Impact of unknown diabetes and prediabetes on clinical outcomes in "nondiabetic" Chinese patients after a primary coronary intervention

Prediabetes and major adverse cardiac events after acute coronary syndrome: An overestimated concept

BACKGROUND

Unlike diabetes, the effect of prediabetes on outcomes in patients with acute coronary syndrome (ACS) who underwent percutaneous coronary intervention (PCI) is not much investigated. We investigated the association between fasting glycemic status and major adverse cardiovascular and cerebrovascular events (MACCE) in patients with ACS undergoing PCI and had mid to long-term follow-up after coronary stenting.

METHODS

Registry-based retrospective cohort study included ACS patients who underwent PCI at the Tehran Heart Center from 2015 to 2021 with a median follow-up of 378 days. Patients were allocated into normoglycemic, prediabetic, and diabetic groups. The primary and secondary outcomes were MACCE and its components, respectively. Unadjusted and adjusted Cox models were used to evaluate the association between glycemic status and outcomes.

RESULTS

Among 13 682 patients, 3151 (23%) were prediabetic, and 5834 (42.6%) were diabetic. MACCE risk was significantly higher for diabetic versus normoglycemic (adjusted hazard ratio [aHR]: 1.22, 95% confidence interval [CI]: 1.06-1.41), but nonsignificantly higher for prediabetic versus normoglycemic (aHR: 0.95, 95% CI: 0.78-1.10). All-cause mortality risk was significantly higher in diabetic versus normoglycemic (aHR: 1.42, 95% CI: 1.08-1.86), but nonsignificantly higher for prediabetic versus normoglycemic (aHR: 1.15, 95% CI: 0.84-1.59). Among other components of MACCE, only coronary artery bypass grafting was significantly higher in diabetic patients, and not prediabetic, compared with normoglycemic.

CONCLUSIONS

Prediabetic ACS patients undergoing PCI, unlike diabetics, are not at increased risk of MACCE and all-cause mortality. While prediabetic patients could be regarded as having the same risk as nondiabetics, careful consideration to provide more intensive pre- and post-PCI care in diabetic patients is mandatory.

The Role of Insulin Resistance in the Development of Complications after Coronary Artery Bypass Grafting in Patients with Coronary Artery Disease

The aim of the study was to investigate the effect of carbohydrate metabolism disorders and insulin resistance indices on the immediate results of coronary artery bypass grafting (CABG).

METHOD

Patients with coronary artery disease who underwent CABG (n = 383) were examined to determine glycemic status, free fatty acid and fasting insulin levels, and insulin resistance indices (Homeostasis Model Assessment of Insulin Resistance (HOMA-IR), McAuley index, Quantitative Insulin Sensitivity Check Index (QUICKI), Revised-QUICKI). Patients were assessed for the development of perioperative complications and their length of stay in the hospital. Two groups were formed: group 1, patients with a combined endpoint (CEP, any complication and/or duration of hospital stay >10 days), n = 291; and group 2 (n = 92) without a CEP. Perioperative characteristics were analyzed, and predictors of hospital complications and prolonged hospital stay were evaluated.

RESULTS

Patients in the CEP group were older, and there were more women among them (p = 0.003). Additionally, in this group, there were more patients with diabetes mellitus (37.5% vs 17.4%, p < 0.001), obesity (p < 0.001), and a higher percentage of combined operations (p = 0.007). In the group with a CEP, the levels of glucose (p = 0.031), glycated hemoglobin (p = 0.009), and free fatty acids (p = 0.007) and the Revised-QUICKI (p = 0.020) were higher than in the group without complications. In a regression analysis, the independent predictors of complications were combined operations (p = 0.016) and the predictors of a long hospital stay (>14 days) were female gender, the left atrium size, and diabetes mellitus (p < 0.001). The predictors of a composite endpoint included female gender, age, the left atrium size, and free fatty acid levels (p < 0.001).

CONCLUSIONS

In the group with in-hospital complications after CABG, not only was the presence of diabetes mellitus more often detected, but there were also higher levels of free fatty acids and a higher Revised-QUICKI. Therefore, additional assessments of insulin resistance and free fatty acid levels are advisable in patients before CABG.

Outcomes of Prediabetes Compared with Normoglycaemia and Diabetes Mellitus in Patients Undergoing Percutaneous Coronary Intervention: A Systematic Review and Meta-analysis

Background: Patients with prediabetes are at increased risk of coronary artery disease (CAD). However, the association between prediabetes and adverse clinical outcomes following percutaneous coronary intervention (PCI) is inconsistent, in contrast to outcomes in patients with diabetes mellitus (DM). Thus, this meta-analysis evaluated the impact of dysglycaemia on PCI outcomes. Methods: The PubMed, Embase, Cochrane, and ClinicalTrials.gov databases were systematically reviewed from inception of databases until June 2022. In 17 studies, outcomes of PCI in patients with prediabetes were compared with patients who were normoglycaemic, and patients with DM. The primary outcome was all-cause mortality at the longest follow-up. Results: Included were 12 prospective and five retrospective studies, with 11,868, 14,894 and 13,536 patients undergoing PCI in the prediabetes, normoglycaemic and DM groups, respectively. Normoglycaemic patients had a statistically lower risk of all-cause mortality, (risk ratio [RR] 0.66, 95% confidence interval [CI] 0.52-0.84), myocardial infarction (MI; RR 0.76, 95% CI 0.61-0.95) and cardiac mortality (RR 0.58, 95% CI 0.39-0.87) compared with prediabetic patients undergoing PCI at the longest follow-up. Patients with prediabetes had a lower risk of all-cause mortality (RR=0.72 [95% CI 0.53-0.97]) and cardiac mortality (RR =0.47 [95% CI 0.23-0.93]) compared with patients with DM who underwent PCI. Conclusion: Among patients who underwent PCI for CAD, the risk of all-cause and cardiac mortality, major adverse cardiovascular events and MI in prediabetic patients was higher compared with normoglycaemic patients but lower compared with patients with DM.

Association between hemoglobin glycation index and subclinical myocardial injury in the general population free from cardiovascular disease

BACKGROUND AND AIMS

The relationship between hemoglobin glycation index (HGI) and the diagnosis and prognosis of cardiovascular disease (CVD) has been verified by previous studies. However, it remains unknown whether HGI has a predictive effect on subclinical myocardial injury (SC-MI). The purpose of the present study was to explore the relationship between HGI and SC-MI in the general population free from CVD.

METHODS AND RESULTS

The present study included 6009 participants free of CVD from the third National Health and Nutrition Examination Survey. Binary Logistic regression analysis was used to tested the association between HGI and SC-MI. As results, the HGI was significantly higher in participants with SC-MI compared with those without, and the HGI was positively correlated with SC-MI and other metabolic disorder parameters. Each 1-unit increase of HGI and glycated hemoglobin A1c (HbA1c) was independently associated with higher risk of SC-MI (P < 0.05), while fasting plasma glucose (FPG) was no longer a predictive indicator of SC-MI with the increase of confounding factors [OR (95% CI): 1.001 (0.999-1.003), P = 0.305]. And in the subgroup analysis, HGI, only in participants without diabetes, was independently associated with higher risk of SC-MI, while HbA1c and FPG had no independent predictive role in both diabetic and non-diabetic participants.

CONCLUSIONS

HGI was a significant predictor of SC-MI in the general population free from CVD.

Impact of prediabetes on long-term cardiovascular outcomes in patients with myocardial infarction with nonobstructive coronary arteries

BACKGROUND

Abnormal glucose metabolism including diabetes (DM) and prediabetes (pre-DM) have been reported as predictors of poorer outcomes after acute myocardial infarction (AMI). However, the prognostic value of pre-DM in patients with myocardial infarction with nonobstructive coronary arteries (MINOCA) remains unclear.

METHODS

A total of 1179 MINOCA patients were prospectively recruited and divided into normoglycemia (NG), pre-DM, and DM groups according to glycated hemoglobin (HbA_1c) levels or past history. The primary endpoint was a composite of major adverse cardiovascular events (MACE), including all-cause death, nonfatal MI, nonfatal stroke, revascularization and hospitalization for unstable angina or heart failure. Kaplan-Meier and Cox regression analyses were performed.

RESULTS

Patients with pre-DM and DM had a significantly higher incidence of MACE compared with NG group (10.8%, 16.1%, 19.4%; p = 0.003) over the median follow-up of 41.7 months. After multivariate adjustment, both pre-DM and DM were significantly associated with an increased risk of MACE (NG as reference; pre-DM: 1.45, 95% CI 1.03-2.09, p = 0.042; DM: HR 1.79, 95% CI 1.20-2.66, p = 0.005). At subgroup analysis, pre-DM remained a robust risk factor of MACE compared to NG. In addition, pre-DM had a similar impact as DM on long-term prognosis in patients with MINOCA.

CONCLUSIONS

Pre-DM defined as raised HbA_1c was associated with a poor prognosis in patients with MINOCA. Routine assessment of HbA_1c enables an early recognition of pre-DM and thus may facilitate risk stratification in this specific population.

Long term prognostic implication of newly detected abnormal glucose tolerance among patients with stable cardiovascular disease: a population-based cohort study

Background

Fasting plasma glucose (FPG) and 2-h post challenge plasma glucose (2 h-PCPG), whether as continuous or categorical variables, are associated with incident cardiovascular disease (CVD) and diabetes; however, their role among patients with existing CVD is a matter of debate. We aimed to evaluate associations of different glucose intolerance states with recurrent CVD and incident diabetes among subjects with previous CVD.

Methods

From a prospective population-based cohort, 408 Iranians aged  ≥  30 years, with history of CVD and without known diabetes were included. Associations of impaired fasting glucose (IFG) according to the American Diabetes Association (ADA) and World Health Organization (WHO) criteria, impaired glucose tolerance (IGT), newly diagnosed diabetes (NDM) with outcomes of interest were determined by multivariable Cox proportional hazard models after adjustment for traditional risk factors. Furthermore, FPG and 2 h-PCPG were entered as continuous variables.

Results

Over a decade of follow-up, 220 CVD events including 89 hard events (death, myocardial infarction and stroke) occurred. Regarding prediabetes, only IFG-ADA was associated with increased risk of hard CVD [hazard ratio(HR), 95%CI: 1.62,1.03–2.57] in the age-sex adjusted model. In patients with NDM, those with FPG ≥ 7 mmol/L were at higher risk of incident CVD/coronary heart disease(CHD) and their related hard outcomes (HR ranged from 1.89 to 2.84, all P < 0.05). Moreover, those with 2 h-PCPG ≥ 11.1 mmol/L had significant higher risk of CVD (1.46,1.02–2.11), CHD (1.46,1.00–2.15) and hard CHD (1.95:0.99–3.85, P = 0.05). In the fully adjusted model, each 1 SD increase in FPG was associated with 20, 27, 15 and 25% higher risk of CVD, hard CVD, CHD and hard CHD, respectively; moreover each 1 SD higher 2 h-PCPG was associated with 21% and 16% higher risk of CVD, and CHD, respectively. Among individuals free of diabetes at baseline (n = 361), IFG-ADA, IFG-WHO and IGT were significantly associated with incident diabetes (all P < 0.05); significant associations were also found for FPG and 2 h-PCPG as continuous variables (all HRs for 1-SD increase > 2, P < 0.05).

Conclusions

Among subjects with stable CVD, NDM whether as high FPG or 2 h-PCPG, but not pre-diabetes status was significantly associated with CVD/CHD and related hard outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12967-021-02950-y.

Acute and long-term effects of saxagliptin on post-prandial glycemic response in obese patients with impaired glucose tolerance

BACKGROUND AND AIMS

Dipeptidyl-peptidase inhibitors might be useful in type 2 diabetes prevention. ACCES (ACute and Chronic Effects of Saxagliptin) was a randomized, placebo-controlled, double-blind, controlled phase 2, pilot study aiming to examine in obese patients with impaired glucose tolerance (IGT) the acute effects and the effects after 12 weeks of treatment by saxagliptin on glucose levels at fasting and postprandially after a standard breakfast, and on glucose tolerance.

METHODS AND RESULTS

We included 24 obese patients with IGT. Patients were randomized to receive saxagliptin 5 mg or placebo in the morning. The treatment was taken on Visit 1 before breakfast, then continued for 12 weeks. Biochemical measurements were performed before, one, two and three hours after a standard breakfast including 75 g of carbohydrates, during Visit 1 and Visit 2 (12 weeks). Glucose variability (GV) was evaluated at Visit 1 from 24-h continuous glucose monitoring including the breakfast. A second OGTT was performed at Visit 3 (3-5 days after Visit 2). Compared with placebo-treated patients, saxagliptin-treated patients had lower 1 h and 2 h post-meal plasma glucose levels at Visit 1 and similar changes at Visit 2 (p < 0.01 to p < 0.004), with lower GV indexes after breakfast at Visit 1. At Visit 3, all patients but one in saxagliptin group and only 4 patients in placebo group turned to normal glucose tolerance. Lower glucose response to breakfast at Visit 1 was predictive of recovery of glucose tolerance.

CONCLUSION

Saxagliptin has metabolically beneficial effects in glucose-intolerant obese patients by significantly lowering postprandial blood glucose levels.

CLINICAL TRIAL REGISTRATION NUMBER

NCT01521312: https://clinicaltrials.gov/ct2/show/NCT01521312.

Has hyperglycemia a different prognostic role in STEMI patients with or without diabetes?

BACKGROUND AND AIMS

Hyperglycemia at hospital admission is a common finding in patients with STEMI. However, whether elevated acute glycemia in these patients may have a direct impact on worsening prognosis or is just a marker of a greater neurohormonal activation in response to the infarction is still unsettled. We sought to investigate the prognostic impact of hyperglycemia at hospital admission in patients undergoing primary PCI (pPCI) for STEMI, and the influence of the presence of diabetes mellitus (DM) on its prognostic impact.

METHODS

and Results, We enrolled 2958 consecutive STEMI patients treated by pPCI. Hyperglycemia was defined as plasma glucose >198 mg/dL (or >11 mmol/L). Patients with hyperglycemia showed a greater risk-profile; they also experienced a higher mortality both at univariable (17.6% vs 5.2%, p < 0.001) and multivariable (HR 1.9, 95%IC 1.5-2.9, p = 0.001) analysis. However, after stratification for DM presence, hyperglycemia resulted as an independent predictor of mortality only in patients without DM (HR 2, 95%IC 1.2-3.4, p = 0.01).

CONCLUSION

Hyperglycemia in the setting of myocardial infarction treated with primary PCI in an independent predictor of all-cause mortality in patients without diabetes; in patients with diabetes, its prognostic impact seems attenuated.

Prognostic Significance of HbA1c Level in Asian Patients with Prediabetes and Coronary Artery Disease

Background: Measuring glycosylated hemoglobin (HbA1c) is a simple way to assess patients with prediabetes ordiabetes mellitus. It has been shown that HbA1c level predicts prognosis in patients with coronary artery disease (CAD)and the incidence of diabetes mellitus. However, the prognostic significance of HbA1c level in Asian patients withprediabetes and CAD is not yet clear. Our study aimed to determine the relationship between HbA1c level and majoradverse cardiovascular events (MACE) in patients with prediabetes and CAD.Methods: We enrolled 1367 patients with prediabetes and CAD in the final analysis, and grouped them according tothe HbA1c level. Primary end points included nonfatal myocardial infarction, hospitalization for unstable angina, andischemia-driven revascularization. Cox proportional-hazards regression analysis was used to determine the relationshipbetween HbA1c level and MACE after our accounting for confounding factors.Results: A total of 1367 patients (age 58.8 ± 10.3 years; 71.6% men) were included. During 43 months of follow-up,197 patients experienced at least one primary end point event. Multivariate Cox proportional-hazards regression analysisshowed in comparison of HbA1c levels that the hazard ratio for primary end points was 4.110, with a 95% confidence interval of 2.097–6.011 (P < 0.001).Conclusions: HbA1c level positively correlated with MACE, demonstrating it is a valuable indicator for independentlypredicting MACE in Asian patients with prediabetes and CAD.