251
|
Ishihara M, Kojima S, Sakamoto T, Kimura K, Kosuge M, Asada Y, Tei C, Miyazaki S, Sonoda M, Tsuchihashi K, Yamagishi M, Shirai M, Hiraoka H, Honda T, Ogata Y, Ogawa H. Comparison of blood glucose values on admission for acute myocardial infarction in patients with versus without diabetes mellitus. Am J Cardiol 2009; 104:769-74. [PMID: 19733709 DOI: 10.1016/j.amjcard.2009.04.055] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2009] [Revised: 04/06/2009] [Accepted: 04/06/2009] [Indexed: 01/08/2023]
Abstract
Previous studies have reported that acute hyperglycemia is associated with high mortality after acute myocardial infarction (AMI). However, optimal plasma glucose level may be different between diabetic and nondiabetic patients. The purpose of this study was to assess the relation between admission glucose and in-hospital mortality after AMI in patients with and without diabetes. This study consisted of 3,750 patients who were admitted to the 35 hospitals participating to the Japanese Acute Coronary Syndrome Study (JACSS) group within 48 hours after the onset of AMI. Plasma glucose was measured at the time of hospital admission. In patients without a history of diabetes, there was a linear relation between admission glucose and in-hospital mortality. Nondiabetic patients with a glucose level <6 mmol/L had the lowest mortality (2.5%). As admission glucose increased by 1 mmol/L, mortality increased by 17% (13% to 21%, p <0.001). In patients with a history of diabetes, however, there was a U-shape relation between glucose and mortality. Diabetic patients with glucose 9 to 10 mmol/L had the lowest mortality (1.9%); not only severe hyperglycemia (glucose > or =11 mmol/L, 9.1%, p <0.001) but also euglycemia (glucose <7 mmol/L, 9.4%, p = 0.009) were associated with higher mortality compared to moderate hyperglycemia (glucose 9 to 11 mmol/L, 3.2%). Diabetic patients with admission glucose 9 to 10 mmol/L had the lowest mortality, whereas lower glucose was better in nondiabetic patients. In conclusion, optimal glucose level on admission may be different between diabetic and nondiabetic patients with AMI.
Collapse
Affiliation(s)
- Masaharu Ishihara
- Department of Cardiology, Hiroshima City Hospital, Hiroshima, Kumamoto University School of Medicine, Kumamoto, Japan.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
252
|
Sourij H, Schmölzer I, Kettler-Schmut E, Eder M, Pressl H, Decampo A, Wascher TC. Efficacy of a continuous GLP-1 infusion compared with a structured insulin infusion protocol to reach normoglycemia in nonfasted type 2 diabetic patients: a clinical pilot trial. Diabetes Care 2009; 32:1669-71. [PMID: 19528368 PMCID: PMC2732139 DOI: 10.2337/dc09-0475] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Continuously administered insulin is limited by the need for frequent blood glucose measurements, dose adjustments, and risk of hypoglycemia. Regimens based on glucagon-like peptide 1 (GLP-1) could represent a less complicated treatment alternative. This alternative might be advantageous in hyperglycemic patients hospitalized for acute critical illnesses, who benefit from near normoglycemic control. RESEARCH DESIGN AND METHODS In a prospective open randomized crossover trial, we investigated eight clinically stable type 2 diabetic patients during intravenous insulin or GLP-1 regimens to normalize blood glucose after a standardized breakfast. RESULTS The time to reach a plasma glucose below 115 mg/dl was significantly shorter during GLP-1 administration (252 +/- 51 vs. 321 +/- 43 min, P < 0.01). Maximum glycemia (312 +/- 51 vs. 254 +/- 48 mg/dl, P < 0.01) and glycemia after 2 h (271 +/- 51 vs. 168 +/- 48 mg/dl, P = 0.012) and after 4 h (155 +/- 51 vs. 116 +/- 27 mg/dl, P = 0.02) were significantly lower during GLP-1 administration. CONCLUSIONS GLP-1 infusion is superior to an established insulin infusion regimen with regard to effectiveness and practicability.
Collapse
Affiliation(s)
- Harald Sourij
- Division of Endocrinology and Nuclear Medicine, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | | | | | | | | | | | | |
Collapse
|
253
|
Abstract
Patients with preoperative endocrinopathies represent a particular challenge not only to anesthesiologists but also to surgeons and perioperative clinicians. The "endocrine axis" is complex and has multiple feedback loops, some of which are endocrine and paracrine related, and others that are strongly influenced by the surgical stress response. Familiarity with several of the common endocrinopathies facilitates management in the perioperative period. This article focuses on 4 of the most common endocrinopathies: diabetes mellitus, hyperthyroidism, hypothyroidism, and adrenal insufficiency. Perioperative challenges in patients presenting with pheochromocytoma are also discussed.
Collapse
Affiliation(s)
- Benjamin A Kohl
- Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA.
| | | |
Collapse
|
254
|
Moghissi ES, Korytkowski MT, DiNardo M, Einhorn D, Hellman R, Hirsch IB, Inzucchi SE, Ismail-Beigi F, Kirkman MS, Umpierrez GE. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Endocr Pract 2009; 15:353-69. [PMID: 19454396 DOI: 10.4158/ep09102.ra] [Citation(s) in RCA: 425] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Etie S Moghissi
- Department of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
255
|
Kolman L, Hu YC, Montgomery DG, Gordon K, Eagle KA, Jackson EA. Prognostic value of admission fasting glucose levels in patients with acute coronary syndrome. Am J Cardiol 2009; 104:470-4. [PMID: 19660596 DOI: 10.1016/j.amjcard.2009.04.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2009] [Revised: 04/06/2009] [Accepted: 04/06/2009] [Indexed: 01/08/2023]
Abstract
Data are limited regarding the best prognostic glucose measure for patients admitted for an acute coronary event. We examined the admission fasting glucose levels among patients with acute coronary syndrome (ACS) from the University of Michigan ACS registry. The glucose levels were grouped into 3 categories (> or =70 to <100, 100 to <126, and > or =126 mg/dl). The primary outcome measures included mortality and a composite end point (stroke, recurrent infarction, and death) in hospital and at 6 months after the ACS event. Of the 1,525 patients (29% with diabetes) for whom glucose levels were available, a fasting glucose level of > or =100 mg/dl was associated with increased in-hospital mortality, after adjusting for the Global Registry of Acute Coronary Events risk score and gender. A fasting glucose level of > or =126 mg/dl in patients with no known history of diabetes was associated with in-hospital adverse events (odds ratio 3.37, 95% confidence interval 1.51 to 7.51). The fasting glucose level was associated with an increased risk of 6-month mortality among nondiabetics (odds ratio 3.03, 95% confidence interval 1.35 to 6.81 for patients with a glucose level of 100 to 125 mg/dl; and odds ratio 2.81, 95% confidence interval 1.07 to 7.36 for patients with a glucose level of > or =126 mg/dl) but not for diabetic patients. In conclusion, we observed a strong association between the admission fasting glucose level and mortality, particularly among nondiabetic patients. Whether improving the diagnosis and treatment of hyperglycemia would result in reductions in adverse events after ACS remains unclear.
Collapse
|
256
|
Braithwaite SS, Godara H, Song J, Cairns BA, Jones SW, Umpierrez GE. Intermediary variables and algorithm parameters for an electronic algorithm for intravenous insulin infusion. J Diabetes Sci Technol 2009; 3:835-56. [PMID: 20144334 PMCID: PMC2769966 DOI: 10.1177/193229680900300432] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Algorithms for intravenous insulin infusion may assign the infusion rate (IR) by a two-step process. First, the previous insulin infusion rate (IR(previous)) and the rate of change of blood glucose (BG) from the previous iteration of the algorithm are used to estimate the maintenance rate (MR) of insulin infusion. Second, the insulin IR for the next iteration (IR(next)) is assigned to be commensurate with the MR and the distance of the current blood glucose (BG(current)) from target. With use of a specific set of algorithm parameter values, a family of iso-MR curves is created, each giving IR as a function of MR and BG. METHOD To test the feasibility of estimating MR from the IR(previous) and the previous rate of change of BG, historical hyperglycemic data points were used to compute the "maintenance rate cross step next estimate" (MR(csne)). Historical cases had been treated with intravenous insulin infusion using a tabular protocol that estimated MR according to column-change rules. The mean IR on historical stable intervals (MR(true)), an estimate of the biologic value of MR, was compared to MR(csne) during the hyperglycemic iteration immediately preceding the stable interval. Hypothetically calculated MR(csne)-dependent IR(next) was compared to IR(next) assigned historically. An expanded theory of an algorithm is developed mathematically. Practical recommendations for computerization are proposed. RESULTS The MR(true) determined on each of 30 stable intervals and the MR(csne) during the immediately preceding hyperglycemic iteration differed, having medians with interquartile ranges 2.7 (1.2-3.7) and 3.2 (1.5-4.6) units/h, respectively. However, these estimates of MR were strongly correlated (R(2) = 0.88). During hyperglycemia at 941 time points the IR(next) assigned historically and the hypothetically calculated MR(csne)-dependent IR(next) differed, having medians with interquartile ranges 4.0 (3.0-6.0) and 4.6 (3.0-6.8) units/h, respectively, but these paired values again were correlated (R(2) = 0.87). This article describes a programmable algorithm for intravenous insulin infusion. The fundamental equation of the algorithm gives the relationship among IR; the biologic parameter MR; and two variables expressing an instantaneous rate of change of BG, one of which must be zero at any given point in time and the other positive, negative, or zero, namely the rate of change of BG from below target (rate of ascent) and the rate of change of BG from above target (rate of descent). In addition to user-definable parameters, three special algorithm parameters discoverable in nature are described: the maximum rate of the spontaneous ascent of blood glucose during nonhypoglycemia, the glucose per daily dose of insulin exogenously mediated, and the MR at given patient time points. User-assignable parameters will facilitate adaptation to different patient populations. CONCLUSIONS An algorithm is described that estimates MR prior to the attainment of euglycemia and computes MR-dependent values for IR(next). Design features address glycemic variability, promote safety with respect to hypoglycemia, and define a method for specifying glycemic targets that are allowed to differ according to patient condition.
Collapse
|
257
|
Glycemia at admission: the metabolic echocardiography in acute coronary syndrome patients. ACTA ACUST UNITED AC 2009; 16:164-8. [PMID: 19293717 DOI: 10.1097/hjr.0b013e328323ad75] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Ventricular dysfunction in acute coronary syndrome (ACS) patients is a recognized predictor of in-hospital and post-discharge morbidity and mortality. Recently, hyperglycemia at admission has been considered as an important marker of poor in-hospital prognosis. AIM To characterize an ACS population and to identify independent predictors of one-year mortality. METHODS This study included 1179 consecutive patients admitted to a single coronary care unit for acute coronary syndrome between May 2004 and December 2006. Patients were followed up for 12 months after ACS. RESULTS In our population, 70.9% of patients were male, with a mean age of 66.6+/-12.5 years; 15.7% were admitted by unstable angina, 44.7% by non-ST elevation myocardial infarction and 38.5% by ST elevation myocardial infarction; 16% of patients had left ventricular systolic dysfunction during the index admission. In-hospital mortality was 3.5% and complications occurred in 5.6% of patients. Mortality rate at 1-year of follow-up was 8.8% and rehospitalization rate for heart failure was 5.5%. After multivariate regression analysis, left ventricular systolic dysfunction [odds ratio (OR): 3.58; confidence interval (CI): 1.57-8.16], glycemia at admission >137 mg/dl (OR: 3.58; CI: 1.52-8.47) and age >65 years (OR: 2.67; CI: 1.08-6.59) were independent predictors of 1-year mortality. CONCLUSION In this population, hyperglycemia at admission was an independent predictor of 1-year mortality, with a predictive value equivalent to that of left ventricular systolic dysfunction. This fact, never before described, emphasizes the importance of metabolic abnormalities and their control in the prognosis of ACS patients.
Collapse
|
258
|
de Mulder M, Oemrawsingh RM, Stam F, Boersma E, Umans VAWM. Current management of hyperglycemia in acute coronary syndromes: a national Dutch survey. Crit Pathw Cardiol 2009; 8:66-71. [PMID: 19491572 DOI: 10.1097/hpc.0b013e3181a27fcf] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Hyperglycemia is common among patients admitted with acute coronary syndromes (ACS) and is associated with less favorable clinical outcomes. Guidelines for the treatment of hyperglycemia in myocardial infarction are confusing, partly because of lack of sufficient evidence. Neither do we know what the everyday practice on hyperglycemia in ACS is. Therefore the aim of our study is to describe current glucose management in ACS patients in The Netherlands. We designed a multiple-choice questionnaire that was emailed to all 94 independent cardiology departments of each of the 114 hospitals within The Netherlands. We interviewed cardiologists about their specific hospital setting, the presence, content, and actual use of a dedicated hyperglycemia protocol in the setting of ACS. Ninety-four questionnaires were returned (response rate 100%). Only 32% of the respondents reported to have a routinely applied, dedicated hyperglycemia protocol in the setting of ACS. An admission glucose of 13.0 mmol/L is considered a stress value by 60% of respondents. Treatment of hyperglycemia is postponed until after the acute phase (ie, after >6 hours) in 41% of the cardiology departments and in 76% HbA1c is not routinely measured before discharge. Only a minority of Dutch cardiology departments have a routinely applied, dedicated hyperglycemia protocol for patients admitted with ACS. Different views exist on the interpretation of admission hyperglycemia in patients without previously diagnosed diabetes. Dedicated protocols with well-established treatment goals allow early treatment and are mandatory to improve timely metabolic regulation.
Collapse
Affiliation(s)
- Maarten de Mulder
- Department of Cardiology, Medical Centre Alkmaar, Alkmaar, The Netherlands
| | | | | | | | | |
Collapse
|
259
|
Moghissi ES, Korytkowski MT, DiNardo M, Einhorn D, Hellman R, Hirsch IB, Inzucchi SE, Ismail-Beigi F, Kirkman MS, Umpierrez GE. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care 2009; 32:1119-31. [PMID: 19429873 PMCID: PMC2681039 DOI: 10.2337/dc09-9029] [Citation(s) in RCA: 852] [Impact Index Per Article: 56.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Etie S Moghissi
- Department of Medicine, University of California, Los Angeles, Los Angeles, California, USA.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
260
|
Abstract
OBJECTIVE To measure temporal trends in blood glucose (BG) control and describe their association with hospital mortality in a cohort of critically ill patients from Australia. DESIGN Interrogation of prospectively collected data from the Australia New Zealand Intensive Care Society Adult Patient Database. SETTING Twenty-four intensive care units (ICU) across Australia. PATIENTS AND PARTICIPANTS A cohort of 66,184 adult ICU admissions for >or=24 hours from January 1, 2000, to December 31, 2005. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Highest and lowest BG values within 24 hours of ICU admission, standard demographic, clinical, and physiologic data, and hospital mortality. Medical, mechanically ventilated surgical, cardiac surgical, and septic subgroups were evaluated. Average BG was evaluated as a continuous variable and by quartiles (low [<5.6 mmol/L], near normal [5.6-8.69 mmol/L], high [8.69-11.79 mmol/L], and highest [>11.79 mmol/L]). There were 132,368 BG values, with a mean (95% confidence intervals) value 8.69 mmol/L (8.66-8.73). There was no trend in BG for the entire cohort (p = 0.66) over the study period; yet, BG increased after 2002 (0.17 mmol/L, p < 0.0001). The mechanically ventilated surgical and cardiac surgical subgroups had decreasing trends in BG (p < 0.001), whereas the septic subgroup had an increasing BG trend (p < 0.001). BG in the low, high, and highest quartiles, compared with the near-normal quartile, were consistently associated with higher hospital mortality in crude (odds ratio 1.31, 1.58, and 2.00) and multivariable analysis (odds ratio 1.29, 1.07, and 1.10), respectively. This association was similarly shown for the mechanically ventilated surgical and cardiac surgical subgroups. CONCLUSIONS In a large cohort of ICU patients from Australia, there was no significant change in early glycemic control from 2000 to 2005. There were differences in selected subgroups. Average BG decreased in surgical subgroups, whereas it increased in septic patients. Both high and early low BG values were independently associated with hospital mortality.
Collapse
|
261
|
Van den Berghe G, Mesotten D, Vanhorebeek I. Intensive insulin therapy in the intensive care unit. CMAJ 2009; 180:799-800. [PMID: 19318386 PMCID: PMC2665938 DOI: 10.1503/cmaj.090500] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Greet Van den Berghe
- Department and Laboratory of Intensive Care Medicine, Catholic University of Leuven, Leuven, Belgium.
| | | | | |
Collapse
|
262
|
Dandona P, Chaudhuri A, Ghanim H. Acute Myocardial Infarction, Hyperglycemia, and Insulin. J Am Coll Cardiol 2009; 53:1437-9. [DOI: 10.1016/j.jacc.2009.01.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2009] [Accepted: 01/25/2009] [Indexed: 01/04/2023]
|
263
|
Goyal A, Mehta SR, Gerstein HC, Díaz R, Afzal R, Xavier D, Zhu J, Pais P, Lisheng L, Kazmi KA, Zubaid M, Piegas LS, Widimsky P, Budaj A, Avezum A, Yusuf S. Glucose levels compared with diabetes history in the risk assessment of patients with acute myocardial infarction. Am Heart J 2009; 157:763-70. [PMID: 19332208 DOI: 10.1016/j.ahj.2008.12.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2008] [Accepted: 12/06/2008] [Indexed: 01/08/2023]
Abstract
BACKGROUND Both a history of diabetes mellitus and elevated inhospital glucose levels predict death after acute myocardial infarction (AMI). However, only diabetes history (and not glucose levels) is routinely considered in AMI risk assessment. METHODS We conducted a post hoc analysis of 2 randomized controlled trials of AMI with ST-segment elevation to compare the prognostic value of inhospital glucose levels with diabetes history in 30,536 subjects. Average inhospital glucose (mean of glucose levels at admission, 6 hours, and 24 hours), diabetes history, and death at 30 days (occurring in 2,808 subjects) were documented. RESULTS Average glucose predicted 30-day death (OR 1.10 per 1-mmol/L [18-mg/dL] increase, 95% CI 1.09-1.11, P < .0001); this was unchanged after adjusting for diabetes history. In contrast, diabetes history alone predicted 30-day death (OR 1.63, 95% CI 1.48-1.78, P < .0001), but not after adjusting for average glucose (OR 0.98, 95% CI 0.88-1.09, P = .72). The C-indices (areas under the receiver operating characteristic curves) for 30-day death were 0.54 for diabetes history alone, 0.64 for average glucose alone, and 0.64 for glucose plus diabetes. Higher glucose levels predicted death in patients with and without diabetes history, but this relationship was more steep in nondiabetic subjects such that their rate of 30-day death (13.2%) matched that of diabetic patients (13.7%) when average glucose was > or =144 mg/dL (8 mmol/L) (P = .55 after multivariable adjustment). CONCLUSIONS Although diabetes history is routinely considered in the risk stratification of AMI patients, inhospital glucose levels are a much stronger predictor of death and should be incorporated in their risk assessment. Patients with AMI with inhospital glucose > or =144 mg/dL have a very high risk of death regardless of diabetes history.
Collapse
|
264
|
Poppe AY, Majumdar SR, Jeerakathil T, Ghali W, Buchan AM, Hill MD. Admission hyperglycemia predicts a worse outcome in stroke patients treated with intravenous thrombolysis. Diabetes Care 2009; 32:617-22. [PMID: 19131465 PMCID: PMC2660481 DOI: 10.2337/dc08-1754] [Citation(s) in RCA: 140] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Admission hyperglycemia has been associated with worse outcomes in ischemic stroke. We hypothesized that hyperglycemia (glucose >8.0 mmol/l) in the hyperacute phase would be independently associated with increased mortality, symptomatic intracerebral hemorrhage (SICH), and poor functional status at 90 days in stroke patients treated with intravenous tissue plasminogen activator (IV-tPA). RESEARCH DESIGN AND METHODS Using data from the prospective, multicenter Canadian Alteplase for Stroke Effectiveness Study (CASES), the association between admission glucose >8.0 mmol/l and mortality, SICH, and poor functional status at 90 days (modified Rankin Scale >1) was examined. Similar analyses examining glucose as a continuous measure were conducted. RESULTS Of 1,098 patients, 296 (27%) had admission hyperglycemia, including 18% of those without diabetes and 70% of those with diabetes. After multivariable logistic regression, admission hyperglycemia was found to be independently associated with increased risk of death (adjusted risk ratio 1.5 [95% CI 1.2-1.9]), SICH (1.69 [0.95-3.00]), and a decreased probability of a favorable outcome at 90 days (0.7 [0.5-0.9]). An incremental risk of death and SICH and unfavorable 90-day outcomes was observed with increasing admission glucose. This observation held true for patients with and without diabetes. CONCLUSIONS In this cohort of IV-tPA-treated stroke patients, admission hyperglycemia was independently associated with increased risk of death, SICH, and poor functional status at 90 days. Treatment trials continue to be urgently needed to determine whether this is a modifiable risk factor for poor outcome.
Collapse
|
265
|
Kosiborod M, Inzucchi SE, Spertus JA, Wang Y, Masoudi FA, Havranek EP, Krumholz HM. Elevated admission glucose and mortality in elderly patients hospitalized with heart failure. Circulation 2009; 119:1899-907. [PMID: 19332465 DOI: 10.1161/circulationaha.108.821843] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Although some professional societies recommend target-driven glucose control for all hospitalized patients, the association between elevated glucose and adverse outcomes has not been well established in patients hospitalized with heart failure. METHODS AND RESULTS We evaluated a nationally representative cohort of 50,532 elderly patients hospitalized with heart failure in the United States between April 1998 and June 2001. The association between admission glucose and all-cause mortality at 30 days and 1 year was analyzed with multivariable Cox regression models, both in the entire cohort and in patients with and without diabetes mellitus. After multivariable adjustment, no significant relationship was found between glucose and 30-day mortality (for glucose groups of >110 to 140, >140 to 170, >170 to 200, and >200 mg/dL; hazard ratios for 30-day mortality were 1.09 (95% confidence interval, 0.98 to 1.22), 1.27 (95% confidence interval, 1.11 to 1.45), 1.16 (95% confidence interval, 0.98 to 1.37), and 1.00 (95% confidence interval, 0.87 to 1.15), respectively, versus glucose < or =110 mg/dL; P for linear trend=0.53). Results were similar for 1-year mortality and did not differ between patients with and without known diabetes mellitus (for diabetesxglucose interaction, P=0.11 and 0.55 for 30-day and 1-year mortality, respectively). CONCLUSIONS We found no significant association between admission glucose levels and mortality in a large cohort of patients hospitalized with heart failure. Our findings suggest that the relationship between hyperglycemia and adverse outcomes seen in acute myocardial infarction cannot be automatically extended to patients hospitalized with other cardiovascular conditions.
Collapse
Affiliation(s)
- Mikhail Kosiborod
- Mid America Heart Institute of Saint Luke's Hospital, Kansas City, MO 64111, USA.
| | | | | | | | | | | | | |
Collapse
|
266
|
Polito A, Thiagarajan RR, Laussen PC, Gauvreau K, Agus MSD, Scheurer MA, Pigula FA, Costello JM. Association between intraoperative and early postoperative glucose levels and adverse outcomes after complex congenital heart surgery. Circulation 2008; 118:2235-42. [PMID: 19001022 DOI: 10.1161/circulationaha.108.804286] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND This study sought to determine whether associations exist between perioperative glucose exposure, prolonged hospitalization, and morbid events after complex congenital heart surgery. METHODS AND RESULTS Metrics of glucose control, including average, peak, minimum, and SD of glucose levels, and duration of hyperglycemia were determined intraoperatively and for 72 hours after surgery for 378 consecutive high-risk cardiac surgical patients. Multivariable regression analyses were used to determine relationships between these metrics of glucose control, hospital length of stay, and a composite morbidity-mortality outcome after controlling for multiple variables known to influence early outcomes after congenital heart surgery. Intraoperatively, a minimum glucose <or=75 mg/dL was associated with greater adjusted odds of reaching the composite morbidity-mortality end point (odds ratio [OR], 3.10; 95% confidence interval [CI], 1.49 to 6.48), but other metrics of glucose control were not associated with the composite end point or length of stay. Greater duration of hyperglycemia (glucose >126 mg/dL) during the 72 postoperative hours was associated with longer duration of hospitalization (P<0.001). In the 72 hours after surgery, average glucose <110 mg/dL (OR, 7.30; 95% CI, 1.95 to 27.25) or >143 mg/dL (OR, 5.21; 95% CI, 1.37 to 19.89), minimum glucose <or=75 mg/dL (OR, 2.85; 95% CI, 1.38 to 5.88), and peak glucose level >or=250 mg/dL (OR, 2.55; 95% CI, 1.20 to 5.43) were all associated with greater adjusted odds of reaching the composite morbidity-mortality end point. CONCLUSIONS In children undergoing complex congenital heart surgery, the optimal postoperative glucose range may be 110 to 126 mg/dL. Randomized trials of strict glycemic control achieved with insulin infusions in this patient population are warranted.
Collapse
Affiliation(s)
- Angelo Polito
- Department of Cardiology, Children's Hospital Boston, Harvard Medical School, Boston, MA 02115, USA
| | | | | | | | | | | | | | | |
Collapse
|
267
|
Goyal A, Nerenberg K, Gerstein HC, Umpierrez G, Wilson PWF. Insulin therapy in acute coronary syndromes: an appraisal of completed and ongoing randomised trials with important clinical end points. Diab Vasc Dis Res 2008; 5:276-84. [PMID: 18958837 PMCID: PMC3746495 DOI: 10.3132/dvdr.2008.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Insulin therapy was first proposed as an adjunctive therapy in patients with acute coronary syndromes (ACS) in the 1960s. Since then, numerous randomised clinical trials have been conducted to determine the efficacy and to define the role of insulin therapy in ACS. This review will discuss: 1) completed trials of insulin therapy in ACS, including both glucose-insulin-potassium (GIK) approaches and non-GIK approaches; 2) trials of insulin therapy in critically ill non-ACS patients and the lessons from these trials that can be applied to trials of insulin in ACS patients; and 3) a summary of ongoing and planned trials of insulin in ACS patients.
Collapse
Affiliation(s)
- Abhinav Goyal
- Department of Epidemiology, Emory Rollins School of Public Health, Atlanta, GA, USA.
| | | | | | | | | |
Collapse
|
268
|
Kosiborod M. Blood glucose and its prognostic implications in patients hospitalised with acute myocardial infarction. Diab Vasc Dis Res 2008; 5:269-75. [PMID: 18958836 DOI: 10.3132/dvdr.2008.039] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Elevated blood glucose and its potential link with adverse outcomes in patients with acute myocardial infarction (AMI) has been the subject of intense study over more than 40 years. The numerous observational studies performed to date have addressed some of the questions in this field, but many critically important questions are still poorly understood, and remain subjects of debate. This review summarises current epidemiological data on the prevalence of hyperglycaemia in the AMI patient population and its relationship to patient outcomes, and addresses some of the existing controversies in the field.
Collapse
Affiliation(s)
- Mikhail Kosiborod
- Mid America Heart Institute of Saint Luke's Hospital, Kansas City, MO 64111, USA.
| |
Collapse
|
269
|
Abstract
Glycaemic memory describes the deferred effects of prior glycaemic status on diabetic complications later in life, independent of more recent glycaemic control. Prospective evidence for glycaemic memory derives from extended studies after trials that compared intensive versus standard glycaemic control. These studies in type 1 diabetes (e.g. DCCT) and type 2 diabetes (e.g. UKPDS) have shown that a period of poor glycaemic control earlier in the course of the disease is associated with an increased burden of complications much later in the course of the disease, even when glycaemic control is latterly improved. The Veterans Affairs Diabetes Trial suggested that more than 12—15 years of poor control in older type 2 patients minimised the benefits of subsequently improved glycaemic control. The delayed adverse effects of hyperglycaemia emphasise the importance of effective early glycaemic control.
Collapse
Affiliation(s)
- Clifford J Bailey
- School of Life and Health Sciences, Aston University, Birmingham, UK,
| | - Caroline Day
- School of Life and Health Sciences, Aston University, Birmingham, UK
| |
Collapse
|
270
|
Schnipper JL, Magee M, Larsen K, Inzucchi SE, Maynard G. Society of Hospital Medicine Glycemic Control Task Force summary: practical recommendations for assessing the impact of glycemic control efforts. J Hosp Med 2008; 3:66-75. [PMID: 18951387 DOI: 10.1002/jhm.356] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Jeffrey L Schnipper
- Brigham and Women's/Faulkner Hospitalist Service and Division of General Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts 02120-1613, USA.
| | | | | | | | | | | |
Collapse
|
271
|
Braithwaite SS, Magee M, Sharretts JM, Schnipper JL, Amin A, Maynard G. The case for supporting inpatient glycemic control programs now: the evidence and beyond. J Hosp Med 2008; 3:6-16. [PMID: 18951385 DOI: 10.1002/jhm.350] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Susan S Braithwaite
- Department of Medicine, University of North Carolina-Chapel Hill, North Carolina 27599, USA.
| | | | | | | | | | | | | |
Collapse
|
272
|
Gandhi M, Finegan BA, Clanachan AS. Role of glucose metabolism in the recovery of postischemic LV mechanical function: effects of insulin and other metabolic modulators. Am J Physiol Heart Circ Physiol 2008; 294:H2576-86. [DOI: 10.1152/ajpheart.00942.2007] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The role of proton (H+) production from glucose metabolism in the recovery of myocardial function during postischemic reperfusion and its alteration by insulin and other metabolic modulators were examined. Rat hearts were perfused in vitro with Krebs-Henseleit solution containing palmitate (1.2 mmol/l) and glucose (11 mmol/l) under nonischemic conditions or during reperfusion following no-flow ischemia. Perfusate contained normal insulin (n-Ins, 50 mU/l), zero insulin (0-Ins), or supplemental insulin (s-Ins, 1,000 mU/l) or other metabolic modulators [dichloroacetate (DCA) at 3 mmol/l, oxfenicine at 1 mmol/l, and N6-cyclohexyladenosine (CHA) at 0.5 μmol/l]. Relative to n-Ins, 0-Ins depressed rates of glycolysis and glucose oxidation in nonischemic hearts and impaired recovery of postischemic function. Relative to n-Ins, s-Ins did not affect aerobic glucose metabolism and did not improve recovery when present during reperfusion. When present during ischemia and reperfusion, s-Ins impaired recovery. Combinations of metabolic modulators with s-Ins stimulated glucose oxidation ∼2.5-fold in nonischemic hearts and reduced H+ production. DCA and CHA, in combination with s-Ins, improved recovery of function, but addition of oxfenicine to this combination provided no further benefit. Although DCA and CHA were each partially protective in hearts perfused with n-Ins, optimal protection was achieved with DCA + CHA; recovery of function was inversely proportional to H+ production during reperfusion. Although supplemental insulin is not beneficial, elimination of H+ production from glucose metabolism by simultaneous inhibition of glycolysis and stimulation of glucose oxidation optimizes recovery of postischemic mechanical function.
Collapse
|
273
|
|
274
|
Opie LH. Metabolic Management of Acute Myocardial Infarction Comes to the Fore and Extends Beyond Control of Hyperglycemia. Circulation 2008; 117:2172-7. [DOI: 10.1161/circulationaha.108.780999] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Lionel H. Opie
- From the Hatter Cardiovascular Research Institute, Department of Medicine, University of Cape Town, South Africa
| |
Collapse
|
275
|
Braithwaite SS. Patient-level glucose reporting: averages, episodes, or something in between? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 12:133. [PMID: 18423064 PMCID: PMC2447579 DOI: 10.1186/cc6842] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The article by Van Herpe and colleagues in the previous issue of Critical Care describes the glycemic penalty index (GPI), which weights both hyperglycemic and hypoglycemic blood glucose measurements commensurate to their clinically significant difference from target. Although certain adverse consequences result from isolated severe hyperglycemic episodes, several specific outcomes depend upon overall hyperglycemia. In contrast, although mortality has been related epidemiologically to overall low blood glucose, specific negative outcomes may depend upon isolated episodes. Capturing both hypoglycemia and hyperglycemia in a single index will be shown to be useful if the GPI enables us to better define insulin strategies, outcomes, and targets.
Collapse
Affiliation(s)
- Susan S Braithwaite
- University of North Carolina - Chapel Hill, Highgate, Durham, NC 27713, USA.
| |
Collapse
|
276
|
|