101
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Davidson P, Kwiatkowski CA, Wien M. Management of Hyperglycemia and Enteral Nutrition in the Hospitalized Patient. Nutr Clin Pract 2015; 30:652-9. [PMID: 26084507 DOI: 10.1177/0884533615591057] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
There has been increased attention on the importance of identifying and distinguishing the differences between stress-induced hyperglycemia (SH), newly diagnosed hyperglycemia (NDH), and hyperglycemia in persons with established diabetes mellitus (DM). Inpatient blood glucose control is now being recognized as not only a cost issue for hospitals but also a concern for patient safety and care. The reasons for the increased incidence of hyperglycemia in hospitalized patients include preexisting DM, undiagnosed DM or prediabetes, SH, and medication-induced hyperglycemia with resulting transient blood glucose variability. It is clear that identifying and documenting hyperglycemia in hospitalized patients with and without a previous diagnosis of DM and initiating prompt insulin treatment are important. Agreement on the optimum treatment goals for hyperglycemia remains quite controversial, and the benefits of intensive glucose management may be lost at the cost of hypoglycemia in intensive care unit patients. Nutrition support in the form of enteral nutrition (EN) increases the risk of hyperglycemia in both critical and non-critically ill hospitalized patients. Reasons for beginning a tube feeding are the same whether a person has NDH or DM. What differs is how to incorporate EN into the established insulin management protocols. The risk for hyperglycemia with the addition of EN is even higher in those without a previous diagnosis of DM. This review discusses the incidence of hyperglycemia, the pathogenesis of hyperglycemia, factors contributing to hyperglycemia in the hospitalized patient, glycemic management goals, current glycemic management recommendations, and considerations for EN formula selection, administration, and treatment.
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Affiliation(s)
| | - Cynthia Ann Kwiatkowski
- Monmouth Medical Center, Long Branch, New Jersey Rutgers University, School of Health Related Professions, Scotch Plains, New Jersey
| | - Michelle Wien
- Human Nutrition and Food Science Department, California State Polytechnic University, Pomona, California
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102
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Sáenz-Abad D, Gimeno-Orna JA, Sierra-Bergua B, Pérez-Calvo JI. [Predictors of mean blood glucose control and its variability in diabetic hospitalized patients]. ENDOCRINOLOGIA Y NUTRICION : ORGANO DE LA SOCIEDAD ESPANOLA DE ENDOCRINOLOGIA Y NUTRICION 2015; 62:257-263. [PMID: 25907976 DOI: 10.1016/j.endonu.2014.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Revised: 05/26/2014] [Accepted: 06/05/2014] [Indexed: 06/04/2023]
Abstract
INTRODUCTION This study was intended to assess the effectiveness and predictors factors of inpatient blood glucose control in diabetic patients admitted to medical departments. MATERIAL AND METHODS A retrospective, analytical cohort study was conducted on patients discharged from internal medicine with a diagnosis related to diabetes. Variables collected included demographic characteristics, clinical data and laboratory parameters related to blood glucose control (HbA1c, basal plasma glucose, point-of-care capillary glucose). The cumulative probability of receiving scheduled insulin regimens was evaluated using Kaplan-Meier analysis. Multivariate regression models were used to select predictors of mean inpatient glucose (MHG) and glucose variability (standard deviation [GV]). RESULTS The study sample consisted of 228 patients (mean age 78.4 (SD 10.1) years, 51% women). Of these, 96 patients (42.1%) were treated with sliding-scale regular insulin only. Median time to start of scheduled insulin therapy was 4 (95% CI, 2-6) days. Blood glucose control measures were: MIG 181.4 (SD 41.7) mg/dL, GV 56.3 (SD 22.6). The best model to predict MIG (R(2): .376; P<.0001) included HbA1c (b=4.96; P=.011), baseline plasma glucose (b=.056; P=.084), mean capillary blood glucose in the first 24hours (b=.154; P<.0001), home treatment (versus oral agents) with basal insulin only (b=13.1; P=.016) or more complex (pre-mixed insulin or basal-bolus) regimens (b=19.1; P=.004), corticoid therapy (b=14.9; P=.002), and fasting on admission (b=10.4; P=.098). CONCLUSION Predictors of inpatient blood glucose control which should be considered in the design of DM management protocols include home treatment, HbA1c, basal plasma glucose, mean blood glucose in the first 24hours, fasting, and corticoid therapy.
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Affiliation(s)
- Daniel Sáenz-Abad
- Servicio de Urgencias, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España.
| | | | - Beatriz Sierra-Bergua
- Servicio de Urgencias, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
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103
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Abstract
The management of inpatient hyperglycemia is a focus of quality improvement projects across many hospital systems while remaining a point of controversy among clinicians. The association of inpatient hyperglycemia with suboptimal hospital outcomes is accepted by clinical care teams; however, the clear benefits of targeting hyperglycemia as a mechanism to improve hospital outcomes remain contentious. Glycemic management is also frequently confused with efforts aimed at intensive glucose control, further adding to the confusion. Nonetheless, several regulatory agencies assign quality rankings based on attaining specified glycemic targets for selected groups of patients (Surgical Care Improvement Project (SCIP) measures). The current paper reviews the data supporting the benefits associated with inpatient glycemic control projects, the components of a successful glycemic control intervention, and utilization of the electronic medical record in implementing an inpatient glycemic control project.
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Affiliation(s)
- Joseph A Aloi
- Eastern Virginia Medical School, Division of Endocrinology and Metabolism, 855 W. Brambleton Avenue, Norfolk, VA, 23510, USA,
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104
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AbuShady MM, Mohamady Y, Enany B, Nammas W. Prevalence of prediabetes in patients with acute coronary syndrome: impact on in-hospital outcomes. Intern Med J 2015; 45:183-8. [DOI: 10.1111/imj.12651] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Accepted: 11/25/2014] [Indexed: 11/29/2022]
Affiliation(s)
- M. M. AbuShady
- Endocrinology Unit; Department of Internal Medicine; Faculty of Medicine; Ain Shams University; Cairo Egypt
| | - Y. Mohamady
- Cardiology Department; Faculty of Medicine; Ain Shams University; Cairo Egypt
| | - B. Enany
- Cardiology Department; Faculty of Medicine; Ain Shams University; Cairo Egypt
| | - W. Nammas
- Cardiology Department; Faculty of Medicine; Ain Shams University; Cairo Egypt
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105
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Mabrey ME, Barton AB, Corsino L, Freeman SB, Davis ED, Bell EL, Setji TL. Managing hyperglycemia and diabetes in patients receiving enteral feedings: A health system approach. Hosp Pract (1995) 2015; 43:74-8. [PMID: 25744356 PMCID: PMC4397647 DOI: 10.1080/21548331.2015.1022493] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
Abstract
Evidence of poor outcomes in hospitalized patients with hyperglycemia has led to new and revised guidelines for inpatient management of diabetes. As providers become more aware of the need for better blood glucose control, they are finding limited guidance in the management of patients receiving enteral nutrition. To address the lack of guidelines in this population, Duke University Health System has developed a consistent practice for managing such patients. Here, we present our practice strategies for insulin use in patients receiving enteral nutrition. Essential factors include assessing the patients' history of diabetes, hyperglycemia, or hypoglycemia and timing and type of feedings. Insulin practices are then designed to address these issues keeping in mind patient safety in the event of abrupt cessation of nutrition. The outcome of the process is a consistent and safe method for glucose control with enteral nutrition.
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Affiliation(s)
- Melanie E. Mabrey
- Duke University School of Nursing, Durham, NC, USA
- Division of Endocrinology, Metabolism and Nutrition, Duke University School of Medicine, Durham, NC, USA
| | - Anna Beth Barton
- Division of Endocrinology, Metabolism and Nutrition, Duke University School of Medicine, Durham, NC, USA
| | - Leonor Corsino
- Division of Endocrinology, Metabolism and Nutrition, Duke University School of Medicine, Durham, NC, USA
| | - Susan B. Freeman
- Department of Advanced Clinical Practice, Duke University Hospital, Durham, NC, USA
| | - Ellen D. Davis
- Duke University School of Nursing, Durham, NC, USA
- Department of Advanced Clinical Practice, Duke University Hospital, Durham, NC, USA
| | - Elizabeth L. Bell
- Division of Endocrinology, Metabolism and Nutrition, Duke University School of Medicine, Durham, NC, USA
| | - Tracy L. Setji
- Division of Endocrinology, Metabolism and Nutrition, Duke University School of Medicine, Durham, NC, USA
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106
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Marelli G, Avanzini F, Iacuitti G, Planca E, Frigerio I, Busi G, Carlino L, Cortesi L, Roncaglioni MC, Riva E. Effectiveness of a nurse-managed protocol to prevent hypoglycemia in hospitalized patients with diabetes. J Diabetes Res 2015; 2015:173956. [PMID: 25961051 PMCID: PMC4415533 DOI: 10.1155/2015/173956] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Revised: 03/23/2015] [Accepted: 03/23/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Hypoglycemia due to inadequate carbohydrate intake is a frequent complication of insulin treatment of diabetic in-patients. Objective. To assess the effectiveness of a nurse-managed protocol to prevent hypoglycemia during subcutaneous insulin treatment. DESIGN Prospective pre-post-intervention study. METHODS In 350 consecutive diabetic in-patients the incidence of hypoglycemia (blood glucose < 70 mg/dL) during subcutaneous insulin treatment was assessed before (phase A) and after (phase B) the protocol was adopted to permit (1) the patient to opt for substitutive food to integrate incomplete carbohydrate intake in the meal; (2) in case of lack of appetite or repeatedly partial intake of the planned food, prandial insulin administered at the end of the meal to be related to the actual amount of carbohydrates eaten; (3) intravenous infusion of glucose during prolonged fasting. RESULTS Eighty-four patients in phase A and 266 in phase B received subcutaneous insulin for median periods of, respectively, 7 (Q1-Q3 6-12) and 6 days (Q1-Q3 4-9). Hypoglycemic events declined significantly from 0.34 ± 0.33 per day in phase A to 0.19 ± 0.30 in phase B (P > 0.001). CONCLUSIONS A nurse-managed protocol focusing on carbohydrate intake reduced the incidence of hypoglycemia in patients with diabetes receiving subcutaneous insulin in hospital.
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Affiliation(s)
- Giuseppe Marelli
- Diabetes and Metabolic Diseases Unit, Ospedale di Desio, Desio, Italy
| | - Fausto Avanzini
- Division of Cardiology and Intensive Cardiac Care Unit, Ospedale di Desio, Desio, Italy
- IRCCS-Istituto di Ricerche Farmacologiche “Mario Negri”, Via Giuseppe La Masa 19, 20156 Milan, Italy
- *Fausto Avanzini:
| | - Giuseppe Iacuitti
- Division of Cardiology and Intensive Cardiac Care Unit, Ospedale di Desio, Desio, Italy
| | - Enrico Planca
- Division of Cardiology and Intensive Cardiac Care Unit, Ospedale di Desio, Desio, Italy
| | - Ilaria Frigerio
- Division of Cardiology and Intensive Cardiac Care Unit, Ospedale di Desio, Desio, Italy
| | - Giovanna Busi
- Division of Cardiology and Intensive Cardiac Care Unit, Ospedale di Desio, Desio, Italy
| | - Liliana Carlino
- Division of Cardiology and Intensive Cardiac Care Unit, Ospedale di Desio, Desio, Italy
| | - Laura Cortesi
- IRCCS-Istituto di Ricerche Farmacologiche “Mario Negri”, Via Giuseppe La Masa 19, 20156 Milan, Italy
| | - Maria Carla Roncaglioni
- IRCCS-Istituto di Ricerche Farmacologiche “Mario Negri”, Via Giuseppe La Masa 19, 20156 Milan, Italy
| | - Emma Riva
- IRCCS-Istituto di Ricerche Farmacologiche “Mario Negri”, Via Giuseppe La Masa 19, 20156 Milan, Italy
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Kahles F, Meyer C, Möllmann J, Diebold S, Findeisen HM, Lebherz C, Trautwein C, Koch A, Tacke F, Marx N, Lehrke M. GLP-1 secretion is increased by inflammatory stimuli in an IL-6-dependent manner, leading to hyperinsulinemia and blood glucose lowering. Diabetes 2014; 63:3221-9. [PMID: 24947356 DOI: 10.2337/db14-0100] [Citation(s) in RCA: 139] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Hypoglycemia and hyperglycemia are both predictors for adverse outcome in critically ill patients. Hyperinsulinemia is induced by inflammatory stimuli as a relevant mechanism for glucose lowering in the critically ill. The incretine hormone GLP-1 was currently found to be induced by endotoxin, leading to insulin secretion and glucose lowering under inflammatory conditions in mice. Here, we describe GLP-1 secretion to be increased by a variety of inflammatory stimuli, including endotoxin, interleukin-1β (IL-1β), and IL-6. Although abrogation of IL-1 signaling proved insufficient to prevent endotoxin-dependent GLP-1 induction, this was abolished in the absence of IL-6 in respective knockout animals. Hence, we found endotoxin-dependent GLP-1 secretion to be mediated by an inflammatory cascade, with IL-6 being necessary and sufficient for GLP-1 induction. Functionally, augmentation of the GLP-1 system by pharmacological inhibition of DPP-4 caused hyperinsulinemia, suppression of glucagon release, and glucose lowering under endotoxic conditions, whereas inhibition of the GLP-1 receptor led to the opposite effect. Furthermore, total GLP-1 plasma levels were profoundly increased in 155 critically ill patients presenting to the intensive care unit (ICU) in comparison with 134 healthy control subjects. In the ICU cohort, GLP-1 plasma levels correlated with markers of inflammation and disease severity. Consequently, GLP-1 provides a novel link between the immune system and the gut with strong relevance for metabolic regulation in context of inflammation.
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Affiliation(s)
- Florian Kahles
- Department of Internal Medicine I, University Hospital Aachen, Aachen, Germany
| | - Christina Meyer
- Department of Internal Medicine I, University Hospital Aachen, Aachen, Germany
| | - Julia Möllmann
- Department of Internal Medicine I, University Hospital Aachen, Aachen, Germany
| | - Sebastian Diebold
- Department of Internal Medicine I, University Hospital Aachen, Aachen, Germany
| | - Hannes M Findeisen
- Department of Internal Medicine I, University Hospital Aachen, Aachen, Germany
| | - Corinna Lebherz
- Department of Internal Medicine I, University Hospital Aachen, Aachen, Germany
| | - Christian Trautwein
- Department of Internal Medicine III, University Hospital Aachen, Aachen, Germany
| | - Alexander Koch
- Department of Internal Medicine III, University Hospital Aachen, Aachen, Germany
| | - Frank Tacke
- Department of Internal Medicine III, University Hospital Aachen, Aachen, Germany
| | - Nikolaus Marx
- Department of Internal Medicine I, University Hospital Aachen, Aachen, Germany
| | - Michael Lehrke
- Department of Internal Medicine I, University Hospital Aachen, Aachen, Germany
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108
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Birkhead J, Weston C, Timmis A, Chen R. The effects of intravenous insulin infusions on early mortality for patients with acute coronary syndromes who present with hyperglycaemia: A matched propensity analysis using data from the MINAP database 2008-2012. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 4:344-52. [PMID: 25202024 DOI: 10.1177/2048872614549733] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 08/07/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND In acute coronary syndrome, the use of intravenous insulin infusions (IVII) to control hyperglycaemia is based on limited evidence of survival benefit. AIMS To compare 7 day survival for patients receiving IVII compared with those receiving routine care to control admission hyperglycaemia (>=11 mmol/l) in acute coronary syndrome. METHODS AND RESULTS We used matched propensity analysis to examine observational data from the MINAP database between 2008 and 2012. We matched 5974 pairs of patients. We separately examined outcomes for ST elevation (STEMI) and non ST segment elevation (NSTEMI) infarctions, and those without known diabetes and those with type 2 diabetes. Survival benefit from the use of IVII was seen only in patients with STEMI not known to have diabetes at admission (adjusted hazard ratio (HR) 0.77 (95% confidence interval (CI) 0.64-0.92), p=0.005). Those with STEMI and existing type 2 diabetes who received IVII showed similar outcomes to routine care (HR 0.99 (95% CI 0.80-1.23), p=0.931). In patients with NSTEMI IVII was associated with significantly worse adjusted 7 day survival outcome than routine care, regardless of diabetes status; for those without known diabetes, HR 1.50 (95% CI 1.04-2.16), p=0.029, and for those with type 2 diabetes, HR 1.35 (95% CI 1.08-1.70), p=0.010. CONCLUSION As used in current clinical practice to treat hyperglycaemia in acute coronary syndromes, IVII appears to be of benefit only for patients with STEMI who are not known to have diabetes. IVII is associated with adverse early outcomes in patients with NSTEMI.
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Affiliation(s)
- John Birkhead
- National Institute for Cardiovascular Outcomes Research, UK
| | | | - Adam Timmis
- NIHR Biomedical Research Unit, Barts Health NHS Trust, UK
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109
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Abstract
Inpatient hyperglycemia, in patients with and without a history of diabetes, is associated with increased risk of complications, mortality, and longer hospital stay in medicine and surgical patients. Bedside capillary point of care testing is widely recommended as the preferred method for glucose monitoring and for guiding glycemic management of individual patients; however, the accuracy of most handheld glucose meters is far from optimal. Recent studies in the hospital setting have reported that the use of continuous glucose monitoring (CGM) can provide real-time information about glucose concentration, direction, and rate of change over a period of several days. Because it provides glucose values every 5-10 minutes 24 hours a day, CGM may have an advantage over point of care testing with respect to reducing the incidence of severe hypoglycemia in acute care. Real-time CGM technology may facilitate glycemic control and to reduce hypoglycemia in insulin-treated patients. Recent guidelines, however, have recommended deferring the use of CGM in the adult hospital setting until further data on accuracy and safety become available. In this study, we review the advantages and disadvantages of the use of real-time CGM in the management of dysglycemia in the hospital setting.
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Affiliation(s)
- Ana Maria Gomez
- Department of Medicine, Universidad Javeriana, Bogota, Colombia
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110
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Gianchandani RY, Esfandiari NH, Haft JW, Prager RL, Pop-Busui R. Diabetes and stress hyperglycemia in the intensive care unit: outcomes after cardiac surgery. Hosp Pract (1995) 2014; 40:22-30. [PMID: 22615075 DOI: 10.3810/hp.2012.04.966] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Hyperglycemia is common in the post-cardiac surgery population and has been associated with increased mortality rates, surgical length of stay, and infection rates. Although hospitalized patients with diabetes are known to have more complications, recent studies in various hospital settings have reported worse outcomes in patients with stress hyperglycemia than in those with diabetes. AIM The primary objective of this study was to analyze 30- and 90-day mortality rates in post-cardiac surgery patients with stress hyperglycemia and diabetes who were managed to achieve similar moderate blood glucose goals using the University of Michigan Hospital (Ann Arbor, MI) insulin protocol between 2005 and 2008. The secondary outcomes were rates of postoperative complications, including hypoglycemia. METHODS A standardized glucose management program was followed to treat all patients in the cardiac intensive care unit, with a blood glucose goal of 100 to 140 mg/dL. Data from 1973 patients with either diabetes or stress hyperglycemia were analyzed to identify associations between mean postoperative blood glucose levels and mortality, incidence of hypoglycemia, and complication rates. RESULTS Mortality rates did not differ between patients with diabetes and stress hyperglycemia (3.4 and 2.3%; P = 0.2). Rates of severe hypoglycemia were low (1%) for both groups and were not associated with an increase in mortality (P = 0.95). Other complication rates were similar between patients with diabetes and stress hyperglycemia. CONCLUSION Maintaining a blood glucose range between 100 to 140 mg/dL in post-cardiac surgery patients was associated with a low mortality rate, low risk of hypoglycemia, and with complications rates that were similar in patients with diabetes and stress hyperglycemia.
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Affiliation(s)
- Roma Y Gianchandani
- Assistant Professor, Department of Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI.
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111
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Sims MW, Winter J, Brennan S, Norman RI, André Ng G, Squire IB, Rainbow RD. PKC-mediated toxicity of elevated glucose concentration on cardiomyocyte function. Am J Physiol Heart Circ Physiol 2014; 307:H587-97. [DOI: 10.1152/ajpheart.00894.2013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
While it is well established that mortality risk after myocardial infarction (MI) increases in proportion to blood glucose concentration at the time of admission, it is unclear whether there is a direct, causal relationship. We investigated potential mechanisms by which increased blood glucose may exert cardiotoxicity. Using a Wistar rat or guinea-pig isolated cardiomyocyte model, we investigated the effects on cardiomyocyte function and electrical stability of alterations in extracellular glucose concentration. Contractile function studies using electric field stimulation (EFS), patch-clamp recording, and Ca2+ imaging were used to determine the effects of increased extracellular glucose concentration on cardiomyocyte function. Increasing glucose from 5 to 20 mM caused prolongation of the action potential and increased both basal Ca2+ and variability of the Ca2+ transient amplitude. Elevated extracellular glucose concentration also attenuated the protection afforded by ischemic preconditioning (IPC), as assessed using a simulated ischemia and reperfusion model. Inhibition of PKCα and β, using Gö6976 or specific inhibitor peptides, attenuated the detrimental effects of glucose and restored the cardioprotected phenotype to IPC cells. Increased glucose concentration did not attenuate the cardioprotective role of PKCε, but rather activation of PKCα and β masked its beneficial effect. Elevated extracellular glucose concentration exerts acute cardiotoxicity mediated via PKCα and β. Inhibition of these PKC isoenzymes abolishes the cardiotoxic effects and restores IPC-mediated cardioprotection. These data support a direct link between hyperglycemia and adverse outcome after MI. Cardiac-specific PKCα and β inhibition may be of clinical benefit in this setting.
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Affiliation(s)
- Mark W. Sims
- Department of Cardiovascular Sciences, University of Leicester, Glenfield General Hospital, Leicester, United Kingdom; and
| | - James Winter
- Department of Cardiovascular Sciences, University of Leicester, Glenfield General Hospital, Leicester, United Kingdom; and
| | - Sean Brennan
- Department of Cardiovascular Sciences, University of Leicester, Glenfield General Hospital, Leicester, United Kingdom; and
| | - Robert I. Norman
- Department of Medical and Social Care Education, University of Leicester, Leicester, United Kingdom
| | - G. André Ng
- Department of Cardiovascular Sciences, University of Leicester, Glenfield General Hospital, Leicester, United Kingdom; and
| | - Iain B. Squire
- Department of Cardiovascular Sciences, University of Leicester, Glenfield General Hospital, Leicester, United Kingdom; and
| | - Richard D. Rainbow
- Department of Cardiovascular Sciences, University of Leicester, Glenfield General Hospital, Leicester, United Kingdom; and
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Lee SA, Cho SJ, Jeong MH, Kim YJ, Kim CJ, Cho MC, Kim HS, Ahn Y, Koh G, Lee JM, Oh SK, Yun KH, Kim HY, Cho CG, Lee DH. Hypoglycemia at admission in patients with acute myocardial infarction predicts a higher 30-day mortality in patients with poorly controlled type 2 diabetes than in well-controlled patients. Diabetes Care 2014; 37:2366-73. [PMID: 24914243 DOI: 10.2337/dc13-2856] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We aimed to evaluate the association between hypoglycemia at admission and 30-day mortality in patients with acute myocardial infarction (AMI) and to determine whether these associations differed according to diabetes-control status in AMI patients with diabetes. RESEARCH DESIGN AND METHODS We analyzed the prognostic significance of hypoglycemia and hyperglycemia in 34,943 AMI patients with or without type 2 diabetes from two AMI registries: the Korea Acute Myocardial Infarction Registry (KAMIR) and the Korea Working Group on Myocardial Infarction (KorMI). RESULTS The patients were divided into five groups according to serum-glucose levels at admission: <3.9 mmol/L (<70 mg/dL); 3.9-7.72 mmol/L (70-139 mg/dL); 7.78-11.06 mmol/L (140-199 mg/dL); 11.11-14.39 mmol/L (200-259 mg/dL); and ≥14.44 mmol/L (≥260 mg/dL). The 30-day mortality rates in the lowest and highest glucose groups were higher than those in other groups; the lowest glucose group had the highest mortality for patients with type 2 diabetes, after adjusting for multiple factors. We also extracted and compared four subgroups from the patients with type 2 diabetes, based on hemoglobin A1c and serum-glucose levels at admission: group A, <6.5% (48 mmol/mol) and <3.9 mmol/L; group B, <6.5% (48 mmol/mol) and ≥11.11 mmol/L; group C, ≥8% (64 mmol/mol) and <3.9 mmol/L; and group D, ≥8% (64 mmol/mol) and ≥11.11 mmol/L. Group C had the highest 30-day mortality rate among the groups. CONCLUSIONS These data suggest that hypoglycemia at admission affects clinical outcomes differently in AMI patients with type 2 diabetes depending on the diabetes-control status.
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Affiliation(s)
- Sang Ah Lee
- Department of Internal Medicine, Jeju National University Hospital, Jeju National School of Medicine, Jeju, Republic of Korea
| | - Suk Ju Cho
- Department of Anesthesiology, Jeju National University Hospital, Jeju National School of Medicine, Jeju, Republic of Korea
| | - Myung Ho Jeong
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Young Jo Kim
- Department of Internal Medicine, Yeungnam University Hospital, Daegu, Republic of Korea
| | - Chong Jin Kim
- Department of Internal Medicine, Kyung Hee University Hospital, Seoul, Republic of Korea
| | - Myeong Chan Cho
- Department of Internal Medicine, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Hyo-Soo Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Youngkeun Ahn
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Gwanpyo Koh
- Department of Internal Medicine, Jeju National University Hospital, Jeju National School of Medicine, Jeju, Republic of Korea
| | - Jeong Mi Lee
- Department of Public Health, Wonkwang University, Iksan, Republic of Korea
| | - Seok Kyu Oh
- Department of Internal Medicine, Wonkwang University School of Medicine, Iksan, Republic of Korea
| | - Kyeong Ho Yun
- Department of Internal Medicine, Wonkwang University School of Medicine, Iksan, Republic of Korea
| | - Ha Young Kim
- Department of Internal Medicine, Wonkwang University School of Medicine, Iksan, Republic of Korea
| | - Chung Gu Cho
- Department of Internal Medicine, Wonkwang University School of Medicine, Iksan, Republic of Korea
| | - Dae Ho Lee
- Department of Internal Medicine, Wonkwang University School of Medicine, Iksan, Republic of Korea
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113
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Bajwa SJS, Sehgal V, Kalra S, Baruah MP. Management of diabetes mellitus type-2 in the geriatric population: Current perspectives. J Pharm Bioallied Sci 2014; 6:151-7. [PMID: 25035634 PMCID: PMC4097928 DOI: 10.4103/0975-7406.130956] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Revised: 06/06/2013] [Accepted: 09/29/2013] [Indexed: 01/04/2023] Open
Abstract
The prevalence of diabetes mellitus (DM) has increased exponentially throughout the world and there is rapid increase in elderly diabetics. DM is associated with increased mortality and considerable morbidity including stroke, heart disease, and diminished quality of life in the elderly. However, the unique features of geriatric diabetes have not been given due a prominence in medical literature. Hypoglycemia remains the biggest complicating factor and needs to be avoided in the elderly. Most people in the geriatric age group have some degree of renal insufficiency and medications need to be adjusted wisely with changing renal profile. Because safer and more effective pharmacological therapy is available, an individual approach to DM in the elderly is essential.
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Affiliation(s)
- Sukhminder Jit Singh Bajwa
- Department of Anaesthesiology and Intensive Care Medicine, Gian Sagar Medical College and Hospital, Patiala, Punjab, India
| | - Vishal Sehgal
- Department of Internal Medicine, The Common Wealth Medical College, Scranton, PA 18510, USA
| | - Sanjay Kalra
- Department of Endocrinology, Bharti Hospital and B.R.I.D.E., Karnal, Haryana, India
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Plummer MP, Bellomo R, Cousins CE, Annink CE, Sundararajan K, Reddi BAJ, Raj JP, Chapman MJ, Horowitz M, Deane AM. Dysglycaemia in the critically ill and the interaction of chronic and acute glycaemia with mortality. Intensive Care Med 2014; 40:973-80. [PMID: 24760120 DOI: 10.1007/s00134-014-3287-7] [Citation(s) in RCA: 134] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 04/01/2014] [Indexed: 02/06/2023]
Abstract
PURPOSE Hyperglycaemia is common in the critically ill. The objectives of this study were to determine the prevalence of critical illness-associated hyperglycaemia (CIAH) and recognised and unrecognised diabetes in the critically ill as well as to evaluate the impact of premorbid glycaemia on the association between acute hyperglycaemia and mortality. METHODS In 1,000 consecutively admitted patients we prospectively measured glycated haemoglobin (HbA1c) on admission, and blood glucose concentrations during the 48 h after admission, to the intensive care unit. Patients with blood glucose ≥7.0 mmol/l when fasting or ≥11.1 mmol/l during feeding were deemed hyperglycaemic. Patients with acute hyperglycaemia and HbA1c <6.5% (48 mmol/mol) were categorised as 'CIAH', those with known diabetes as 'recognised diabetes', and those with HbA1c ≥6.5% but no previous diagnosis of diabetes as 'unrecognised diabetes'. The remainder were classified as 'normoglycaemic'. Hospital mortality, HbA1c and acute peak glycaemia were assessed using a logistic regression model. RESULTS Of 1,000 patients, 498 (49.8%) had CIAH, 220 (22%) had recognised diabetes, 55 (5.5%) had unrecognised diabetes and 227 (22.7%) were normoglycaemic. The risk of death increased by approximately 20% for each increase in acute glycaemia of 1 mmol/l in patients with CIAH and those with diabetes and HbA1c levels <7% (53 mmol/mol), but not in patients with diabetes and HbA1c ≥7%. This association was lost when adjusted for severity of illness. CONCLUSIONS Critical illness-associated hyperglycaemia is the most frequent cause of hyperglycaemia in the critically ill. Peak glucose concentrations during critical illness are associated with increased mortality in patients with adequate premorbid glycaemic control, but not in patients with premorbid hyperglycaemia. Optimal glucose thresholds in the critically ill may, therefore, be affected by premorbid glycaemia.
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Affiliation(s)
- Mark P Plummer
- Department of Critical Care Services, Royal Adelaide Hospital, North Terrace, Adelaide, SA, 5000, Australia
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115
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Umpierrez GE, Kosiborod M. Inpatient dysglycemia and clinical outcomes: association or causation? J Diabetes Complications 2014; 28:427-9. [PMID: 24813860 DOI: 10.1016/j.jdiacomp.2014.03.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Accepted: 03/12/2014] [Indexed: 12/23/2022]
Affiliation(s)
| | - Mikhail Kosiborod
- Department of Cardiovascular Disease, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO
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116
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Shore S, Maddox TM. Response to comment on Shore et al. Association between hyperglycemia at admission during hospitalization for acute myocardial infarction and subsequent diabetes: insights from the Veterans Administration Cardiac Care Follow-up Clinical Study. Diabetes Care 2014;37:409-418. Diabetes Care 2014; 37:e168. [PMID: 24963121 DOI: 10.2337/dc14-0751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Supriya Shore
- VA Eastern Colorado Health Care System, Denver, CO, and University of Colorado School of Medicine, Aurora, CO
| | - Thomas M Maddox
- VA Eastern Colorado Health Care System, Denver, CO, and University of Colorado School of Medicine, Aurora, CO
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Wernerman J, Desaive T, Finfer S, Foubert L, Furnary A, Holzinger U, Hovorka R, Joseph J, Kosiborod M, Krinsley J, Mesotten D, Nasraway S, Rooyackers O, Schultz MJ, Van Herpe T, Vigersky RA, Preiser JC. Continuous glucose control in the ICU: report of a 2013 round table meeting. Crit Care 2014; 18:226. [PMID: 25041718 PMCID: PMC4078395 DOI: 10.1186/cc13921] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Achieving adequate glucose control in critically ill patients is a complex but important part of optimal patient management. Until relatively recently, intermittent measurements of blood glucose have been the only means of monitoring blood glucose levels. With growing interest in the possible beneficial effects of continuous over intermittent monitoring and the development of several continuous glucose monitoring (CGM) systems, a round table conference was convened to discuss and, where possible, reach consensus on the various aspects related to glucose monitoring and management using these systems. In this report, we discuss the advantages and limitations of the different types of devices available, the potential advantages of continuous over intermittent testing, the relative importance of trend and point accuracy, the standards necessary for reporting results in clinical trials and for recognition by official bodies, and the changes that may be needed in current glucose management protocols as a result of a move towards increased use of CGM. We close with a list of the research priorities in this field, which will be necessary if CGM is to become a routine part of daily practice in the management of critically ill patients.
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Affiliation(s)
- Jan Wernerman
- Department of Anesthesiology and Intensive Care Medicine, K32, Karolinska University Hospital, Stockholm, Huddinge 14186, Sweden
| | - Thomas Desaive
- GIGA - Cardiovascular Sciences, University of Liege, Institute of Physics, B5, Allee du 6 aout, 17, Liege 4000, Belgium
| | - Simon Finfer
- The George Institute for Global Health and Royal North Shore Hospital, University of Sydney, St Leonards, Sydney, NSW 2065, Australia
| | - Luc Foubert
- Department of Anesthesia and Intensive Care Medicine, OLV Clinic, Aalst 9300, Belgium
| | - Anthony Furnary
- Starr-Wood Cardiac Group, 9155 SW Barnes Road, Portland, OR 97225-6629, USA
| | - Ulrike Holzinger
- Department of Medicine III - Division of Gastroenterology and Hepatology, Medical University of Vienna, Waehringer Guertel 18-20, Vienna 1090, Austria
| | - Roman Hovorka
- University of Cambridge Metabolic Research Laboratories, Level 4, Wellcome trust MRC Institute of Metabolic Science, Box 289, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Jeffrey Joseph
- Jefferson Artificial Pancreas Center and Anesthesiology Program for Translational Research, Department of Anesthesiology, Jefferson Medical College of Thomas Jefferson University, 1020 Walnut Street, Philadelphia, PA 19107, USA
| | - Mikhail Kosiborod
- Saint-Luke’s Mid America Heart Institute, University of Missouri - Kansas City, 4401 Wornall Road, Kansas City, MO 64111, USA
| | - James Krinsley
- Division of Critical Care, Stamford Hospital and Columbia University College of Physicians and Surgeons, 30 Shelburne Road, Stamford, CT 06904, USA
| | - Dieter Mesotten
- Department of Intensive Care Medicine, University Hospitals Leuven, Herestraat 49, Leuven B-3000, Belgium
| | - Stanley Nasraway
- Surgical Intensive Care Units, Tufts Medical Center, 800 Washington Street, NEMC 4360, Boston, MA 02111, USA
| | - Olav Rooyackers
- Anesthesiology and Intensive Care Clinic, Karolinska Institute and University Hospital, Huddinge 14186, Sweden
| | - Marcus J Schultz
- Department of Intensive Care Medicine, Academic Medical Center at the University of Amsterdam, Meibergdreef 9, Amsterdam 1105 AZ, The Netherlands
| | - Tom Van Herpe
- Department of Intensive Care Medicine, University Hospitals Leuven, Herestraat 49, Leuven B-3000, Belgium
- Department of Electrical Engineering (STADIUS) - iMinds Future Health Department, Katholieke Universiteit Leuven, Leuven, Heverlee B-3001, Belgium
| | - Robert A Vigersky
- Diabetes Institute, Walter Reed National Military Medical Center, Bethesda, MD 20895, USA
| | - Jean-Charles Preiser
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, 808 route de Lennik, Brussels 1070, Belgium
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Savonitto S, Morici N, Cavallini C, Antonicelli R, Petronio AS, Murena E, Olivari Z, Steffenino G, Bonechi F, Mafrici A, Toso A, Piscione F, Bolognese L, De Servi S. One-Year Mortality in Elderly Adults with Non-ST-Elevation Acute Coronary Syndrome: Effect of Diabetic Status and Admission Hyperglycemia. J Am Geriatr Soc 2014; 62:1297-303. [DOI: 10.1111/jgs.12900] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
| | - Nuccia Morici
- Division of Cardiology; Ospedale S. Carlo; Milano Italy
| | - Claudio Cavallini
- Department of Cardiology; Ospedale Santa Maria della Misericordia; Perugia Italy
| | | | - Anna Sonia Petronio
- Institute of Cardiology Azienda Ospedaliera Universitaria Pisana; Pisa Italy
| | - Ernesto Murena
- Division of Cardiology; Ospedale S Maria delle Grazie; Pozzuoli Italy
| | - Zoran Olivari
- Division of Cardiology; Ospedale Ca' Foncello; Treviso Italy
| | | | - Francesco Bonechi
- Division of Cardiology; Ospedale San Giuseppe; Empoli-Fucecchio Italy
| | | | - Anna Toso
- Division of Cardiology; Ospedale Misericordia e Dolce; Prato Italy
| | - Federico Piscione
- Department of Medicine and Surgery; University of Salerno; Salerno Italy
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Lazzeri C, Valente S, Gensini GF. Hyperglycemia in Acute Heart Failure: An Opportunity to Intervene? Curr Heart Fail Rep 2014; 11:241-5. [DOI: 10.1007/s11897-014-0205-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Mabrey ME, McFarland R, Young SL, Cooper PL, Chidester P, Rhinehart AS. Effectively identifying the inpatient with hyperglycemia to increase patient care and lower costs. Hosp Pract (1995) 2014; 42:7-13. [PMID: 24769779 DOI: 10.3810/hp.2014.04.1098] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
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.
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Affiliation(s)
- Melanie E Mabrey
- Assistant Professor, Duke University School of Nursing; Division of Endocrinology, Duke University School of Medicine, Durham, NC.
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121
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Rydén L, Grant PJ, Anker SD, Berne C, Cosentino F, Danchin N, Deaton C, Escaned J, Hammes HP, Huikuri H, Marre M, Marx N, Mellbin L, Ostergren J, Patrono C, Seferovic P, Uva MS, Taskinen MR, Tendera M, Tuomilehto J, Valensi P, Zamorano JL. ESC guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD - summary. Diab Vasc Dis Res 2014; 11:133-73. [PMID: 24800783 DOI: 10.1177/1479164114525548] [Citation(s) in RCA: 141] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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122
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Schwartz S, DeFronzo RA. The use of non-insulin anti-diabetic agents to improve glycemia without hypoglycemia in the hospital setting: focus on incretins. Curr Diab Rep 2014; 14:466. [PMID: 24515252 DOI: 10.1007/s11892-013-0466-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Patients with hyperglycemia in hospital have increased adverse outcomes compared with patients with normoglycemia, and the pathophysiological causes seem relatively well understood. Thus, a rationale for excellent glycemic control exists. Benefits of control with intensive insulin regimes are highly likely based on multiple published studies. However, hypoglycemia frequency increases and adverse outcomes of hypoglycemia accrue. This has resulted in a 'push' for therapeutic nihilism, accepting higher glycemic levels to avoid hypoglycemia. One would ideally prefer to optimize glycemia, treating hyperglycemia while minimizing or avoiding hypoglycemia. Thus, one would welcome therapies and processes of care to optimize this benefit/ risk ratio. We review the logic and early studies that suggest that incretin therapy use in-hospital can achieve this ideal. We strongly urge randomized prospective controlled studies to test our proposal and we offer a process of care to facilitate this research and their use in our hospitalized patients.
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Affiliation(s)
- Stanley Schwartz
- Main Line Health System, University of Pennsylvania, Philadelphia, PA, USA,
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123
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Guía de práctica clínica de la ESC sobre diabetes, prediabetes y enfermedad cardiovascular, en colaboración con la European Association for the Study of Diabetes. Rev Esp Cardiol 2014. [DOI: 10.1016/j.recesp.2013.10.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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124
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Shore S, Borgerding JA, Gylys-Colwell I, McDermott K, Ho PM, Tillquist MN, Lowy E, McGuire DK, Stolker JM, Arnold SV, Kosiborod M, Maddox TM. Association between hyperglycemia at admission during hospitalization for acute myocardial infarction and subsequent diabetes: insights from the veterans administration cardiac care follow-up clinical study. Diabetes Care 2014; 37:409-18. [PMID: 24089537 DOI: 10.2337/dc13-1125] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Among patients with acute myocardial infarction (AMI) without known diabetes, hyperglycemia at admission is common and associated with worse outcomes. It may represent developing diabetes, but this association is unclear. Therefore, we examined the association between hyperglycemia (≥140 mg/dL) at admission and evidence of diabetes among patients with AMI without known diabetes within 6 months of their hospitalization. RESEARCH DESIGN AND METHODS We studied a national cohort of consecutive patients with AMI without known diabetes presenting at 127 Veterans Affairs hospitals between October 2005 and March 2011. Evidence of diabetes either at discharge or in the following 6 months was ascertained using diagnostic codes, medication prescriptions, and/or elevated hemoglobin A1c. Association between hyperglycemia at admission and evidence of diabetes was evaluated using regression modeling. RESULTS Among 10,499 patients with AMI without known diabetes, 98% were men and 1,761 (16.8%) had hyperglycemia at admission. Within 6 months following their index hospitalization, 208 patients (11.8%) with hyperglycemia at admission had evidence of diabetes compared with 443 patients (5.1%) without hyperglycemia at admission (P < 0.001). After multivariable adjustment, hyperglycemia at admission was significantly associated with subsequent diabetes odds ratio 2.56 (95% CI 2.15-3.06). Among those with new evidence of diabetes, 41% patients (267 of 651) had a hemoglobin A1c ≥6.5% without accompanying diagnostic codes or medication prescriptions, suggesting they had unrecognized diabetes. CONCLUSIONS Hyperglycemia at admission occurred in one of six patients with AMI without known diabetes and was significantly associated with new evidence of diabetes in the 6 months following hospitalization. In addition, two of five patients with evidence of diabetes were potentially unrecognized. Accordingly, diabetes-screening programs for hyperglycemic patients with AMI may be an important component of optimal care.
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125
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Bogun M, Inzucchi SE. Inpatient management of diabetes and hyperglycemia. Clin Ther 2013; 35:724-33. [PMID: 23688537 DOI: 10.1016/j.clinthera.2013.04.008] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Accepted: 04/19/2013] [Indexed: 01/09/2023]
Abstract
Illness, particularly when severe, leads to increased concentrations of counter-regulatory factors which induce insulin resistance and predispose patients to stress hyperglycemia. Elevated glucose concentrations are common in hospitalized patients, both those with as well as without recognized diabetes. Substantial data has emerged over the past decade that quality glucose management in these individuals actually improves clinical outcomes. Controlling glucose in this setting is challenging, given the phenotypic variability amongst patients, with fluctuating courses of acute illnesses and unpredictable nutritional schedules. We review the evidence basis that has informed national standards and glucose targets in both critically and non-critically ill patients. In the intensive care setting, insulin infusions are now widely endorsed to quickly achieve and maintain glucose control. On the hospital wards, physiological subcutaneous insulin therapy, incorporating both basal and nutritional components, is emerging as the optimal treatment strategy. The transition to outpatient care is another important aspect of any hospital glycemic management program.
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Affiliation(s)
- Magdalena Bogun
- Section of Endocrinology, Yale University School of Medicine, New Haven, CT 06520-8056, USA
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126
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Kmet M, Rajer B, Pernat A. Hemoglobin A1c is a better predictor of prognosis following the non-ST elevation acute coronary syndrome than fasting and admission glucose. Wien Klin Wochenschr 2013; 126:156-62. [PMID: 24297265 DOI: 10.1007/s00508-013-0468-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2013] [Accepted: 11/06/2013] [Indexed: 01/04/2023]
Abstract
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.
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Affiliation(s)
- Marko Kmet
- Medical Intensive Care Unit, Novo mesto General Hospital, Novo mesto, Slovenia
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127
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Beltramello G, Manicardi V, Mazzuoli F, Rivellese A. Trialogue Plus: Management of cardiovascular risk in hyperglycaemic/diabetic patients at hospital discharge. Acta Diabetol 2013; 50:989-98. [PMID: 24121870 DOI: 10.1007/s00592-013-0508-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2013] [Accepted: 07/27/2013] [Indexed: 01/08/2023]
Abstract
Diabetes mellitus and hyperglycaemia are both independent risk factors (RF) for cardiovascular (CV) events and increased general and CV mortality. Type 2 diabetes, which is often associated with obesity, hypertension and dyslipidaemia, is accompanied by an up to fourfold increase in the incidence of acute coronary heart disease compared to normoglycaemia, even when other CV RF are equal. In the diabetic population, acute CV events are more likely to have associated cardiac complications, such as heart failure, and CV mortality is increased by twofold–fourfold. Several patients, hospitalised in medical, cardiology and intensive care departments, have undiagnosed diabetes mellitus or elevated glucose levels at the time of admission. These conditions require intensive care in the acute phase and dedicated follow-up at discharge. The Trialogue Plus project was created with the goal of providing good clinical practice guidelines and recommendations for the management of CV risk in patients with diabetes/hyperglycaemia at discharge from hospital. The aim is developing a document that defines timing, diagnostics, targets and therapeutic strategy for the management of CV risk, both in primary and in secondary prevention of patients with diabetes/hyperglycaemia who have experienced an event, involving the Diabetologist, Cardiologist, Internist, GP and area Specialists. This document concerns the implementation of existing guidelines and consensus statements, and as such, the recommendations have not been classified on the basis of scientific evidence and strength.
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128
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Deckers JW, van Domburg RT, Akkerhuis M, Nauta ST. Relation of admission glucose levels, short- and long-term (20-year) mortality after acute myocardial infarction. Am J Cardiol 2013; 112:1306-10. [PMID: 23866731 DOI: 10.1016/j.amjcard.2013.06.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2013] [Revised: 06/04/2013] [Accepted: 06/04/2013] [Indexed: 01/08/2023]
Abstract
We examined temporal trends in mortality after myocardial infarction from 1985 to 2008 depending on admission glucose levels. We included 11,324 consecutive patients admitted to our intensive coronary care unit for myocardial infarction from 1985 to 2008. Patients were categorized into normal, mild, and severe hyperglycemia groups (admission glucose levels <140, 140 to 200, and ≥200 mg/dl, respectively). Temporal trends were determined using 3 groups: 1985 to 1990, 1990 to 2000, and 2000 to 2008. The prevalence of hyperglycemia increased from 26% in the 1980s to 49% in the 2000s. The prevalence of hyperglycemia primarily increased in patients without diabetes. Kaplan-Meier mortality was 4%, 8%, and 17% at 30 days and 64%, 71%, and 82% at 20 years in patients with normal, mild, and severe hyperglycemia, respectively. Compared with normal admission glucose level, adjusted 30-day mortality was 3.6-fold greater (95% confidence interval 2.9 to 4.3) in patients with severe hyperglycemia. This association was not dependent on diabetic status (p for interaction = 0.43) but was dependent on the decade of hospitalization with a stronger association from 2000 to 2008 (adjusted odds ratio 7.7, 95% confidence interval 5.4 to 11, p for interaction <0.001). Compared with diabetes, hyperglycemia was a better discriminator for 30-day mortality. Mortality at 30 days decreased from 1985 to 2008, however, it decreased less in patients with hyperglycemia compared with those with normoglycemia. In conclusion, elevated admission glucose levels are common in patients with myocardial infarction and are strongly associated with increased mortality. Mortality decreased less from 1985 to 2008 in patients with hyperglycemia compared with those with normoglycemia. Efforts that establish optimal treatment for these patients remain warranted.
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129
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Prise en charge des syndromes coronariens aigus. Can J Diabetes 2013. [DOI: 10.1016/j.jcjd.2013.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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130
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Impact of hyperglycemia in patients with ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention: The HORIZONS-AMI trial. Int J Cardiol 2013; 167:2572-9. [DOI: 10.1016/j.ijcard.2012.06.054] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2012] [Accepted: 06/16/2012] [Indexed: 01/08/2023]
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131
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Rydén L, Grant PJ, Anker SD, Berne C, Cosentino F, Danchin N, Deaton C, Escaned J, Hammes HP, Huikuri H, Marre M, Marx N, Mellbin L, Ostergren J, Patrono C, Seferovic P, Uva MS, Taskinen MR, Tendera M, Tuomilehto J, Valensi P, Zamorano JL, Zamorano JL, Achenbach S, Baumgartner H, Bax JJ, Bueno H, Dean V, Deaton C, Erol C, Fagard R, Ferrari R, Hasdai D, Hoes AW, Kirchhof P, Knuuti J, Kolh P, Lancellotti P, Linhart A, Nihoyannopoulos P, Piepoli MF, Ponikowski P, Sirnes PA, Tamargo JL, Tendera M, Torbicki A, Wijns W, Windecker S, De Backer G, Sirnes PA, Ezquerra EA, Avogaro A, Badimon L, Baranova E, Baumgartner H, Betteridge J, Ceriello A, Fagard R, Funck-Brentano C, Gulba DC, Hasdai D, Hoes AW, Kjekshus JK, Knuuti J, Kolh P, Lev E, Mueller C, Neyses L, Nilsson PM, Perk J, Ponikowski P, Reiner Z, Sattar N, Schächinger V, Scheen A, Schirmer H, Strömberg A, Sudzhaeva S, Tamargo JL, Viigimaa M, Vlachopoulos C, Xuereb RG. ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD: the Task Force on diabetes, pre-diabetes, and cardiovascular diseases of the European Society of Cardiology (ESC) and developed in collaboration with the European Association for the Study of Diabetes (EASD). Eur Heart J 2013; 34:3035-87. [PMID: 23996285 DOI: 10.1093/eurheartj/eht108] [Citation(s) in RCA: 1409] [Impact Index Per Article: 128.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
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- The disclosure forms of the authors and reviewers are available on the ESC website www.escardio.org/guidelines
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Abuannadi M, Kosiborod M, Riggs L, House JA, Hamburg MS, Kennedy KF, Marso SP. Management of hyperglycemia with the administration of intravenous exenatide to patients in the cardiac intensive care unit. Endocr Pract 2013. [PMID: 23186969 DOI: 10.4158/ep12196.or] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To evaluate the feasibility, effectiveness, and safety of intravenous exenatide to control hyperglycemia in the cardiac intensive care unit (CICU). METHODS A prospective, single-center, open-label, nonrandomized pilot study. Forty patients admitted to the CICU with glucose levels of 140 to 400 mg/dL received intravenous exenatide as a bolus followed by a fixed dose infusion for up to 48 hours. Exenatide effectiveness was benchmarked to two historical insulin infusion cohorts, one (INT) with a target glucose of 90 to 119 mg/dL (n = 84) and the other (MOD) with a target of 100 to 140 mg/dL (n = 71). RESULTS Median admission glucose values were 185.5 mg/dL (161.0, 215.5), 259.0 mg/dL (206.0, 343.0), and 189.5 mg/dL (163.5, 245.0) in the exenatide, MOD, and INT groups, respectively (P<.001). Steady state glucose values were similar between the exenatide (132.0 mg/dL [110.0, 157.0]) and the MOD groups (127.0 mg/dL [105.0, 161.0], P = .15), but lower in the INT group (105.0 mg/dL [92.0, 128.0], P<.001 for exenatide versus INT). Median (IQR) time to steady state was 2.0 hours (1.5, 5.0) in the exenatide group compared to 12.0 hours (7.0, 15.0) in the MOD group (P<.001) and 3.0 hours (1.0, 5.0) in the INT group (P = .80 for exenatide versus INT). Exenatide was discontinued in 3 patients after failure to achieve glycemic control. No episodes of severe hypoglycemia (<50 mg/dL) occurred in patients who received exenatide. Nausea was reported by 16 patients and vomiting by 2 patients. CONCLUSION Intravenous exenatide is effective in lowering glucose levels in CICU patients, but its use may be limited by nausea.
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Affiliation(s)
- Mohammad Abuannadi
- Saint Luke's Mid America Heart Institute University of Missouri-Kansas City, Kansas City, MO 64111, USA
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133
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Venkitachalam L, McGuire DK, Gosch K, Lipska K, Inzucchi SE, Lind M, Goyal A, Spertus JA, Masoudi FA, Jones PG, Kosiborod M. Temporal trends and hospital variation in the management of severe hyperglycemia among patients with acute myocardial infarction in the United States. Am Heart J 2013; 166:315-324.e1. [PMID: 23895815 DOI: 10.1016/j.ahj.2013.05.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2012] [Accepted: 05/13/2013] [Indexed: 01/08/2023]
Abstract
BACKGROUND Elevated blood glucose is associated with higher mortality in patients with acute myocardial infarction (AMI). Although clinical guidelines recommend targeted glucose control in this group, clinical trials have yielded inconclusive results. Our objective was to understand how this lack of evidence impacts the management of severe hyperglycemia in routine practice. METHODS We examined insulin use among 4,297 AMI admissions with a mean hospitalization blood glucose of ≥200 mg/dL across 55 US hospitals from 2000 to 2008. Temporal trends and interhospital variation in 2 measures of insulin use during hospitalization-any (subcutaneous, intravenous [IV], short acting, long acting) and IV insulin-were examined using hierarchical Poisson regression models. RESULTS Of the 4,297 admissions, 2,618 (61%) received any insulin and 538 (13%) received IV insulin. After multivariable adjustment, a slight increase in insulin use was observed per admission year (relative risk [RR] 1.06, 95% CI 1.01-1.11). There was a modest (albeit nonsignificant) increase in IV insulin use seen before May 2004 (RR 1.18, 95% CI 0.96-1.47), with no significant change thereafter (RR 0.99, 95% CI 0.92-1.09). Marked variability in insulin use was observed across hospitals (median rate ratio 1.5 [any insulin] and 1.8 [IV insulin]), which did not change over time. CONCLUSIONS Insulin use among patients with AMI and severe hyperglycemia has remained low over the past decade, with substantial and persistent interhospital variation. These observations reflect marked clinical uncertainty with regard to glucose management in AMI, underscoring the imperative for a definitive clinical trial in this field.
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Draznin B, Gilden J, Golden SH, Inzucchi SE, Baldwin D, Bode BW, Boord JB, Braithwaite SS, Cagliero E, Dungan KM, Falciglia M, Figaro MK, Hirsch IB, Klonoff D, Korytkowski MT, Kosiborod M, Lien LF, Magee MF, Masharani U, Maynard G, McDonnell ME, Moghissi ES, Rasouli N, Rubin DJ, Rushakoff RJ, Sadhu AR, Schwartz S, Seley JJ, Umpierrez GE, Vigersky RA, Low CC, Wexler DJ. Pathways to quality inpatient management of hyperglycemia and diabetes: a call to action. Diabetes Care 2013; 36:1807-14. [PMID: 23801791 PMCID: PMC3687296 DOI: 10.2337/dc12-2508] [Citation(s) in RCA: 119] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Currently patients with diabetes comprise up to 25-30% of the census of adult wards and critical care units in our hospitals. Although evidence suggests that avoidance of hyperglycemia (>180 mg/dL) and hypoglycemia (<70 mg/dL) is beneficial for positive outcomes in the hospitalized patient, much of this evidence remains controversial and at times somewhat contradictory. We have recently formed a consortium for Planning Research in Inpatient Diabetes (PRIDE) with the goal of promoting clinical research in the area of management of hyperglycemia and diabetes in the hospital. In this article, we outline eight aspects of inpatient glucose management in which randomized clinical trials are needed. We refer to four as system-based issues and four as patient-based issues. We urge further progress in the science of inpatient diabetes management. We hope this call to action is supported by the American Diabetes Association, The Endocrine Society, the American Association of Clinical Endocrinologists, the American Heart Association, the European Association for the Study of Diabetes, the International Diabetes Federation, and the Society of Hospital Medicine. Appropriate federal research funding in this area will help ensure high-quality investigations, the results of which will advance the field. Future clinical trials will allow practitioners to develop optimal approaches for the management of hyperglycemia in the hospitalized patient and lessen the economic and human burden of poor glycemic control and its associated complications and comorbidities in the inpatient setting.
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Affiliation(s)
- Boris Draznin
- Division of Endocrinology, Diabetes and Metabolism, University of Colorado School of Medicine, Aurora, Colorado, USA.
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Roehl KA, Lach K, Coltman AE, Bacon CA, Singh S, Peterson SJ, Sowa DC. Predictors of insulin requirements among hospitalized adults receiving parenteral nutrition. JPEN J Parenter Enteral Nutr 2013; 37:755-62. [PMID: 23770842 DOI: 10.1177/0148607113492927] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The objective of this quality improvement project was to determine factors predictive of parenteral nutrition (PN) insulin therapy. METHODS Patients receiving PN at a tertiary care academic medical center between January 1, 2009, and December 1, 2012, 18 years or older were included. Variables collected included demographics, medical information, and PN-specific data. χ(2) and Student t tests were used to determine differences between patients who did and did not require PN insulin. Odds ratios (ORs) with 95% confidence intervals (CIs) were used to determine associations between characteristics. Stepwise forward logistic regression was used determine the best predictors of PN insulin. RESULTS A total of 1388 patients were started on PN. After adjusting for potential confounders, strong associations existed between PN insulin requirements and diabetes mellitus (DM) diagnosis (OR, 8.90; 95% CI, 4.98-15.90, P < .001), overweight/obese status (body mass index ≥25.0 kg/m(2)) (OR, 2.12; 95% CI, 1.04-4.30, P = .04), intensive care unit (ICU) admission (OR, 1.79; 95% CI, 1.03-3.11, P = .04), blood glucose (BG) on day of PN start >120 mg/dL (OR, 2.32; 95% CI, 1.32-4.05, P = .003), mean BG >180 mg/dL while receiving PN (OR, 6.10; 95% CI, 2.18-17.04, P = .001), and hemoglobin A1c (A1c) ≥5.7% (OR, 3.18; 95% CI, 1.84-5.50, P < .001). Among variables available at PN initiation, DM diagnosis (P < .001), A1c ≥5.7% (P < .001), BG >120 mg/dL on PN start day (P < .001), and ICU admission (P < .001) predicted the need for PN insulin.
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Burt MG, Roberts GW, Aguilar-Loza NR, Quinn SJ, Frith PA, Stranks SN. Relationship between glycaemia and length of hospital stay during an acute exacerbation of chronic obstructive pulmonary disease. Intern Med J 2013; 43:721-4. [DOI: 10.1111/imj.12157] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Accepted: 11/13/2012] [Indexed: 01/08/2023]
Affiliation(s)
| | | | - N. R. Aguilar-Loza
- Southern Adelaide Diabetes and Endocrine Services; Repatriation General Hospital; Australia
| | - S. J. Quinn
- Faculty of Health Science; Flinders University; Adelaide; South Australia; Australia
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Giraldez RR, Clare RM, Lopes RD, Dalby AJ, Prabhakaran D, Brogan GX, Giugliano RP, James SK, Tanguay JF, Pollack CV, Harrington RA, Braunwald E, Newby LK. Prevalence and clinical outcomes of undiagnosed diabetes mellitus and prediabetes among patients with high-risk non-ST-segment elevation acute coronary syndrome. Am Heart J 2013; 165:918-925.e2. [PMID: 23708162 DOI: 10.1016/j.ahj.2013.01.005] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Accepted: 01/11/2013] [Indexed: 01/08/2023]
Abstract
BACKGROUND We examined the prevalence of undiagnosed diabetes or prediabetes and associations with ischemic outcomes among non-ST-segment elevation acute coronary syndrome (ACS) patients. METHODS We categorized 8795 EARLY ACS trial patients into one of the following groups: "known diabetes" (n = 2860 [32.5%]; reported on the case report form), "undiagnosed diabetes" (n = 1069 [12.2%]; no diabetes history and fasting glucose ≥126 mg/dL or hemoglobin A1c ≥6.5%), "prediabetes" (n = 947 [10.8%]; fasting glucose ≥110 to <126 mg/dL, or "normal" (n = 3919 [44.5%]). Adjusted associations of known diabetes, undiagnosed diabetes, and prediabetes (versus normal) with 30-day and 1-year outcomes were determined. RESULTS Undiagnosed diabetes was associated with greater 30-day death or myocardial infarction (MI) (ORadj 1.28, 95% CI 1.05-1.57), driven primarily by greater 30-day mortality (ORadj 1.65, 95% CI 1.09-2.48). Known diabetic patients had 30-day death or MI outcomes similar to those of normal patients, but 30-day mortality was higher (ORadj 1.40, 95% CI 1.01-1.93). Prediabetic patients had 30-day death or MI outcomes similar to those of normal patients. One-year mortality was greater among known diabetic patients (HRadj 1.38, 95% CI 1.13-1.67) but not among those with undiagnosed diabetes or prediabetes. CONCLUSIONS Undiagnosed diabetes and prediabetes were common among high-risk non-ST-segment elevation ACS patients. Routine screening for undiagnosed diabetes may be useful since these patients seem to have worse short-term outcomes and deserve consideration of alternative management strategies.
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Lazzeri C, Valente S, Chiostri M, Attanà P, Picariello C, Gensini GF. The glucose dysmetabolism in the acute phase of non-diabetic ST-elevation myocardial infarction: from insulin resistance to hyperglycemia. Acta Diabetol 2013; 50:293-300. [PMID: 21984048 DOI: 10.1007/s00592-011-0325-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2011] [Accepted: 08/31/2011] [Indexed: 01/27/2023]
Abstract
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.
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Affiliation(s)
- Chiara Lazzeri
- Intensive Cardiac Coronary Unit, Department of Heart and Vessel, Azienda Ospedaliero-Universitaria Careggi, Viale Morgagni 85, 50134, Florence, Italy.
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Feldman-Billard S, Joubert M, Morello R, Dorey F, Seret-Begue D, Getin-Bouyer F, Jan P, Colobert A, Verlet E, Roques M, Reznik Y. High prevalence of diabetes mellitus and hospital-related hyperglycaemia in French general wards. DIABETES & METABOLISM 2013; 39:454-8. [PMID: 23726314 DOI: 10.1016/j.diabet.2013.04.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Revised: 04/12/2013] [Accepted: 04/15/2013] [Indexed: 01/08/2023]
Abstract
AIM The study evaluated the in-hospital prevalence of diabetes and hospital-related hyperglycaemia in a variety of French general wards. METHODS The multicentre cross-sectional study involving nine French hospitals measured venous fasting plasma glucose (FPG) on a single day in patients hospitalized in adult medical and surgical short-term wards. Diabetes status and length of stay were recorded. RESULTS Of the 2141 inpatients included in the study, 355 (16.5%) had known diabetes, 156 (7.3%) had screened diabetes (FPG ≥7 mmol/L with no diabetes history), 515 (24.1%) had impaired fasting glucose (IFG; FPG 5.5-6.9 mmol/L) and 1115 (52.1%) had normal glucose values (FPG < 5.5 mmol/L). Diabetes prevalence varied from 11% in hospitals in the west of France to 21% in hospitals in northern and eastern regions. The highest known diabetes prevalence was observed in units for cardiovascular surgery (33%), infectious diseases (27%) and kidney disorders (26%). In cancer units, one-fifth of patients had screened diabetes and one-sixth had known diabetes. Among the known diabetes patients, 127 (36%) were already being treated with insulin, while an additional 41 (12%) started insulin therapy during their hospital stay. Patients with known and screened diabetes were older (70.8 ± 12.2 and 71.1 ± 15.6 years, respectively) than the normal-glucose patients (65.6 ± 18.9 years; P<0.001). Average length of stay was no different between known diabetes and normal-glucose patients after adjusting for age (11.3 ± 7.7 vs 10.0 ± 7.4 days; NS). CONCLUSION Overall, metabolic glucose disorders (known or screened diabetes and IFG) were found in 48% of inpatients in various French hospital general wards.
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Affiliation(s)
- S Feldman-Billard
- CHNO des Quinze-Vingts, Department of Internal Medicine, 75012 Paris, France.
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141
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Hage C, Brismar K, Efendic S, Lundman P, Rydén L, Mellbin L. Sitagliptin improves beta-cell function in patients with acute coronary syndromes and newly diagnosed glucose abnormalities--the BEGAMI study. J Intern Med 2013; 273:410-21. [PMID: 23331339 DOI: 10.1111/joim.12032] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Newly detected impaired glucose tolerance (IGT) or type 2 diabetes mellitus (T2DM) are common in patients with acute coronary syndrome (ACS; i.e. unstable angina/myocardial infarction) and related to disturbed beta-cell function. The aim of this study is to test the hypothesis that treatment with a dipeptidyl peptidase-4 inhibitor initiated soon after a coronary event improves beta-cell function. METHODS Acute coronary syndrome ACS patients with IGT or T2DM (n = 71), screened by oral glucose tolerance test (OGTT) 4-23 days (median 6 days) after hospital admission, were randomly assigned to sitagliptin 100 mg (n = 34) or placebo (n = 37) and treated for a duration of 12 weeks. All patients received lifestyle advice but no glucose-lowering agents other than the study drug. The study end-point was beta-cell function assessed using the insulinogenic index (IGI = ΔInsulin30 /ΔGlucose30 ), derived from an OGTT, and acute insulin response to glucose (AIRg) assessed by a frequently sampled intravenous glucose tolerance test. RESULTS The IGI and AIRg did not differ at baseline between the sitagliptin and placebo groups (69.9 vs. 66.4 pmol mmol(-1) and 1394 vs. 1106 pmol L(-1) min(-1) respectively). After 12 weeks, the IGI was 85.0 in the sitagliptin and 58.1 pmol/mmol in the placebo group (P = 0.013) and AIRg was 1909 and 1043 pmol L(-1) min(-1) (P < 0.0001) in the sitagliptin and placebo groups respectively. Fasting glucose at baseline was 6.1 mmol L(-1) in sitagliptin-treated patients and 6.0 mmol L(-1) in those who received placebo compared with 5.8 and 5.9 mmol L(-1) respectively, after 12 weeks of treatment. Post load glucose metabolism improved in significantly more sitagliptin-treated patients compared with the placebo group (P = 0.003). Sitagliptin was well tolerated. CONCLUSION Sitagliptin improved beta-cell function and glucose perturbations in patients with ACS and newly diagnosed glucose disturbances.
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Affiliation(s)
- C Hage
- Cardiology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.
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Hsu PF, Sung SH, Cheng HM, Yeh JS, Liu WL, Chan WL, Chen CH, Chou P, Chuang SY. Association of clinical symptomatic hypoglycemia with cardiovascular events and total mortality in type 2 diabetes: a nationwide population-based study. Diabetes Care 2013; 36:894-900. [PMID: 23223349 PMCID: PMC3609481 DOI: 10.2337/dc12-0916] [Citation(s) in RCA: 182] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Hypoglycemia is associated with serious health outcomes for patients treated for diabetes. However, the outcome of outpatients with type 2 diabetes who have experienced hypoglycemia episodes is largely unknown. RESEARCH DESIGN AND METHODS The study population, derived from the National Health Insurance Research Database released by the Taiwan National Health Research Institutes during 1998-2009, comprised 77,611 patients with newly diagnosed type 2 diabetes. We designed a prospective study consisting of randomly selected hypoglycemic type 2 diabetic patients and matched type 2 diabetic patients without hypoglycemia. We investigated the relationships of hypoglycemia with total mortality and cardiovascular events, including stroke, coronary heart disease, cardiovascular diseases, and all-cause hospitalization. RESULTS There were 1,844 hypoglycemic events (500 inpatients and 1,344 outpatients) among the 77,611 patients. Both mild (outpatient) and severe (inpatient) hypoglycemia cases had a higher percentage of comorbidities, including hypertension, renal diseases, cancer, stroke, and heart disease. In multivariate Cox regression models, including diabetes treatment adjustment, diabetic patients with hypoglycemia had a significantly higher risk of cardiovascular events during clinical treatment periods. After constructing a model adjusted with propensity scores, mild and severe hypoglycemia still demonstrated higher hazard ratios (HRs) for cardiovascular diseases (HR 2.09 [95% CI 1.63-2.67]), all-cause hospitalization (2.51 [2.00-3.16]), and total mortality (2.48 [1.41-4.38]). CONCLUSIONS Symptomatic hypoglycemia, whether clinically mild or severe, is associated with an increased risk of cardiovascular events, all-cause hospitalization, and all-cause mortality. More attention may be needed for diabetic patients with hypoglycemic episodes.
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Affiliation(s)
- Pai-Feng Hsu
- Healthcare and Management Center, Taipei Veterans General Hospital, Taipei, Taiwan
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Burt MG, Roberts GW, Aguilar-Loza NR, Stranks SN. Brief report: Comparison of continuous glucose monitoring and finger-prick blood glucose levels in hospitalized patients administered basal-bolus insulin. Diabetes Technol Ther 2013; 15:241-5. [PMID: 23360391 DOI: 10.1089/dia.2012.0282] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Previous studies have assessed the efficacy of basal-bolus insulin (BBI) in hospitalized patients by measuring four finger-prick blood glucose levels (BGLs) per day. The aim of this study was to investigate whether this BGL monitoring regimen provides an accurate reflection of glycemia in hospitalized patients administered BBI. We hypothesized that, as three of four readings are preprandial, finger-prick BGLs would underestimate the mean glucose concentration. SUBJECTS AND METHODS Twenty-six consecutive consenting subjects with type 1 (n=3) or type 2 (n=23) diabetes mellitus admitted to the hospital and administered insulin glargine once daily and rapid-acting insulin before meals underwent continuous glucose monitoring for up to 72 h. Finger-prick BGLs were performed before each main meal (0700, 1200, and 1700 h) and at 2100 h. RESULTS Mean daily glucose concentration was not significantly different when assessed by continuous glucose monitoring and finger-prick BGLs (9.6±2.4 vs. 9.6±2.7 mmol/L, P=0.84). A Bland-Altman plot revealed some variability but no bias between the two methods of measurement of glucose concentration. There were 88 postprandial hyperglycemic excursions recorded on continuous glucose monitoring; 61 (69%) were identified by finger-prick BGL monitoring. There were 10 glucose excursions <4 mmol/L during continuous glucose monitoring; only one was detected by finger-prick BGL monitoring. CONCLUSIONS Traditional finger-prick BGL monitoring provides a reasonable approximation of mean daily glucose concentration in the majority of hospitalized patients receiving BBI but underestimates the prevalence of postprandial hyperglycemia and hypoglycemia.
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Affiliation(s)
- Morton G Burt
- Southern Adelaide Diabetes and Endocrine Services, Repatriation General Hospital, Adelaide, Australia.
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Luo M, Guan X, Luczak ED, Lang D, Kutschke W, Gao Z, Yang J, Glynn P, Sossalla S, Swaminathan PD, Weiss RM, Yang B, Rokita AG, Maier LS, Efimov IR, Hund TJ, Anderson ME. Diabetes increases mortality after myocardial infarction by oxidizing CaMKII. J Clin Invest 2013; 123:1262-74. [PMID: 23426181 DOI: 10.1172/jci65268] [Citation(s) in RCA: 190] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Accepted: 12/20/2012] [Indexed: 01/08/2023] Open
Abstract
Diabetes increases oxidant stress and doubles the risk of dying after myocardial infarction, but the mechanisms underlying increased mortality are unknown. Mice with streptozotocin-induced diabetes developed profound heart rate slowing and doubled mortality compared with controls after myocardial infarction. Oxidized Ca(2+)/calmodulin-dependent protein kinase II (ox-CaMKII) was significantly increased in pacemaker tissues from diabetic patients compared with that in nondiabetic patients after myocardial infarction. Streptozotocin-treated mice had increased pacemaker cell ox-CaMKII and apoptosis, which were further enhanced by myocardial infarction. We developed a knockin mouse model of oxidation-resistant CaMKIIδ (MM-VV), the isoform associated with cardiovascular disease. Streptozotocin-treated MM-VV mice and WT mice infused with MitoTEMPO, a mitochondrial targeted antioxidant, expressed significantly less ox-CaMKII, exhibited increased pacemaker cell survival, maintained normal heart rates, and were resistant to diabetes-attributable mortality after myocardial infarction. Our findings suggest that activation of a mitochondrial/ox-CaMKII pathway contributes to increased sudden death in diabetic patients after myocardial infarction.
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Affiliation(s)
- Min Luo
- Division of Cardiovascular Medicine, Department of Internal Medicine, Cardiovascular Research Center, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
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Relevance of the Surgical Care Improvement Project on glycemic control in patients undergoing cardiac surgery who receive continuous insulin infusions. J Thorac Cardiovasc Surg 2013; 145:590-4; discussion 595-7. [DOI: 10.1016/j.jtcvs.2012.09.031] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Revised: 08/16/2012] [Accepted: 09/13/2012] [Indexed: 12/29/2022]
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Abstract
Hyperglycemia, hypoglycemia, preexisting diabetes, and glycemic variability each may affect hospital outcomes. Observational findings derived from randomized trials or retrospective studies suggest that independent of hypoglycemia and hyperglycemia, a relationship exists between variability and hospital outcomes. A review of studies conducted in diverse hospital populations is reported here, showing a relationship between measures of variability and nonglycemic outcomes, including ICU and hospital mortality and length of stay. "Glycemic variability" has an intuitive meaning, understood as a propensity of a single patient to develop repeated episodes of excursions of BG over a relatively short period of time that exceed the amplitude expected in normal physiology. It is proposed that each of 3 dimensions of variability should be separately studied: (1) magnitude of glycemic excursions during intervals of relative stability of the moving average of BG, (2) frequency with which a critical magnitude of excursion is exceeded, and (3) presence or absence of fine tuning. Multiple hospital studies have found that the standard deviation (SD) of the data set of blood glucose values (BG) of individual patients predicts outcomes. An appropriate refinement would be to report the "Reverse-transformed group mean of the SD of the logarithmically transformed BG data set of each patient," with confidence intervals. In logarithmic space, group means of the SD of BGs of each patient may be compared, using an appropriate parametric test. Upon reverse transformation, the upper and lower bounds of the confidence intervals become asymmetric about the reverse-transformed group mean of the SD. There is a need to understand what patterns of dispersion of BG over time are captured by SD as a predictor of outcomes. Among the causes of high SD, a subgroup may consist of patients having frequent oscillations of BG. Another subgroup may consist of patients experiencing a major change of overall glycemia during the timeframe of data collection. Appropriate metrics should be developed to recognize both variability in the sense of recurrent large oscillations of BG, and separately to recognize any time-dependent change of overall glycemia during hospitalization. Especially in relation to uncontrolled diabetes, there is a need to know whether rapid correction of chronic hyperglycemia adversely affects hospital outcomes. We have some understanding of how to control or prevent change of overall glycemia, and less understanding of how to control variability. Each may be associated with outcomes, and each may be detected by a high SD, but it remains uncertain whether intervention to prevent either pattern of changing glycemia would affect outcomes.
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Affiliation(s)
- Susan S Braithwaite
- Section of Endocrinology, Diabetes and Metabolism, Visiting Clinical Professor of Medicine, University of Illinois at Chicago, 1819 W. Polk Street, M/C 640, Chicago, IL 60612, USA,
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Brodovicz KG, Mehta V, Zhang Q, Zhao C, Davies MJ, Chen J, Radican L, Engel SS. Association between hypoglycemia and inpatient mortality and length of hospital stay in hospitalized, insulin-treated patients. Curr Med Res Opin 2013. [PMID: 23198978 DOI: 10.1185/03007995.2012.754744] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To assess the impact of hypoglycemia on clinical outcomes among hospitalized, insulin-treated patients. METHODS In a retrospective study, hospitalizations in 2005-2007 were identified from a US inpatient electronic medical records database. All encounters for insulin-treated patients with valid blood glucose measurement were included, except for those with a length of stay <24 hours or >30 days. In an encounter-based analysis, associations between hypoglycemic (glucose ≤70 mg/dL) or severe hypoglycemic (glucose ≤50 mg/dL) episodes and inpatient mortality, ischemic events, neurologic complications, and length of stay were evaluated. RESULTS Among 107,312 admissions, hypoglycemia occurred in 21,561 (20%) and severe hypoglycemia in 7539 (7%). Inpatient mortality occurred in 6.5% of hospitalizations with hypoglycemia and 3.8% of those without (p < 0.001). Inpatient mortality occurred in 7.6% of hospitalizations with a severe hypoglycemic event. Ischemic events (8.1 vs. 8.0%) and neurologic complications (3.8 vs. 3.7%) were similar in hospitalizations with and without a hypoglycemic event, respectively. In multivariate logistic regression analyses adjusting for age, gender, and selected comorbidities, hypoglycemia was associated with a significant increase in inpatient mortality risk (adjusted odds ratio (OR) = 1.66 [95% CI: 1.55, 1.78]). Similar results were observed with severe hypoglycemia (adjusted OR = 1.44 [1.38, 1.52]). Length of stay was increased in hospitalizations with hypoglycemia (median [interquartile range]: 8.2 days [4.9, 13.9] vs. 5.2 days [3.1, 8.3]; p < 0.0001). LIMITATIONS Due to the nature of the data source, some data of interest were not available, including insulin dose and dose regimen, outpatient medical histories (including diabetes history), pre-hospitalization medications, and cause of death. CONCLUSIONS Hypoglycemia was common among hospitalized patients receiving insulin and, while a direct causal relationship cannot be assumed, was associated with an increased risk of inpatient mortality and increased length of hospital stay. Hypoglycemia is an undesirable event and efforts to minimize in-hospital hypoglycemic events are warranted across the spectrum of hospitalized patients.
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Adigopula S, Feng Y, Babu V, Parperis KM, Amoateng-Adjepong Y, Zarich S. Hyperglycemia is associated with increased length of stay and total cost in patients hospitalized for congestive heart failure. ACTA ACUST UNITED AC 2013. [DOI: 10.4236/wjcd.2013.32038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Shoaib Zaheer M, Uwais Ashraf M, Rabbani MU, Ahmad J. Prognostic importance of admission versus persistent glycemia in acute coronary syndrome. Diabetes Metab Syndr 2013; 7:42-47. [PMID: 23517796 DOI: 10.1016/j.dsx.2013.02.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Whether persistent hyperglycemia (PG) during hospitalisation has a greater impact on adverse outcomes in acute myocardial infarction (AMI) than a single random glucose measurement is not well defined. AIMS To find out the association of admission glycemia (AG) VS PG on outcomes in patients of ACS. STUDY DESIGN AND METHODS Prospective, cohort, hospital-based. We evaluated 200 patients of ACS for admission and in-hospital glycemia and their impacts on outcomes. AG was defined as a plasma glucose >198 mg/dl and PG as a random glucose >140 mg/dl at any point during hospitalisation. Demographic and biochemistry including risk factors recorded. A multiple regression was done to evaluate association of various parameters with worse prognosis. RESULTS Of the 200 patients evaluated, 35 (17.5%) presented with AG. 31 (15.5%) had PG. Males were predominant and 47 (23%) previously known diabetic patients. 62 (31%) had unstable angina, 52 (26%) NSTEMI and 86 (43%) STEMI, between PG and LEF, higher troponin levels and in-hospital mortality and between LEF and age (p<0.001), serum creatinine (p 0.023) and mean in-hospital glucose (p 0.005). F-indices were compared with AG for their ability to discriminate hospitalization survivors from non-survivors. All average glucose metrics performed better than AG. The ability of these models improved as the time window increased (F-indices for admission, mean 24h, 48 h and 72 h were 2.51, 12.05, 8.3 and 5.72, respectively). CONCLUSION The present study demonstrates that PG is a better discriminator of prognosis than AG in patients of ACS.
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Affiliation(s)
- M Shoaib Zaheer
- Department of Medicine, J N Medical College, AMU, Aligarh, UP, India
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O'Gara PT, Kushner FG, Ascheim DD, Casey DE, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX, Anderson JL, Jacobs AK, Halperin JL, Albert NM, Brindis RG, Creager MA, DeMets D, Guyton RA, Hochman JS, Kovacs RJ, Kushner FG, Ohman EM, Stevenson WG, Yancy CW. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2012; 127:e362-425. [PMID: 23247304 DOI: 10.1161/cir.0b013e3182742cf6] [Citation(s) in RCA: 1071] [Impact Index Per Article: 89.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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