European Journal of Cardiovascular Medicine

Cardiovascular diseases (CVD), particularly coronary artery disease (CAD), remain the foremost cause of global mortality and morbidity, accounting for approximately 22% of all deaths worldwide—a figure projected to rise to over 26% by the year 2030 [1]. Among the established risk factors for CAD, diabetes mellitus (DM) exerts a uniquely pervasive and multifactorial influence. The global burden of diabetes is rapidly increasing, with an estimated 285 million individuals affected in 2010, a number expected to escalate to 438 million by 2030. The majority of this burden lies in low- and middle-income countries, which bear over 80% of global cases [2].

Diabetes is widely recognized not only as a metabolic disorder but also as a coronary artery disease risk equivalent. This was emphasized in the Third Report of the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) guidelines, which classified diabetes as a CAD-risk equivalent due to its strong association with atherosclerotic cardiovascular events [3]. The pathophysiological mechanisms linking diabetes and CAD include chronic hyperglycemia, endothelial dysfunction, dyslipidemia, pro-inflammatory states, and increased oxidative stress—all of which contribute to the acceleration of atherosclerosis [4].

Epidemiological studies further underscore the impact of diabetes on cardiovascular outcomes. Data from the Framingham Heart Study demonstrated a twofold increase in cardiovascular mortality among men with diabetes and a fourfold increase among women [4]. In population-based studies, such as the Wisconsin Epidemiologic Study of Diabetic Retinopathy, cardiovascular disease has been shown to account for 65% to 75% of deaths among individuals with diabetes [5,6].

Although the microvascular complications of diabetes are well characterized, its macrovascular effects—particularly the extent and severity of CAD—are of growing clinical concern. The Diabetes Control and Complications Trial (DCCT) highlighted that intensive glycemic control reduces the incidence of microvascular complications. However, its impact on macrovascular endpoints, such as myocardial infarction and cardiovascular mortality, has been less conclusive [7].

Given the increasing prevalence of diabetes and its critical role in the pathogenesis of CAD, it is essential to examine the angiographic severity of coronary disease across the glycemic spectrum—including non-diabetic, pre-diabetic, and diabetic individuals—particularly in the context of acute coronary syndrome (ACS). Such an evaluation offers valuable insight into early identification, risk stratification, and targeted management of high-risk patients.

Aims and Objectives

Primary Objectives

• To assess the angiographic severity of coronary artery disease (CAD) using the Gensini score among patients presenting with acute coronary syndrome (ACS), stratified by their glycemic status (diabetics, pre-diabetics, and non-diabetics).
• To evaluate the correlation between glycemic control and the severity of CAD.

Secondary Objective

• To determine the relationship between the duration of diabetes mellitus and the severity of coronary artery involvement in diabetic patients.

Study Design and Setting

This was a cross-sectional observational study conducted at PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India. The study period extended from August 2011 to December 2012 and included consecutive patients admitted with a first episode of acute coronary syndrome (ACS) who subsequently underwent invasive coronary angiography.

Study Population

A total of 412 patients presenting with ACS were included in the final analysis. Patients were categorized into three groups based on their glycemic status:

• Diabetics (n = 213)
• Pre-diabetics (n = 76)
• Non-diabetics (n = 123)

The classification was based on the American Diabetes Association (ADA) 2011 criteria, using fasting blood sugar (FBS), postprandial blood sugar (PPBS), and glycated hemoglobin (HbA1c) levels.

Inclusion Criteria

• Patients aged ≥18 years.
• Patients admitted with a first-time presentation of ACS, including ST-elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), and unstable angina.
• Patients who underwent coronary angiography during the index hospitalization.

Exclusion Criteria

• Patients with previously diagnosed coronary artery disease or prior coronary interventions.
• Patients with anemia, renal failure, or other systemic illnesses that could confound the analysis.
• Patients who declined angiography or withdrew consent.

Glycemic Classification

Glycemic status was classified as follows:

• Diabetics: HbA1c ≥ 6.5% and/or FBS ≥ 126 mg/dL and/or PPBS ≥ 200 mg/dL or previously known diagnosis of diabetes.
• Pre-diabetics:
• Impaired fasting glucose (IFG): FBS 100–125 mg/dL.
• Impaired glucose tolerance (IGT): 2-hour OGTT 140–199 mg/dL.
• HbA1c between 5.7% and 6.4%.
• Non-diabetics: HbA1c < 5.7%, FBS < 100 mg/dL, and PPBS < 140 mg/dL.

Clinical and Laboratory Evaluation

All patients underwent a comprehensive clinical assessment, including:

• Detailed history and physical examination.
• Evaluation of cardiovascular risk factors (hypertension, smoking, obesity, family history of ischemic heart disease).
• Standard 12-lead electrocardiogram (ECG).
• Transthoracic echocardiography to assess left ventricular function and regional wall motion abnormalities.

Laboratory investigations included:

• Complete blood count, renal function tests, and lipid profile.
• Blood glucose levels (random, fasting, and postprandial).
• Glycated hemoglobin (HbA1c) for long-term glycemic control.
• Cardiac biomarkers (Troponin-T).
• Fundus examination for microvascular diabetic changes (where indicated).

Angiographic Assessment

Coronary angiography was performed using standard techniques. The severity of coronary artery disease was quantified using the Gensini scoring system, which assigns a severity score based on the degree of luminal narrowing and the anatomical location of the lesion.

• Stenosis scores:
• 1–25%: 1 point
• 26–50%: 2 points
• 51–75%: 4 points
• 76–90%: 8 points
• 91–99%: 16 points
• 100% occlusion: 32 points

These scores were then multiplied by a weighting factor based on the importance of the coronary segment (e.g., left main artery: ×5, proximal LAD: ×2.5, etc.). The total Gensini score for each patient was calculated to assess overall disease burden.

Statistical Analysis

All statistical analyses were performed using SPSS software version 24 . Continuous variables were expressed as mean ± standard deviation (SD), while categorical variables were presented as frequencies and percentages. Comparisons across groups were conducted using one-way ANOVA for continuous variables and Chi-square test for categorical variables. Pearson’s correlation coefficient was used to evaluate the relationship between Gensini scores and variables such as duration of diabetes and HbA1c.A p-value of <0.05 was considered statistically significant.

Ethical Considerations

Ethical clearance for the study was obtained from the Institutional Ethics Committee of PSG Institute of Medical Sciences and Research. Written informed consent was obtained from all participants prior to inclusion in the study.

Study Flowchart

ACS Patients
  ↓
History → ┌─────────────── Known Diabetes ───────────────┐
          │                                               ↓
          │                                 Diabetic Group (HbA1c: <6.5 /6.5–9 / >9)
          ↓
No Known DM → HbA1c → ┌────────────┬────────────┐
↓            ↓            ↓
            Pre-diabetic (IFG)  Pre-diabetic (IGT)  Non-diabetic
                                ↓
                      All groups → Coronary Angiogram → Gensini Score

Figure 1.

Schematic representation of patient selection and classification based on glycemic status.
Patients presenting with acute coronary syndrome (ACS) were initially evaluated for a history of diabetes. Those without prior diabetes underwent HbA1c testing and, when required, oral glucose tolerance testing (OGTT) to classify them as pre-diabetic or non-diabetic. All categorized patients underwent coronary angiography, and the severity of coronary artery disease (CAD) was quantified using the Gensini score.

Baseline Characteristics

A total of 412 patients with first-time acute coronary syndrome were included in the study, comprising 213 diabetics (51.7%), 76 pre-diabetics (18.4%), and 123 non-diabetics (29.9%) (Table 1).

The mean age at presentation was 56.3 ± 10.2 years among diabetics, 54.4 ± 9.3 years among pre-diabetics, and 54.5 ± 12.2 years among non-diabetics. Thus, patients with diabetes tended to present at a slightly older age compared to the other groups, though the difference was not clinically substantial.

A consistent male predominance was noted across all groups, with the highest proportion among non-diabetics (86.2%) and the lowest among diabetics (81.7%). Female patients constituted 18.3% of diabetics, 15.8% of pre-diabetics, and 13.8% of non-diabetics.

Overall, the baseline demographic profile showed that patients with diabetes were marginally older at presentation and that CAD in the setting of ACS was overwhelmingly more common in males across all glycemic categories.

Table 1. Baseline characteristics of the study population

Notes: Values are expressed as mean ± standard deviation or percentages as appropriate.

Clinical Presentation

The majority of patients in all three groups presented with ST-elevation myocardial infarction (STEMI), which accounted for 56.3% of diabetics, 61.8% of pre-diabetics, and 69.1% of non-diabetics. Non-diabetic patients thus had the highest proportion of STEMI at presentation. In contrast, NSTEMI was relatively more common among diabetics (32.9%) compared with pre-diabetics (31.6%) and non-diabetics (20.3%). The prevalence of unstable angina was low overall, ranging from 6.6% in pre-diabetics to about 10.8% in diabetics (Table 2).

With respect to symptomatology, chest pain was the most frequent presenting symptom across all groups (>93%), followed by sweating (52.6% in diabetics, 46% in pre-diabetics, and 43.9% in non-diabetics). Dyspnoea occurred in approximately 15–17% of patients, while atypical symptoms such as abdominal pain, giddiness, or syncope were relatively infrequent (<7%) and occurred slightly more often in diabetics.

Overall, while STEMI was the most common ACS presentation across all groups, NSTEMI and unstable angina were proportionally more frequent in diabetic patients, whereas non-diabetics more often presented with STEMI.

Table 2. Distribution of acute coronary syndrome (ACS) types among study groups

Notes: Values represent percentage distribution within each glycemic category. STEMI = ST-elevation myocardial infarction; NSTEMI = non-ST-elevation myocardial infarction.

Biochemical and Lipid Profile

The glycemic parameters showed expected gradients across groups (Table 4). The mean random blood sugar (RBS) was highest among diabetics (205 ± 86.7 mg/dL), followed by pre-diabetics (134.7 ± 27.4 mg/dL) and non-diabetics (120 ± 31.7 mg/dL). Similarly, mean fasting blood sugar (FBS) was significantly higher in diabetics (150.9 ± 58.5 mg/dL) compared with pre-diabetics (110.3 ± 13.4 mg/dL) and non-diabetics (111.4 ± 93.7 mg/dL). Postprandial blood sugar (PPBS) levels also followed the same trend, with the highest levels among diabetics (188.5 ± 55.3 mg/dL) compared to pre-diabetics (148.9 ± 16.6 mg/dL) and non-diabetics (134.1 ± 17.1 mg/dL). HbA1c values averaged 8.23 ± 1.88% in diabetics, 6.0 ± 0.19% in pre-diabetics, and 5.40 ± 0.30% in non-diabetics (Table 5).

With respect to lipid profile (Table 3), low HDL cholesterol was the most common abnormality across all groups, affecting 69% of diabetics, 73% of pre-diabetics, and 63% of non-diabetics. Elevated triglycerides were also more frequent in pre-diabetics (17%) compared with diabetics (13%) and non-diabetics (11%). High LDL cholesterol was uncommon overall, observed in 6% of diabetics, 9% of pre-diabetics, and 3% of non-diabetics. Very high triglyceride levels were rare (≤1%) across all groups.

Overall, the biochemical analysis confirmed that patients with diabetes had the highest glycemic burden, while dyslipidemia, particularly low HDL, was highly prevalent across all categories, with only minor differences between groups.

Table 3. Lipid profile abnormalities among study groups

Table 4. Glycemic indices among study groups

Angiographic Severity (Primary Outcome)

The severity of coronary artery disease, assessed using the Gensini scoring system, differed significantly across glycemic categories (Table 5). The mean Gensini score was 47.1 ± 31.1 in diabetics, compared with 41.5 ± 25.1 in pre-diabetics and 38.5 ± 33.9 in non-diabetics (p = 0.049). Thus, diabetic patients had the highest angiographic disease burden, while non-diabetics had the least severe disease.

Corresponding mean HbA1c values were 8.23 ± 1.88% in diabetics, 6.0 ± 0.19% in pre-diabetics, and 5.40 ± 0.30% in non-diabetics. Despite the increasing HbA1c gradient, the direct correlation between HbA1c level and angiographic severity did not reach statistical significance when analyzed within the diabetic subgroup (see Table 8, later section).

Overall, these findings indicate that glycemic status was associated with progressive increases in CAD severity, with the greatest burden seen in diabetic patients.

Table 5. Gensini scores and HbA1c levels across study groups

Figure 1. Comparison of mean Gensini scores across glycemic categories. Diabetic patients exhibited the highest angiographic severity of coronary artery disease, followed by pre-diabetics and non-diabetics (p = 0.049).

Subgroup Analyses

1. Prediabetic Subgroups

Among the 76 pre-diabetic patients, angiographic severity varied across those with impaired fasting glucose (IFG), impaired glucose tolerance (IGT), and combined IFG+IGT (Table 6).

• Mean Gensini scores were 44.4 ± 25.3 for IFG, 41.0 ± 25.7 for IGT, and 43.9 ± 26.9 for combined IFG+IGT.
• These differences were not statistically significant (p = 0.12).
  Thus, within the pre-diabetic group, the mode of glycemic abnormality (fasting vs postprandial) did not significantly alter angiographic severity.

2. Duration of Diabetes

A progressive increase in Gensini score was observed with longer duration of diabetes (Table 7).

• Patients with newly detected diabetes had the lowest mean Gensini score (34.5), whereas those with >10 years’ duration had the highest (85).
• Intermediate values were seen in those with shorter durations, with a strong positive correlation between duration of diabetes and CAD severity (r = 0.69, p< 0.001).
  This highlights that longer diabetes exposure confers greater atherosclerotic burden.

3. HbA1c Categories in Diabetic Patients

When diabetic patients (n = 213) were stratified by glycemic control, the distribution was as follows:

• Good control (HbA1c <6.5%) – 14 patients, mean Gensini score 53.2 ± 27.8
• Suboptimal control (HbA1c 6.5–8.9%) – 141 patients, mean Gensini score 45.1 ± 30.9
• Poor control (HbA1c >9%) – 58 patients, mean Gensini score 50.4 ± 31.6

Although the mean scores varied slightly between categories, the differences were not statistically significant (p = 0.484). Thus, glycemic control as assessed by HbA1c at a single time point did not correlate with angiographic severity, in contrast to the duration of diabetes, which showed a strong positive association.

Table 6. Gensini scores in pre-diabetic subgroups

Table 7. Duration of diabetes and angiographic severity

Table 8. HbA1c and angiographic severity in diabetics

Figure 2. Relationship between duration of diabetes and angiographic severity of coronary artery disease. A progressive increase in mean Gensini score was observed with longer diabetes duration, with the highest burden seen in patients with >10 years’ history.

Coronary Artery Involvement

The distribution of coronary vessel involvement varied significantly across the three groups (Table 9). Single-vessel disease was most frequent among non-diabetics (71.5%) and pre-diabetics (67.1%), while only 49.3% of diabetics presented with single-vessel involvement. In contrast, triple-vessel disease was disproportionately more common among diabetics (29.1%) compared with pre-diabetics (14.5%) and non-diabetics (14.6%) (p< 0.001).

Double-vessel disease occurred in 21.6% of diabetics, 18.4% of pre-diabetics, and 13.8% of non-diabetics.

Taken together, these findings demonstrate that diabetic patients had more extensive coronary involvement, with a markedly higher burden of multi-vessel disease compared with both pre-diabetics and non-diabetics.

Table 9. Coronary artery involvement across study groups

Correlation Analysis

Correlation analyses between glycemic indices and angiographic severity (Gensini score) are summarized in Table 10.

In the diabetic group, there was a statistically significant positive correlation between Gensini score and multiple glycemic parameters:

• Random blood sugar (RBS): p = 0.0001
• Fasting blood sugar (FBS): p = 0.0079
• Postprandial blood sugar (PPBS): p = 0.0043

In pre-diabetics, none of the correlations reached statistical significance (RBS p = 0.211, FBS p = 0.179, PPBS p = 0.127).

In non-diabetics, significant correlations were observed with FBS (p = 0.012) and PPBS (p = 0.008), while the association with RBS was weaker and did not achieve significance (p = 0.069).

Overall, these findings indicate that glycemic status is strongly associated with CAD severity in diabetics, and even among non-diabetics, fasting and postprandial glucose values were linked to angiographic burden.

Table 10. Correlation between glycemic indices and angiographic severity (Gensini score)

In the present study of 412 patients with acute coronary syndrome, we found that the angiographic severity of CAD was greatest in diabetics (mean Gensini score 47.1 ± 31.1), intermediate in pre-diabetics (41.5 ± 25.1), and lowest in non-diabetics (38.5 ± 33.9, p = 0.049). Moreover, duration of diabetes showed a strong positive correlation with CAD severity (r = 0.69, p< 0.001), with patients having more than 10 years’ disease exhibiting the highest mean Gensini score (85.0). In contrast, HbA1c categories at a single time point did not correlate significantly with angiographic severity (p = 0.484).

Our findings are consistent with the results of the LIPID trial, which demonstrated that aggressive lipid lowering in patients with established CAD reduced recurrent cardiovascular events, underscoring the importance of metabolic control in modifying CAD outcomes [8]. Similarly, Calton et al. (1995) showed that patients with non-insulin dependent diabetes mellitus had more severe and diffuse coronary lesions compared to non-diabetics, corroborating our observation that diabetics carried the highest Gensini scores [9].

Natali et al. (2000) reported that type 2 diabetic patients had both a higher prevalence and greater extent of angiographically proven CAD compared to non-diabetics, and that this translated into poorer clinical outcomes [10]. Our results align with these findings, with diabetic patients not only having higher severity scores but also a greater prevalence of triple vessel disease (29.1% vs 14.6% in non-diabetics). Earlier, Hamby and Sherman (1979) observed that the duration of diabetes was strongly related to severity of CAD, which is echoed in our dataset where patients with >10 years’ diabetes had more than double the Gensini scores of newly detected cases [11].

Other angiographic comparisons also support this relationship. Pajunen et al. (1997) demonstrated that non-insulin dependent diabetes was associated with significantly more complex and multi-vessel disease compared to matched controls [12], while Thomas et al. (2002) found that Arab women with diabetes had more severe CAD than their non-diabetic counterparts [13]. In contrast, Abadie et al. (1983) reported no significant difference in CAD extent between diabetics and non-diabetics, highlighting that patient selection and methodological variation may influence reported outcomes [14].

The lack of correlation between HbA1c levels and CAD severity in our cohort contrasts with some earlier findings. Krishnaswami et al. (1994) reported that traditional coronary risk factors, including glycemic markers, were not reliable predictors of angiographic burden [15], which is consistent with our null result for HbA1c. However, Moosavi et al. (2004) and Peppes et al. (2011) observed a significant association between HbA1c and CAD extent [16,17], and Yan et al. (2009) found that even impaired glucose regulation was independently linked with higher angiographic burden [18]. Similarly, the DECODE study (1999) emphasized that fasting glucose alone underestimates cardiovascular risk, supporting the concept that postprandial glycemia and long-term glycemic exposure may be more important determinants [19].

Our finding that pre-diabetics had intermediate Gensini scores (41.5 ± 25.1) also echoes prior work. Haffner (1997) and Laakso and Lehto (1998) both concluded that impaired glucose tolerance and insulin resistance are powerful risk factors for atherosclerosis and CVD [20,21]. Indeed, Saleem et al. (2008) showed that both HbA1c levels and duration of diabetes were independently associated with CAD severity, underscoring the cumulative effect of long-term dysglycemia [22]. While Syvänne et al. (1997) noted that lipid abnormalities were major determinants of CAD severity in type 2 diabetes [23], our results suggest that low HDL was the most prevalent lipid abnormality across all groups (69–73%), reinforcing its central role in CAD risk in South Asian populations.

Interestingly, some recent studies diverge. Ayhan et al. (2012) demonstrated that HbA1c correlated with CAD severity even in young patients, independent of other risk factors [24]. The discrepancy with our results may be explained by differences in study design: while Ayhan’s study evaluated HbA1c as a continuous variable in a younger cohort, our categorical analysis of HbA1c may have diluted potential associations. Regional variation, ethnicity, and sample size differences could also account for the heterogeneity in findings.

Taken together, our data add to the growing evidence that diabetes confers a substantial angiographic burden, with disease duration emerging as a stronger predictor of severity than HbA1c at a single time point. The high prevalence of multi-vessel disease in diabetics underscores the need for aggressive early intervention, while the intermediate severity observed in pre-diabetics highlights the importance of timely identification and risk factor modification in this group.

Limitations

This study was conducted at a single tertiary care centre, which may limit the generalizability of the findings to broader populations. The cross-sectional design allowed assessment of angiographic severity at a single point in time, but it did not evaluate long-term outcomes. HbA1c values were analyzed at a single admission and may not fully reflect long-term glycemic control. Finally, although the Gensini scoring system provides a validated measure of angiographic burden, intravascular imaging and functional assessments such as FFR were not performed, which could have added further insights.

In this study of patients presenting with acute coronary syndrome, we demonstrated that the angiographic severity of coronary artery disease was greatest among diabetics, intermediate in pre-diabetics, and lowest in non-diabetics. Diabetic patients not only had higher mean Gensini scores (47.1 ± 31.1) but also a greater prevalence of triple-vessel disease (29.1%) compared with non-diabetics. The duration of diabetes showed a strong and graded association with CAD severity, whereas HbA1c levels at a single time point were not significantly correlated.

These findings underscore the cumulative impact of chronic hyperglycemia on coronary atherosclerosis and highlight the need for early identification and aggressive management of both diabetes and pre-diabetes. Preventive strategies targeting glycemic control, lipid abnormalities, and other modifiable risk factors may attenuate the long-term burden of severe, multi-vessel coronary disease in this high-risk population.

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