Impact of Pre-percutaneous Coronary Intervention Thrombolysis in Myocardial Infarction Flow Grade in Patients With ST-segment Elevation Myocardial Infarction and Prediabetes or Diabetes After Successful Newer-generation Drug-eluting Stent Implantation

doi:10.21203/rs.3.rs-84380/v1

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Impact of Pre-percutaneous Coronary Intervention Thrombolysis in Myocardial Infarction Flow Grade in Patients With ST-segment Elevation Myocardial Infarction and Prediabetes or Diabetes After Successful Newer-generation Drug-eluting Stent Implantation

https://doi.org/10.21203/rs.3.rs-84380/v1

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Background: Studies comparing long-term clinical outcomes between prediabetes and diabetes based on pre-percutaneous coronary intervention (PCI) Thrombolysis in Myocardial Infarction (TIMI) flow grade in patients with ST-segment elevation myocardial infarction (STEMI) after successful PCI with newer-generation drug-eluting stents are limited. We compared 2-year clinical outcomes of these two groups.

Methods: Overall, 6448 STEMI patients were divided into two groups: pre-PCI TIMI 0/1 group (n = 4854) and pre-PCI TIMI 2/3 group (n = 1594). Subsequently, these two groups were further divided into patients with normoglycemia, prediabetes, and type 2 diabetes mellitus (T2DM). The major endpoint was the occurrence of major adverse cardiac events (MACEs), defined as all-cause death, recurrent myocardial infarction, or any repeat revascularization.

Results: After adjustment, in the pre-PCI TIMI 0/1 group, the cumulative incidence of all-cause death was higher in both prediabetes (adjusted hazard ratio [aHR]: 1.633, p = 0.045) and T2DM (aHR: 2.064, p = 0.002) groups than in the normoglycemia group. In the pre-PCI TIMI 2/3 group, the cumulative incidence of any repeat revascularization was higher in both prediabetes (aHR: 2.511, p = 0.039) and T2DM (aHR: 3.156, p = 0.009) groups than in the normoglycemia group. However, in each group (pre-PCI TIMI 0/1 or 2/3), the cumulative incidences of MACEs and all other clinical outcomes were not significantly different between the prediabetes and T2DM groups.

Conclusions: In this retrospective registry study, prediabetes showed worse clinical outcomes similar to those of T2DM regardless of the pre-PCI TIMI flow grade. However, further studies are warranted to confirm these results.

Cardiac & Cardiovascular Systems

Diabetes mellitus

Outcomes

Prediabetes

Thrombolysis in myocardial infarction

Thrombolysis in myocardial infarction (TIMI) flow grade 2/3 before percutaneous coronary intervention (PCI) has shown better clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) than TIMI flow grade 0/1 [1, 2]. Patients with acute myocardial infarction (AMI) and diabetes mellitus (DM) show a more than two-fold higher risk for recurrent MI (Re-MI) and long-term mortality than patients without DM [3, 4]. According to recent reports, prediabetes is also associated with worse cardiovascular outcomes [5–7]. However, studies [6, 7] comparing between prediabetes and diabetes did not investigate long-term clinical outcomes based on the TIMI flow grade. Hence, in this study, we aimed to compare the 2-year clinical outcomes between prediabetes and type 2 diabetes mellitus (T2DM) according to the pre-PCI TIMI flow grade of the infarct-related artery (IRA) in patients with ST-segment elevation myocardial infarction (STEMI) who underwent successful PCI with newer-generation drug-eluting stents (DESs).

Study Population

Patients from the Korea AMI Registry (KAMIR) were included in this study. KAMIR [8] is a nationwide, prospective, multicenter registry in South Korea that was established in November 2005 to evaluate the current epidemiology, as well as short-term and long-term clinical outcomes of patients with AMI. The details of the registry can be found at the KAMIR website (http://www.kamir.or.kr). In the current study, we attempted to confine to type 2 DM (T2DM) patients for diabetes. We considered T2DM based on a previous study [9], which included patients from the KAMIR. In that study, T2DM was defined by self-reported history (medical treatment, age at DM onset [≥ 30 years], and absence of a history of ketoacidosis). Hence, a total of 13,006 STEMI patients aged ≥ 30 years at the onset of diabetes, who underwent successful PCI using newer-generation DESs from November 2005 to June 2015 were evaluated. Among them, patients with incomplete laboratory results including unidentified results of blood glycated hemoglobin (HbA1c) and blood glucose (n = 5,895, 45.3%) and those who were lost to follow-up (n = 663, 5.1%) were excluded. Finally, a total of 6,448 STEMI patients who underwent successful primary PCI with newer-generation DESs were included. These patients were divided into two groups: pre-PCI TIMI flow grade 0/1 group (n = 4,854, 75.3%) and pre-PCI TIMI flow grade 2/3 group (n = 1,594, 24.7%). Subsequently, these two groups were further divided into patients with normoglycemia (group A1 [n = 1,303, 26.8%] and group A2 [n = 446, 28.0%]), prediabetes (group B1 [n = 1,632, 33.6%] and group B2 [n = 471, 29.5%]), and T2DM (group C1 [n = 1,919, 39.5%] and group C2 [n = 677, 42.5%]) (Fig. 1). All patients provided written informed consent before enrollment. We followed up the enrolled patients through face-to-face interview, phone call, and chart review. A total of 6,448 STEMI patients completed the scheduled follow-up. Additionally, all clinical events were evaluated by an independent event adjudicating committee. The process of event adjudication has been described in a previous publication of the KAMIR investigators [8]. The study protocol was approved by the institutional review board of each participating center, and the study was conducted in accordance with the 1975 Declaration of Helsinki.

PCI Procedures and Medical Treatment

Diagnostic coronary angiography (CAG) and PCI were performed using standard techniques.¹⁰ Unfractionated heparin at a dose of 50–100 IU/kg was administered during the procedure to maintain an activated clotting time of 250 to 300 s. Before PCI, all patients received loading doses of aspirin (200–300 mg) and other anti-platelet agents, including clopidogrel, ticagrelor, or prasugrel before PCI. After the index PCI, aspirin at a dose of 100 mg once daily was continued indefinitely, and clopidogrel (75 mg once daily) was recommended for at least one year and dual antiplatelet therapy (DAPT; a combination of aspirin 100 mg/day with clopidogrel 75 mg/day or ticagrelor 90 mg twice daily or prasugrel 5–10 mg/day) was recommended for at least one year. Optimal medications therapy, including β-blocker, renin-angiotensin system blockade, calcium channel blocker, and lipid-lowering agents were also recommended to all patients at the discretion of the responsible clinicians. Additionally, the use of triple antiplatelet therapy (TAPT, cilostazol 100 mg twice daily added to DAPT) was left to the discretion of the individual operators.

Study Definitions and Clinical Outcomes

The inclusion criteria of STEMI was defined according to the current guidelines [11, 12]. The degree of coronary flow before PCI was classified according to TIMI flow grade as assessed by the investigators [13]. Glycemic categories were determined according to medical history and HbA1c and fasting plasma glucose (FPG) or random plasma glucose (RPG) levels at the index hospitalization [7]. We classified glycemic categories according to the American Diabetes Association guidelines [14]. Normoglycemia was defined as HbA1c < 5.7% and FPG < 100 mg/dL (5.6 mmol/L), prediabetes as HbA1c 5.7–6.4% and FPG 100–125 mg/dL (5.6–6.9 mmol/L), and T2DM as known T2DM for which patients receive medical treatment (insulin or antidiabetics) or as newly diagnosed T2DM defined as HbA1c ≥ 6.5%, FPG ≥ 126 mg/dL (7.0 mmol/L), or RPG ≥ 200 mg/dL (11.1 mmol/L) [7]. If there were some discrepancy between the level of HbA1c and those FPG or RPG, we made the level of HbA1c a priority [15]. The major clinical endpoint of this study was the occurrence of major adverse cardiac events (MACEs), defined as all-cause death, Re-MI, or any coronary repeat revascularization. All-cause death was classified as cardiac death (CD) or non-CD. Any repeat revascularization included target lesion revascularization (TLR), target vessel revascularization (TVR), and non-TVR. The definitions of successful PCI, complete or incomplete revascularization, Re-MI, TLR, TVR, and non-TVR were also previously reported [16, 17].

Statistical Analysis

Baseline characteristics were described by using counts and percentage for categorical data and the differences between the groups were analyzed using the chi-square test or Fisher’s exact test. In case of continuous variables, data are expressed as mean ± standard deviation, or as median (quartile 1–quartile 3). The differences among the three groups were evaluated using analysis of variance or the Jonckheere-Terpstra test. Moreover, post-hoc analysis between two groups was performed using the Hochberg test or Dunnett T3 test. Various clinical outcomes were estimated using Kaplan-Meier curve analysis, and differences between the groups were compared using the log-rank test. A two-tailed p-value of < 0.05 was considered statistically significant. In order to adjust for possible confounders as much as possible, the Cox proportional hazard regression analysis was performed. Variables with a p value of < 0.001 in the univariate analysis were entered into the multivariate analysis. The statistical analysis was performed with Statistical Package for the Social Sciences (SPSS) version 20 (IBM, Armonk, NY, USA).

Baseline Characteristics

Table 1A, 1B and Supplemental material 1 show the baseline characteristics of the study population. In both the pre-PCI TIMI flow grade 0/1 and 2/3 groups, the normoglycemia group (groups A1 and A2) included the highest proportion of men, highest prescription rates of ticagrelor and angiotensin-converting enzyme inhibitors, highest number of patients with single-vessel disease, and highest mean diameter of deployed stents. The prediabetes group (groups B1 and B2) included the greatest number of smokers, patients with the highest mean value of total cholesterol and low-density lipoprotein-cholesterol, and patients with the highest prescription rates of clopidogrel. The T2DM group (groups C1 and C2) included the oldest mean patient age; the highest number of patients with hypertension, dyslipidemia, and a previous history of PCI; the greatest proportion of patients who received the highest number of stents; the highest mean values of N-terminal pro-brain natriuretic peptide and triglyceride; the highest prescription rates of angiotensin receptor blockers; the highest number of patients who had the right coronary artery as the IRA and treated vessel; the highest number of patients with three-vessel disease; and the lowest mean estimated glomerular ﬁltration rates.

Clinical Outcomes

The cumulative incidences of major clinical outcomes during the 2-year follow-up period are summarized in Table 2 and Fig. 2. In the total study population, after adjustment, the cumulative incidences of MACEs (adjusted hazard ratio [aHR]: 1.380; 95% confidence interval [CI]: 1.073–1.775; p = 0.012), all-cause death (aHR: 1.602; 95% CI: 1.092–2.350; p = 0.016), CD (aHR: 1.993; 95% CI: 1.262–3.149; p = 0.003), and Re-MI (aHR: 1.717; 95% CI: 1.030–2.860; p = 0.038) were significantly higher in the pre-PCI TIMI flow grade 0/1 group than in the pre-PCI TIMI flow grade 2/3 group. The cumulative incidences of MACEs (aHR: 1.402; 95% CI: 1.069–1.839; p = 0.010), all-cause death (aHR: 1.530; 95% CI: 1.009–2.319; p = 0.035), and CD (aHR: 1.630; 95% CI: 1.011–2.628; p = 0.032) were significantly higher in the prediabetes group (groups B1 and B2) than in the normoglycemia group (groups A1 and A2). The cumulative incidences of MACEs (aHR: 1.716; 95% CI: 1.332–2.211; p < 0.001), all-cause death (aHR: 1.879; 95% CI: 1.265–2.791; p = 0.002), CD (aHR: 2.117; 95% CI: 1.345–3.333; p = 0.001), and any repeat revascularization (aHR: 1.597; 95% CI: 1.087–2.348; p = 0.017) were significantly higher in the T2DM group (groups C1 and C2) than in the normoglycemia group. Moreover, the cumulative incidence MACEs (aHR: 1.277; 95% CI: 1.029–1.584; p = 0.026) was significantly higher in the T2DM group (groups C1 and C2) than in the prediabetes group (groups B1 and B2). However, the cumulative incidences of all-cause death, CD, Re-MI, and any repeat revascularization were similar between these two groups (group B1 and B2 vs. group C1 and C2) (Table 2).

In the pre-PCI TIMI flow grade 0/1 group, after adjustment, the cumulative incidence of all-cause death (aHR: 1.633; 95% CI: 1.001–2.636; p = 0.045) was significantly higher in group B1 than in group A1. The cumulative incidences of MACEs (aHR: 1.509; 95% CI: 1.122–2.029; p = 0.006), all-cause death (aHR: 2.064; 95% CI: 1.294–3.290; p = 0.002), and CD (aHR: 2.244; 95% CI: 1.326–3.798; p = 0.003) were also significantly higher in group C1 than in group A1. However, the cumulative incidences of MACEs, all-cause death, CD, Re-MI, and any repeat revascularization were similar between groups B1 and C1.

In the pre-PCI TIMI flow grade 2/3 group, after adjustment, the cumulative incidence of any repeat revascularization (aHR: 2.511; 95% CI: 0.978–5.945; p = 0.039) was significantly higher in group B2 than in group A2. The cumulative incidences of MACEs (aHR: 1.807; 95% CI: 1.034–3.158; p = 0.038) and any repeat revascularization (aHR: 3.156; 95% CI: 1.336–7.455; p = 0.009) were also significantly higher in group C2 than in group A2. However, the cumulative incidences of MACEs, all-cause death, CD, Re-MI, and any repeat revascularization were similar between groups B2 and C2.

Table 3A shows the independent predictors for all-cause death and any repeat revascularization in the pre-PCI TIMI flow grade 0/1 group at 2 years. Old age (≥ 65 years) decreased left ventricular ejection fraction (LVEF, < 40%), dyslipidemia, use of lipid-lowering agents, more than three-vessel disease, and a > 28 mm length of the deployed stent were independent predictors of MACEs. More than three-vessel disease and culprit-only PCI were independent predictors of any repeat revascularization. Table 3B shows the independent predictors of all-cause death and any repeat revascularization in the pre-PCI TIMI flow grade 2/3 group at 2 years. Decreased LVEF, use of lipid-lowering agents, and culprit-only PCI were independent predictors of all-cause death. More than three-vessel disease, culprit-only PCI, a < 3.0 mm diameter of deployed stents, and a > 28 mm length of deployed stents were independent predictors of any repeat revascularization in this study.

The main findings of this study were as follows: (1) In the total study population, the cumulative incidences of MACEs, all-cause death, CD, and Re-MI were significantly higher in the pre-PCI TIMI flow grade 0/1 group (groups A1, B1, and C1) than in the pre-PCI TIMI flow grade 2/3 group (groups A2, B2, and C2), and the cumulative incidence of MACEs was significantly higher in the T2DM group (groups C1 and C2) than in the prediabetes group (groups B1 and B2). (2) However, in each group (pre-PCI TIMI flow grade 0/1 or 2/3), the cumulative incidences of all major clinical outcomes were not significantly different between the prediabetes and T2DM groups (group B1 vs. C1 or group B2 vs. C2). (3) In the pre-PCI TIMI flow grade 0/1 group, the cumulative incidence of all-cause death was higher in both the prediabetes and T2DM groups (groups B1 and C1) than in the normoglycemia group (group A1). (4) In the pre-PCI TIMI flow grade 2/3 group, the cumulative incidence of any repeat revascularization was higher in both the prediabetes and T2DM groups (groups B2 and C2) than in the normoglycemia group (group A2).

The main focus of this study was comparing the major clinical outcomes between prediabetes and T2DM in patients with STEMI based on the TIMI flow grade of the IRA, especially after the implantation of newer-generation DESs. As previously mentioned, TIMI flow grade 2/3 at the initial CAG has been reported to show better clinical outcomes than TIMI flow grade 0/1 in patients with STEMI [1, 2]. The suggested explanations for this result include the observation that compared with “a lack of patency (TIMI flow grade 0/1),” “patency (TIMI flow 2/3)” [18] had lower in-hospital rates for new-onset heart failure and hypotension and were less likely to require intubation for respiratory failure, which are all surrogates of improved myocardial function.¹ Moreover, patients with TIMI flow grade 3 at the initial CAG were more likely to have TIMI flow grade 3 at the end of the procedure [1, 19]. Recent reports [20, 21] also showed that the patency of the IRA in patients with STEMI was related to procedural success and decreased enzymatic infarct size, fatal arrhythmic events, and in-hospital mortality. Because recent studies [5-7] did not use TIMI flow grade as a variable in estimating the clinical outcomes between these two groups, we considered that the TIMI flow grade can be used as a meaningful variable for the comparison of major clinical outcomes between prediabetes and T2DM.

In this study, the pre-PCI TIMI flow 2/3 group showed better major clinical outcomes, including the cumulative incidences of MACEs, all-cause death, CD, and Re-MI, in the total study population (Table 2). These results were consistent with previous findings [1, 2]. In each group (pre-PCI TIMI flow 0/1 or 2/3), the major clinical outcomes were similar between prediabetes and T2DM. Despite these comparable results, in the total study population, the cumulative incidence of MACEs (aHR: 1.277; 95% CI: 1.029–1.584; p = 0.026, Table 3) was significantly higher in the T2DM group than in the prediabetes group. This difference of MACE rates may be related to the summation of numerical differences in each group (pre-PCI TIMI flow 0/1 or 2/3) between prediabetes and T2DM. Hence, we can speculate that prediabetes was a worse condition similar to T2DM regardless of pre-PCI TIMI flow grade in this study.

The suggested underlying pathological mechanisms related to the adverse clinical outcomes in hyperglycemia include thrombus formation, vascular inflammation, and platelet aggregation [22, 23]. Although prediabetes is associated with increased risks for microvascular and macrovascular complications [24] and the composite of cardiovascular and all-cause mortality [5], these harmful effects of prediabetes on long-term clinical outcomes in patients with AMI are relatively less well understood than those of diabetes. Diabetes and prediabetes are observed in at least two-third of patients with AMI, who have a two-fold higher long-term mortality rate than those with normoglycemia [25]. Kok et al. [15] and Arnold et al. [26] demonstrated that the comparative clinical outcomes were similar between prediabetes and diabetes. In contrast, Cueva-Recalde et al. [27] suggested that prediabetes, as determined by HbA1c, is not associated with long-term adverse cardiovascular outcomes in patients with coronary artery disease and PCI. However, these studies [25-27] were not confined to STEMI patients and newer-generation DES. Therefore, we believe that our results could be more suitable for reflecting the contemporary real-world practice of primary PCI.

Based on our results, we suggest that much more attention and careful treatment strategies similar to those for T2DM are required for prediabetes population. Furthermore, we believe that our study can provide meaningful information about the significance of prediabetes to interventional cardiologists who perform PCI with contemporary newer-generation DESs in patients with STEMI.

This study had several limitations. First, although KAMIR is prospective registry,⁸ this is a retrospective study. Therefore, some data might have usual limitations and biases inherent to retrospective study designs [7, 28]. Especially, because patients of this study were enrolled over a wide range of time (from November 2005 to June 2015), the various treatment options, the different guidelines suggestions, and treatment goals for patients with T2DM that have risen during this period were able to have a great impact on this study and our results may differ over time. This point is a big weakness of this study. Second, we defined T2DM according to medical history and adult-onset diabetes (after the age of 30). However, < 5% of the diabetes cases that occur in adulthood are type 1 DM [29] and we could not exclude latent autoimmune diabetes in adults [30] because limitation of this KAMIR data information. Hence these might have affected the outcomes. Third, in circumstances in which there may be some difficulty in performing and interpreting such testing in the milieu of an acute illness such as AMI [31]. This potential stress-induced hyperglycemia may have served as an important bias in this study. Fourth, compared with an oral glucose test, measurement of HbA1c may not be ideal [7]. Moreover, it has been proposed that impaired glucose tolerance (IGT) prediabetes may be associated with a higher cardiovascular risk compared to the impaired fasting glucose (IFG) subtype [32]. However, in this KAMIR data, prediabetes was not classified according to these subtypes (isolated IGT, isolated FGT, and combined IGT and IFG). Therefore, these were other important bias in this study. Fifth, we could not provide complete information about the degree of glycemic control in the enrolled patients during the follow-up period because detailed information on this variable was not included in KAMIR [28]. Six, we could not consider the duration of diabetes as a major determinant factor for long-term clinical outcomes in this study because lack of information of this variable. Seventh, because this study was based on discharge medications, we could not precisely know the adherence or non-adherence to antidiabetic drugs of the enrolled patients [7, 15, 28]. Moreover, the choice of DAPT or TAPT was not predefined but was individualized by physician discretion. However, our finding could reflect real-world practice. Eighth, although multivariate analysis was performed to account for baseline differences, the effect of unmeasured baseline confounders or variables not included in KAMIR may have affected the study outcomes [7].

In the era of contemporary newer-generation DESs, prediabetes was found to show worse clinical outcomes similar to those of diabetes regardless of pre-PCI TIMI flow grade in this study. However, larger randomized controlled studies are warranted to confirm these results in the future.

cardiac death; DESs:drug-eluting stents; DM:diabetes mellitus; KAMIR:Korea Myocardial Infarction Registry; MACEs:major adverse cardiac events; Re-MI:recurrent myocardial infarction; STEMI:ST-segment elevation myocardial infarction; T2DM; type 2 DM; TIMI:thrombolysis in myocardial infarction

Ethics approval and consent to participate: This study protocol was approved by the ethics committee at each participating center and the Chonnam National University Hospital Institutional Review Board (IRB) ethics committee (CNUH-2011-172) according to the ethical guidelines of the 1975 Declaration of Helsinki. All patients provided written informed consent prior to enrollment.

Consent for publication: Not applicable.

Availability of data and materials: All data generated or analysed during this study are included in this published article [and its supplementary information files].

Competing interests: The authors declare that they have no competing interests.

Funding: This research was supported by a fund (2016-ER6304-02) by Research of Korea Centers for Disease Control and Prevention.

Author’s contributions: Yong Hoon Kim, Ae-Young Her, Myung Ho Jeong, Byeong-Keuk Kim, Jung-Sun Kim, Donghoon Choi, Myeong-Ki Hong and Yangsoo Jang conceived the conceptualization of this study. Yong Hoon Kim, Ae-Young Her, Sung-Jin Hong, Seunghwan Kim, Jung-Sun Kim, Young-Guk Ko, Myeong-Ki Hong, and Yangsoo Jang performed data curation. Yong Hoon Kim, Ae-Young Her, Sung-Jin Hong, and Seunghwan Kim were involved in formal analysis. Yong Hoon Kim, Ae-Young Her, Myung Ho Jeong, Byeong-Keuk Kim, Jung-Sun Kim, Young-Guk Ko, Myeong-Ki Hong, and Yangsoo Jang were participated in investigation. Yong Hoon Kim, Ae-Young Her, Byeong-Keuk Kim, Seunghwan Kim, Jung-Sun Kim, Young-Guk Ko, Donghoon Choi, Myeong-Ki Hong, and Yangsoo Jang were involved in methodology. Yong Hoon Kim, Ae-Young Her, Myung Ho Jeong, Myeong-Ki Hong, and Yangsoo Jang performed project administration. Myung Ho Jeong, Byeong-Keuk Kim, Sung-Jin Hong, Seunghwan Kim, Jung-Sun Kim, Donghoon Choi, Myeong-Ki Hong, and Yangsoo Jang provided resources. Myung Ho Jeong, Donghoon Choi, Myeong-Ki Hong, and Yangsoo Jang have done the supervisors’ roles. Yong Hoon Kim, Ae-Young Her, Myung Ho Jeong, Byeong-Keuk Kim, Sung-Jin Hong, Seunghwan Kim, Jung-Sun Kim, Young-Guk Ko, Donghoon Choi, Myeong-Ki Hong, and Yangsoo Jang were involved in validation. Yong Hoon Kim and Ae-Young Her wrote and revised the manuscript. All authors read and approved the final manuscript.

Acknowledgements: The authors thank all of the clinical investigators who contributed time and effort to this study, as well as the Korea Acute Myocardial Infarction (KAMIR) Investigators.

Korea Acute Myocardial infarction Registry (KAMIR) investigators

Myung Ho Jeong, MD, Youngkeun Ahn, MD, Sung Chul Chae, MD, Jong Hyun Kim, MD, Seung-Ho Hur, MD, Young Jo Kim, MD, In Whan Seong, MD, Donghoon Choi, MD, Jei Keon Chae, MD, Taek Jong Hong, MD, Jae Young Rhew, MD, Doo-Il Kim, MD, In-Ho Chae, MD, Jung Han Yoon, MD, Bon-Kwon Koo, MD, Byung-Ok Kim, MD, Myoung Yong Lee, MD, Kee-Sik Kim, MD, Jin-Yong Hwang, MD, Myeong Chan Cho, MD, Seok Kyu Oh, MD, Nae-Hee Lee, MD, Kyoung Tae Jeong, MD, Seung-Jea Tahk, MD, Jang-Ho Bae, MD, Seung-Woon Rha, MD, Keum-Soo Park, MD, Chong Jin Kim, MD, Kyoo-Rok Han, MD, Tae Hoon Ahn, MD, Moo-Hyun Kim, MD, Ki Bae Seung, MD, Wook Sung Chung, MD, Ju-Young Yang, MD, Chong Yun Rhim, MD, Hyeon-Cheol Gwon, MD, Seong-Wook Park, MD, Young-Youp Koh, MD, Seung Jae Joo, MD, Soo-Joong Kim, MD, Dong Kyu Jin, MD, Jin Man Cho, MD, Sang-Wook Kim, MD, Jeong Kyung Kim, MD, Tae Ik Kim, MD, Deug Young Nah, MD, Si Hoon Park, MD, Sang Hyun Lee, MD, Seung Uk Lee, MD, Hang-Jae Chung, MD, Jang-Hyun Cho, MD, Seung Won Jin, MD, Myeong-Ki Hong, MD, Yangsoo Jang, MD, Jeong Gwan Cho, MD, Hyo-Soo Kim, MD and Seung-Jung Park, MD.

Authors’ information (optional): ¹Division of Cardiology, Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Republic of Korea. ²Department of Cardiology, Cardiovascular Center, Chonnam National University Hospital, Gwangju, Republic of Korea. ³Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea. ⁴Division of Cardiology, Inje University College of Medicine, Haeundae Paik Hospital, Busan, Republic of Korea

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Table 1A Baseline clinical, laboratory, and discharge medication characteristics.

Variables	Pre-PCI TIMI 0/1 (n = 4854)				Pre-PCI TIMI 2/3 (n = 1954)
Variables	Group A1 Normoglycemia (n = 1303)	Group B1 Prediabetes (n = 1632)	Group C1 T2DM (n = 1919)	p value	Group A2 Normoglycemia (n = 446)	Group B2 Prediabetes (n = 471)	Group C2 T2DM (n = 677)	p value
Men, n (%)	1064 (81.7)	1257 (77.0)	1430 (74.5)	<0.001	355 (79.6)	362 (76.9)	491 (72.5)	<0.001
Age, years	60.0 ± 12.9	62.4 ± 12.9	62.6 ± 12.0	<0.001	61.1 ± 13.6	63.5 ± 12.9	64.3± 11.4	<0.001
LVEF, %	50.7 ± 10.4	50.8 ± 11.1	49.8 ± 11.0	0.020	53.0 ± 11.0	52.1 ± 11.3	50.1 ± 11.8	<0.001
BMI, kg/m²	24.0 ± 3.1	24.3 ± 3.3	24.6 ± 3.2	<0.001	23.5 ± 3.4	23.9 ± 3.4	24.2 ± 3.1	0.006
SBP, mmHg	127.7 ± 27.4	126.3 ± 28.2	127.4 ± 29.1	0.344	130.1 ± 28.9	125.0 ± 26.4	130.0 ± 28.3	0.008
DBP, mmHg	79.3 ± 17.2	77.9 ± 17.3	77.6 ± 17.5	0.016	80.0 ± 16.4	77.1 ± 15.5	78.1 ± 16.3	0.022
Cardiogenic shock, n (%)	75 (5.8)	103 (6.3)	142 (7.4)	0.156	19 (4.3)	24 (5.1)	29 (4.3)	0.771
CPR on admission, n (%)	94 (7.2)	107 (6.6)	109 (5.7)	0.205	26 (5.8)	27 (5.7)	32 (4.7)	0.651
Hypertension, n (%)	494 (37.9)	663 (40.6)	1084 (56.5)	<0.001	173 (38.8)	192 (40.8)	396 (58.5)	<0.001
Dyslipidemia, n (%)	109 (8.4)	175 (10.7)	255 (13.3)	<0.001	37 (8.3)	54 (11.5)	93 (13.7)	0.020
Previous MI, n (%)	38 (2.9)	38 (2.3)	69 (3.6)	0.086	11 (2.5)	11 (2.3)	28 (4.1)	0.144
Previous PCI, n (%)	43 (3.3)	65 (4.0)	101 (5.3)	0.019	16 (3.6)	18 (3.8)	47 (6.9)	0.014
Previous CABG, n (%)	4 (0.3)	1 (0.1)	13 (0.7)	0.010	0 (0.0)	1 (0.2)	1 (0.1)	0.647
Previous CVA, n (%)	50 (3.8)	63 (3.9)	127 (6.6)	<0.001	18 (4.0)	22 (4.7)	42 (6.2)	0.235
Previous HF, n (%)	5 (0.4)	13 (0.8)	22 (1.1)	0.062	1 (0.2)	6 (1.3)	7 (1.0)	0.199
Current smokers, n (%)	632 (48.5)	822 (50.4)	843 (43.9)	<0.001	216 (48.4)	238 (50.5)	290 (42.8)	0.025
Peak CK-MB, mg/dL	201.1 ± 253.3	200.6 ± 220.6	164.0 ± 167.2	<0.001	124.1 ± 197.8	146.3 ± 172.6	114.3 ± 144.1	0.007
Peak Troponin-I, ng/mL	76.8 ± 108.8	73.3 ± 171.8	78.7 ± 211.7	0.626	34.3 ± 59.3	49.7 ± 87.9	50.2 ± 140.4	0.066
Fasting glucose, mg/dL	146.1 ± 50.1	156.6 ± 50.5	235.3 ± 96.3	<0.001	141.4 ± 47.7	153.1 ± 45.9	234.4 ± 99.4	<0.001
Hemoglobin A1c (%)	5.3 ± 0.4	6.0 ± 0.2	7.9 ± 3.0	<0.001	5.3 ± 0.3	6.0 ± 0.2	8.0 ± 3.2	<0.001
NT-ProBNP (pg/mL)	1042.4 ± 3448.7	1147.7 ± 2872.3	1530.4 ± 3997.7	0.006	1356.7 ± 4363.0	1130.4 ± 3048.0	2821.4 ± 6676.9	<0.001
Hs-sensitivity CRP (mg/dL)	6.0 ± 33.8	8.9 ± 45.3	12.6 ± 54.5	0.004	6.1 ± 29.8	4.5 ± 15.3	8.3 ± 27.5	0.083
Serum creatinine (mg/L)	1.02 ± 1.08	1.09 ± 1.87	1.10 ± 0.83	0.222	0.98 ± 0.69	0.98 ± 0.83	1.13 ± 1.05	0.003
eGFR, mL/min/1.73m²	88.5 ± 30.4	87.2 ± 39.3	84.6 ± 42.4	0.015	91.4 ± 32.2	89.6 ± 27.5	85.6 ± 39.2	0.016
Total cholesterol, mg/dL	181.5 ± 40.2	191.0 ± 44.0	180.7 ± 46.1	<0.001	176.7 ± 40.1	188.7 ± 44.4	177.7 ± 47.6	<0.001
Triglyceride, mg/L	119.7 ± 84.8	136.9 ± 109.4	153.6 ± 128.2	<0.001	120.8 ± 89.7	135.1 ± 106.3	146.0 ± 123.0	0.001
HDL cholesterol, mg/L	44.2 ± 13.7	43.8 ± 17.7	42.1 ± 14.8	<0.001	44.9 ± 18.2	44.3 ± 16.2	40.9 ± 11.6	<0.001
LDL cholesterol, mg/L	114.6 ± 35.7	122.6 ± 40.2	111.8 ± 39.2	<0.001	110.5 ± 34.5	123.0 ± 64.6	109.1 ± 37.4	<0.001
Diabetes management
Diet			173 (9.0)				61 (9.0)
Oral agent			1115 (58.1)				430 (63.5)
Insulin			93 (4.8)				34 (5.0)
Untreated			538 (28.0)				152 (22.5)
Discharge medications, n (%)
Aspirin, n (%)	1265 (97.1)	1571 (96.3)	1837 (95.7)	0.137	433 (97.1)	451 (95.8)	655 (96.8)	0.506
Clopidogrel, n (%)	1037 (79.0)	1397 (85.6)	1619 (84.4)	<0.001	361 (80.9)	408 (86.6)	577 (85.2)	0.045
Ticagrelor, n (%)	156 (12.0)	139 (8.5)	163 (8.5)	0.001	55 (12.3)	35 (7.4)	54 (8.0)	0.016
Prasugrel, n (%)	97 (7.4)	82 (5.0)	103 (5.4)	0.012	22 (4.9)	26 (5.5)	37 (5.5)	0.906
Cilostazole, n (%)	203 (15.6)	300 (18.4)	381 (19.9)	0.008	55 (12.3)	88 (18.7)	122 (18.0)	0.016
BBs, n (%)	1086 (83.3)	1376 (84.3)	1598 (83.3)	0.666	378 (84.8)	384 (81.5)	572 (84.5)	0.317
ACEIs, n (%)	783 (60.1)	953 (58.4)	1044 (54.4)	0.003	279 (62.6)	255 (54.1)	342 (50.5)	<0.001
ARBs, n (%)	280 (21.5)	351 (21.5)	478 (24.9)	0.022	104 (23.3)	121 (25.7)	215 (31.8)	0.004
CCBs, n (%)	29 (2.2)	46 (2.8)	68 (3.5)	0.088	28 (6.3)	19 (4.0)	42 (6.2)	0.218
Lipid-lowering agents	1184 (90.9)	1453 (89.0)	1644 (85.7)	<0.001	394 (88.3)	417 (88.5)	582 (86.0)	0.338

Values are means ± SD or numbers and percentages. The P values for continuous data obtained from the analysis of variance. The P values for categorical data from chi-square or Fisher’s exact test.

T2DM type 2 diabetes mellitus, LVEF left ventricular ejection fraction, BMI body mass index, SBP systolic blood pressure, DBP diastolic blood pressure, MI myocardial infarction, PCI percutaneous coronary intervention, CABG coronary artery bypass graft, CVA cerebrovascular accident, HF heart failure, CK-MB creatine kinase myocardial band, NT-ProBNP N-terminal pro-brain natriuretic peptide, Hs-CRP high sensitivity C-reactive protein, eGFR estimated glomerular filtration rate, HDL high-density lipoprotein, LDL low-density lipoprotein, BBs ß-blockers, ACEIs angiotensin-converting enzyme inhibitors, ARBs angiotensin receptor blockers, CCBs calcium channel blockers.

Table 1B Angiographic characteristics.

Variables	Pre-PCI TIMI 0/1 (n = 4854)				Pre-PCI TIMI 2/3 (n = 1954)
Variables	Group A1 Normoglycemia (n = 1303)	Group B1 Prediabetes (n = 1632)	Group C1 T2DM (n = 1919)	P value	Group A2 Normoglycemia (n = 446)	Group B2 Prediabetes (n = 471)	Group C2 T2DM (n = 677)	P value
IRA
Left main, n (%)	16 (1.2)	10 (0.6)	14 (0.7)	0.157	10 (2.2)	9 (1.9)	18 (2.7)	0.704
LAD, n (%)	700 (53.7)	848 (52.0)	895 (46.6)	<0.001	267 (59.9)	292 (62.0)	393 (58.1)	0.406
LCx, n (%)	120 (9.2)	152 (9.3)	172 (9.0)	0.933	39 (8.7)	34 (7.2)	53 (7.8)	0.690
RCA, n (%)	467 (35.8)	622 (38.1)	838 (43.7)	<0.001	130 (29.1)	136 (28.9)	213 (31.5)	0.570
Treated vessel
Left main, n (%)	22 (1.7)	18 (1.1)	23 (1.2)	0.336	17 (3.8)	15 (3.2)	23 (3.4)	0.869
LAD, n (%)	777 (59.6)	958 (58.7)	1066 (55.5)	0.043	297 (66.6)	328 (69.6)	463 (68.4)	0.609
LCx, n (%)	196 (15.0)	254 (15.6)	308 (16.1)	0.740	72 (16.1)	82 (17.4)	136 (20.1)	0.214
RCA, n (%)	522 (40.1)	695 (42.6)	924 (48.2)	<0.001	148 (33.2)	165 (35.0)	274 (40.5)	0.029
Extent of CAD
Single-vessel, n (%)	778 (59.7)	921 (56.4)	937 (48.8)	<0.001	251 (56.3)	259 (55.0)	286 (42.2)	<0.001
Two-vessel, n (%)	363 (27.9)	487 (29.8)	598 (31.2)	0.132	130 (29.1)	136 (28.9)	215 (31.8)	0.495
≥ Three-vessel, n (%)	162 (12.4)	224 (13.7)	384 (20.0)	<0.001	65 (14.6)	76 (16.1)	176 (26.0)	<0.001
ACC/AHA lesion type
Type B1, n (%)	148 (11.4)	213 (13.1)	220 (11.5)	0.254	77 (17.3)	80 (17.0)	102 (15.1)	0.543
Type B2, n (%)	388 (29.8)	454 (27.8)	551 (28.7)	0.507	178 (39.9)	179 (38.0)	279 (41.2)	0.551
Type C, n (%)	671 (51.5)	828 (50.7)	1009 (52.6)	0.543	157 (45.5)	165 (35.0)	249 (36.8)	0.789
IVUS, n (%)	209 (16.0)	336 (20.6)	349 (18.2)	0.006	117 (26.2)	113 (24.0)	154 (22.7)	0.409
OCT, n (%)	3 (0.2)	5 (0.3)	8 (0.4)	0.649	1 (0.2)	3 (0.6)	1 (0.1)	0.319
FFR, n (%)	11 (0.8)	17 (1.0)	15 (0.8)	0.700	4 (0.9)	5 (1.1)	9 (1.3)	0.787
Drug-eluting stents
ZES, n (%)	419 (32.2)	592 (36.3)	725 (37.8)	0.004	142 (31.8)	157 (33.3)	213 (31.5)	0.791
EES, n (%)	665 (51.0)	843 (51.7)	939 (48.9)	0.235	234 (52.5)	246 (52.2)	349 (51.6)	0.950
BES, n (%)	209 (16.0)	194 (11.9)	227 (11.8)	0.001	63 (14.1)	55 (11.7)	95 (14.0)	0.440
Others, n (%)	29 (2.2)	34 (2.1)	53 (2.8)	0.378	14 (3.1)	22 (4.7)	33 (4.9)	0.342
Symptom-to-balloon time (min)	184 (120-275)	187 (129-293)	186 (127-289)	0.215	186 (126-301)	189 (131-309)	187 (130-303)	0.323
Door-to-balloon time (min)	59.0 (46.0-71.0)	60.5 (45.0-76.0)	61.0 (45.0-79.0)	0.628	60.0 (46.0-77.0)	61.5 (45.0-80.0)	59.5 (46.0-72.0)	0.605
Culprit-only PCI	816 (62.6)	880 (53.9)	1071 (55.8)	<0.001	252 (56.5)	231 (49.0)	347 (51.3)	0.067
Multivessel PCI	487 (37.4)	752 (46.1)	848 (44.2)	<0.001	194 (43.5)	240 (51.0)	330 (48.7)	0.067
PCI for non-IRA
During index PCI, n (%)	311 (63.9)	497 (66.1)	548 (64.6)	0.622	126 (64.9)	151 (62.9)	211 (63.9)	0.879
Before discharge, n (%)	176 (36.1)	255 (33.9)	300 (35.4)	0.622	68 (35.1)	89 (37.1)	119 (36.1)	0.879
Completeness of PCI
CR, n (%)	333 (68.4)	534 (71.4)	585 (69.0)	0.545	136 (70.1)	173 (72.1)	236 (71.5)	0.880
IR, n (%)	154 (31.6)	218 (29.0)	263 (31.0)	0.545	58 (29.9)	67 (27.9)	94 (28.5)	0.880
Stent diameter (mm)	3.20 ± 0.42	3.19 ± 0.41	3.16 ± 0.43	0.025	3.21 ± 0.45	3.20 ± 0.40	3.12 ± 0.40	<0.001
Stent length (mm)	27.3 ± 10.6	26.7 ± 10.4	27.3 ± 10.7	0.192	25.6 ± 8.9	25.8 ± 10.3	26.4 ± 10.8	0.397
Number of stent	1.34 ± 0.63	1.38 ± 0.69	1.41 ± 0.72	0.013	1.35 ± 0.65	1.45 ± 0.76	1.54 ± 0.83	<0.001

Values are means ± SD or numbers and percentages or median (quartile 1- quartile 3). The P values for continuous data obtained from the analysis of variance. The P values for categorical data from chi-square or Fisher’s exact test.

T2DM type 2 diabetes mellitus, IRA infarct-related artery, LAD left anterior descending coronary artery, LCx left circumflex coronary artery, RCA right coronary artery, CAD coronary artery disease, ACC/AHA American College of Cardiology/American Heart Association, IVUS intravascular ultrasound, OCT optical coherence tomography, FFR fractional flow reserve, ZES zotarolimus-eluting stent, EES everolimus-eluting stent, BES biolimus-eluting stents, CR complete revascularization, IR incomplete revascularization.

Table 2 Clinical outcomes by Kaplan-Meier analysis and Cox-proportional hazard ratio analysis at 2 years.

Pre-PCI TIMI 0/1
	Cumulative Events (%)				Unadjusted			Adjusted^a
Outcomes	Group A1 Normoglycemia (n = 1303)	Group B1 Prediabetes (n = 1632)	Log-rank		HR (95% CI)		p value	HR (95% CI)	p value
MACEs	76 (6.3)	122 (7.8)	0.121		1.254 (0.942 – 1.670)		0.122	1.320 (0.975 – 1.795)	0.077
All-cause death	28 (2.2)	59 (3.7)	0.026		1.658 (1.058 – 2.600)		0.028	1.633 (1.001 – 2.636)	0.045
Cardiac death	22 (1.7)	48 (3.0)	0.032		1.724 (1.041 – 2.856)		0.034	1.627 (0.945 – 2.804)	0.079
Re-MI	18 (1.5)	32 (2.1)	0.275		1.377 (0.733 – 2.454)		0.277	1.418 (0.780 – 2.577)	0.252
Any revascularization	36 (3.2)	45 (3.0)	0.869		1.037 (0.669 – 1.608)		0.869	1.133 (0.701 – 1.833)	0.610
	Cumulative Events (%)				Unadjusted			Adjusted^a
Outcomes	Group A1 Normoglycemia (n = 1303)	Group C1 T2DM (n = 1919)	Log-rank		HR (95% CI)		p value	HR (95% CI)	p value
MACEs	76 (6.3)	183 (10.1)	<0.001		1.607 (1.230 – 2.100)		0.001	1.509 (1.122 – 2.029)	0.006
All-cause death	28 (2.2)	94 (5.1)	<0.001		2.259 (1.481 – 3.445)		<0.001	2.064 (1.294 – 3.290)	0.002
Cardiac death	22 (1.7)	80 (4.3)	<0.001		2.452 (1.529 – 3.930)		<0.001	2.244 (1.326 – 3.798)	0.003
Re-MI	18 (1.5)	45 (2.6)	0.067		1.656 (0.959 – 2.861)		0.070	1.609 (0.897 – 2.885)	0.111
Any revascularization	36 (3.2)	65 (3.8)	0.403		1.189 (0.791 – 1.787)		0.404	1.207 (0.763 – 1.909)	0.382
	Cumulative Events (%)				Unadjusted			Adjusted^a
Outcomes	Group B1 Prediabetes (n = 1632)	Group C1 T2DM (n = 1919)	Log-rank		HR (95% CI)		p value	HR (95% CI)	p value
MACEs	122 (7.8)	183 (10.1)	0.030		1.287 (1.023 – 1.618)		0.031	1.105 (0.861 – 1.419)	0.433
All-cause death	59 (3.7)	94 (5.1)	0.060		1.365 (0.985 – 1.890)		0.061	1.208 (0.839 – 1.739)	0.310
Cardiac death	48 (3.0)	80 (4.3)	0.051		1.426 (0.997 – 2.039)		0.052	1.247 (0.833 – 1.866)	0.283
Re-MI	32 (2.1)	45 (2.6)	0.409		1.210 (0.769 – 1.903)		0.410	1.026 (0.639 – 1.648)	0.915
Any revascularization	45 (3.0)	65 (3.8)	0.260		1.244 (0.850 – 1.819)		0.261	1.126 (0.749 – 1.693)	0.569
Pre-PCI TIMI 2/3
	Cumulative Events (%)				Unadjusted			Adjusted^b
Outcomes	Group A2 Normoglycemia (n = 446)	Group B2 Prediabetes (n = 471)	Log-rank		HR (95% CI)		p value	HR (95% CI)	p value
MACEs	22 (5.2)	30 (6.9)	0.378		1.280 (0.738 – 2.219)		0.379	1.372 (0.740 – 2.543)	0.298
All-cause death	11 (2.5)	13 (2.9)	0.795		1.113 (0.498 – 2.483)		0.795	1.195 (0.485 – 2.946)	0.699
Cardiac death	7 (1.6)	9 (1.9)	0.700		1.214 (0.452 – 3.260)		0.700	1.636 (0.359 – 5.514)	0.427
Re-MI	4 (1.0)	4 (1.0)	0.915		1.079 (0.270 – 4.313)		0.915	1.891 (0.317 – 11.27)	0.484
Any revascularization	9 (2.3)	19 (4.4)	0.084		1.987 (0.899 – 4.392)		0.090	2.511 (0.978 – 5.945)	0.039
	Cumulative Events (%)				Unadjusted			Adjusted^b
Outcomes	Group A2 Normoglycemia (n = 446)	Group C2 T2DM (n = 677)	Log-rank		HR (95% CI)	p value		HR (95% CI)	p value
MACEs	22 (5.2)	63 (10.1)	0.009		1.889 (1.163 – 3.069)	0.010		1.807 (1.034 – 3.158)	0.038
All-cause death	11 (2.5)	23 (3.6)	0.394		1.365 (0.666 – 2.801)	0.396		1.024 (0.448 – 2.341)	0.956
Cardiac death	7 (1.6)	16 (2.5)	0.374		1.492 (0.614 – 3.626)	0.377		1.078 (0.393 – 2.960)	0.884
Re-MI	4 (1.0)	18 (3.0)	0.047		2.931 (0.992 – 8.662)	0.049		4.203 (0.933 – 18.93)	0.061
Any revascularization	9 (2.3)	31 (5.1)	0.026		2.273 (1.082 – 4.775)	0.028		3.156 (1.336 – 7.455)	0.009
Outcomes	Cumulative Events (%)				Unadjusted			Adjusted^c
Outcomes	Group B2 Prediabetes (n = 471)	Group C2 T2DM (n = 677)	Log-rank		HR (95% CI)		p value	HR (95% CI)	p value
MACEs	30 (6.9)	63 (10.1)	0.076		1.479 (0.958 – 2.285)		0.078	1.297 (0.817 – 2.061)	0.190
All-cause death	13 (2.9)	23 (3.6)	0.550		1.230 (0.623 – 2.428)		0.551	1.067 (0.515 – 2.209)	0.861
Cardiac death	9 (1.9)	16 (2.5)	0.610		1.236 (0.546 – 2.798)		0.611	1.254 (0.516 – 3.045)	0.607
Re-MI	4 (1.0)	18 (3.0)	0.032		3.162 (1.070 – 9.342)		0.037	1.921 (0.615 – 0.600)	0.261
Any revascularization	19 (4.4)	31 (5.1)	0.640		1.146 (0.647 – 2.028)		0.641	1.116 (0.607 – 2.050)	0.724
Total population (Normoglycemia vs. Prediabetes vs. Diabetes)
	Cumulative Events (%)				Unadjusted			Adjusted^c
Outcomes	Group A1+A2 Normoglycemia (n = 1749)	Group B1+B2 Prediabetes (n = 2103)	Log-rank		HR (95% CI)		p value	HR (95% CI)	p value
MACEs	98 (6.0)	152 (7.6)	0.068		1.265 (0.982 – 1.631)		0.069	1.402 (1.069 – 1.839)	0.010
All-cause death	39 (2.3)	72 (3.5)	0.034		1.517 (1.028 – 2.241)		0.036	1.530 (1.009 – 2.319)	0.035
Cardiac death	29 (1.7)	57 (2.8)	0.032		1.623 (1.038 – 2.539)		0.034	1.630 (1.011 – 2.628)	0.032
Re-MI	22 (1.4)	36 (1.9)	0.298		1.324 (0.779 – 2.251)		0.299	1.577 (0.892 – 2.791)	0.117
Any revascularization	45 (2.9)	64 (3.4)	0.479		1.148 (0.784 – 1.680)		0.479	1.376 (0.913 – 2.075)	0.127
	Cumulative Events (%)				Unadjusted			Adjusted^c
Outcomes	Group A1+A2 Normoglycemia (n = 1749)	Group C1+C2 T2DM (n = 2596)	Log-rank		HR (95% CI)		p value	HR (95% CI)	p value
MACEs	98 (6.0)	246 (10.1)	<0.001		1.668 (1.320 – 2.109)		<0.001	1.716 (1.332 – 2.211)	<0.001
All-cause death	39 (2.3)	117 (4.7)	<0.001		2.002 (1.393 – 2.877)		<0.001	1.879 (1.265 – 2.791)	0.002
Cardiac death	29 (1.7)	96 (3.8)	<0.001		2.214 (1.462 – 3.354)		<0.001	2.117 (1.345 – 3.333)	0.001
Re-MI	22 (1.4)	63 (2.5)	0.009		1.887 (1.161 – 3.066)		0.010	1.577 (0.892 – 2.791)	0.117
Any revascularization	45 (2.9)	96 (4.2)	0.059		1.405 (0.986 – 2.002)		0.060	1.597 (1.087 – 2.348)	0.017
	Cumulative Events (%)				Unadjusted			Adjusted^c
Outcomes	Group B1+B2 Prediabetes (n = 2103)	Group C1+C2 T2DM (n = 2596)	Log-rank		HR (95% CI)		p value	HR (95% CI)	p value
MACEs	152 (7.6)	246 (10.1)	0.006		1.324 (1.081 – 1.620)		0.007	1.277 (1.029 – 1.584)	0.026
All-cause death	72 (3.5)	117 (4.7)	0.060		1.323 (0.987 – 1.775)		0.061	1.286 (0.937 – 1.765)	0.120
Cardiac death	57 (2.8)	96 (3.8)	0.058		1.370 (0.979 – 1.902)		0.060	1.341 (0.843 – 1.908)	0.102
Re-MI	36 (1.9)	63 (2.5)	0.083		1.433 (0.952 – 2.159)		0.085	1.335 (0.870 – 2.048)	0.186
Any revascularization	64 (3.4)	96 (4.2)	0.199		1.230 (0.896 – 1.687)		0.200	1.196 (0.854 – 1.674)	0.298
Total population (Pre-PCI TIMI 0/1 vs. Pre-PCI TIMI 2/3)
	Cumulative Events (%)				Unadjusted			Adjusted^d
Outcomes	Group A1+B1+C1 TIMI 0/1 (n = 4854)	Group A2+B2+C2 TIMI 2/3 (n = 1594)		Log-rank	HR (95% CI)		p value	HR (95% CI)	p value
MACEs	381 (8.3)	115 (7.8)		0.336	1.108 (0.899 – 1.365)		0.336	1.380 (1.073 – 1.775)	0.012
All-cause death	181 (3.9)	47 (3.1)		0.133	1.277 (0.927 – 1.761)		0.135	1.602 (1.092 – 2.350)	0.016
Cardiac death	150 (3.2)	32 (2.1)		0.023	1.552 (1.060 – 2.273)		0.024	1.993 (1.262 – 3.149)	0.003
Re-MI	95 (2.2)	26 (1.9)		0.361	1.223 (0.793 – 1.888)		0.362	1.717 (1.030 – 2.860)	0.038
Any revascularization	146 (3.4)	59 (4.2)		0.224	1.206 (0.891 – 1.632)		0.224	1.043 (0.719 – 1.512)	0.826

T2DM type 2 diabetes mellitus, HR hazard ratio, CI confidence interval, MACEs major adverse cardiac events, Re-MI recurrent myocardial infarction, BMI body mass index, CVA cerebrovascular accident, CK-MB creatine kinase myocardial band, Hb hemoglobin, HDL high-density lipoprotein, LDL low-density lipoprotein, IRA infarct-related artery, LAD left anterior descending coronary artery, RCA right coronary artery, PCI percutaneous coronary intervention, LVEF left ventricular ejection fraction, NT-ProBNP N-terminal pro-brain natriuretic peptide, ACEIs angiotensin-converting enzyme inhibitors, ARBs angiotensin receptor blockers, ACC/AHA American College of Cardiology/American Heart Association, IVUS intravascular ultrasound, DESs drug-eluting stents.

^aAdjusted by male sex, age, BMI, hypertension, dyslipidemia, previous CVA, current smokers, peak CK-MB, total cholesterol, triglyceride, HDL-cholesterol, LDL-cholesterol, clopidogrel, lipid lowering agents, IRA (LAD and RCA), treated vessel (RCA), one-vessel disease, ≥ three-vessel disease, and culprit-only PCI.

^bAdjusted by male sex, age, LVEF, hypertension, total cholesterol, HDL-cholesterol, LDL-cholesterol, ACEIs, one-vessel disease, ≥ three-vessel disease, stent diameter, and number of stent.

^cAdjusted by male sex, age, LVEF, BMI, hypertension, dyslipidemia, previous PCI and CVA, peak CK-MB, total cholesterol, triglyceride, HDL-cholesterol, LDL-cholesterol, clopidogrel, ticagrelor, cilostazole, ACEIs, ARBs, lipid lowering agents, IRA (LAD and RCA), treated vessel (RCA), one-vessel disease, ≥ three-vessel disease, culprit-only PCI, stent diameter, and number of stent.

^dAdjusted by age, BMI, peak CK-MB, peak Troponin-I, ARBs, CCBs, IRA (left main, LAD and RCA), treated vessel (left main, LAD, and RCA), ≥ three-vessel disease, ACC/AHA type B1, B2, and C lesion, IVUS, other DESs, stent length, and number of stent.

Table 3A Independent predictors for all-cause death and any revascularization in pre-PCI TIMI grade 0/1 group at 2 years.

	All-cause death				Any revascularization
	Univariate		multivariate		Univariate		multivariate
Variables	HR (95% CI)	p value	HR (95% CI)	p value	HR (95% CI)	p value	HR (95% CI)	p value
Group A1 vs. Group B1	1.658 (1.058 – 2.600)	0.028	1.632 (1.024 – 2.543)	0.042	1.037 (0.669 – 1.608)	0.869	1.032 (0.663 – 1.606)	0.890
Group A1 vs. Group C1	2.259 (1.481 – 3.445)	<0.001	1.983 (1.232 – 3.024)	0.009	1.189 (0.791 – 1.787)	0.404	1.244 (0.805 – 1.861)	0.345
Group B1 vs. Group C1	1.365 (0.985 – 1.890)	0.061	1.116 (0.798 – 1.562)	0.521	1.244 (0.850 – 1.819)	0.261	1.187 (0.805 – 1.749)	0.387
Age (≥ 65 years)	3.282 (2.391 – 4.505)	<0.001	2.333 (1.651 – 3.296)	<0.001	1.067 (0.765 – 1.487)	0.704	1.248 (0.866 – 1.799)	0.234
Male	1.888 (1.392 – 2.560)	<0.001	1.106 (0.798 – 1.535)	0.545	1.127 (0.848 – 1.776)	0.278	1.237 (0.825 – 1.855)	0.303
LVEF (< 40%)	4.404 (3.276 – 5.920)	<0.001	2.897 (2.097 – 4.002)	<0.001	1.374 (0.805 – 2.344)	0.244	1.443 (0.836 – 2.491)	0.188
Hypertension	1.740 (1.293 – 2.341)	<0.001	1.244 (0.894 – 1.676)	0.207	1.233 (0.884 – 1.692)	0.223	1.197 (0.853 – 1.679)	0.299
Dyslipidemia	1.628 (1.100 – 2.408)	0.015	1.842 (1.236 – 2.744)	0.003	1.480 (0.800 – 2.736)	0.212	1.528 (0.823 – 2.836)	0.179
LAD (IRA)	1.252 (0.934 – 1.679)	0.133	1.098 (0.802 – 1.503)	0.560	1.087 (0.786 – 1.505)	0.613	1.057 (0.755 – 1.481)	0.745
Lipid-lowering agents	7.691 (5.747 – 10.29)	<0.001	5.974 (4.403 – 8.106)	<0.001	1.265 (0.715 – 2.235)	0.419	1.219 (0.687 – 2.165)	0.498
≥ three-vessel disease	1.963 (1.414 – 2.724)	<0.001	1.426 (1.015 – 2.005)	0.041	1.997 (1.388 – 2.872)	<0.001	1.946 (1.339 – 2.828)	<0.001
Culprit-only PCI	1.244 (0.922 – 1.678)	0.153	1.264 (0.929 – 1.721)	0.136	1.957 (1.374 – 2.788)	<0.001	1.787 (1.251 – 2.553)	0.001
Stent diameter < 3.0mm	1.305 (0.946 – 1.800)	0.105	1.134 (0.808 – 1.592)	0.468	1.111 (0.765 – 1.612)	0.582	1.036 (0.709 – 1.514)	0.854
Stent length ≥ 28mm	1.549 (1.154 – 2.079)	0.004	1.391 (1.033 – 1.873)	0.030	1.082 (0.780 – 1.500)	0.636	1.007 (0.724 – 1.400)	0.969

Group A1, normoglycemia; Group B1, prediabetes; Group C1, T2DM

HR hazard ratio, CI confidence interval, LVEF left ventricular ejection fraction, LAD left anterior descending artery, IRA infarct-related artery, PCI percutaneous coronary intervention, T2DM type 2 diabetes mellitus.

Table 3B Independent predictors for all-cause death and any revascularization in pre-PCI TIMI grade 2/3 group at 2 years.

	All-cause death				Any revascularization
	Univariate		multivariate		Univariate		multivariate
Variables	HR (95% CI)	p value	HR (95% CI)	p value	HR (95% CI)	p value	HR (95% CI)	p value
Group A2 vs. Group B2	1.113 (0.498 – 2.483)	0.795	1.321 (0.555 – 3.142)	0.529	1.987 (0.899 – 4.392)	0.090	2.312 (1.173 – 5.400)	0.021
Group A2 vs. Group C2	1.365 (0.666 – 2.801)	0.396	1.037 (0.474 – 2.268)	0.928	2.273 (1.082 – 4.775)	0.028	2.867 (1.357 – 6.068)	0.004
Group B2 vs. Group C2	1.230 (0.623 – 2.428)	0.551	1.192 (0.583 – 2.433)	0.631	1.146 (0.647 – 2.028)	0.641	1.072 (0.590 – 1.948)	0.819
Age (≥ 65 years)	2.527 (1.369 – 4.667)	0.003	1.446 (0.709 – 2.950)	0.311	1.249 (0.743 – 2.100)	0.402	1.364 (0.757 – 2.456)	0.301
Male	1.948 (1.082 – 3.507)	0.026	1.565 (0.807 – 3.032)	0.185	1.137 (0.614 – 2.105)	0.682	1.059 (0.541 – 2.073)	0.867
LVEF (< 40%)	6.548 (3.696 – 11.60)	<0.001	5.049 (2.651 – 9.616)	<0.001	1.804 (0.957 – 3.401)	0.068	1.386 (0.688 – 2.791)	0.361
Hypertension	1.469 (0.824 – 2.620)	0.192	1.083 (0.592 – 1.984)	0.795	1.097 (0.658 – 1.831)	0.722	1.293 (0.752 – 2.225)	0.353
Dyslipidemia	1.108 (0.439 – 2.802)	0.828	1.078 (0.417 – 2.783)	0.877	2.107 (1.138 – 3.900)	0.018	1.633 (0.836 – 3.193)	0.151
LAD (IRA)	1.109 (0.622 – 1.978)	0.725	1.816 (0.975 – 3.382)	0.060	1.110 (0.662 – 1.860)	0.692	1.039 (0.599 – 1.805)	0.891
Lipid-lowering agents	7.443 (4.200 – 13.19)	<0.001	5.560 (3.038 – 10.18)	<0.001	1.835 (0.973 – 3.460)	0.061	1.586 (0.809 – 3.108)	0.179
≥ Three-vessel disease	1.702 (0.911 – 3.180)	0.095	1.147 (0.588 – 2.235)	0.687	2.583 (1.531 – 4.359)	<0.001	2.140 (1.205 – 3.801)	0.009
Culprit-only PCI	2.743 (1.447 – 5.199)	0.002	2.542 (1.330 – 4.858)	0.005	1.682 (1.074 – 2.528)	0.048	1.921 (1.151 – 3.553)	0.010
Stent diameter < 3.0mm	1.574 (0.861 – 2.878)	0.140	1.016 (0.537 – 1.921)	0.962	1.839 (1.085 – 3.117)	0.024	1.743 (1.007 – 3.018)	0.032
Stent length ≥ 28mm	1.468 (0.823 – 2.618)	0.194	1.269 (0.692 – 2.327)	0.441	1.862 (1.107 – 3.132)	0.019	1.687 (0.991 – 2.873)	0.048

Group A2, normoglycemia; Group B2, prediabetes; Group C2, T2DM

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Impact of Pre-percutaneous Coronary Intervention Thrombolysis in Myocardial Infarction Flow Grade in Patients With ST-segment Elevation Myocardial Infarction and Prediabetes or Diabetes After Successful Newer-generation Drug-eluting Stent Implantation

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