Fasting glucose is an important independent risk factor for 30-day mortality in patients with acute myocardial infarction: a prospective study

Effectively identifying the inpatient with hyperglycemia to increase patient care and lower costs

Recent years have seen an increased focus on merging quality care and financial results. This focus not only extends to the inpatient setting but also is of major importance in assuring effective transitions of care from hospital to home. Inducements to meld the 2 factors include tying payment to quality standards, investing in patient safety, and offering new incentives for providers who deliver high-quality and coordinated care. Once seen as the purview of primary care or specific surgical screening programs, identification of patients with hyperglycemia or undiagnosed diabetes mellitus now presents providers with opportunities to improve care. Part of the new focus will need to address the length of stay for patients with diabetes mellitus. These patients are proven to require longer hospital stays regardless of the admission diagnosis. With reducing length of stay as a major objective, efficiency combined with improved quality is the desired outcome. Even with the mounting evidence supporting the benefits of improving glycemic control in the hospital setting, institutions continue to struggle with inpatient glycemic control. Multiple national groups have provided recommendations for blood glucose assessment and glycated hemoglobin testing. This article identifies the key benefits in identifying patients with hyperglycemia and reviews possible ways to identify, monitor, and treat this potential problem area and thereby increase the level of patient care and cost-effectiveness.

One-year clinical impact of cardiac arrest in patients with first onset acute ST-segment elevation myocardial infarction

BACKGROUND

Cardiac arrest complicating acute ST elevation myocardial infarction (STEMI) is known to be associated with increased in-hospital mortality. However, little is known about the long-term outcomes after cardiac arrest complicating first onset STEMI in contemporary percutaneous coronary intervention (PCI) era.

METHODS

We analyzed 7942 consecutive patients who were diagnosed with STEMI and had no previous history of MI. They were divided into two groups according to the presence of cardiac arrest (group I, patients with cardiac arrest; n=481, group II, patients without cardiac arrest; n=7641).

RESULTS

In a stepwise multivariate model, previous history of chronic kidney disease, high serum level of glucose and low high density lipoprotein-cholesterol was an independent predictor of cardiac arrest complicating STEMI. Group I had significantly higher in-hospital mortality (adjusted hazard ratio [HR] 3.06, 95% confidence interval [CI] 2.08-4.51, p<0.001) and 30-day mortality after hospital discharge (adjusted HR 2.92, 95% CI 1.86-4.58, log-rank p<0.001). However, there was no significant increase in mortality beyond 30 days (6-month, adjusted HR 1.46, 95% CI 0.45-4.77, log rank p=0.382; 1-year, adjusted HR 1.84, 95% CI 0.83-4.05, log-rank p=0.107). Also, there were no significant differences in 6-month and 1-year major adverse cardiac events in 30-day survivors. Performing PCI was associated with decreased 12-month mortality in 30-day survivors.

CONCLUSIONS

Although patients with cardiac arrest complicating first onset STEMI had higher in-hospital and 30-day mortality after hospital discharge, cardiac arrest itself did not have any residual impact on mortality as well as clinical outcomes.

Fasting hyperglycemia increases in-hospital mortality risk in nondiabetic female patients with acute myocardial infarction: a retrospective study

Previous studies had shown that elevated admission plasma glucose (APG) could increase mortality rate and serious complications of acute myocardial infarction (AMI), but whether fasting plasma glucose (FPG) had the same role remains controversial. In this retrospective study, 253 cases of AMI patients were divided into diabetic (n = 87) and nondiabetic group (n = 166). Our results showed that: compared with the nondiabetic patients, diabetic patients had higher APG, FPG, higher plasma triglyceride, higher rates of painless AMI (P < 0.01), non-ST-segment elevation myocardial infarction (NSTEMI), and reinfraction (P < 0.05). They also had lower high density lipoprotein cholesterol and rate of malignant arrhythmia, but in-hospital mortality rate did not differ significantly (P > 0.05). While nondiabetic patients were subgrouped in terms of APG and FPG (cut points were 11.1 mmol/L and 7.0 mmol/L, resp.), the mortality rate had significant difference (P < 0.01), whereas glucose level lost significance in diabetic group. Multivariate logistic regression analysis showed that FPG (OR: 2.014; 95% confidence interval: 1.296-3.131; p < 0.01) but not APG was independent predictor of in-hospital mortality for nondiabetic patients. These results indicate that FPG can be an independent predictor for mortality in nondiabetic female patients with AMI.

Hemoglobin A1c is a better predictor of prognosis following the non-ST elevation acute coronary syndrome than fasting and admission glucose

BACKGROUND

Glucometabolic status is an important predictor of prognosis in patients with acute myocardial infarction. Both plasma glucose levels and glycosylated hemoglobin A1c (HbA1c) were implicated as predictors of prognosis. However, previous data yielded conflicting results. We evaluated the prognostic role of plasma glucose levels and HbA1c in patients with non-ST elevation acute coronary syndrome (NSTEACS).

METHODS

A total of 106 consecutive patients with NSTEACS (55 with unstable angina and 51 with non-ST elevation myocardial infarction) were included. The average age was 66.1 years; 61% were male. HbA1c was measured at admission, along with other standard laboratory values. The follow-up period lasted for a year. The main combined outcome variable included death from cardiovascular causes and rehospitalization due to another acute coronary syndrome or due to heart failure.

RESULTS

Combined end point occurred in 43 (41%) patients. Mean HbA1c value was significantly higher in the group of patients who had complications (7.6 ± 2.6 vs. 5.8 ± 1.2, p < 0.05). Logistic regression identified HbA1c [odds ratio (OR): 1.6] and male sex (OR: 0.25) as the only independent predictors of major adverse cardiac events (MACE). A Kaplan-Meier analysis showed a 2.7 times higher risk of MACE in patients with HbA1c > 6.5%.

CONCLUSIONS

Results from our study indicate that the admission level of HbA1c, but not admission or fasting glucose, is a predictor of mortality and major adverse events in patients with NSTEACS. These results identify HbA1c to be an independent predictor also in patients with NSTEACS, and not only in those with ST elevation myocardial infarction as observed before our study.

Patients with chronic endocrine disease

This article summarizes the key features and clinical considerations related to preoperative management and planning for the care of patients of common endocrine disorders (diabetes mellitus, adrenal insufficiency, thyroid disease), a less common disorder but one that has significant perioperative implications (acromegaly), and 2 disorders for which preoperative management is essential to good postoperative outcomes (pheochromocytoma and carcinoid syndrome). There are few evidence-based guidelines for preoperative management of chronic endocrine disease; hence, this review is based on recent subspecialty society consensus guidelines and professional society clinical practice recommendations.

Influence on prognosis and prevalence of stress hyperglycemia in a cohort of patients with acute coronary syndrome

Objective

To demonstrate the prevalence of stress hyperglycemia in a cohort of patients with acute coronary syndrome and to determine the correlation of stress hyperglycemia with death, heart failure and/or left ventricular systolic dysfunction during the intrahospital phase.

Methods

A prospective initial cohort study of hospitalized patients with acute coronary syndrome with or without ST segment elevation. The groups were compared to demonstrate the correlation between stress hyperglycemia and cardiovascular events. The chi-square test or Fisher's exact test and student's t-test were used to compare the groups with and without stress hyperglycemia. The variables with p<0.20 in the univariate analysis were submitted to logistic regression.

Results

In total, 363 patients with an average age of 12.45 ± 62.06 were studied. There was a predominance of males (64.2%). In total, 96 patients (26.4%) presented with stress hyperglycemia. There were no differences between the groups with or without stress hyperglycemia. The area under the ROC curve was 0.67 for the relationship between stress hyperglycemia and the composite outcome heart failure, left ventricular systolic dysfunction or death at the end of the hospital admission. The ROC curve proved that stress hyperglycemia was the predictor of the composite outcome (death, heart failure and/or ventricular dysfunction). The multivariate analysis did not indicate age, stress hyperglycemia or admission heart rate as risk factors.

Conclusion

Stress hyperglycemia was common in the studied sample. In the univariate analysis, the presence of stress hyperglycemia was associated with such events as death, heart failure and/or intrahospital ventricular dysfunction in patients with acute coronary syndrome.

The glucose dysmetabolism in the acute phase of non-diabetic ST-elevation myocardial infarction: from insulin resistance to hyperglycemia

In the setting of acute myocardial infarction, hyperglycemia and acute insulin resistance may represent a stress response to myocardial injury mainly related to acute catecholamine release. By measuring glucose values and insulin resistance (Homeostatic Model Assessment index-HOMA), we evaluated in 356 non-diabetic patients with ST-elevation myocardial infarction (STEMI) undergone mechanical revascularization: (a) the acute glycometabolic response by evaluating insulin resistance, glucose levels, and their combination and (b) whether insulin resistance and increased glucose values (and their combination) are able to affect in-Intensive Cardiac Care Unit (ICCU) mortality and complications. In the overall population, 226 (63.5%) patients showed glucose values ≤140 mg/dl (group B), while 130 patients had glucose values >140 mg/dl (group A) (36.5%). Within group B, insulin resistance (as inferred by positive HOMA index) was present in 125 patients (55.3%), whereas 101 patients (44.7%) exhibited normal values of HOMA index. Within group A, 109 patients (83.8%) were insulin resistant, while 21 patients (16.2%) had normal values of HOMA index. At multivariable analysis, glucose values were independently associated with in-ICCU mortality (OR: 7.387; 95% CI 2.701-20.201; P < 0.001) and complications (OR: 1.786; 95% CI 1.089-2.928; P = 0.022). In the early phase of STEMI, the acute glycometabolic response to stress is heterogeneous (ranging from no insulin resistance to glucose levels >140 mg/dl and, finally, to the combination of increased glucose values and insulin resistance). Increased glucose values are stronger prognostic factors since they are independently associated with in-ICCU mortality and complications.

Hyperglycemia at admission and during hospital stay are independent risk factors for mortality in high risk cardiac patients admitted to an intensive cardiac care unit

AIMS

Hyperglycemia is associated with increased mortality in cardiac patients. However, the predictive value of admission- and average glucose levels in patients admitted to an intensive cardiac care unit (ICCU) has not been described.

METHODS

Observational study of patients admitted to the ICCU of a tertiary medical center in whom glucose levels were measured at and during admission. Over a 19-month period, 1713 patients were included. Mean age was 63±14 years, 1228 (72%) were male, 228 (17%) had known diabetes. Median (interquartile) glucose levels at admission were 7.9 (6.5-10.1) mmol/l; median glucose levels during ICCU admission (873 patients with three or more measurements) were 7.3 (6.7-8.3) mmol/l. Cox regression analysis was performed including the variables age, gender, admission diagnosis, length of stay, prior (cardio)vascular disease and diabetes.

RESULTS

A 1 mmol/l increase in admission glucose level (above 9 mmol/l) was associated with a 10% (95% confidence interval (CI): 7 -13%) increased risk for all-cause mortality. A 1 mmol/l higher average glucose level (above 8 mmol/l) was an additional independent predictor of mortality (HR 1.11, 95% CI: 1.03 - 1.20). At 30 days, 16.8% (97/579) of the patients with an admission glucose level in the highest tertile (>9.8 mmol/L) had died vs 5.2% (59/1134) of those with a lower admission glucose level.

CONCLUSION

In a high risk ICCU population, both high admission glucose levels as well as high average glucose levels during hospitalization were independently associated with increased mortality, even when accounting for other risk factors and parameters of disease severity.

Elevated postoperative blood glucose and preoperative hemoglobin A1C are associated with increased wound complications following total joint arthroplasty

BACKGROUND

Diabetes is an established risk factor for complications following total joint arthroplasty. However, the correlation between postoperative blood glucose and preoperative hemoglobin A1C levels with complications following total joint arthroplasty is not well described.

METHODS

All patients undergoing elective primary total joint arthroplasty at our institution from 2004 through 2011 with both postoperative blood glucose and preoperative hemoglobin A1C levels were identified in a retrospective review. From among 1702 patients, those with wound complications within thirty days after the index arthroplasty were identified. A control group matched for exact age, sex, procedure, tourniquet use, surgical approach, and use of antibiotic cement was also created. Thirty patients met the study group inclusion criteria. The mean patient age was seventy-two years (range, fifty-three to eighty-nine years); the majority (53%) of patients were female.

RESULTS

The odds ratio for developing a wound complication was 3.75 (95% confidence interval, 1.25 to 11.22; p = 0.02) in patients with a mean postoperative glucose of >200 mg/dL, 3.0 (95% confidence interval, 0.97 to 9.30; p = 0.08) in patients with a maximum postoperative blood glucose of >260 mg/dL, and 9.0 (95% confidence interval, 1.14 to 71.20; p = 0.03) in patients with a preoperative hemoglobin A1C value of >6.7%.

CONCLUSIONS

Patients with a mean postoperative blood glucose of >200 mg/dL or a preoperative hemoglobin A1C level of >6.7% are at increased risk for wound complications following elective primary total joint arthroplasty. These results show that poor preoperative and postoperative glucose control is independently associated with wound complications.

Acute hyperglycemia and insulin resistance in acute heart failure syndromes without previously known diabetes

No data is so far available on the relation between glucose values and insulin resistance and mortality, both at short- and long-term, in patients with acute heart failure syndromes (AHF). We prospectively assessed in 100 consecutive non-diabetic AHF patients whether acute glucose metabolism, as indicated by fasting glycemia and insulin resistance (HOMA index) was able to affect short- and long-term mortality. In the overall population, 51 patients showed admission glucose values >140 mg/dl. No significant difference was observed in admission and peak glycemia, insulin and C-peptide values and in HOMA-index between dead and survived patients. At multivariate logistic backward stepwise analysis the following variables were independent predictors for in-ICCU mortality (when adjusted for left ventricular ejection fraction): Fibrinogen (1 mg/dl increase) [OR (95% CI) 0.991 (0.984-0.997); p = 0.004]; NT-pro BNP (100 UI increase) [OR (95%CI) 1.005 (1.002-1.009); p = 0.004]; leukocyte count (1,000/μl increase) [OR (95%CI) 1.252 (1.070-1.464); p = 0.005]. eGFR was independently correlated with long-term mortality (HR 0.96, 95%CI 0.94-0.98, p < 0.001). In consecutive patients with acute heart failure without previously known diabetes, we documented, for the first time, that fasting glucose and insulin values and insulin resistance do not affect mortality at short- and long-term. Inflammatory activation (as indicated by the leukocyte count and the fibrinogen) and NT-pro BNP levels are independent predictors for early death while the eGFR affects the long-term mortality.

Glycemic Control during Coronary Artery Bypass Graft Surgery

Hyperglycemia, which occurs in the perioperative period during cardiac surgery, has been shown to be associated with increased morbidity and mortality. The management of perioperative hyperglycemia during coronary artery bypass graft surgery and all cardiac surgical procedures has been the focus of intensive study in recent years. This report will paper the pathophysiology responsible for the detrimental effects of perioperative hyperglycemia during cardiac surgery, show how continuous insulin infusions in the perioperative period have improved outcomes, and discuss the results of trials designed to determine what level of a glycemic control is necessary to achieve optimal clinical outcomes.

Prognostic impact of hyperglycemia in nondiabetic and diabetic patients with ST-elevation myocardial infarction: insights from contrast-enhanced magnetic resonance imaging

BACKGROUND

Hyperglycemia on admission is associated with increased mortality rates in patients with ST-elevation myocardial infarction (STEMI). However, data regarding the relationship between hyperglycemia and myocardial damage in STEMI are scarce. The aim of this study was to determine the relationship of diabetes mellitus status and hyperglycemia on myocardial damage assessed by cardiovascular magnetic resonance imaging and to evaluate the long-term prognostic significance of hyperglycemia in a high-risk STEMI population.

METHODS AND RESULTS

Glucose levels were determined on admission in 411 consecutive STEMI patients reperfused by primary angioplasty. Patients were categorized on the basis of diabetes mellitus status and admission glucose level. Magnetic resonance imaging was performed for assessment of infarct size and microvascular obstruction. The primary clinical end point was the occurrence of major adverse cardiovascular events at long-term follow-up. STEMI patients with pre-existing diabetes mellitus were at greater risk for major adverse cardiovascular events (32% versus 11%; P<0.001) despite having similar infarct sizes and extent of reperfusion injury than nondiabetic patients. Glycemic status on admission was associated with greater myocardial damage and an increased risk for major adverse cardiovascular events (P<0.001). In nondiabetic patients, the risk of severe myocardial injury started to rise once admission glucose exceeded 7.8 mmol/L, whereas the threshold was higher among patients with diabetes mellitus (≥11.1 mmol/L).

CONCLUSIONS

The higher mortality rate in diabetic versus nondiabetic STEMI patients is not explained by more pronounced myocardial damage. Hyperglycemia on admission is associated with greater myocardial injury and an increased risk of major adverse cardiovascular events at long-term follow-up. However, hyperglycemia has a stronger relationship to myocardial injury in nondiabetic compared with diabetic patients.

Glucose Control in Critical Care Oncology

The optimal strategy for glucose control in critically ill patients remains controversial and may vary depending on their diagnostic groups. This retrospective study addresses this question in a cohort of critically ill oncology patients. Serial blood glucose levels were measured in a specialist oncology intensive care unit (ICU) in England between January 2009 and May 2010. Intravenous sliding scale insulin was started when blood glucose levels were greater than 8.3 mmol/L, aiming for a target glucose level below 10 mmol/L. There were 565 patients admitted to the ICU, of whom 181 (32%) were medical and 384 (68%) surgical. The mean blood glucose was 7.8 mmol/L. Mortality rates relative to mean glucose levels followed a U-shaped curve. There was a statistically significant increase in mortality among patients who spent longer periods with blood glucose levels less than 6 mmol/L, and those whose glucose was greater than 10 mmol/L (20% vs 7.3%; p <0.001). Fluctuations in blood glucose levels measured by the coefficient of variation against mean glucose levels demonstrated a significant increase in mortality in patients with higher variability (p<0.01). Higher coefficients of variation were also associated with an increased length of ICU stay and increased readmission rates to ICU. In this study, hypoglycaemia, hyperglycaemia and increased variability in glucose levels were each independently associated with worse outcomes in critically ill patients.

Prognostic value of admission blood glucose concentration and diabetes diagnosis on survival after acute myocardial infarction: results from 4702 index cases in routine practice

The diagnosis of diabetes and admission blood glucose concentration are associated with adverse outcome after acute coronary syndromes. We compared the relative association with survival after ST elevation AMI (acute myocardial infarction) of admission blood glucose concentration and of diabetes diagnosis. We carried out a retrospective cohort study in 4702 consecutive patients with STEMI (ST elevation AMI) occurring from 1 April 1993 to 31 December 2005, assessed for mortality at 30 days and 1 year. Patients were classified according to antecedent diabetes and by blood glucose concentration at admission (quartile 1, <7 mmol/l; quartile 2, 7–8.2 mmol/l;quartile 3, 8.3–10.9 mmol/l; quartile 4, 11 mmol/l). Multivariable models were constructed for determinants of mortality, including year of STEMI and demographic variables, entering blood glucose concentration and antecedent diabetes individually and together. All-cause 30-day and 1-year mortality were 22.8% and 31.3% for patients with antecedent diabetes, compared with 16.3% and 23.0% respectively for those without. For glucose quartiles 1, 2, 3 and 4, crude 30-day mortality was 9.0%, 10.6%, 17.9% and 31.0%. Adjusted 30-day mortality risk was similar in quartile 2, higher by >80% in quartile 3 and by >150% in quartile 4, compared with glucose quartile 1. Antecedent diabetes was associated with an increase in mortality [unadjusted odds ratio (OR)1.52 (95% CI 1.24, 1.86)]. On multivariable analysis (excluding glucose quartile), this reduced to 1.24 (0.98, 1.58) and changed to a small, statistically non-significant reduction in risk when glucose quartile was added to the analysis [adjusted OR 0.87 (0.67, 1.13)]. Inclusion of antecedent diabetes in multivariable models did not add to the predictive value for mortality of glucose quartile(P=0.368). Similar relationships were observed for 1 year mortality. In patients with STEMI, blood glucose concentration shows graded association with risk of 30-day and 1-year mortality and is of greater prognostic relevance than antecedent diabetes diagnosis. Moderate elevation of blood glucose, below levels previously considered to be clinically relevant, is associated with adverse impact on survival.

Admission hyperglycemia and acute myocardial infarction: outcomes and potential therapies for diabetics and nondiabetics

Hyperglycemia, in both diabetic and nondiabetic patients, has a significant negative impact on the morbidity and mortality of patients presenting with an acute myocardial infarction (AMI). Contemporary evidence indicates that persistent hyperglycemia after initial hospital admission continues to exert negative effects on AMI patients. There have been a number of studies demonstrating the benefit of tight glucose control in patients presenting with AMI, but a lack of convincing clinical data has led to loose guidelines and poor implementation of glucose targets for this group of patients. The CREATE-ECLA study, which hypothesized that a fixed high dose of glucose, insulin, and potassium (GIK) would change myocardial substrate utilization from free fatty acids to glucose and therefore protect ischemic myocardium, failed to demonstrate improved clinical outcomes in AMI patients. Studies that specifically investigated intensive insulin therapy, including DIGAMI-2 and HI-5, also failed to improve clinical outcomes such as mortality. There are a number of reasons that these trials may have fallen short, including the inability to reach glucose targets and inadequate power. There is now a need for a large placebo-controlled randomized trial with an adequate sample size and adherence to glucose targets in order to establish the benefit of treating hyperglycemia in patients presenting with AMI.

Hyperglycemia in nondiabetic patients presenting with acute myocardial infarction

Hyperglycemia is common in nondiabetic patients with acute myocardial infarction (AMI). Elevated blood glucose level may reflect a response to stress, an underlying abnormal glucometabolic state or both. Regardless of mechanism, hyperglycemia complicating AMI is associated with an inflammatory and prothrombotic state, depressed myocardial contractility and increased short- and long-term mortality. Studies are needed to define optimal monitoring and management of hyperglycemia in nondiabetic patients with AMI.

Serum osmolarity as an outcome predictor in hospital emergency medical admissions

BACKGROUND

To determine whether the serum osmolarity, calculated at the time of an emergency medical presentation, alone or combined with other predictors, could identify patients at low and high risks of an inpatient death by day 30.

METHODS

A retrospective analysis of all emergency medical patients admitted to St. James's Hospital (SJH), Dublin between the 1st of January 2002 and the 31st of December 2009, using the hospital in-patient enquiry (HIPE) system, linked to the patient administration system, and laboratory datasets. Hospital inpatient mortality (30 days) was obtained from a database of deaths over the same period. Multivariate logistic regression was used to derive the best predictive model, with goodness of fit and Area Under the Receiver Operator Curves (AUROC) assessing the predictive accuracy.

RESULTS

Univariate analysis identified two quantiles of <10% and >75% of the osmolarity distribution as being at an increased mortality risk. Their respective mortality rates were 13.7% and 15.7% respectively, with unadjusted odds rate that were 1.66 (1.47, 1.88): p<0.0001 and 3.14 (2.87, 3.43): p<0.0001. After adjustment for other outcome predictors, a significant association with increased mortality remained, with OR=1.82 (1.61, 2.06), p<0.0001. Although the calculated osmolarity alone was not sufficiently predictive with AUROC=0.74 (95% CI: 0.73, 0.76), when combined with other predictors, the AUROC increased to 0.86 (95% CI: 0.84, 0.88).

CONCLUSION

Admission osmolarity, a simple calculation, is associated with the risk of mortality in acutely ill medical patients; deviations outside the normal range are relevant. A useful clinical predictive algorithm requires the incorporation of additional predictors.

Piloting a novel algorithm for glucose control in the coronary care unit: the RECREATE (REsearching Coronary REduction by Appropriately Targeting Euglycemia) trial

OBJECTIVE

Elevated glucose levels are common after an acute myocardial infarction (AMI) and increase the risk of death. Prior trials of glucose control after AMI have been inconsistent in their ability to lower glucose levels and have reported mixed effects on mortality. We developed a paper-based glucose-lowering algorithm and assessed its feasibility and safety in the setting of AMI.

RESEARCH DESIGN AND METHODS

A total of 287 participants with an acute ST segment elevation myocardial infarction (STEMI) and a capillary glucose level ≥8.0 mmol/L were randomly allocated to glucose management with intravenous glulisine insulin using this algorithm in the coronary care unit (CCU), followed by once-daily subcutaneous insulin glargine for 30 days versus standard glycemic approaches. The primary outcome was a difference in mean glucose levels at 24 h. Participants were followed for clinical outcomes through 90 days.

RESULTS

At 24 h, the mean glucose level was 1.41 mmol/L (95% CI 0.69-2.13) lower in the insulin (6.53 vs. 7.94 mmol/L). Differences in glucose levels were maintained at 72 h and 30 days. A total of 22.7% of the insulin group versus 4.4% of the standard group had biochemical hypoglycemia (with neither signs nor symptoms) in the CCU because of lower glycemic goals. However, there were no differences in symptomatic hypoglycemia or clinical outcomes between the groups.

CONCLUSIONS

A paper-based insulin algorithm targeting glucose levels of 5.0-6.5 mmol/L (90-117 mg/dL) can be feasibly implemented in the CCU. A cardiovascular outcomes trial using this approach can determine whether targeted glucose lowering improves patient outcomes.

Clinical significance of hyperglycaemia in acute coronary syndrome patients

BACKGROUND

The clinical significance of moment measurements (admission and fasting glycaemia), persistent (hyperglycaemic index, HGI; time average glucose, TAG; mean glucose; maximum glucose) or chronic hyperglycaemia (HbA1c), estimated average glucose, eAG) is still elusive in clinical practice.

AIM

To identify the clinical significance of hyperglycaemia in ACS.

METHODS

The study included 226 consecutive patients with ACS. Indicators for hyperglycaemia were defined, calculated and a correlation analysis with standard parameters-EF, maximum CPK, maximum CPK-MB and troponin was performed. Patients were followed up for 12 months.

RESULTS

Indicators for persistent and chronic hyperglycaemia correlated neither to ejection fraction, nor to the enzymes for myocardial necrosis (P > 0.05). In contrast, acute hyperglycaemia correlated negatively with ventricular systolic dysfunction (P = 0.001/0.007) and positively with maximum CPK, MB and troponin (P = 0.0001/0.008). TAG was an independent predictor for 6-month re-hospitalization (P = 0.027) because of cardiac complications.

CONCLUSION

Glycaemia at admission and fasting glucose could be used as metabolic surrogate markers for ventricular systolic dysfunction and TAG as an independent surrogate marker for six-month re-hospitalization. None of the indicators for hyperglycaemia could be used as independent prognostic factors for survival. Hyperglycaemia rather reflects an underlying impairment in glucose metabolism.

Acute Phase Hyperglycemia among Patients Hospitalized with Acute Coronary Syndrome: Prevalence and Prognostic Significance

OBJECTIVES

Regardless of diabetes status, hyperglycemia on arrival for patients presenting with acute coronary syndrome, has been associated with adverse outcomes including death. The aim of this study is to look at the frequency and prognostic significance of acute phase hyperglycemia among patients attending the coronary care unit with acute coronary syndrome over the in-hospital admission days.

METHODS

The study included 287 consecutive patients in the Al-Faiha Hospital in Basrah (Southern Iraq) during a one year period from December 2007 to November 2008. Patients were divided into two groups with respect to admission plasma glucose level regardless of their diabetes status (those with admission plasma glucose of <140 mg/dl (7.8 mmol/L) and those equal to or more than that). Acute phase hyperglycemia was defined as a non-fasting glucose level equal to or above 140 mg/dl (7.8 mmol/L) regardless of past history of diabetes.

RESULTS

Sixty one point seven percent (177) of patients were admitted with plasma glucose of ³140 mg/dl (7.8 mmol/L). There were no differences were found between both groups regarding the mean age, qualification, and smoking status, but males were predominant in both groups. A family history of diabetes, and hypertension, were more frequent in patients with plasma glucose of ³140 mg/dl (7.8 mmol/L). There were no differences between the two groups regarding past history of ischemic heart disease, stroke, lipid profile, troponin-I levels or type of acute coronary syndrome. Again heart failure was more common in the admission acute phase hyperglycemia group, but there was no difference regarding arrhythmia, stroke, or death. Using logistic regression with heart failure as the dependent variable we found that only the admission acute phase hyperglycemia (OR=2.1344, 95% CI=1.0282-4.4307; p=0.0419) was independently associated with heart failure. While male gender, family history of diabetes mellitus, hypertension and diabetes were not independently associated with heart failure.

CONCLUSION

Admission acute phase hyperglycemia of ³140 mg/dl (7.8 mmol/L) was associated with heart failure in this study.

Prognostic significance of hemoglobin A1c level in patients hospitalized with coronary artery disease. A systematic review and meta-analysis

BACKGROUND

The prognostic value of hemoglobin A1c (HbA1c) in coronary artery disease (CAD) remains controversial. Herein, we conducted a systematic review to quantify the association between elevated HbA1c levels and all-cause mortality among patients hospitalized with CAD.

METHODS

A systematic search of electronic databases (PubMed, EMBASE, OVID, Web of Science, The Cochrane Library) for studies published from 1970 to May 2011 was performed. Cohort, case-control studies, and randomized controlled trials that examined the effect of HbA1c on all-cause mortality were included.

RESULTS

Twenty studies met final inclusion criteria (total n = 13, 224). From the pooled analyses, elevated HbA1c level was significantly associated with increased short-term (OR 2.32, 95% CI, 1.61 to 3.35) and long-term (OR 1.54, 95% CI, 1.23 to 1.94) mortality risk. Subgroup analyses suggested elevated HbA1c level predicted higher mortality risk in patients without diabetes (OR 1.84, 95% CI, 1.51 to 2.24). In contrast, in patients with diabetes, elevated HbA1c level was not associated with increased risk of mortality (OR 0.95, 95% CI, 0.70 to 1.28). In a risk-adjusted sensitivity analyses, elevated HbA1c was also associated with a significantly high risk of adjusted mortality in patients without diabetes (adjusted OR 1.49, 95% CI, 1.24 to 1.79), but had a borderline effect in patients with diabetes (adjusted OR 1.05, 95% CI, 1.00 to 1.11).

CONCLUSIONS

Our findings demonstrate that elevated HbA1c level is an independent risk factor for mortality in CAD patients without diabetes, but not in patients with established diabetes. Prospective studies should further investigate whether glycemic control might improve outcomes in CAD patients without previously diagnosed diabetes.

Intensive control of diabetes in the hospital: why, how, and what is in the future?

Intensive management of diabetes is identified as a critical component of inpatient care. However, the fundamental question that remains is whether controlling glycemia in noncritically ill diabetes patients at the lower end of the current guidelines improves outcomes of hospitalization, long-term outcomes of the primary condition, and long-term outcomes of diabetes compared with average glycemia greater than 180 mg/dl. A group of clinical investigators--Planning Research in Inpatient Diabetes (PRIDE)--is preparing randomized controlled trials with the hope of defining optimal glycemic targets for hospitalized patients with diabetes. Given the variety of clinical situations that can occur in the inpatient setting, many medical centers have established dedicated inpatient diabetes teams. There is ample evidence, albeit retrospective, that these teams improve inpatient glucose control and reduce lengths of hospital stays. Using hospitalization as an opportunity to educate patients about diabetes and to optimize their treatment regimen may improve long-term outpatient glycemic control.

Glucose and collagen regulate human platelet activity through aldose reductase induction of thromboxane

Diabetes mellitus is associated with platelet hyperactivity, which leads to increased morbidity and mortality from cardiovascular disease. This is coupled with enhanced levels of thromboxane (TX), an eicosanoid that facilitates platelet aggregation. Although intensely studied, the mechanism underlying the relationship among hyperglycemia, TX generation, and platelet hyperactivity remains unclear. We sought to identify key signaling components that connect high levels of glucose to TX generation and to examine their clinical relevance. In human platelets, aldose reductase synergistically modulated platelet response to both hyperglycemia and collagen exposure through a pathway involving ROS/PLCγ2/PKC/p38α MAPK. In clinical patients with platelet activation (deep vein thrombosis; saphenous vein graft occlusion after coronary bypass surgery), and particularly those with diabetes, urinary levels of a major enzymatic metabolite of TX (11-dehydro-TXB2 [TX-M]) were substantially increased. Elevated TX-M persisted in diabetic patients taking low-dose aspirin (acetylsalicylic acid, ASA), suggesting that such patients may have underlying endothelial damage, collagen exposure, and thrombovascular disease. Thus, our study has identified multiple potential signaling targets for designing combination chemotherapies that could inhibit the synergistic activation of platelets by hyperglycemia and collagen exposure.

Understanding glycemic control in the critically ill: 2011 update

Intensive monitoring of blood glucose concentrations in critically ill patients has become a standard of care in intensive care units over the past 10 years, following the publication of a single-center randomized trial targeting euglycemia in postoperative patients. This article summarizes the literature describing the relationship between hyperglycemia and mortality in the critically ill, the main findings of the major interventional trials of intensive insulin therapy, the association between hypoglycemia and increased glycemic variability with adverse outcomes, and the impact of a preexisting diagnosis of diabetes. A framework for understanding dysglycemia in the critically ill, an approach that recognizes disturbances in the "3 domains" of glycemic control--hyperglycemia, hypoglycemia, and increased glycemic variability--is presented. Finally, practical considerations relating to the implementation of glycemic management protocols are discussed.

On Arrival High Blood Glucose Level is Associated With Detrimental and Fatal Hospitalization Outcomes for Acute Coronary Syndrome

Background

High blood glucose level is frequently encountered in acute coronary syndrome. We investigated the effects of high blood glucose measured on arrival on hospitalization adverse events in acute coronary syndrome. Our study patients were Javanese in ethnicity, which constitute half of population in Indonesia. We hypothesized that elevated blood glucose has detrimental effects on hospitalization for acute coronary syndrome.

Methods

We designed an observasional cohort study and recruited 148 consecutive patients with acute coronary syndrome. Venous blood was collected on hospital arrival. High blood glucose level was determined as plasma glucose > 140 mg/dL. Adverse hospitalization events were recorded, i.e. mortality, acute heart failure, cardiogenic shock and heart rhythm disorders. Echocardiography examination was performed to determine left ventricular function.

Results

The prevalence of on arrival high blood glucose among Javanese patients with acute coronary syndrome was considerably high (36%). On arrival high blood glucose was associated with acute heart failure (P < 0.001) and shock cardiogenic (P = 0.02). Heart rhythm disorders were higher in high blood glucose patients (P = 0.004). Left ventricular dysfunction was more prevalent in high blood glucose patients (P = 0.001) and ejection fraction was lower (P = 0.001). On arrival high blood glucose was independently associated with hospitalization adverse events (adjusted odds ratio = 2.3, 95% confidence interval: 1.1-4.9, P = 0.03) and hospital mortality (adjusted odds ratio = 6.9, 95% confidence interval: 1.2-38.6, P = 0.03).

Conclusions

Our study suggests that on arrival high blood glucose among Javanese patients with acute coronary syndrome is considerably high and is associated with detrimental and fatal hospitalization outcomes.

Influence of Abnormal Fasting Plasma Glucose on Left Ventricular Function in Older Patients With Acute Myocardial Infarction

We assessed whether the admission fasting plasma glucose (FPG) levels were associated with all-cause mortality and left ventricular (LV) function in older patients with acute myocardial infarction (AMI). A total of 1854 consecutive patients were categorized into 4 groups: hypoglycemia, euglycemia, mild hyperglycemia, and severe hyperglycemia. The primary outcomes were in-hospital/3-year mortality and LV function. There was a near-linear relationship between FPG and Killip class. However, no significant correlation was found between FPG levels and LV ejection fraction. Both FPG levels and Killip classes were all independent significant predictors of mortality. Compared with the euglycemia group, both the hypo- and hyperglycemia groups were associated with higher in-hospital and 3-year mortality. In older patients with AMI, the FPG values had differential influences on LV function and mortality. There was a U-shaped relationship between FPG and in-hospital/3-year mortality, and a near-linear relationship between increased admission glucose levels and higher Killip classification.

Management of tight intraoperative glycemic control during off-pump coronary artery bypass surgery in diabetic and nondiabetic patients

OBJECTIVES

To optimize intra- and postoperative insulin management in cardiac surgical patients.

DESIGN

A prospective, randomized, open-label, single-center study.

SETTING

A large nonuniversity hospital.

PARTICIPANTS

Sixty diabetics and 60 nondiabetics undergoing off-pump cardiac bypass surgery.

INTERVENTIONS

Intra- and postoperative tight glycemic control were achieved using different approaches with a modified insulin protocol.

MEASUREMENTS AND MAIN RESULTS

Nondiabetics were divided randomly: in the ND-ind group (n = 30), insulin was started at induction according to preinduction blood glucose (BG) concentrations. In group ND >110 (n = 30), insulin was started when BG concentrations exceeded 110 mg/dL during surgery. Up to 85% of the ND >110 group started on insulin intraoperatively. Intraoperatively, the ND-ind group had more BG within target (80-110 mg/dL) (p = 0.002), less BG >130 mg/dL (p = 0.015), and more BG between 70 and 79 mg/dL (p = 0.002). In diabetics, BG concentration was checked every 30 (DM-30), n = 30) versus 60 minutes (DM-60, n = 30) to improve the protocol's performance. Intraoperatively, there were more BG concentrations within target (80-110 mg/dL) (p = 0.02) and less >130 mg/dL (p = 0.0002) in the DM-30 group. During surgery, the hyperglycemic index and the glycemic penalty index were lower in the ND-ind group (p < 0.05). Postoperatively, the mean BG concentrations, hyperglycemic index, and glycemic penalty index in diabetics and nondiabetics were comparable between groups (p < 0.05). In the overall 2,641 BG samples, the lowest BG concentration in the operating room was 71 and in the intensive care unit (ICU) it was 61 mg/dL.

CONCLUSIONS

In diabetics and nondiabetics undergoing off-pump coronary artery bypass surgery, tight perioperative glycemic control is feasible and efficient, with minimal risks for hypo- and hyperglycemia. In nondiabetics, starting insulin therapy from induction onwards results in more measurements within target, without affecting the mean BG. In diabetics, decreasing the sampling interval from 60 to 30 minutes results in more measurements within target and in a mean blood glucose within target at ICU arrival.

Effect of abnormal fasting plasma glucose level on all-cause mortality in older patients with acute myocardial infarction: results from the Beijing Elderly Acute Myocardial Infarction Study (BEAMIS)

OBJECTIVE

To assess whether the relationship between abnormal fasting plasma glucose (FPG) levels and patient outcomes holds for both older men and older women with acute myocardial infarction (AMI).

PATIENTS AND METHODS

From April 1, 2004, to October 31, 2006, a total of 2016 consecutive older patients (age ≥65 years) presenting with AMI were screened. Of these patients, 1854 were consecutively enrolled in the study. Patients were categorized into 4 groups: the hypoglycemic group (FPG, ≤90.0 mg/dL [to convert to mmol/L, multiply by 0.0555]; n=443, 23.9%), the euglycemic group (FPG, 90.1-126.0 mg/dL; n=812, 43.8%), the mildly hyperglycemic group (FPG, 126.1-162.0 mg/dL; n=308, 16.6%), and the severely hyperglycemic group (FPG, ≥162.1 mg/dL; n=291, 15.7%). The primary outcomes were rates of in-hospital and 3-year mortality.

RESULTS

Female patients were older and had a higher incidence of diabetes mellitus but lower rates of smoking and use of invasive therapy. Men tended to have a higher frequency of hypoglycemia, whereas women tended to have a higher frequency of hyperglycemia. No significant difference was found in in-hospital (10.9% vs 9.1%; P=.36) or 3-year (24.5% vs 24.5%; P=.99) mortality between male and female patients, and FPG-associated mortality did not vary significantly by sex.

CONCLUSION

An increased FPG level was associated with a relatively higher risk of in-hospital mortality in men but not in women. Nonetheless, increased and decreased FPG levels at admission could predict higher mortality rates regardless of sex. There was a striking U-shaped relationship between FPG levels and in-hospital and 3-year mortality. The effect of abnormal FPG level on outcomes among older patients with AMI did not vary significantly by sex.

Correlates of acute insulin resistance in the early phase of non-diabetic ST-elevation myocardial infarction

The relationship between insulin secretion and acute insulin resistance (as assessed by Homeostatic Model Assessment [HOMA] index) and clinical and biochemical parameters in the early phase of non-diabetic ST-elevation myocardial infarction (STEMI) is so far unexplored. We aimed at assessing this relation in 286 consecutive STEMI patients without previously known diabetes submitted to primary percutaneous coronary intervention (PCI). Insulin resistance (as indicated by HOMA) was detectable in 67.1%. Non-parametric correlation showed that HOMA index was significantly correlated with BMI (r = 0.242; p < 0.0001) and HbA(1c) (r = 0.189; p < 0.001). At multivariable backward linear regression analysis, glycaemia was directly related to leukocyte count (p = 0.0003), age (p = 0.0001), creatine kinase isoform MB (CK-MB) (p = 0.00278) and lactate (p < 0.0001). Insulin was directly and significantly related to glycaemia (p = 0.0006), body mass index (BMI) (p = 0.00028) and lactate (p = 0.0096) In the early phase of STEMI without previously known diabetes the acute glucose dysmetabolism is quite complex, comprising increased glucose values and the development of acute insulin resistance. While insulin secretion is strictly related to BMI, apart from glucose levels, increased glucose values can be mainly related to the acute inflammatory response (as indicated to leukocyte count and C-RP), to age and to the degree of myocardial damage (as inferred by CK-MB).

In-hospital peak glycemia and prognosis in STEMI patients without earlier known diabetes

BACKGROUND

Acute myocardial infarction is known as an acute metabolic stress, but clinicians currently have limited guidance regarding the evaluation and management of hyperglycemia after revascularization.

METHODS AND RESULTS

We assessed the prognostic role of three different ranges of in-hospital peak glycemia (<140, 140-180, and >180 mg/dl) in 252 acute ST-segment elevation myocardial infarction patients without earlier known diabetes submitted to percutaneous coronary intervention consecutively admitted to our intensive cardiac care unit (ICCU). Patients with highest peak glycemia showed the highest intra-ICCU mortality (7/44, 15.9%), which was significantly higher with respect to the other two subgroups (P=0.001 and 0.034, respectively). At backward stepwise logistic regression analysis, peak glycemia (odds ratio: 3.14; 95% confidence interval: 1.01-9.74, P=0.047) was an independent predictor of intra-ICCU mortality.

CONCLUSION

In acute ST-segment elevation myocardial infarction patients without earlier known diabetes submitted to mechanical revascularization, the poorer in-hospital glucose control was associated with higher mortality; peak glycemia greater than 180 mg/dl was associated with the highest mortality, whereas patients with peak glycemia comprised between 140 and 180 mg/dl exhibited intermediate mortality rates. According to our data during hospitalization intensivists should achieve glucose control values less than 140 mg/dl, as peak glycemia resulted in the independent predictor of intra-ICCU mortality.

Blood glucose control and coronary heart disease

Epidemiologic data support the hypothesis of a direct and independent relationship between hyperglycemia and cardiovascular disease. The lack of a clear-cut threshold value in diabetic patients, and the persistence of the relationship in nondiabetic population as well, suggest that glycemia is a continuous variable, similarly to other cardiovascular risk factors. Moreover, increased plasma glucose levels contribute to cardiovascular risk by activating multiple atherogenic mechanisms. In spite of evident plausibility for hyperglycemia as a cardiovascular risk factor per se, intervention data remain controversial. Results of recent large-scale intervention trials, such as ACCORD, ADVANCE, and VADT, seem to undermine the concept that tight glycemic control confers some protection against cardiovascular disease in patients with type 2 diabetes, while maintenance of near-normal glycemic control from earlier stage of the disease and during acute coronary events seems to be more beneficial. However, individualized therapies remain the cornerstone of strategies aimed to reduce cardiovascular risk associated to hyperglycemia.

In-hospital complications after invasive strategy for the management of Non STEMI: women fare as well as men

BACKGROUND

To analyze the in-hospital complication rate in women suffering from non-ST elevation myocardial infarction treated with percutaneous coronary intervention (PCI) compared to men.

METHODS

The files of 479 consecutive patients (133 women and 346 men) suffering from a Non STEMI (Non ST-segment elevation myocardial infarction) between the January 1st 2006 and March 21st 2009 were retrospectively analyzed with special attention to every single complication occurring during hospital stay. Data were analyzed using nonparametric tests and are reported as median unless otherwise specified. A p value < .05 was considered significant.

RESULTS

As compared to men, women were significantly older (75.8 vs. 65.2 years; p < .005). All cardiovascular risk factors but tobacco and hypertension were similar between the groups: men were noticeably more often smoker (p < .0001) and women more hypertensive (p < .005). No difference was noticed for pre-hospital cardiovascular drug treatment. However women were slightly more severe at entry (more Killip class IV; p = .0023; higher GRACE score for in-hospital death - p = .008 and CRUSADE score for bleeding - p < .0001). All the patients underwent PCI of the infarct-related artery after 24 or 48 hrs post admission without sex-related difference either for timing of PCI or primary success rate. During hospitalization, 130 complications were recorded. Though the event rate was slightly higher in women (30% vs. 26% - p = NS), no single event was significantly gender related. The logistic regression identified age and CRP concentration as the only predictive variables in the whole group. After splitting for genders, these parameters were still predictive of events in men. In women however, CRP was the only one with a borderline p value.

CONCLUSIONS

Our study does not support any gender difference for in-hospital adverse events in patients treated invasively for an acute coronary syndrome without ST-segment elevation and elevated troponin.

Influence of admission plasma glucose level on short- and long-term prognosis in patients with ST-segment elevation myocardial infarction

BACKGROUND/AIM

Hyperglicemia is common in patients with ST-elevation myocardial infarction (STEMI) and is associated with high risk of mortality and morbidity. Relationship between admission plasma glucose (APG) levels and mortality in diabetic and nondiabetic patients with STEMI needs further investigation. The aim of this study was to analyse the short- and long-term prognostic significance of APG levels in patients with STEMI with and without diabetes.

METHODS

This study included 115 patients with STEMI, 86 (74.8%) nondiabetic and 29 (25.2%) dibaetic patients, in which we performed a prospective analysis of the relationship between APG levels and short- and long-term mortality.

RESULTS

Comparison of APG levels between nondiabetic (8.32 +/- 2.4 mmol/L) and diabetic (10.09 +/- 2.5 mmol/L) patients showed statistically significantly higher average APG levels in diabetic patients (p = 0.001). In all patients observed who died either after one month or one year after STEMI, average APG values were significantly higher in comparison with those in survived patients. There was no statistical significance in average APG levels in the diabetic patients with STEMI who died after one month and those who survived (10.09 +/- 2.68 vs 10.0 +/- 2.51 mmol/L, respectively; p = 0.657), as well as those who died after one year and those who survived (10.1 +/- 1.92 vs 10.09 +/- 2.8 mmol/L, respectively; p = 0.996). There was, however, statistical significance in average APG levels in the nondiabetic patients with STEMI who died after one month and those who survived (9.97 +/- 2.97 vs 7.91 +/- 2.08 mmol/L, respectively; p = 0.001), as well as those who died after one year and those who survived (9.17 +/- 2.49 vs 7.84 +/- 2.24 mmol/L, respectively; p = 0.013).

CONCLUSION

Acute hyperglicemia in the settings of STEMI worsenes the prognosis in patients with and without diabetes. Our study showed that nondiabetic patients with high APG levels are at higher risk of mortality than patients with a known history of diabetes.

Postprocedural hyperglycemia in ST elevation myocardial infarction submitted to percutaneous coronary intervention: a prognostic indicator and a marker of metabolic derangement

BACKGROUND

Hyperglycemia in acute coronary syndrome is associated with an increased risk of death in patients without previously known diabetes but the prognostic role of postrevascularization hyperglycemia in these patients is so far incompletely elucidated.

MATERIALS AND METHODS

In 175 consecutive patients without previously known diabetes and with ST elevation myocardial infarction treated with primary angioplasty, we evaluated the relation between acute and chronic glucose dysmetabolism and early and late mortality and the relation between hyperglycemia and extension of myocardial damage [creatine phosphokinase-MB (CPK-MB), troponin I levels, ejection fraction], inflammation (leukocyte count, erythrocyte sedimentation rate, C-reactive protein) and prognostic biohumoral markers [N-terminal brain natriuretic peptide (NT-proBNP) and lactic acid].

RESULTS

Highest glucose levels were associated with higher Killip class, lower ejection fraction and increased values of CPK, CPK-MB, troponin I, proBNP, lactic acid, leukocytes and insulin. At multivariate logistic regression analysis, the following variables were independent predictors of intraintensive cardiac care unit mortality: postprocedural glycemia [odds ratio (OR) 8.79; 95% confidence interval (CI) 1.41-54.94; P = 0.020] and troponin I (OR 1.003; 95% CI 1.0004-1.006; P = 0.023) when adjusted for insulinemia [OR 0.98; 95% CI 0.92-1.06; P = not significant (NS)], HbA1c (OR 0.51; 95% CI 0.11-2.37; P = NS), ST elevation myocardial infarction location (OR 1.27; 95% CI 0.44-3.66; P = NS) and creatininemia (OR 1.48; 95% CI 0.90-2.45; P = NS).

CONCLUSION

In ST elevation myocardial infarction patients without previously known diabetes submitted to percutaneous coronary intervention, glucose serum levels measured after mechanical revascularization were independent predictors of in-hospital mortality.

The influence of stress hyperglycaemia on the prognosis of patients with acute myocardial infarction and temporary electrical cardiac pacing

Introduction. Elevated glucose levels on admission in many emergency conditions, including acute myocardial infarction (AMI), have been identified as a predictor of hospital mortality. Objective. Since there are no data in the literature related to stress hyperglycaemia (SH) in patients with both AIM and temporary electrical cardiac pacing, we aimed to investigate the influence of stress hyperglycaemia on the prognosis of patients with AMI and temporary electrical cardiac pacing. Methods. The prospective study included 79 patients with diagnosed AMI with ST-segment elevation (STEMI), admitted to the Coronary Care Unit of the Clinic for Cardiovascular Diseases, Clinical Centre Nis, from 2004 to 2007, who were indicated for temporary electrical cardiac pacing. The blood was sampled on admission for lab analysis, glucose levels were determined (as well as markers of myocardial necrosis - troponin I, CK-MB). Echocardiographic study was performed and ejection fraction was evaluated by using area length method. Results. The ROC analysis indicated that the best glycaemic level on admission, which could be used as a predictor of mortality, was 10.00 mmol/l, and the area under the curve was 0.82. In the group without SH, hospital mortality was 3-fold lower 11/48 (22.91%) compared to the group with SH 19/31 (61.29%), p<0.0001. Patients with SH were more likely to have higher troponin levels, Killip >1, lower ejection fraction and heart rate, as well as systolic blood pressure. Conclusion. The best cut-off value for SH in patients with AMI (STEMI) and temporary electrical cardiac pacing is 10 mmol/l (determined by ROC curve) and may be used in risk stratification; patients with glucose levels <10 mmol/l on admission are at 3-fold lower risk compared to those with glucose levels >10 mml/l. Our results suggest that SH is a more reliable marker of poor outcome in AMI patients with temporary pace maker, without previously diagnosed DM.