Glycohaemoglobin as a determinant of increased fibrinogen concentrations and low-grade inflammation in apparently healthy nondiabetic individuals

Baseline high-sensitivity C-reactive protein and glycosylated hemoglobinA1c predict adverse outcomes in patients with chronic coronary syndromes undergoing percutaneous coronary intervention

Introduction

This study explored the ability of high-sensitivity C-reactive protein (hs-CRP) and glycosylated hemoglobin A1c (HbA1c) to predict adverse cardiac and cerebrovascular outcomes in patients with chronic coronary syndromes (CCS) undergoing percutaneous coronary intervention (PCI).

Methods

In total, 4083 consecutive patients with CCS undergoing PCI were investigated throughout 2013 at a single center. The primary endpoint was all-cause death at the 5-year follow-up. Hs-CRP and HbA1c data were collected on admission.

Results

The highest quartile of hs-CRP had a significantly increased the risk of all-cause death, with an adjusted HR of 1.747 (95 % CI 1.066-2.863), while, there was no difference in all-cause death among the groups of HbA1c after adjustment, with an adjusted HR of 1.383 (95 % CI 0.716-2.674). The highest quartiles for hs-CRP and HbA1c in the study population had a significantly increased risk of major adverse cardiac and cerebrovascular events (MACCE), with an adjusted hazard ratios (HR) of 1.263 (95 % confidence intervals [CI] 1.032-1.545) for hs-CRP and an adjusted HR of 1.417 (95 % CI 1.091-1.840) for HbA1c. Remarkably, the incidence of all-cause death and that of MACCE were significantly increased when both hs-CRP and HbA1c were elevated (HR 1.971, 95 % CI 1.079-3.601, P = 0.027 and HR 1.560, 95 % CI 1.191-2.042), P = 0.001, respectively). Addition of hs-CRP and HbA1c to conventional risk factors significantly improved prediction of the risk of all cause death (net reclassification index 0.492, P < 0.001; integrated discrimination improvement 0.007, P = 0.011) and MACCE (net reclassification index 0.160, P < 0.001; integrated discrimination improvement 0.006, P < 0.001).

Conclusions

Hs-CRP and HbA1c can serve as independent predictors of MACCE in patients with CCS undergoing PCI. Furthermore, a combination of hs-CRP and HbA1c could predict all cause death and MACCE better than each component individually.

Sepsis Related Mortality Associated with an Inflammatory Burst in Patients Admitting to the Department of Internal Medicine with Apparently Normal C-Reactive Protein Concentration

Background: Patients who are admitted to the Department of Internal Medicine with apparently normal C-reactive protein (CRP) concentration impose a special challenge due the assumption that they might not harbor a severe and potentially lethal medical condition. Methods: A retrospective cohort of all patients who were admitted to the Department of Internal Medicine with a CRP concentration of ≤31.9 mg/L and had a second CRP test obtained within the next 24 h. Seven day mortality data were analyzed. Results: Overall, 3504 patients were analyzed with a mean first and second CRP of 8.8 (8.5) and 14.6 (21.6) mg/L, respectively. The seven day mortality increased from 1.8% in the first quartile of the first CRP to 7.5% in the fourth quartile of the first CRP (p < 0.0001) and from 0.6% in the first quartile of the second CRP to 9.5% in the fourth quartile of the second CRP test (p < 0.0001), suggesting a clear relation between the admission CRP and in hospital seven day mortality. Conclusions: An association exists between the quartiles of CRP and 7-day mortality as well as sepsis related cause of death. Furthermore, the CRP values 24 h after hospital admission improved the discrimination.

Associations Among Depression, Hemoglobin A1c Level, and Prognosis in Patients With Coronary Artery Disease: A Prospective Study

BACKGROUND

Depression is ubiquitous in patients with coronary artery disease (CAD). The relationship between depression and hemoglobin A1c (HbA1c) is controversial. The combined effect of high HbA1c and depression on prognosis is unclear, especially in non-diabetic CAD patients. We sought to explore these associations.

METHODS

558 CAD patients were included in this prospective study. Patients were grouped by HbA1c levels and the status of clinical depression. The average follow-up period was about 2.2 years, and Cox proportional hazards models were used to compare the differences of prognosis in all the groups.

RESULTS

Clinical depression had no associations with HbA1c in all CAD patients (P for Pearson correlation = 0.74). In the all four groups, compared to group 1 (patients without clinical depression and low HbA1c), group 3 (without clinical depression and high HbA1c) had a higher risk of MACE (adjusted hazard ratio [aHR], 1.97; 95% confidence interval [CI], 1.2-3.25) and composite events (aHR, 1.67; 95% CI, 1.09-2.053). Group 4 (patients with clinical depression and high HbA1c) had higher HRs for MACE (aHR, 2.9; 95%CI, 1.32-6.38) and composite events (aHR, 2.12; 95% CI, 1.06-4.25). In CAD patients without diabetes, patients with clinical depression and high HbA1c had a higher risk of MACE (HR, 2.71; 95% CI, 1.02-7.19), non-cardiac readmission (HR,3.48; 95% CI, 1.26-9.57) and composite events (HR,2.44; 95% CI, 1.08-5.53) than those with no clinical depression and low HbA1c. In patients with comorbidities of depression and diabetes, patients with depression and high HbA1c more likely to experienced non-cardiac readmissions (HR, 4.49; 95% CI, 1.31-15.38) than patients with no depression and low HbA1c only. In all the above analysis, p-values for interaction between clinical depression and HbA1c were not statistically significant.

CONCLUSIONS

The presence of both depression and high HbA1c lead to a worse prognosis in CAD patients than one risk factor alone, no matter with or without the comorbidity of diabetes in these CAD patients. For patients with CAD and depression, lower HbA1c may be required.

The U-Shape Relationship Between Glycated Hemoglobin Level and Long-Term All-Cause Mortality Among Patients With Coronary Artery Disease

Background: Although glycated hemoglobin (HbA1c) was considered as a prognostic factor in some subgroup of coronary artery disease (CAD), the specific relationship between HbA1c and the long-term all-cause death remains controversial in patients with CAD.

Methods: The study enrolled 37,596 CAD patients and measured HbAlc at admission in Guangdong Provincial People's Hospital. The patients were divided into 4 groups according to HbAlc level (Quartile 1: HbA1c ≤ 5.7%; Quartile 2: 5.7% < HbA1c ≤ 6.1%; Quartile 3: 6.1% < HbA1c ≤ 6.7%; Quartile 4: HbA1c > 6.7%). The study endpoint was all-cause death. The restricted cubic splines and cox proportional hazards models were used to investigate the association between baseline HbAlc levels and long-term all-cause mortality.

Results: The median follow-up was 4 years. The cox proportional hazards models revealed that HbAlc is an independent risk factor in the long-term all-cause mortality. We also found an approximate U-shape association between HbA1c and the risk of mortality, including increased risk of mortality when HbA1c ≤ 5.7% and HbA1c > 6.7% [Compared with Quartile 2, Quartile 1 (HbA1c ≤ 5.7), aHR = 1.13, 95% CI:1.01–1.26, P < 0.05; Quartile 3 (6.1% < HbA1c ≤ 6.7%), aHR = 1.04, 95% CI:0.93–1.17, P =0.49; Quartile 4 (HbA1c > 6.7%), aHR = 1.32, 95% CI:1.19–1.47, P < 0.05].

Conclusions: Our study indicated a U-shape relationship between HbA1c and long-term all-cause mortality in CAD patients.

Sex difference in the risk for exercise-induced albuminuria correlates with hemoglobin A1C and abnormal exercise ECG test findings

BACKGROUND

Albuminuria is an established marker for endothelial dysfunction and cardiovascular risk in diabetes and prediabetes. Exercise induced albuminuria (EiA) appears earlier and may be a more sensitive biomarker for renal endothelial damage. We sought to examine the association between EiA, parameters of the metabolic syndrome, A1C levels, exercise ECG test results and sex related differences in a large cohort of healthy, pre-diabetic and diabetic subjects.

METHODS

A total of 3029 participants from the Tel-Aviv Medical Center Inflammation Survey cohort (mean age 46 years, 73% men) were analyzed. Multiple physiologic and metabolic parameters including A1C were collected and albuminuria was measured in all subjects before and immediately after completing an exercise ECG test.

RESULTS

Exercise increased urinary albumin to creatinine ratio (ΔEiA) by 2.8 (0-13.6) mg/g for median (IQR) compared to rest albuminuria (p < 0.001). An increase in ΔEiA was observed with accumulating parameters of the metabolic syndrome. ΔEiA showed significant interaction with sex and A1C levels; i.e. women with A1C > 6.5% had an increased risk of higher ΔEiA (p < 0.001). Using a cutoff of ΔEiA > 13 mg/g (top quartile) we found that women with ΔEiA > 13 mg/g were at greater risk for abnormal exercise ECG findings, (OR = 2.7, p = 0.001).

CONCLUSION

Exercise promotes excessive urinary albumin excretion in dysmetabolic patients. In women, a significant correlation exists between ΔEiA and A1C levels. A cutoff of ΔEiA > 13 mg/g in women may be used to identify populations at risk for abnormal exercise ECG test findings and perhaps increased cardiovascular risk. Future studies will be needed to further validate the usefulness of ΔEiA as a biomarker for cardiovascular risk in women with and without diabetes.

Elevated hemoglobin A1c Is Associated with Carotid Plaque Vulnerability: Novel Findings from Magnetic Resonance Imaging Study in Hypertensive Stroke Patients

The association between hemoglobin A1c (HbA1c) level and carotid plaque vulnerability has been rarely studied by magnetic resonance imaging (MRI). The present study of MRI-identified carotid atherosclerotic lesions in hypertensive patients with acute stroke therefore sought to determine the associations between HbA1c level and plaque morphological and compositional characteristics and acute cerebral infarction (ACI) severity. Eighty hypertensive patients with acute stroke were enrolled; stratified into high (≥6.5%) and low (<6.5%) HbA1c groups; and underwent carotid and brain MRI to assess carotid plaque features and ACI volume in the region supplied by the internal carotid artery (ICA) in the symptomatic side. Plaque burden [percent wall volume (PWV), max wall thickness (max-WT)] and lipid-rich necrotic core (LRNC) were larger in the high as compared to the low HbA1c group. High HbA1c was an independent risk factor for the presence of plaque (odds ratio [OR] = 3.71) and LRNC plaque (OR = 7.08). HbA1c independently correlated with ACI severity among patients with ICA region cerebral infarction and carotid plaque. Our study suggested that an elevated HbA1c may have an adverse effect on carotid plaque vulnerability especially those with larger LRNC volumes in hypertensive stroke patients, which might exacerbate the severity of ACIs.

Longitudinal association of C-reactive protein and Haemoglobin A1c over 13 years: the European Prospective Investigation into Cancer--Norfolk study

Background

Type-2 diabetes is associated with systemic inflammation and higher C-reactive protein (CRP) levels. However, the longitudinal association of CRP and haemoglobin-A_1c (HbA_1c) has not been described in large prospective studies. Understanding such associations may shed light on the role of inflammation in development of type-2 diabetes and its complications such as cardiovascular diseases.

Methods

EPIC-Norfolk is a cohort study of men and women aged 40–79 years at time of recruitment (1993–1997). Serum CRP (mg/l) was measured using a high-sensitivity assay at baseline and 13-years follow-up. HbA_1c (%) was measured at baseline, 4, and 13 years. Participants were excluded if they were diagnosed with diabetes or were taking diabetes medication. Data on at least one measurement of CRP and HbA_1c was available for 14228 participants (55 % of the cohort).

Results

In the cross-sectional analysis of baseline data, a 1-SD higher log_e-CRP (about three-fold higher CRP) was associated with 0.06 (95 % CI 0.04, 0.08) higher HbA_1c (%) adjusted for potential confounders. In longitudinal analysis using multivariable linear mixed models, change in CRP over 13 years was to a similar extent positively associated with increase in HbA_1c, such that 1-SD higher longitudinal change in log_e-CRP was associated with 0.04 (95 % CI 0.02, 0.05) increase in HbA_1c.

Conclusion

In this study we found longitudinal observational evidence suggesting that increase in systemic inflammation is associated with an increase in HbA_1c and thus systemic inflammation may have a role in development of type-2 diabetes and its complications.

Glycosylated hemoglobin A1c as a marker predicting the severity of coronary artery disease and early outcome in patients with stable angina

Background

Glycosylated hemoglobin A1C (HbA1c) has been widely recognized as a marker for predicting the severity of diabetes mellitus (DM) and several cardiovascular diseases. However, whether HbA1c could predict the severity and clinical outcomes in patients with stable coronary artery disease (CAD) remains largely unknown. We determine relationship of HbA1c with severity and outcome in patients with stable CAD.

Methods

We enrolled 1433 patients with stable angina who underwent coronary angiography and were followed up for an average 12 months. The patients were classified into three groups by tertiles of baseline HbA1c level (low group <5.7%, n = 483; intermediate group 5.7 - 6.3%, n = 512; high group >6.3%, n = 438). The relationships between the plasma HbA1c and severity of CAD and early clinical outcomes were evaluated.

Results

High HbA1c was associated with three-vessel disease. Area under the receivers operating characteristic curve (AUC = 0.67, 95% CI: 0.63-0.71, P < 0.001) and multivariate logistic regression analysis suggested that HbA1C was an independent predictor of severity of CAD (OR = 1.60, 95% CI: 1.29-1.99, P < 0.001) even after adjusting for gender, age, risk factor of CAD, lipid profile and fasting blood glucose. During follow-up, 133 patients underwent pre-specified outcomes. After adjusting for multiple variables in the Cox regression model, HbA1C remained to be an independent predictor of poor prognosis (HR = 1.28, 95% CI: 1.12-1.45, P < 0.001).

Conclusions

We concluded that high level of baseline HbA1c appeared to be an independent predictor for the severity of CAD and poor outcome in patients with stable CAD.

Association of fibrinogen with severity of stable coronary artery disease in patients with type 2 diabetic mellitus

Background. Some studies have suggested a relation of plasma fibrinogen to the severity of coronary artery disease (CAD). However, whether plasma fibrinogen can predict the presence and severity of CAD in patients with diabetes mellitus has not been determined. Methods. A total of consecutive 373 diabetic patients with typical angina pectoris who received coronary angiography were enrolled and classified into three groups by tertiles of Gensini score (GS, low group <8; intermediate group 8~28; high group >28). The relationship between fibrinogen and GS was evaluated. Results. There were correlations of fibrinogen with hemoglobin A1c, C-reactive protein, and GS (r = 0.17, r = 0.52, and r = 0.21, resp.; all P < 0.001). Area under the receivers operating characteristic curve of fibrinogen was 0.62 (95% CI 0.56–0.68, P < 0.001) for predicting a high GS. Multivariate analysis suggested that plasma fibrinogen was an independent predictor of a high GS for diabetic patients (OR = 1.40, 95% CI 1.04–1.88, and P = 0.026) after adjusting for traditional risk factors of CAD. Conclusions. The present data indicated that plasma fibrinogen, a readily measurable systematic inflammatory marker, appeared to be an independent predictor for the severity of CAD in diabetic patients.

The association of higher levels of within-normal-limits liver enzymes and the prevalence of the metabolic syndrome

Background

Metabolic syndrome (MetS) is frequently characterized by elevated liver enzymes, including gamma-glutamyl transferase (GGT) and alanine aminotransferase (ALT). Our objective was to evaluate the range of prevalence of MetS in apparently healthy individuals whose liver enzyme concentrations were all within-normal-range.

Methods

We have performed a cross sectional analysis on participants of the Tel-Aviv medical center inflammation survey (TAMCIS) recruited between the years 2003-2009. Analyzed were a cohort of 6,561 men and 3,389 women.

Results

The prevalence of MetS increased significantly from the first quintile to the fifth for both GGT and ALT, all the five quintiles being in the normal range. Logistic regression analysis for the presence of MetS showed crude odds ratios of 2.7 and 2.4 between the first and fourth quintiles and 3.6 and 3.2 for the fifth quintile in men and women respectively for ALT. For GGT the respective odds being 3.6 and 3.2 for the fourth quintile and 3.9 and 3.4 for the fifth quintile in men and women, respectively.

Conclusions

A relatively high prevalence of MetS was noted in a cohort of apparently healthy individuals with liver enzyme concentrations within-normal-limits. Practical consequences include the need to follow up these enzyme concentrations as continuous variables and to take into consideration that even relatively small elevations within the normal range might reflect the presence of dysmetabolism.