we included all consecutive patients > 18 years of age admitted for st - segment elevation mi ( stemi ) or non  st - segment elevation mi ( nstemi ) to the intensive coronary care unit ( iccu ) of the thoraxcenter between june 1985 and december 2008 ( 12 ) . the primary discharge diagnosis of mi was made in the presence of the following characteristics : chest pain or equivalent symptoms in combination with dynamic electrocardiogram changes consistent with mi and a typical serial rise ( to at least three times the upper normal value ) and fall in serum biochemical markers of cardiac necrosis such as creatine kinase - muscle brain type or troponin - t ( as of 2002 ) . patients were diagnosed as stemi in the presence of st - segment elevation > 0.1 mv in at least two contiguous peripheral leads on the electrocardiogram , or > 0.2 mv in at least two contiguous precordial leads on the electrocardiogram , and as nstemi otherwise . for patients admitted more than once , only the first hospitalization was taken into account . diabetes was defined as previously diagnosed by a physician or as receiving medication to lower glucose levels . trained physicians and nurses accustomed to the use of standardized case report forms collected the data . demographic characteristics ( age and sex ) , cardiac history ( previous mi , pci , or coronary artery bypass surgery [ cabg ] ) , risk factors ( hypertension , family history , and smoking status ) , anemia ( hemoglobin level < 13.0 g / dl in men and < 12.0 g / dl in women ) , renal dysfunction ( creatinine > 150 mol / l ) , and pharmacological and invasive treatment modalities ( thrombolysis and pci ) were collected . hypertension was defined as previously diagnosed by a physician or receiving medication to lower blood pressure . family history was defined as one or more relatives ( parent or sibling ) with an mi diagnosed before the age of 60 years . survival status and date were assessed through municipal civil registries in 2010 and were available for 99% of all patients . register - based studies are approved by the ethical committee of the erasmus medical center and do not require informed consent according to dutch laws ( medical research including human species act ) . patients were stratified into three groups according to the year of hospitalization : 19851989 , 19901999 , and 20002008 . these strata were chosen according to important improvements in therapy , with complete introduction of thrombolytic therapy in 1990 and a substantial increase in the use of primary pci since 2000 . we assessed temporal mortality trends by comparing one - minus - survival curves that were constructed using the kaplan - meier method . we examined the independent association between decade of hospitalization and mortality according to diabetes status , using logistic regression for 30-day outcome and the cox proportional hazards model for long - term outcome . adjustment was performed for age , sex , previous mi , previous cabg , hypertension , dyslipidemia , family history , smoking status , renal dysfunction , anemia , and discharge diagnosis . results are reported as odds ratios ( for 30-day mortality ) and hazard ratios ( hrs ) ( for long - term mortality ) and their respective 95% cis . for all analyses that compared decades of hospitalization , we analyzed up to 10 years of follow - up , because longer follow - up is unavailable for patients hospitalized in the last decade ( 20002008 ) . interaction between diabetes status and study period and mortality was assessed using multivariable regression models . all statistical tests were two tailed , and p values were considered significant at < 0.05 . analysis was performed using spss software version 17.0 ( spss , chicago , il ) . diabetes was defined as previously diagnosed by a physician or as receiving medication to lower glucose levels . trained physicians and nurses accustomed to the use of standardized case report forms demographic characteristics ( age and sex ) , cardiac history ( previous mi , pci , or coronary artery bypass surgery [ cabg ] ) , risk factors ( hypertension , family history , and smoking status ) , anemia ( hemoglobin level < 13.0 g / dl in men and < 12.0 g / dl in women ) , renal dysfunction ( creatinine > 150 mol / l ) , and pharmacological and invasive treatment modalities ( thrombolysis and pci ) were collected . hypertension was defined as previously diagnosed by a physician or receiving medication to lower blood pressure . family history was defined as one or more relatives ( parent or sibling ) with an mi diagnosed before the age of 60 years . survival status and date were assessed through municipal civil registries in 2010 and were available for 99% of all patients . register - based studies are approved by the ethical committee of the erasmus medical center and do not require informed consent according to dutch laws ( medical research including human species act ) . patients were stratified into three groups according to the year of hospitalization : 19851989 , 19901999 , and 20002008 . these strata were chosen according to important improvements in therapy , with complete introduction of thrombolytic therapy in 1990 and a substantial increase in the use of primary pci since 2000 . we assessed temporal mortality trends by comparing one - minus - survival curves that were constructed using the kaplan - meier method . we examined the independent association between decade of hospitalization and mortality according to diabetes status , using logistic regression for 30-day outcome and the cox proportional hazards model for long - term outcome . adjustment was performed for age , sex , previous mi , previous cabg , hypertension , dyslipidemia , family history , smoking status , renal dysfunction , anemia , and discharge diagnosis . results are reported as odds ratios ( for 30-day mortality ) and hazard ratios ( hrs ) ( for long - term mortality ) and their respective 95% cis . for all analyses that compared decades of hospitalization , we analyzed up to 10 years of follow - up , because longer follow - up is unavailable for patients hospitalized in the last decade ( 20002008 ) . interaction between diabetes status and study period and mortality was assessed using multivariable regression models . all statistical tests were two tailed , and p values were considered significant at < 0.05 . analysis was performed using spss software version 17.0 ( spss , chicago , il ) . we included 14,434 patients , of whom 2,015 ( 14% ) had prevalent diabetes . for each calendar year , the relative risk of presenting with diabetes increased by 5% , from a prevalence of 8% in the 1980s to 17% in the last decade . the distribution of risk factors at baseline varied according to diabetes status and according to decade of admission ( table 1 ) . patients with diabetes were older and more often female , and more often had a history of previous mi , hypertension , dyslipidemia , anemia , and renal impairment . patients with diabetes were less often current smokers and more often had a discharge diagnosis of nstemi . baseline characteristics and clinical presentation of patients hospitalized for mi according to diabetes status the medical care provided to mi patients with and without diabetes was comparable , with no clinically relevant sex differences . the use of reperfusion therapy ( either by thrombolytic therapy or pci ) increased over time in both groups with stemi ( p < 0.001 ) , and stemi patients with diabetes were equally likely to receive primary pci as those without diabetes . prescription of evidence - based medical care ( class 1a ) , including aspirin , -blockers , statins , and ace inhibitors / angiotensin - receptor blockers ( arbs ) , also increased over time in both groups . overall , patients with diabetes were more likely to receive ace inhibitors / arbs and less likely to receive aspirin and -blockers . other medical therapies with a lower level of evidence for the treatment of mi , including calcium antagonists , were prescribed at equal rates in both study groups ( table 1 ) . , a total of 663 patients with and 3,285 patients without baseline diabetes had died . the unadjusted risk of 30-day mortality decreased between 1985 and 2008 , both in the diabetes group , from 17% in 19851989 to 5% in 20002008 , and in the nondiabetes group , from 10% in 19851989 to 4% in 20002008 ( fig . 1 ) . also , unadjusted 10-year mortality decreased between 1985 and 2008 , both in the diabetes group , from 53% in 19851989 to 39% in 20002008 , and in the nondiabetes group , from 38% in 19851989 to 29% in 20002008 . patients with diabetes benefitted from a higher 30-day and long - term absolute survival increase ( fig . kaplan - meier curves of mortality according to a decade of hospitalization in patients with and without diabetes . from 1985 to 2008 , the adjusted risk of 30-day mortality decreased by 80% , both in the diabetes group ( adjusted odds ratio 0.17 [ 95% ci 0.100.30 ] ) and in the nondiabetes group ( 0.29 [ 0.240.37 ] ) ( table 2 ) . the risk of 10-year mortality decreased by 40% , both in the diabetes group ( adjusted hr 0.56 [ 95% ci 0.430.73 ] ) and in the nondiabetes group ( 0.66 [ 0.600.73 ] ) ( table 2 ) . there was no significant interaction between diabetes status and study period ( p = 0.39 and p = 0.83 for interaction for 30-day and 10-year mortality , respectively ) . hence , the relative risk reductions in 30-day and long - term mortality over the 24-year study period were at least as high for mi patients with diabetes compared with those without . temporal trends in 30-day and 10-year mortality in mi patients as expected , the risk of mortality was higher in mi patients with prevalent diabetes . the increased mortality risk persisted up to the 20-year follow - up ( fig . patients with diabetes had a median survival of 11 years compared with 15 years for those without . patients in the diabetes group had a 50% increased adjusted long - term mortality risk in all three decades studied ( adjusted hr for 10-year mortality = 1.5 , 1.5 , and 1.4 in 19851989 , 19901999 , and 20002008 , respectively ; p < 0.001 for all ) . we included 14,434 patients , of whom 2,015 ( 14% ) had prevalent diabetes . for each calendar year , the relative risk of presenting with diabetes increased by 5% , from a prevalence of 8% in the 1980s to 17% in the last decade . the distribution of risk factors at baseline varied according to diabetes status and according to decade of admission ( table 1 ) . patients with diabetes were older and more often female , and more often had a history of previous mi , hypertension , dyslipidemia , anemia , and renal impairment . patients with diabetes were less often current smokers and more often had a discharge diagnosis of nstemi . the medical care provided to mi patients with and without diabetes was comparable , with no clinically relevant sex differences . the use of reperfusion therapy ( either by thrombolytic therapy or pci ) increased over time in both groups with stemi ( p < 0.001 ) , and stemi patients with diabetes were equally likely to receive primary pci as those without diabetes . prescription of evidence - based medical care ( class 1a ) , including aspirin , -blockers , statins , and ace inhibitors / angiotensin - receptor blockers ( arbs ) , also increased over time in both groups . overall , patients with diabetes were more likely to receive ace inhibitors / arbs and less likely to receive aspirin and -blockers . other medical therapies with a lower level of evidence for the treatment of mi , including calcium antagonists , were prescribed at equal rates in both study groups ( table 1 ) . a total of 106,517 person - years were analyzed . at 10-year follow - up , a total of 663 patients with and 3,285 patients without baseline diabetes had died . the unadjusted risk of 30-day mortality decreased between 1985 and 2008 , both in the diabetes group , from 17% in 19851989 to 5% in 20002008 , and in the nondiabetes group , from 10% in 19851989 to 4% in 20002008 ( fig . 1 ) . also , unadjusted 10-year mortality decreased between 1985 and 2008 , both in the diabetes group , from 53% in 19851989 to 39% in 20002008 , and in the nondiabetes group , from 38% in 19851989 to 29% in 20002008 . patients with diabetes benefitted from a higher 30-day and long - term absolute survival increase ( fig . kaplan - meier curves of mortality according to a decade of hospitalization in patients with and without diabetes . from 1985 to 2008 , the adjusted risk of 30-day mortality decreased by 80% , both in the diabetes group ( adjusted odds ratio 0.17 [ 95% ci 0.100.30 ] ) and in the nondiabetes group ( 0.29 [ 0.240.37 ] ) ( table 2 ) . the risk of 10-year mortality decreased by 40% , both in the diabetes group ( adjusted hr 0.56 [ 95% ci 0.430.73 ] ) and in the nondiabetes group ( 0.66 [ 0.600.73 ] ) ( table 2 ) . there was no significant interaction between diabetes status and study period ( p = 0.39 and p = 0.83 for interaction for 30-day and 10-year mortality , respectively ) . hence , the relative risk reductions in 30-day and long - term mortality over the 24-year study period were at least as high for mi patients with diabetes compared with those without . as expected , the risk of mortality was higher in mi patients with prevalent diabetes . the increased mortality risk persisted up to the 20-year follow - up ( fig . patients with diabetes had a median survival of 11 years compared with 15 years for those without . patients in the diabetes group had a 50% increased adjusted long - term mortality risk in all three decades studied ( adjusted hr for 10-year mortality = 1.5 , 1.5 , and 1.4 in 19851989 , 19901999 , and 20002008 , respectively ; p < 0.001 for all ) . in this study comprising a cohort of 14,434 patients with acute mi , studied over a period of 24 years , we showed that there is an increasing prevalence of diabetes in patients with an acute mi . more important , we showed that the temporal reductions in all - cause mortality in patients suffering acute mi , achieved between 1985 and 2008 , were at least as high in patients with diabetes as in those without diabetes . this improvement in outcome is most likely related to the fact that during the study period , the use of mi - related medical care improved significantly both for patients with and without diabetes . indeed , in the most recent decade , diabetes was no longer associated with underuse of treatment . finally , we demonstrated that the increased mortality risk associated with diabetes persisted for up to 20 years of follow - up . a previous study ( 13 ) demonstrated the increasing burden of diabetes in relation to cardiovascular disease mortality in the general population . relatively few studies have evaluated temporal trends in ( long - term ) mortality of mi patients with and without diabetes ( 9,11,14 ) . moreover , the results of these studies were inconsistent . two studies ( 11,14 ) show temporal mortality reductions in patients with and without diabetes , whereas one study ( 9 ) concludes that patients with diabetes do not benefit from a reduction in long - term post - mi mortality over time . the awareness of the higher cardiovascular risk associated with diabetes has probably intensified cardioprotective treatment in these patients over time . we and others ( 9,10,15 ) showed that from 1985 to 1999 , the use of thrombolytic therapy and -blockers was lower in patients with diabetes compared with those without . studies ( 15,16 ) have shown the effectiveness of these therapies in patients with diabetes . it is therefore encouraging to observe that these inequalities in medical care are no longer present in the last decade of observation . further , our data showed that in the last decade , 40% of diabetic patients were treated with ace inhibitors / arbs at iccu discharge ( a median of 12 days after admission ) , a percentage higher than that for nondiabetic patients . ace inhibitors / arbs slow myocardial remodeling and the progression of diabetic nephropathy ( 17 ) . diabetic patients received diuretics more often compared with nondiabetic patients probably due to the higher risk profile in diabetic patients , with more frequent hypertension and heart failure ( 9 ) . we found a reduction in both 30-day and long - term mortality rates over time for mi patients with and without diabetes . patients with diabetes benefitted from a higher 30-day and long - term absolute mortality reduction . the relative morality reductions were statistically equal for patients with and without diabetes , which is consistent with another study reporting on patients hospitalized with an mi between 1979 and 1998 ( 11 ) . furthermore , other studies in the general population have shown that mortality from coronary heart disease has decreased over the past decades , and some of these studies speculated that patients with diabetes have also benefited from this reduction ( 1820 ) . the temporal mortality reduction observed in the current study may be a result of several factors , including improved treatment in the acute phase of mi and increased long - term survival resulting from aggressive secondary prevention ( 1,4,5,7,8,21 ) . although patients with diabetes benefitted at least equally from improved mortality rates over the last 25 years , their absolute long - term mortality remained 1.5-fold higher compared with patients without diabetes . therefore , optimal medical care for diabetes patients and awareness of their high - risk profile remains warranted and may even further improve outcomes in these patients in the future . to our knowledge , this is the first article investigating temporal trends in clinical characteristics and treatment and outcome of mi patients with diabetes over a time period of 24 years and with follow - up data of up to 20 years . although this could result in a lower external validity , we think that this is unlikely to be the case given the uniform definition and therapeutic modalities of mi . also , our definition of diabetes did not include patients who were diagnosed on the basis of glucose values during hospitalization for acute mi only . therefore , the real prevalence of diabetes might have been underestimated ; alternatively , our definition is not biased by altered glucose levels resulting from the acute event ( 22 ) and allows for better comparison of our results with previous studies . last , given the nature of diabetes , this study reveals important associations but can not prove causation . in conclusion , we show that there is an increasing prevalence of diabetes in patients with an mi . medical care improved substantially for mi patients both with and without diabetes during the 24 years of observation . in the most recent decade , diabetes was not associated with underuse of evidence - based therapies , including primary pci for stemi . in the study period , outcome improved and temporal mortality reductions were at least as high in patients with diabetes compared with those without diabetes . however , the absolute long - term mortality rate remained about 1.5-fold higher in patients with diabetes compared with those without . therefore , optimal medical care for diabetes patients and awareness of their high - risk profile remains warranted . the awareness of the higher cardiovascular risk associated with diabetes has probably intensified cardioprotective treatment in these patients over time . we and others ( 9,10,15 ) showed that from 1985 to 1999 , the use of thrombolytic therapy and -blockers was lower in patients with diabetes compared with those without . studies ( 15,16 ) have shown the effectiveness of these therapies in patients with diabetes . it is therefore encouraging to observe that these inequalities in medical care are no longer present in the last decade of observation . further , our data showed that in the last decade , 40% of diabetic patients were treated with ace inhibitors / arbs at iccu discharge ( a median of 12 days after admission ) , a percentage higher than that for nondiabetic patients . ace inhibitors / arbs slow myocardial remodeling and the progression of diabetic nephropathy ( 17 ) . diabetic patients received diuretics more often compared with nondiabetic patients probably due to the higher risk profile in diabetic patients , with more frequent hypertension and heart failure ( 9 ) . we found a reduction in both 30-day and long - term mortality rates over time for mi patients with and without diabetes . patients with diabetes benefitted from a higher 30-day and long - term absolute mortality reduction . the relative morality reductions were statistically equal for patients with and without diabetes , which is consistent with another study reporting on patients hospitalized with an mi between 1979 and 1998 ( 11 ) . furthermore , other studies in the general population have shown that mortality from coronary heart disease has decreased over the past decades , and some of these studies speculated that patients with diabetes have also benefited from this reduction ( 1820 ) . the temporal mortality reduction observed in the current study may be a result of several factors , including improved treatment in the acute phase of mi and increased long - term survival resulting from aggressive secondary prevention ( 1,4,5,7,8,21 ) . although patients with diabetes benefitted at least equally from improved mortality rates over the last 25 years , their absolute long - term mortality remained 1.5-fold higher compared with patients without diabetes . therefore , optimal medical care for diabetes patients and awareness of their high - risk profile remains warranted and may even further improve outcomes in these patients in the future . to our knowledge , this is the first article investigating temporal trends in clinical characteristics and treatment and outcome of mi patients with diabetes over a time period of 24 years and with follow - up data of up to 20 years . although this could result in a lower external validity , we think that this is unlikely to be the case given the uniform definition and therapeutic modalities of mi . also , our definition of diabetes did not include patients who were diagnosed on the basis of glucose values during hospitalization for acute mi only . therefore , the real prevalence of diabetes might have been underestimated ; alternatively , our definition is not biased by altered glucose levels resulting from the acute event ( 22 ) and allows for better comparison of our results with previous studies . last , given the nature of diabetes , this study reveals important associations but can not prove causation . in conclusion , we show that there is an increasing prevalence of diabetes in patients with an mi . medical care improved substantially for mi patients both with and without diabetes during the 24 years of observation . in the most recent decade , diabetes was not associated with underuse of evidence - based therapies , including primary pci for stemi . in the study period , outcome improved and temporal mortality reductions were at least as high in patients with diabetes compared with those without diabetes . however , the absolute long - term mortality rate remained about 1.5-fold higher in patients with diabetes compared with those without . therefore , optimal medical care for diabetes patients and awareness of their high - risk profile remains warranted .
objectiveto study temporal trends in short- and long - term outcome after myocardial infarction ( mi ) according to diabetes status.research design and methodswe included all 14,434 consecutive patients admitted for st - segment elevation mi or non 
 st - segment elevation mi at our center between 1985 and 2008 . 
 the study patients were compared according to prevalent diabetes . 
 temporal trend analyses were performed by comparing decades of admission ( 19851989 vs. 19901999 vs. 20002008).resultsa total of 2,015 ( 14% ) of the patients had prevalent diabetes . 
 the risk of presenting with diabetes increased from 8 to 17% from 1985 to 2008 . 
 diabetic patients presented with a higher prevalence of cardiovascular risk factors . with time , the use of evidence - based therapies increased in both patients with and without diabetes . 
 diabetes is associated with a 1.5-fold increased risk of mortality at the 20-year follow - up . 
 ten - year mortality decreased over time in patients with diabetes , from 53% in 19851989 to 39% in 20002008 ( adjusted hazard ratio 0.56 [ 95% ci 0.430.73 ] ) , and in those without diabetes , from 38% in 19851989 to 29% in 20002008 ( 0.66 [ 0.600.73 ] ; p interaction = 0.83 ) . 
 patients with diabetes benefitted from a higher 30-day and 10-year absolute survival increase.conclusionstemporal mortality reductions after mi between 1985 and 2008 were at least as high in patients with diabetes compared with those without diabetes . 
 however , long - term mortality remained higher in diabetic patients . 
 awareness of the high - risk profile of diabetic patients is warranted and might stimulate optimal medical care and outcome .