A significant worldwide health burden is caused by atherosclerotic vascular illnesses, which include cerebrovascular disease and coronary heart disease. They account for 21.9% of all deaths worldwide and by 20301, it is expected that their share would rise to 26.3%. Data from the International Diabetes Federation (IDF) Diabetes Atlas show that 463 million individuals worldwide—or 9.3% of the adult population—are thought to have diabetes, diabetes for the year 2019. By 2030, this figure is projected to increase to 578 Million, or 10.2% of the adult population; by 20452, it is predicted to reach 10.9%, or 700 Million. Diabetes is the primary cause of blindness, renal failure, CAD, MI, and Amputation, taking the lives of4.2 million people annually. Diabetes affects more people in cities (10.8%) than in rural areas (7.2%), as well as in high- and low-income countries (10.4% and 4%, respectively), and by 2045, those percentages will rise to 11.9% and 4.7%. According to estimates, 9.0%of women in 2019 will have diabetes, and 9.6% among males. The increase of diabetes prevalence with age leads to a Prevalence of 19.9% (111.2million) in people aged 65-79years. Although diabetes is a major economic burden on all countries, less developed countries are affected disproportionately, as more than 80% of instances take place there. Diabetes is thought to be a distinct risk factor for coronary artery disease and cardiovascular diseases. Diabetes is regarded as an analogous condition to coronary artery disease according to NCEP ATPIII guidelines3.Diabetes denatures glycation products, which hastens the onset of atherosclerosis by affecting the endothelium. Patients with diabetes have a two to four times higher chance of acquiring coronary artery disease (CAD) and a higher risk of getting vascular problems as compared to non-diabetics.4They have an increased risk of developing vascular problems that impact all of the body's major organs. Cardiovascular illnesses account for approximately 65-75% of fatalities among diabetics and are a major source of morbidity and mortality in this population.5, 6According to the Framingham study, women with diabetes have a 4-5 times risk of cardiovascular death, whereas males have a 2-fold risk. They are the main reason why adult diabetes patients pass away. Those with diabetes are more likely than non-diabetics to have low HDL values. There is a substantial correlation between low HDL levels and an increased risk of CAD.  Peripheral vascular disease, cerebrovascular accidents, and coronary artery disease account for between 75% and 80% of diabetic patient mortality. The four main risk factors for cardiovascular disease in diabetics are obesity, dyslipidaemia, hypertension, and hyperglycemia. Numerous interventional investigations have demonstrated a direct relationship between chronic hyperglycemia and cardiovascular complications7,8. The HbA1c test, which averages blood sugar levels throughout fasting and after meals, is currently used to diagnose chronic hyperglycemia9, 10.. The most frequent cardiac symptom in individuals with diabetes is CAD, which is followed by autonomic cardiovascular neuropathy and dilated cardiomyopathy. Diabetes eliminates a woman's defence against coronary artery disease11.In a population study conducted in the West, women with diabetes died from cardiovascular disease at a rate of 65 percent12.Diabetes was found to raise the risk of death by 57.6% in the OASIS study13 and to increase the risk of death by 58% in males with diabetes in the FINISH study14. The INTERHEARTstudy15 provided additional evidence in favour of the link between diabetes and CAD. In patients with or without diabetes, having elevated blood sugar has been identified as a separate risk factor for death16.A high blood sugar level at admission may indicate impaired glucose tolerance, hyperglycemia brought on by stress, or diabetes. Therefore, it's critical to research the range of clinical manifestations and CAD involvement patterns in both diabetics and non-diabetics. We statistically evaluated coronary artery involvement severity in diabetics, pre-diabetics, and non-diabetics using the GENSINI score17 [Angiographic severity score] in our research. We have examined how the patients' CAD patterns have changed based on their glycaemic condition. This study has studied the quantitative comparison of CAD and its relationship to blood sugar levels and glycaemic state.

This study was undertaken in the Cardiology icu/wards of Shri BM Patil super speciality hospital and research Centre, Vijayapura, Karnataka during the study period between JANUARY 2023to january 2024.During the study period, 335 patients were admitted with acute coronary syndrome and underwent coronary angiography was incorporated into the research. Criteria for Inclusion: Participants in the study were those who received an invasive coronary angiography after being admitted with acute coronary syndrome (STEMI, NSTEMI, and marker-positive unstable angina).Criteria for Exclusion: Individuals with established CAD and recognized ischaemic heart disease. Those suffering from anaemia. Failure of the renal system. More recognised systemic illnesses.Every patient underwent a thorough evaluation based on their symptomatology. Upon admission, routine blood investigations including blood sugar estimation and HbA1c, ECG, and ECHO were performed, along with a thorough physical examination. Based on their HbA1c readings, they were divided into three groups: non-diabetics, diabetics, and pre-diabetics. Based on their hbA1c levels, diabetic individuals were divided into three subgroups: good control (<6.5), suboptimal control (6.5–5.9) and bad control (>9). Patients within the pre-diabetic category were assessed using PPBS and FBS. Every patient received medical stabilisation and, where appropriate, had a coronary angiography. The Gensini score was used to determine the coronary artery disease's angiographic severity. Everyone who was enrolled in the study gave their consent. In accordance with institution policies, ethical clearance was acquired. Statistical analysis was assessed using Mean± standard deviation, Pearson’s correlation coefficient, Chi square test and ANOVA tests using SPSS software. Statistical Analysis The data obtained will be entered in a Microsoft Excel sheet, and statistical analysis will be performed using JMP SAS Software Results will be presented as Mean (Median) ±SD, counts and percentages and diagrams.  For normally distributed continuous variables between three groups will be compared using ANOVA test for not normally distributed variables Kruskal wallies test. Pearson’s correlation/Sperman’s correlation will be used to find the correlation between the Variables. Categorical variables will be compared using Chi square test. p<0.05 will be considered statistically significant. All statistical tests will perform two tailed.

A total of 335 patients who were admitted due to acute coronary syndrome were examined. Out of them, 84 individuals did not have diabetes, 50 had pre-diabetes, and 201 had diabetes. In each of the three categories, men were more affected than women; the non-diabetics had the largest sex ratio (3.14:1), while the diabetics had the lowest ratio (1.64:1). It is clear that, in comparison to pre-diabetics and non-diabetics, female with diabetes had a higher prevalence of CAD. Diabetics' average age at presentation was 60.8±10.5 years, while non-diabetics' was 53.9 years. ±12.2 years, and 61.3 ± 12.9 years in pre-diabetics. The study groups' mean age of presentation did not significantly differ from one another. Most of the patients in all three groups fell within the 56–65 age range. Non-diabetics were more affected than diabetics among patients under 45 years of age. In all three groups, dyspnoea was the most common symptom, followed by chest discomfort. Abdominal pain and giddiness were among the unusual symptoms that were more common in the diabetes group. ST elevation myocardial infarction was the most prevalent kind of ACS in each of the three groups. The percentage of STEMI was higher in the diabetic group (51.5%) than non-diabetic group (48.8%). This could imply subtly that ACS in these populations could be caused by pro-thrombotic pathways. Patients with diabetes had greater rates of unstable angina and NSTEMI. In all three groups, anterior wall myocardial infarction (MI) was the most common kind of STEMI, followed by inferior wall MI. The mean HbA1c values were 5.94±0.23 in pre-diabetic groups and 8.10±1.70 in diabetics. The gensini score has been utilised to assess the degree of coronary artery disease. This provides a more thorough evaluation of CAD and takes into account insignificant lesions. With a mean gensini score of 40.9±33.4, diabetics had a higher severity of CAD than pre-diabetics, who had a mean score of 33.7±26.4. Patients without diabetes exhibited a mean score of 23.8±28.1, indicating a reduced severity of CAD. Our research shows that diabetics had more severe CAD than non-diabetics, which is in line with earlier studies. Diabetics showed higher multivascular involvement. Triple vessel disease was present in only approximately 28% of pre-diabetic and 14.3% of non-diabetic patients, compared to 42.3% of diabetics. Single vessel disease was seen in 40.5% of non-diabetic patients and 30.0% of pre-diabetic patients, but only in 20.9% of diabetic patients. There was also a trend towards single vessel disease among pre-diabetics. Numerous investigations have demonstrated a greater involvement of multivascular disease in diabetes. Gensini score has been used in other investigations with similar results. Out of all the patients with diabetes, 26 develop the disease within a year. It was found that patients with diabetes for a longer period of time had more severe cases of CAD. Patients with diabetes for a longer period of time—greater than six years—had a mean score of 43.6 for more severe CAD. The severity of CAD and the length of diabetes had a positive linear relationship. 

Table1: Angiographic severity of CAD in different groups

The P value is 0.001.

Figure 1: Correlation between glycemic control (HbA1c) and gensini score in Diabetics

Table 2: DURATION OF DIABETES AND GENSINI SCORE IN THE DIABETIC GROUP

p=<0.001

Figure 2: Correlation between duration of diabetes and gensini score in the diabetic group

Table3: Association between glycemic control (HbA1c) and gensini score in Diabetics

 During the study period, 335 patients who were admitted due to acute coronary syndrome were examined. Out of them, 84 individuals did not have diabetes, 50 had pre-diabetes, and 201 had diabetes. The most of the patients were diabetics. Each group's mean age, sex, and lipid levels were compared. anomalies, clinical profile, risk profile, and ACS type. Analysis was done on the relationship between glycaemic state as determined by FBS, PPBS, and HbA1c levels and the severity of CAD as determined by the gensini score. Diabetics made up the majority of our sample, as they have in previous research. . Our study's findings were consistent with the GUSTO-1¹⁸ trial, which found that patients with diabetes were older than non-diabetic patients. In each of the three categories, men were more affected than women; the non-diabetics had the largest sex ratio (3.14:1), while the diabetics had the lowest ratio (1.64:1). It is clear that, in comparison to pre-diabetics and non-diabetics, female with diabetes had a higher prevalence of CAD. In general, premenopausal women are protected against IHD; however, when diabetes is present, this cardio protection is compromised. ST elevation myocardial infarction was the most prevalent kind of ACS in each of the three groups. The percentage of STEMI was higher in the non-diabetic group (48.8%) and diabetic group (51.5%). This could imply subtly that ACS in these populations could be caused by pro-thrombotic pathways. Patients with diabetes had greater rates of unstable angina and NSTEMI. In all three groups, anterior wall myocardial infarction (MI) was the most common kind of STEMI, followed by inferior wall MI. The mean HbA1c values were 5.94±0.23 in pre-diabetic groups and 8.10±1.70 in diabetics. The gensini score has been utilised to assess the degree of coronary artery disease. This provides a more thorough evaluation of CAD and takes into account insignificant lesions. With a mean gensini score of 40.9±33.4, diabetics had a higher severity of CAD than pre-diabetics, who had a mean score of 33.7±26.4. Patients without diabetes exhibited mean score of 23.8±28.1, indicating a reduced severity of CAD. Our research shows that diabetics had more severe CAD than non-diabetics, which is in line with earlier studies. Diabetics showed higher multivascular involvement. Triple vessel disease was present in only approximately 28% of pre-diabetic and 14.3% of non-diabetic patients, compared to 42.3% of diabetics. Single vessel disease was seen in 40.5% of non-diabetic patients and 30.0% of pre-diabetic patients, but only in 20.9% of diabetic patients. There was also a trend towards single vessel disease among pre-diabetics. Numerous investigations have demonstrated a greater involvement of multivascular disease in diabetes ^{(21, 22). .}Genesini score ^19–21 has been used in other investigations with similar results. Using the gensini score, we were able to quantitatively evaluate the severity of CAD in our investigation. The results of our study indicate a substantial difference in CAD severity between pre-diabetics and non-diabetics. Patients with diabetes have been shown to have more severe cases of CAD after extensive research. Between these groups, there was a statistically significant variation in the severity of CAD. Pre-diabetics had more severe CAD than diabetics, according to Yan et al. ²³. Patients with pre-diabetes are more likely to die as a result of CAD. This is mostly explained by the fact that thrombus development at susceptible plaque sites was the primary cause of ACS in pre-diabetic patients^. Out of all the patients with diabetes, 26 develop the disease within a year. It was found that patients with diabetes for a longer period of time had more severe cases of CAD. Patients with diabetes for a longer period of time—greater than six years—had a mean score of 43.6 for more severe CAD. The severity of CAD and the length of diabetes had a positive linear relationship. There was statistical significance here. [P = <0.001 for the correlation coefficient]. Research by Tahir et al. (²⁴⁾ and Syvanne et al. (²⁵) also discovered a positive linear relationship between the severity of CAD and the length of diabetes. For diabetics with good glycaemic control (HbA1c level<6.5), the mean gensini score was 27.5±27.8.

 
Individuals with poor control (HbA1c>9) and haemoglobin A1c 6.5-8.9 had statistically significant mean42.3±35.9 and 36.8±24.7, respectively, were the gensini scores. There was a positive statistically significant There is a linear link (correlation coefficient: p=<0.01) between the gensini score and the HbA1c levels. The positive linear relationship between Tahir and Ayhan et al. ²⁶ is supported by our data and found a relationship between the severity of CAD in patients with diabetes and their hbA1c levels. At 151±54.1 mg/dl, the mean fasting blood glucose levels were higher in the diabetic group. The The mean postprandial blood sugar levels were higher in the diabetic group (232±81.2). There was a significant positive linear correlation between the gensini and each of the three research groups. FBS, PPBS, and score. This implies a causal relationship between hyperglycemia and more advanced CAD.

Number of patients in the study is small. Hence more studies on pre-diabetics and non-diabetics are needed in future Duration of study is short, hence follow up of patients was not included in the study. Possible underlying mechanism (such as insulin resistance, pro-thrombotic work up) of patients was not studied. Large prospective studies in pre-diabetic patients are needed in future for better understanding and planning management strategies. Assessment of coronary angiographic findings and Echocardiographic findings was limited to visual interpretation, with inter- and intra-observer variability.

The severity and extent of CAD in diabetics was more compared to non-diabetics. Involvement and occlusion of vessels were more commonly seen in diabetic patients. The incidence of triple vessel or multi-vessel disease was significantly higher in diabetics. Patients with poor glycemic control with elevated levels of HbA1c had diffuse pattern of atherosclerotic disease and high levels of HbA1c mildly correlated with gensini score.

1. World Health Organization. World Health Statistics. Department of Measurement & Health Information Systems of the Information. Evidence and Research Cluster. 2008:29-31.
2. Unwin N, Whiting D, Gan D, Jacqmain O, Ghyoot G, editors. IDF Diabetes Atlas. 4th ed.Brussels: International Diabetes Federation, 2009.
3. Third Report of the NCEP Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (ATPIII).Circulation.2002;106:3143-3421.
4. Kannel WB, Mc Gee DL.Diabetes and cardiovascular disease. The Framingham study
5. ;JAMA 1979; 241:2035-8.
6. Moss SE, Klein R, Klein BE. Cause-specific mortality in a population-based study of diabetes. Am JPublicHealth1991; 81 : 1158-62.
7. Geiss LS, Herman WM, Smith PJ. Mortality in non-insulin-dependent diabetes. In:National Diabetes Data Group, editor. Diabetes in America, 2nd ed. Bethesda, MD:NIH&NIDDK: National Diabetes Information Clearing house;1995. p.233-55.
8. Diabetes Control and Complications Trial Research Group: The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. NEngl JMed1993, 329(14):977-986.
9. Stratton IM, Adler AI, Neil HA, Matthews DR, Manley SE, Cull CA, Hadden D,TurnerRC,HolmanRR: Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS35): prospective observational study.BMJ2000, 321(7258):405-412.
10. Sacks DB, Bruns DE, Goldstein DE ,Maclaren NK ,McDonald JM,Parrott M: Guidelines and recommendations for laboratory analysis in the diagnosis and management of diabetes mellitus. ClinChem2002, 48(3):436-472.
11. Gorus F, Mathieu C, Gerlo E :How should HbA1c measurements be reported? Diabetologia 2006,49(1):7-10.
12. BrezinkaV, PadmosI.Coronary heart disease risk factors in women. Eur HeartJ. 1994;15:1571–1584.
13. GeissLS, Herman WH, SmithPJ, National Diabetes DataGroup. Diabetes in Bethesda, Md: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 1995: 233–257.
14. Malmberg K, Yusuf S, Gerstein HC, et al. Impact of diabetes on long-term prognosis in patients with unstable angina and non-Q-wave myocardial infarction: results of the OASIS (Organization to Assess Strategies for Ischemic Syndromes) Registry.Circulation.2000;102:1014-1019.
15. Miettinen H, Lehto S, Salomaa V, et al. Impact of diabetes on mortality after the first myocardial infarction .Diabetes Care. 1998;21:69-75.
16. Ceriello A, Hanefeld M, Leiter L, Monnier L, Moses A, Owens D et al. Postprandial glucose regulation and diabetic complications. Arch Intern Med 2004;164:2090–2095.
17. Ceriello A. Acute hyperglycemia: A new risk factor during myocardial infarction ;European Heart J2005; 26(4): 328-31.
18. Gensini GG .A more meaningful scoring system for determining these verity of coronary heart disease.Am JCardiol1983;51:606.
19. Mak.K.H., Granger C.B.,MillerD.P.,etal―Influence of Diabetes Mellitus on clinical Out come in the thrombolytic era of Acute Myocardial Infarction GUSTO1 Investigations ‖J.Am.Coll.Cardiol1997;30:171-179.
20. The Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID) Study Group. Prevention of cardiovascular events and death with pravastatin in patients with coronary heart disease and a broad range of initial cholesterol levels. N Engl JMed.1998;339:1349 –1357.
21. Calton R, Calton R, Dhanoa J, et al. Angiographic severity and morphological spectrum of coronary artery disease in non insulin dependent diabetes mellitus. Indian Heart J1995;47:343–8.
22. Natali,A. L'Abbate,E. Ferrannini Coronary atherosclerosis in Type II diabetes:angiographic findings and clinical outcome ,DiabetologiaJ:May2000,Volume43,Issue5, pp 632-641.
23. Abadie E, Masquet C, Guiomard A, et al. Coronary angiography in diabetic andnon-diabetic patients with severe ischaemic heart disease. Diabetes Metab1983;9:53–7.
24. Yan Q,Gu WQ,Hong J, Zhang YF,Su YX,Gui MH,Zhang Y,Chi ZN,ZhangYW, Li XY, Ning G; Coronary angiographic studies of impaired glucose regulation and coronary artery disease in Chinese non diabetic subjects ;Endocrine. 2009Dec;36(3):457-63.
25. Tahir Saleem, Kazim Hameedullah Mohammad, Moataz M Abdel-Fattah and Abdul; Association of glycosylated haemoglobin level and diabetes mellitus duration with the severity of coronary artery disease; Diabetes and Vascular Disease Research2008 5: 184.
26. Syvänne M ,PajunenP, Taskinen MR. Determinants of severity and extent of coronary disease in type2 diabetic nondiabetic patients(abstr).Diabetologia1997;40(suppl 1):A29.
27. Ayhan SS, Tosun M, Ozturk S, Alcelik A, Ozlu MF, Erdem A,Erdem K,ErdemFH,Yazici M; Glycated haemoglobin is correlated with the severity of coronary artery disease