazards Model Regression of Major Adverse Events in Patients Undergoing PCI with ACS

	Univariate Analysis		Multiple Analysis
	Coefficient (95% CI)	P value	Coefficient (95% CI)	P value
Bifurcation	4.428 (2.681–7.313)	0	3.394 (2.033–5.667)	0
Syntax score	1.119 (1.079–1.16)	0	1.084 (1.039–1.130)	0.001
Stent length	1.028 (1.013–1.043)	0.011	1.017 (1.002–1.032)	0.03
Stent diameter	0.791 (0.489–1.281)	0.341	–	–
Small vessel	1.609 (1.053–2.461)	0.028	1.713 (1.111–2.642)	0.015
HOMA	1.113 (0.980–1.265)	0.099	0.980 (0.825–1.093)	0.473
Hyperinsulinemia	2.586 (1.694–3.950)	0	1.870 (1.202—2.909)	0.006
BMI	1.034 (0.971–1.101)	0.297	–	–
Waist line	1.006 (0.997–1.016)	0.205	–	–
Multivessel disease	1.765 (0.978–3.185)	0.059	1.051 (0.559–1.978)	0.877
Age	1.014 (0.991–1.037)	0.246	–	–
Hypertension	0.897 (0.579–1.389)	0.627	–	–
Smoke	1.533 (0.936–2.511)	0.09	1.386 (0.888–2.163)	0.15
Prior MI	0.783 (0.480–1.277)	0.321	–	–
LDL-C	0.918 (0.690–1.222)	0.559	–	–

Abbreviations: PCI, percutaneous coronary intervention; ACS, acute myocardial syndrome; MI, myocardial infarction; LDL-C, low-density lipoprotein cholesterol; BMI, body mass index; HOMA, homeostasis model assessment; CI, confidence interval.