Impact of Metabolic Syndrome and Diabetes on Prognosis and Outcomes With Early Percutaneous Coronary Intervention in the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) Trial

doi:10.1016/j.jacc.2011.02.046

Journal of the American College of Cardiology

Volume 58, Issue 2, 5 July 2011, Pages 131-137

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Objectives

Our purpose was to clarify the clinical utility of identifying metabolic syndrome (MetS) in patients with coronary artery disease (CAD).

Background

It is uncertain whether MetS influences prognosis in patients with CAD and whether the risk associated with MetS exceeds the risk associated with the sum of its individual components.

Methods

In a post hoc analysis, we compared the incidence of death or myocardial infarction (MI) in stable CAD patients in the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial according to the presence (+) or absence (−) of MetS and diabetes: Group A, −MetS/−diabetes; Group B, +MetS/−diabetes; Group C, −MetS/+diabetes; and Group D, +MetS/+diabetes. We explored which MetS components best predicted adverse outcomes and whether MetS had independent prognostic significance beyond its individual components.

Results

Of 2,248 patients, 61% had MetS and 34% diabetes. Risk for death or MI increased from Group A (14%) to Group D (25%, p < 0.001). Hypertension (hazard ratio [HR]: 1.30; 95% confidence interval [CI]: 0.98 to 1.71; p = 0.07), low high-density lipoprotein cholesterol (HR: 1.26; 95% CI: 1.03 to 1.55; p = 0.03), and elevated glucose (HR: 1.17; 95% CI: 0.96 to 1.47; p = 0.11) most strongly predicted death or MI. MetS was associated with an increased risk of death or MI (unadjusted HR: 1.41; 95% CI: 1.15 to 1.73; p = 0.001). However, after adjusting for its individual components, MetS was no longer significantly associated with outcome (HR: 1.15; 95% CI: 0.79 to 1.68; p = 0.46). Allocation to initial percutaneous coronary intervention did not affect the incidence of death or MI within any group.

Conclusions

Among stable CAD patients in the COURAGE trial, the presence of MetS identified increased risk for death or MI, but MetS did not have independent prognostic significance after adjusting for its constituent components. The addition of early percutaneous coronary intervention to optimal medical therapy did not significantly reduce the risk of death or MI regardless of MetS or diabetes status. (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation [COURAGE]; NCT00007657)

Key Words

coronary disease

diabetes

medical therapy

metabolic syndrome

percutaneous coronary intervention

Abbreviations and Acronyms

BMI

body mass index

CAD

coronary artery disease

confidence interval

HDL

high-density lipoprotein

hazard ratio

MetS

metabolic syndrome

myocardial infarction

NCEP

National Cholesterol Education Program

OMT

optimal medical therapy

PCI

percutaneous coronary intervention

Cited by (0)

: Dr. O'Rourke is deceased. Supported by the Cooperative Studies Program of the U.S. Department of Veterans Affairs Office of Research and Development, in collaboration with the Canadian Institutes of Health Research; and by unrestricted research grants from Merck, Pfizer, Bristol-Myers Squibb, Fujisawa, Kos Pharmaceuticals, Datascope, AstraZeneca, Key Pharmaceutical, sanofi-aventis, First Horizon, and GE Healthcare, including in-kind support with FDA-approved drugs used by study participants. All industrial funding in support of the trial was directed through the U.S. Department of Veterans Affairs. Dr. Spertus has received grant support from Amgen, Bristol-Myers Squibb, sanofi-aventis, Eli Lilly, Johnson & Johnson, and Evaheart Medical; and has copyright ownership of the Seattle Angina Questionnaire. Dr. Mancini has received consulting fees from Merck, AstraZeneca, and Abbott; grant support from Merck (<$60,000); and honoraria from Merck, Pfizer, and AstraZeneca (<$10,000). Dr. Chaitman has received consulting fees from Pfizer, Merck, and Lilly. All other authors have reported that they have no relationships to disclose. A full list of COURAGE Study Group members can be found in Boden et al. (8).