Glycosylated hemoglobin levels and clinical outcomes in nondiabetic patients with coronary artery disease: A meta-analysis

The glycosylated hemoglobin level and the severity of cardiovascular involvement in patients with the first episode of acute coronary syndrome

Background

The current study was carried out aiming at investigating the relationship between glycosylated hemoglobin level and coronary atherosclerosis in patients with the first episode of acute coronary syndrome.

Methods

This case-control study evaluated 450 patients with the first episode of acute coronary syndrome in Ayatollah Rouhani Hospital in Babol (Iran) from 2011 to 2018. Based on glycosylated hemoglobin, patients were divided into three groups of non-diabetic, pre-diabetic, and diabetic (n=150 in each group). Since SYNTAX score and Gensini score are employed to evaluate the extent of cardiovascular disease and predict CVD in patients with CAD over long-term follow-up, we calculated SYNTAX score and Gensini score based on angiographic results.

Results

Concerning the factors related to the severity of cardiovascular involvement, the results revealed no significant difference between the diabetic and pre-diabetic groups in terms of the frequency of patients in terms of SYNTAX score, Gensini score, and the number of vessels involved (0.142 and 87, respectively, and P=0.102). However, this difference between the diabetic and non-diabetic groups, as well as between the pre-diabetic and non-diabetic groups was statistically significant (respectively for SYNTAX score, p< 0.001 and P=0.001; for Gensini score, P=0.013 and P=0.019; and for the number of vessels involved P=0.001and p<0.001).

Conclusion

According to the findings of the current study, since there was no significant difference between diabetic and pre-diabetic patients in terms of the components indicating the severity of cardiovascular involvement, pre-diabetes itself may be associated with the severity of cardiovascular involvement as a predisposing factor.

Elevation of Hemoglobin A1c Increases the Atherosclerotic Plaque Vulnerability and the Visit-to-Visit Variability of Lipid Profiles in Patients Who Underwent Elective Percutaneous Coronary Intervention

Background

Increased plaque vulnerability and higher lipid variability are causes of adverse cardiovascular events. Despite a close association between glucose and lipid metabolisms, the influence of elevated glycated hemoglobin A1c (HbA1c) on plaque vulnerability and lipid variability remains unclear.

Methods

Among subjects undergoing percutaneous coronary intervention (PCI) from 2009 through 2019, 366 patients received intravascular optical coherence tomography (OCT) assessment and 4,445 patients underwent the scheduled follow-ups within 1 year after PCI. Vulnerability features of culprit vessels were analyzed by OCT examination, including the assessment of lipid, macrophage, calcium, and minimal fibrous cap thickness (FCT). Visit-to-visit lipid variability was determined by different definitions including standard deviation (SD), coefficient of variation (CV), and variability independent of the mean (VIM). Multivariable linear regression analysis was used to verify the influence of HbA1c on plaque vulnerability features and lipid variability. Exploratory analyses were also performed in non-diabetic patients.

Results

Among enrolled subjects, the pre-procedure HbA1c was 5.90 ± 1.31%, and the average follow-up HbA1c was 5.98 ± 1.16%. By OCT assessment, multivariable linear regression analyses demonstrated that patients with elevated HbA1c had a thinner minimal FCT (β = −6.985, P = 0.048), greater lipid index (LI) (β = 226.299, P = 0.005), and higher macrophage index (β = 54.526, P = 0.045). Even in non-diabetic patients, elevated HbA1c also linearly decreased minimal FCT (β = −14.011, P = 0.036), increased LI (β = 290.048, P = 0.041) and macrophage index (β = 120.029, P = 0.048). Subsequently, scheduled follow-ups were performed during 1-year following PCI. Multivariable linear regression analyses proved that elevated average follow-up HbA1c levels increased the VIM of lipid profiles, including low-density lipoprotein cholesterol (β = 2.594, P < 0.001), high-density lipoprotein cholesterol (β = 0.461, P = 0.044), non-high-density lipoprotein cholesterol (β = 1.473, P < 0.001), total cholesterol (β = 0.947, P < 0.001), and triglyceride (β = 4.217, P < 0.001). The result was consistent in non-diabetic patients and was verified when SD and CV were used to estimate variability.

Conclusion

In patients undergoing elective PCI, elevated HbA1c increases the atherosclerotic plaque vulnerability and the visit-to-visit variability of lipid profiles, which is consistent in non-diabetic patients.

Glycemic gap and the outcome of diabetic patients presenting with acute coronary syndrome

Background

Acute hyperglycemia is a common finding in both diabetic and non-diabetic patients with acute coronary syndrome (ACS) who present to the emergency department (ED). The prognostic role of hyperglycemia in diabetic patients with ACS remains controversial at least on the short-term basis. The aim of the present study was to find the relation between the glycemic gap and clinical outcome in diabetic patients with ACS.

Methods

The study included 100 diabetic patients with ACS to who were prospectively followed during their hospital stay. Admission blood glucose was measured and glycemic gap was calculated.

Results

In diabetic patients suffering ACS, there was a significant relation between the glycemic gap value, occurrence of major adverse cardiovascular events (MACE) and length of hospital stay.

Conclusion

Glycemic gap is a better marker than admission blood glucose alone in diabetic patients presenting with ACS. This study added the optimal cut-off value for this important biomarker.

The association of subclinical atherosclerosis with prediabetes is stronger in people with dyslipidaemia than in those with normoglycaemia: A cross-sectional study in Chinese adults

BACKGROUND

Prediabetes is associated with a high risk of cardiovascular disease (CVD) and often occurs with dyslipidaemia. The present study investigated the association between subclinical atherosclerosis profiles and prediabetes with and without dyslipidaemia.

METHODS

This cross-sectional analysis included 4786 participants (1441 subjects with prediabetes and 3345 healthy controls). Prediabetes was defined by fasting plasma glucose (FPG) 5.6-6.9mmol/L or HbA1c 5.7-6.4% without antidiabetic drugs. Different markers of subclinical atherosclerosis were analysed: the carotid intima-media thickness (CIMT), carotid plaques (CP), and brachial-ankle pulse wave velocity (baPWV).

RESULTS

Subclinical atherosclerosis was significantly more prevalent in prediabetic subjects than in normoglycaemic subjects (P<0.001). Only individuals with prediabetes in the dyslipidaemic group had significantly elevated adjusted odds ratios for subclinical atherosclerosis profiles. When stratified by FPG-only, HbA1c-only or both, the three subcategories in combination with dyslipidaemia shared a similarly increased risk of subclinical atherosclerosis compared to normoglycaemia without dyslipidaemia (P<0.05). The risk profile increased directionally from FPG-only to HbA1c-only to both overall.

CONCLUSION

Our data suggest that subclinical atherosclerotic changes in the prediabetic state are mainly seen in dyslipidaemic subjects. Thus, strategies to prevent atherogenic changes might focus on persons with prediabetes combined with dyslipidaemia, especially for the prediabetes-both subcategory, because of potential effects on CVD risk.

Prognostic significance of the hemoglobin A1c level in non-diabetic patients undergoing percutaneous coronary intervention: a meta-analysis

Background

The predictive value of hemoglobin A1c (HbA1c) levels in non-diabetic patients with myocardial infarction undergoing percutaneous coronary intervention (PCI) is still controversial. This study aimed to evaluate whether HbA1c levels were independently associated with adverse clinical outcomes in non-diabetic patients with coronary artery disease (CAD) who had undergone PCI by performing a meta-analysis of cohort studies.

Methods

This meta-analysis included non-diabetic patients with CAD who had undergone PCI. A systematic search for publications listed in the PubMed, Embase, and Cochrane Library databases from commencement to December 2018 was conducted. Studies evaluating the adverse clinical outcomes according to abnormal HbA1c levels in non-diabetic patients diagnosed with CAD who had undergone PCI were eligible. The primary outcomes were long-term all-cause deaths and long-term major adverse cardiac events, and the secondary outcome was short-term all-cause deaths. The meta-analysis was conducted with RevMan 5.3 and Stata software 14.0. Odds ratios (ORs) were pooled using a random or fixed-effects model, depending on the heterogeneity of the included studies. Sub-group analysis or sensitivity analysis was conducted to explore potential sources of heterogeneity, when necessary.

Results

Six prospective cohort studies involving 10,721 patients met the inclusion criteria. From the pooled analysis, abnormal HbA1c levels were associated with increased risk for long-term all-cause death (OR 1.39, 95% confidence interval [CI] 1.16–1.68, P = 0.001, I² = 45%). Sub-group analysis suggested that abnormal HbA1c levels between 6.0% and 6.5% predicted higher long-term major adverse cardiac event (including all-cause deaths, non-fatal myocardial infarction, target lesion revascularization, target vessel revascularization, recurrent acute myocardial infarction, heart failure requiring hospitalization, and stent thrombosis) risk (OR 2.05, 95% CI 1.46–2.87, P < 0.001, I² = 0). Contrarily, elevated HbA1c levels were not associated with increased risk of short-term all-cause death (OR 1.16, 95% CI 0.88–1.54, P = 0.300, I² = 0).

Conclusions

An abnormal HbA1c level is an independent risk factor for long-term adverse clinical events in non-diabetic patients with CAD after PCI. Strict control of HbA1c levels may improve patient survival. Further studies in different countries and prospective cohort studies with a large sample size are required to verify the association.

[Prognostic value of HbA1c and plasma glucose on one-year mortality in non-diabetic patients after myocardial infarction]

BACKGROUND

The usefulness of the combined assessment of HbA1c and plasma glucose (PG) in acute myocardial infarction (AMI) in non-diabetic patients remains unclear.

PURPOSE

In a large observational study, we aimed to identify the prognostic values of these biomarkers regarding one-year all-cause mortality in non-diabetic patients after AMI.

METHODS

From the "obseRvatoire des Infarctus de Côte d'Or" (RICO) survey database, we included all consecutive non-diabetic patients with AMI (n=6617) from May 2001 to December 2016. Exclusion criteria were: admission known or unknown diabetes, in-hospital death. The primary endpoint was all-cause one-year mortality. The secondary endpoints were: MACE, infarct size, LVEF<40% and GRACE risk score. Cut-off levels (high/low) were determined by ROC curve analysis for the prediction of one-year death (HbA1c 5.9% and PG 131mg/dL) to set up 4 groups: low HbA1c/low glucose (n=3158), low HbA1c/high glucose (n=1264), high HbA1c/low glucose (n=1378) and high HbA1c/high glucose (n=817).

RESULTS

Elevation of PG was associated with elevated rate of LVEF<40%, STEMI, anterior wall location, DFG<60mL/min/m² and higher troponin Ic pic (all P<0.001); HbA1c>5.9% was associated with elevated rate of CRP>3mg/L (P<0.001); high HbA1c and high PG together were associated with higher rate of MACE (P<0.001). By multivariate logistic regression analysis, elevated admission PG remained a strong predictor of one-year all-cause [OR (95%CI): 1.64 (1.31-2.05)] mortality and cardiovascular mortality [OR (95%CI): 1.75 (1.33-2.31)], beyond GRACE score [OR (95%CI): 1.03 (1.03-1.04)], as well as elevated HbA1c [OR (95%CI): 1.43 (1.15-1.78) and OR (95%CI): 1.83 (1.39-2.41) respectively].

CONCLUSIONS

Admission PG and HbA1c had strong independent predictive value regarding one-year all-cause mortality in our non-diabetic patients with AMI. These biomarkers could be useful to identify the most-at-risk patients after AMI in order to reduce residual risk in this target population.

Two-Hour Post-Load Plasma Glucose, a Biomarker to Improve the GRACE Score in Patients without Known Diabetes

OBJECTIVE

To assess improvement in predictive performance of Global Registry of Acute Coronary Events risk score (GRS) by addition of a glucose matrix.

METHODS

1,056 acute coronary syndrome (ACS) survivors without known diabetes had pre-discharge fasting (FPG) and 2-h post-load plasma glucose (2h-PG) measured. GRS was calculated. Major adverse cardiac events (MACE; death and non-fatal myocardial infarction) were recorded during follow-up. Cox proportional hazard regression predicted event-free survival. Likelihood ratio test, Akaike's information criteria, continuous net reclassification index (NRI>0), and integrated discrimination improvement (IDI) were used to test the additional prognostic value of glycaemic indices over GRS.

RESULTS

During a median follow-up of 36.5 months, 211 MACEs (20.0%), 96 deaths (9.1%), and 115 non-fatal re-infarctions (10.9%), occurred. 2h-PG, but not FPG, independently predicted MACE-free survival at all time points (HR 1.08, 95% CI 1.03-1.13, p = 0.002, at 3 years). Risk of MACE increased by 8-11% with every 1 mmol/L rise in 2h-PG. 2h-PG significantly improved the prognostic models containing GRS. Models containing GRS and 2h-PG yielded lowest corrected Akaike's information criteria compared to that with only GRS. 2h-PG, but not FPG, improved NRI>0 (NRI>0 0.169, p = 0.028 at 3 years) and IDI (IDI of 0.66%, p = 0.018 at 3 years) significantly at all time points during the follow-up.

CONCLUSIONS

2h-PG, but not FPG, improves performance of GRS-containing models in predicting post-ACS prognosis in the short to medium term.

Newly diagnosed abnormal glucose tolerance determines post-MI prognosis in patients with hospital related hyperglycaemia but without known diabetes

AIMS

Investigate if abnormal glucose tolerance (AGT) affects post-myocardial infarction (MI) prognosis in patients with hospital-related hyperglycaemia (HRH) but without known diabetes mellitus (KDM).

METHODS

Post-MI survivors without KDM underwent pre-discharge oral glucose tolerance test. Cardiovascular death and non-fatal re-infarction (MACE) were recorded. We compare the ability of admission (APG), fasting (FPG) and 2 h post-load (2 h-PG) plasma glucose to predict MACE in patients with (HRH) and without HRH (NoHRH).

RESULTS

50.2% and 73% of NoHRH and HRH had AGT respectively. MACE occurred in 19.5% and 18.1% in HRH and NoHRH groups. MACE-free survival was lower in patient with AGT in both groups (NoHRH: HR 1.82, 95% CI 1.19-2.78, p = 0.005; HRH: HR 2.48, 95% CI 1.24-4.96, p = 0.010). AGT predicted MACE-free survival (NoHRH: HR 1.60, 95% CI 1.02-2.51, p = 0.042; HRH: HR 3.09, 95% CI 1.07-8.94, p = 0.037). 2 h-PG, but not FPG or APG, independently predicted MACE free survival (NoHRH: HR 1.17, 95% CI 1.07-1.27, p ≤0.001 and HRH: HR 1.18, 95% CI 1.03-1.37, p = 0.020). Addition of AGT and 2 h-PG, not FPG or APG, improved net reclassification of events in both groups.

CONCLUSION

Post-MI prognosis is worse with AGT irrespective of presence of HRH. 2 h-PG, predicts prognosis in HRH and NoHRH groups.

Prognostic value of early glycosylated hemoglobin and blood glucose levels in patients with basal ganglia cerebral hemorrhage

OBJECTIVE

This study was performed to analyze the relationships of the early glycosylated hemoglobin (GHb) level and blood glucose level (BGL) with prognosis in patients with basal ganglia cerebral hemorrhage (BGCH).

METHODS

In total, 186 patients with BGCH were included in this prospective study. The GHb level, fasting BGL, bleeding volume, degree of consciousness disorder, intracerebral hemorrhage (ICH) score, functional outcome in patients with primary ICH (FUNC) score, ICH grading scale (ICH-GS) score, and neurological impairment were recorded during a 30-day observation period.

RESULTS

The mean BGCH volume was 58.42 mL. The 30-day mortality rate was 22.32%. The ICH-GS score [odds ratio (OR) = 0.815, 95% confidence interval (95% CI) = 0.504-0.688, R = 0.624] and bleeding volume (OR = 0.882, 95% CI = 0.785-0.918, R = 0.784) were significant predictors of 30-day mortality. The GHb level (OR = 6.138, R = 0.705) and BGL (OR = 1.055, R = 0.418) were independent predictors of 30-day mortality according to the multivariate logistic regression analysis.

CONCLUSION

The GHb level and BGL are strong predictors of 30-day mortality in patients with BGCH and accurately predict the prognosis in these patients.

Glycated hemoglobin predicts coronary artery disease in non-diabetic adults

BACKGROUND

Coronary artery disease (CAD) is a major cause of morbidity and mortality worldwide. Due to increased CAD risk factors in Saudi Arabia, research on more feasible and predictive biomarkers is needed. We aimed to evaluate glycated hemoglobin (HbA1c) as a predictor of CAD in low-risk profile non-diabetic patients living in the Al Qassim region of Saudi Arabia.

METHODS

Thirty-eight patients with no history of CAD were enrolled in this cross-sectional study. They provided demographic data, and their HbA1c estimation followed the National Glycohemoglobin Standardization Program parameters. All patients underwent coronary computed tomography angiography (CCTA) for evaluation of chest pain. The extent of coronary artery stenosis (CAS) was quantified as percentage for each patient based on plaques detected in CCTA.

RESULTS

Mean blood pressure of the patients was (91.2 ± 11.9 mmHg), BMI (28.3 ± 5.8 kg/m2), serum cholesterol level (174 ± 33.1 mg/dl), and HbA1c levels (mean 5.7 ± 0.45, median 5.7 and range 4.7-6.4%). Eighteen patients showed no CAS (47.4%), 12 showed minimal stenosis (31.6%), 3 showed mild stenosis (7.9%), 3 showed moderate stenosis (7.9%) and 2 showed severe stenosis (5.3%). A moderate correlation was detected between HbA1c and CAS percentages (r = 0.47, p < 0.05) as well as between HbA1c and the number of affected coronary vessels (r = 0.53, p < 0.001).

CONCLUSION

Glycated hemoglobin can be used as a predictive biomarker for CAD in non-diabetic low-risk patients.

Prognostic value of HbA1c for in-hospital and short-term mortality in patients with acute coronary syndrome: a systematic review and meta-analysis

Background

HbA1c, the most commonly used indicator of chronic glucose metabolism, is closely associated with cardiovascular disease. However, the relationship between HbA1c and the mortality of acute coronary syndrome (ACS) patients has not been elucidated yet. Here, we aim to conduct a systematic review assessing the effect of HbA1c on in-hospital and short-term mortality in ACS patients.

Methods

Relevant studies reported before July 2019 were retrieved from databases including PubMed, Embase, and Central. Pooled relative risks (RRs) and the corresponding 95% confidence interval (CI) were calculated to evaluate the predictive value of HbA1c for the in-hospital mortality and short-term mortality.

Results

Data from 25 studies involving 304,253 ACS patients was included in systematic review. The pooled RR of in-hospital mortality was 1.246 (95% CI 1.113–1.396, p: 0.000, I² = 48.6%, n = 14) after sensitivity analysis in studies reporting HbA1c as categorial valuable. The pooled RR was 1.042 (95% CI 0.904–1.202, p: 0.57, I² = 82.7%, n = 4) in random-effects model for studies reporting it as continuous valuable. Subgroup analysis by diabetic status showed that elevated HbA1c is associated increased short-term mortality in ACS patients without diabetes mellitus (DM) history and without DM (RR: 2.31, 95% CI (1.81–2.94), p = 0.000, I² = 0.0%, n = 5; RR: 2.56, 95% CI 1.38–4.74, p = 0.003, I² = 0.0%, n = 2, respectively), which was not the case for patients with DM and patients from studies incorporating DM and non-DM individuals (RR: 1.16, 95% CI 0.79–1.69, p = 0.451, I² = 31.9%, n = 3; RR: 1.10, 95% CI 0.51–2.38), p = 0.809, I² = 47.4%, n = 4, respectively).

Conclusions

Higher HbA1c is a potential indicator for in-hospital death in ACS patients as well as a predictor for short-term mortality in ACS patients without known DM and without DM.

Adjustment of the GRACE score by 2-hour post-load glucose improves prediction of long-term major adverse cardiac events in acute coronary syndrome in patients without known diabetes

Aims

Global Registry of Acute Coronary Events (GRACE) risk score (GRS), a powerful predictor of prognosis after acute coronary event (ACE), does not include a glucometabolic measure. We investigate whether 2 h post-load plasma glucose (2h-PG) could improve GRS based prognostic models in ACE patients without known diabetes mellitus (DM).

Methods and results

A retrospective cohort study of 1056 ACE survivors without known DM who had fasting plasma glucose (FPG) and 2h-PG measured pre-discharge. Death and non-fatal myocardial infarction were recorded as major adverse cardiac events (MACE) during follow-up. GRS for discharge to 6 months was calculated. Cox proportional-hazards regression was used to identify predictors of event free survival. The predictive value of 2h-PG alone and combined with GRS was estimated using likelihood ratio test, Akaike's information criteria, continuous net reclassification improvement (NRI>0), and integrated discrimination improvement (IDI). During 40.8 months follow-up 235 MACEs (22.3%) occurred, more frequently in the upper 2h-PG quartiles. Two-hour PG, but not FPG, adjusted for GRS independently predicted MACE (hazard ratio 1.091, 95% confidence interval 1.043-1.142; P = 0.0002). likelihood ratio test showed that 2h-PG significantly improved the prognostic models including GRS (χ2 = 20.56, 1 df; P = 0.000). Models containing GRS and 2h-PG yielded lowest corrected Akaike's information criteria, compared to that with only GRS. 2h-PG, when added to GRS, improved net reclassification significantly (NRIe>0 6.4%, NRIne>0 24%, NRI>0 0.176; P = 0.017 at final follow-up). Two-hour PG, improved integrated discrimination of models containing GRS (IDI of 0.87%, P = 0.008 at final follow-up).

Conclusion

Two-hour PG, but not FPG, is an independent predictor of adverse outcome after ACE even after adjusting for the GRS. Two-hour PG, but not FPG, improves the predictability of prognostic models containing GRS.

Prognostic value of neutrophil gelatinase-associated lipocalin and glycosylated hemoglobin for non-ST-segment elevation myocardial infarction patients with single concomitant chronic total occlusion following primary percutaneous coronary intervention: A prospective observational study

To investigate factors predicting the onset of major adverse cardiovascular and cerebrovascular events (MACCEs) after primary percutaneous coronary intervention (pPCI) for patients with non-ST-segment elevation infarction (NSTEMI) and single concomitant chronic total occlusion (CTO). Neutrophil gelatinase-associated lipocalin (NGAL) and glycosylated hemoglobin (HbA1c) both play essential role in cardiovascular and cerebrovascular homoeostasis. However, current knowledge of its predictive prognostic value is limited.422 patients with NSTEMI and CTO (59.7 ± 12.4 years, 74.2% men) who underwent successful pPCI were enrolled and followed for 2 years. Multivariate cox regression analysis and receiver operating characteristic (ROC) curve analysis were performed to determine the factors predicting MACCEs.140 patients (33.2%) experienced MACCEs in the follow-up period. Multivariate cox regression analysis found when we process the model with NGAL at admission, low left ventricular ejection fraction (LVEF, HR = 0.963, 95% CI 0.940 to 0.987, P = .003) and fasting blood glucose (HR = 1.078, 95% CI 1.002 to 1.159, P = .044), but not NGAL at admission, were independent predictors of 2 years MACCEs. While HbA1C (HR = 1.119, 95% CI 1.014 to 1.234, P = .025), LVEF (HR = 0.963, 95% CI 0.939 to 0.987, P = .003), estimated glomerular filtration rate (HR = 1.020, 95% CI 1.006 to 1.035, P = .006) and NGAL value 7 day (HR = 1.020, 95% CI 1.006 to 1.035, P = .006) showed their predictive value in another model. ROC analysis indicated NGAL 7 day (AUC = 0.680, P = .0054 and AUC = 0.622, P = .0005) and LVEF (AUC = 0.691, P = .0298 and AUC = 0.605, P = .0021) could predict both in-hospital and 2 years MACCEs, while higher NGAL at admission could only predict poorer in-hospital prognosis (AUC = 0.665, P = .0103). Further analysis showed the prognostic value of NGAL was particularly remarkable among those HbA1C<6.5%.Patients with NSTEMI and single concomitant CTO receiving pPCI with higher NGAL on 7 days during hospitalization are more likely to suffer 2 years MACCEs, particularly in those with lower HbA1C.

Prediabetes and its impact on clinical outcome after coronary intervention in a broad patient population

AIMS

It is unclear whether detection of prediabetes (pre-DM) by routine assessment of glycated haemoglobin A1c (HbA1c) and fasting plasma glucose (FPG) among patients undergoing percutaneous coronary intervention (PCI) with contemporary drug-eluting stents (DES) may help identify subjects with increased event risk. We assessed the relation between glycaemia status and one-year outcome after PCI.

METHODS AND RESULTS

Glycaemia status was determined in 2,362 non-diabetic BIO-RESORT participants, treated at all four study sites, to identify pre-DM (HbA1c 42-47 mmol/mol; FPG 6.1-6.9 mmol/L) and unknown diabetes mellitus (DM) (HbA1c ≥48 mmol/mol; FPG ≥7.0 mmol/L). Another 624 patients had medically treated DM. The main composite endpoint consisted of death, myocardial infarction, or revascularisation. Glycaemic state was known in 2,986 participants: 324 (11%) patients had pre-DM, 793 (27%) had DM (known or new), and 1,869 (63%) patients had normoglycaemia. Pre-DM and DM patients differed from normoglycaemic patients in cardiovascular risk factors. The composite endpoint occurred in 11.1% in pre-DM, 10.5% in DM, and 5.7% in normoglycaemia (p<0.001). Pre-DM was associated with a twofold higher event risk compared to normoglycaemia (adj. HR 2.0, 95% CI: 1.4-3.0).

CONCLUSIONS

Following PCI with contemporary DES, all-comers with pre-DM had significantly higher event risks than normoglycaemic patients. In non-DM patients requiring PCI, routine assessment of HbA1c and FPG appears to be of value to identify subjects with increased event risk.

Distinguishing reference intervals and clinical decision limits - A review by the IFCC Committee on Reference Intervals and Decision Limits

Reference Intervals (RIs) and clinical decision limits (CDLs) are a vital part of the information supplied by laboratories to support the interpretation of numerical clinical pathology results. RIs describe the typical distribution of results seen in a healthy reference population while CDLs are associated with a significantly higher risk of adverse clinical outcomes or are diagnostic for the presence of a specific disease. However, as the two concepts are sometimes confused, there is a need to clarify the differences between these terms and to ensure they are easily distinguished, especially because CDLs have a clinical association with specific diseases and risks, thereby implying that effective clinical interventions are available. It is important to note that, because population-based RIs are derived from the range of values expected in a typical community population, laboratory results that fall outside a RI do not necessarily indicate a disease but rather that additional medical follow-up and/or treatment may be warranted. In contrast, CDLs are associated with a risk of specific adverse outcomes, and are commonly used to interpret laboratory test results, including lipid parameters, glucose, hemoglobin A1c (HbA1c), and tumor markers, to determine risk of disease, to diagnose or to treat. In recent years, the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) Committee on Reference Intervals and Decision Limits (C-RIDL) has focused primarily on RIs and has performed multicenter studies to obtain common RIs. However, the broader responsibility of the Committee, from its name, includes "decision limits". C-RIDL now aims to emphasize the importance of the correct use of both RIs and CDLs and to encourage laboratories to specify the appropriate information to clinicians as needed. This review discusses RIs and CDLs in detail, describes the similarities and the differences between these two important tools in laboratory medicine, and clearly explains the processes used to define them. C-RIDL encourages the involvement of laboratory professionals in the establishment of both RIs and CDLs.

Two-hour post-challenge glucose is a better predictor of adverse outcome after myocardial infarction than fasting or admission glucose in patients without diabetes

AIMS

We evaluate prevalence of new abnormal glucose tolerance (AGT) in post-MI survivors without known diabetes (DM) if guidelines are followed and compare the ability of admission (APG), fasting (FPG) and 2-h post-load plasma glucose (2h-PG) to predict prognosis.

METHODS

A total of 674 patients were followed up for 4 years for incidence of major adverse cardiovascular events (MACE) of cardiovascular death, non-fatal re-infarction or non-haemorrhagic stroke. Ability of models including APG, FPG and 2h-PG to predict MACE was compared.

RESULTS

Of the total, 93-96% of impaired glucose tolerance and 64-75% of DM would be missed with current guidelines. MACE was higher in the upper quartiles of 2h-PG. When 2h-PG and FPG were included simultaneously in models, only 2h-PG predicted MACE (HR 1.12, CI 1.04-1.20, p = 0.0012), all cause mortality (HR 1.17, CI 1.05-1.30, p = 0.0039), cardiovascular mortality (HR 1.17, CI 1.02-1.33, p = 0.0205) and non-fatal MI (HR 1.10, CI 1.01-1.20, p = 0.0291). Adding 2h-PG significantly improved ability of models including FPG (χ² = 16.01, df = 1, p = 0.0001) or FPG and APG (χ² = 17.36, df = 1, p = 0.000) to predict MACE. Model including 2h-PG only had the lowest Akaike's information criteria and highest Akaike weights suggesting that this was the best in predicting events. Adding 2h-PG to models including FPG or APG with other co-variates yielded continuous net reclassification improvement (NRI) of 0.22 (p = 0.026) and 0.27 (p = 0.005) and categorical NRI of 0.09 (p = 0.032) and 0.12 (p = 0.014), respectively. Adding 2 h-PG to models including only FPG, only APG and both yielded integrated discrimination improvement of 0.012 (p = 0.015), 0.022 (p = 0.001) and 0.013 (p = 0.014), respectively.

CONCLUSIONS

AGT is under-diagnosed on current guidelines. 2h-PG is a better predictor of prognosis compared to APG and FPG.

Renoprotective effect of nicorandil in patients undergoing percutaneous coronary intervention: a meta-analysis of 4 randomized controlled trials

Many studies have evaluated the renoprotective effect of nicorandil in patients undergoing percutaneous coronary intervention (PCI), but the results are inconsistent. We therefore conducted this meta-analysis to evaluate the protective effect of nicorandil against contrast-induced nephropathy (CIN). We searched PubMed, Embase, the Cochrane Library, Web of Science, and clinical trials database. Studies compared the nicorandil (plus hydration) with hydration alone in patients receiving PCI were eligible. The primary outcome was the incidence of CIN. Four randomized controlled trials (RCTs) with 730 patients were included. All enrolled patients were with renal dysfunction or with moderate risk for CIN. Meta-analysis showed that nicorandil was associated with a decrease of CIN (odds ratio 0.33, 95% confidence interval [CI], 0.19~0.58, p < 0.001), without heterogeneity across the studies (I² = 33.7%, p = 0.210). Moreover, nicorandil treatment could significantly reduce the level of serum creatinine, estimated glomerular filtration rate and cystatin C at 48 hours after procedures (standardized mean difference [SMD] -0.17, 95%CI -0.33~-0.01; SMD 0.29, 95% CI 0.11~0.48; SMD -0.17, 95%CI -0.33~-0.01, respectively). Nicorandil can reduce the incidence of CIN and result in favorable changes in renal function in patients undergoing PCI. More RCTs with large sample size and high quality are needed to confirm our results.

Off-hours presentation is associated with short-term mortality but not with long-term mortality in patients with ST-segment elevation myocardial infarction: A meta-analysis

BACKGROUND

The association between off-hours presentation and mortality in patients with ST-segment elevation myocardial infarction (STEMI) remains unclear. We performed a meta-analysis to assess the impact of off-hours presentation on short- and long-term mortality among STEMI patients.

METHODS

We searched PubMed, EMBASE, and the Cochrane Library from their inception to 10 July 2016. Studies were eligible if they evaluated the relationship of off-hours (weekend and/or night) presentation with short- and/or long-term mortality.

RESULTS

A total of 30 studies with 33 cohorts involving 192,658 STEMI patients were included. Off-hours presentation was associated with short-term mortality (odds ratio [OR] 1.07, 95% confidence interval [CI] 1.02-1.12, P = 0.004) but not with long-term mortality (OR 1.00, 95% CI 0.94-1.07, P = 0.979). No significant heterogeneity was observed. The outcomes remained the same after sensitivity analyses and trim and fill analyses. Subgroup analyses showed that STEMI patients undergoing primary percutaneous coronary intervention do not have a higher risk of short-term mortality (OR 1.061, 95% CI 0.993-1.151). In addition, higher mortality was observed only during hospitalization (OR 1.072, 95% CI 1.022-1.125), not at the 30-day, 1-year or long-term follow-ups.

CONCLUSIONS

Off-hours presentation was associated with an increase in short-term mortality, but not long-term mortality, among STEMI patients. Clinical approaches to decrease short-term mortality regardless of the time of presentation should be evaluated in future studies.