Glycometabolic state at admission: important risk marker of mortality in conventionally treated patients with diabetes mellitus and acute myocardial infarction: long-term results from the Diabetes and Insulin-Glucose Infusion in Acute Myocardial Infarction (DIGAMI) study

A systematic review and meta-analysis of the effect of hyperglycemia on admission for acute myocardial infarction in diabetic and non-diabetic patients

INTRODUCTION

Regarding a potential relationship between diabetes and the prognostic significance of hyperglycemia in patients presenting with acute myocardial infarction (AMI), there is still debate. Therefore, we aimed in this study to demonstrate the effect of hyperglycemia on different outcomes in AMI patients, whether they are diabetic or not.

METHODS

We searched PubMed, Web of Science, and Scopus using the following search strategy: "Diabetes" or "Diabetic" AND "Acute myocardial infarction" OR "AMI" AND "hyperglycemia" OR "glucose level" to find eligible articles that needed to go through the screening process for inclusion in our study. We conducted a meta-analysis of 19 included studies from Japan, Germany, China, the United Kingdom, and others using Review Manager version 5.4 software, pooling the mean difference in continuous variables, the number and total of dichotomous variables to measure the odds ratio (OR), and the generic inverse variance of OR or hazard ratio (HR) as reported in the included studies.

RESULTS

The mean age of the participants ranged from 56.3 to 72.3 years old. The difference in blood glucose levels between diabetes and non-diabetes patients was found to be statistically significant, with an SMD of 1.39 (95%CI: 1.12, 1.66, p < 0.00001). In diabetic patients, hyperglycemia was statistically significantly associated with mortality, with a HR of 1.92 (95% CI: 1.45, 2.55, p < 0.00001) and an OR of 1.76 (95% CI: 1.15, 2.7, p = 0.01). In non-diabetic patients admitted with AMI, hyperglycemia was statistically significantly associated with mortality, with a HR of 1.56 (95% CI: 1.31, 1.86, p < 0.00001) and an OR of 2.89 (95% CI: 2.47, 3.39, p < 0.00001). AMI patients who were diabetic were statistically more likely to have a major adverse cardiovascular event (MACE) (HR = 1.9; 95% CI: 1.19-3.03; p = 0.007). AMI patients who were not diabetic were also statistically more likely to have a MACE (HR = 1.6; 95% CI: 1.15-2.23, p = 0.006).

CONCLUSION

Hyperglycemia in AMI patients is a predictor of worse outcomes, including MACE and mortality, regardless of whether these patients are diabetic or not. In these patients, some factors act as predictors of mortality, including older age, higher glucose levels on admission, and a high Killip class.

Effect of hemoglobin A1c change on 24-month clinical outcomes in patients with diabetes after acute myocardial infarction

BACKGROUND

The average glycated hemoglobin (HbA1c) may not accurately reflect glycemic control status during the mid-term after acute myocardial infarction (AMI). We aimed to evaluate changes in HbA1c and their effect on mid-term clinical outcomes in patients with diabetes and AMI.

METHODS

We enrolled patients with diabetes ( n  = 967) who underwent HbA1c measurement in the Korean nationwide registry. These patients were categorized into three groups based on changes in HbA1c from index admission to the 1-year follow-up visit: a decrease in HbA1c > 1%, changes in HbA1c within 1%, and an increase in HbA1c > 1%. Clinical outcomes at 24 months were examined.

RESULTS

The baseline HbA1c levels were 8.55 ± 0.85, 7.00 ± 0.98 and 7.07 ± 1.05 ( P  = 0.001) and HbA1c levels after 1 year were 6.62 ± 0.73, 7.05 ± 0.98 and 9.26 ± 1.59 ( P  = 0.001) for patients with 3 groups, respectively. Patients with a 1% decrease in HbA1c had significantly lower incidence of major adverse cardiovascular events (MACE), cardiac death, and rehospitalization after 24 months than those with a 1% increase in HbA1c. However, in the Cox regression analysis, a >1% decrease in HbA1c change was not an independent factor for MACE, cardiac death, and rehospitalization.

CONCLUSIONS

Our analysis indicates that an HbA1c decrease of >1% within the first 12 months was not an independent prognostic factor until the 24-month mark. Therefore, standard diabetic control is recommended for patients with diabetes and AMI for up to 2 years.

Acute Hyperglycemia-Induced Injury in Myocardial Infarction

Acute hyperglycemia is a transient increase in plasma glucose level (PGL) frequently observed in patients with ST-elevation myocardial infarction (STEMI). The aim of this review is to clarify the molecular mechanisms whereby acute hyperglycemia impacts coronary flow and myocardial perfusion in patients with acute myocardial infarction (AMI) and to discuss the consequent clinical and prognostic implications. We conducted a comprehensive literature review on the molecular causes of myocardial damage driven by acute hyperglycemia in the context of AMI. The negative impact of high PGL on admission recognizes a multifactorial etiology involving endothelial function, oxidative stress, production of leukocyte adhesion molecules, platelet aggregation, and activation of the coagulation cascade. The current evidence suggests that all these pathophysiological mechanisms compromise myocardial perfusion as a whole and not only in the culprit coronary artery. Acute hyperglycemia on admission, regardless of whether or not in the context of a diabetes mellitus history, could be, thus, identified as a predictor of worse myocardial reperfusion and poorer prognosis in patients with AMI. In order to reduce hyperglycemia-related complications, it seems rational to pursue in these patients an adequate and quick control of PGL, despite the best pharmacological treatment for acute hyperglycemia still remaining a matter of debate.

Correlation Between Hemoglobin A1c (HbA1c) and High-Sensitivity C-Reactive Protein (hs-CRP) in Myocardial Infarction Patients and Their Six-Month Mortality Follow-Up

Background Acute coronary syndrome (ACS), encompassing unstable angina (UA), non-ST-elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI), poses significant global health challenges because of its associated high mortality and morbidity rates. Vascular inflammation plays a crucial role in the pathogenesis of atherosclerosis, and it is often assessed using biomarkers such as high-sensitivity C-reactive protein (hs-CRP). Hyperglycemia, common in myocardial infarction patients, is linked to increased complications and mortality, with glycosylated hemoglobin A1c (HbA1c) serving as a key indicator of long-term glycemic control. Objective This study investigates the correlation between hs-CRP and HbA1c levels in patients with acute myocardial infarction (AMI) and type 2 diabetes mellitus (T2DM) and evaluates their impact on six-month mortality outcomes. Methods A prospective observational study was conducted with 80 patients diagnosed with AMI. Data collection included demographic information, medical history, clinical assessments, laboratory investigations (including hs-CRP and HbA1c levels), and imaging studies. Patients received standard treatment and were followed up for six months. Statistical analyses were performed to examine the relationships between hs-CRP, HbA1c, and clinical outcomes. Results Higher HbA1c levels at admission were significantly correlated with elevated hs-CRP levels (p < 0.05). Both biomarkers showed a reduction at six months, correlating with improved glycemic control and reduced inflammation. Each unit increase in HbA1c was associated with a 21% increase in the hazard of mortality, and, similarly, each unit increase in hs-CRP was associated with a 17% increase in the hazard of mortality. The positive correlation between HbA1c and hs-CRP suggests that HbA1c can serve as an independent marker for predicting mortality in this patient population. Conclusion The study demonstrates a significant correlation between hs-CRP and HbA1c levels in patients with AMI and T2DM, with both biomarkers serving as strong predictors of six-month mortality. HbA1c, because of its positive correlation with hs-CRP, could be used as an independent marker for assessing the risk of adverse outcomes in these patients. These findings highlight the importance of managing both glycemic control and inflammation in diabetic patients with ACSs.

Stress, Hyperglycemia, and Insulin Resistance Correlate With Neutrophil Activity and Impact Acute Myocardial Infarction Outcomes

Introduction Acute insulin resistance (IR) and hyperglycemia are frequently observed during acute myocardial infarction (AMI), significantly influencing both immediate and long-term patient outcomes, irrespective of diabetic status. Neutrophilia and increased neutrophil activity, which are common in these scenarios, have been associated with poorer prognoses, as demonstrated in our recent findings. While it is well established that neutrophils and stress-induced hyperglycemia exacerbate inflammation and hinder recovery, the complex interplay between these factors and their combined impact on AMI prognosis remains inadequately understood. This study aims to investigate the effects of stress hyperglycemia and IR on AMI patients at the onset of the event and to elucidate the relationship between these metabolic disturbances and inflammatory markers, particularly neutrophils. Methods We conducted a longitudinal prospective study on 219 AMI patients at Elias Emergency Hospital in Bucharest, Romania, from April 2021 to September 2022. Patients were included within 24 hours of AMI with ST-segment elevation and excluded if they had acute infections or chronic inflammatory diseases. Blood samples were collected to study inflammatory biomarkers, including neutrophil extracellular traps (NETs), S100A8/A9, interleukin (IL)-1β, IL-18, and IL-6. Diabetic and pre-diabetic statuses were defined using glycated hemoglobin (HbA1c) and medical history (ADA 2019 criteria). To assess glycemic parameters, we employed the glycemia ratio (GR) and the homeostatic model assessment of insulin resistance (HOMA-IR) index, enabling a precise evaluation of stress hyperglycemia, acute IR, and their prognostic implications. Patients were stratified into groups based on GR calculations, categorized as under-average glycemia, normal glycemia, and stress hyperglycemia. Results The majority of patients in the stress hyperglycemia group exhibited an unfavorable prognosis. This group also demonstrated significantly elevated neutrophil counts and neutrophil-to-lymphocyte ratios (NLR). The GR was significantly and positively correlated with inflammation markers, including neutrophil count (Pearson's R = 0.181, P = 0.008) and NLR (Pearson's R = 0.318, P < 0.001), but showed no significant correlation with other evaluated inflammatory markers. Conclusions Our findings suggest that poor outcomes in AMI patients may be associated with stress hyperglycemia, as indicated by GR. AcuteIR, quantified by GR and HOMA-IR, exhibits a strong correlation with neutrophil count and NLR within the first 24 hours of AMI onset. However, no significant correlation was observed with other inflammatory markers, such as IL-1β, IL-18, and IL-6, underscoring the specific interplay between IR and neutrophil activity in this setting.

Differential Association between Blood Glucose Levels and Nonrelapse Mortality after Allogeneic Hematopoietic Cell Transplantation Based on Presence or Absence of Preexisting Diabetes

Malglycemia, defined as hyperglycemia, hypoglycemia, or increased glycemic variability, has been associated with increased mortality after allogeneic hematopoietic cell transplantation (HCT). Among critically ill non-HCT recipients with diabetes and poor glycemic control, compared to those without diabetes, stringent blood glucose control has been associated with increased mortality. This study investigated whether a pre-HCT diagnosis of diabetes and the type of pre-HCT diabetes treatment modulate the previously reported negative impact of malglycemia on post-HCT nonrelapse mortality (NRM). We performed a single-institution retrospective analysis of mortality outcomes after allogeneic HCT as a function of post-HCT blood glucose levels, pre-HCT diagnosis of diabetes, and type of pre-HCT diabetes treatment (insulin, no insulin). A total of 1062 patients who underwent allogeneic HCT between 2015 and 2020 were included in this study. Among these patients, 84 (8%) had a pre-HCT diagnosis of diabetes, of whom 38 (4%) used insulin and 46 (4%) used a noninsulin antiglycemic agent. Post-HCT blood glucose values measured within 100 days from HCT, modeled as a continuous nonlinear time-varying covariate, were associated with day-200 NRM, with both lower and higher glycemic values associated with higher NRM compared to normoglycemic values (adjusted P < .0001). The association between post-HCT blood glucose and NRM varied, however, depending on the presence or absence of a pre-HCT diagnosis of diabetes; that is, there was evidence of a statistical interaction between blood glucose levels and diabetes (adjusted P = .008). In particular, the detrimental impact of hyperglycemic values was more pronounced in patients without a pre-HCT diagnosis of diabetes compared to those with a pre-HCT diagnosis of diabetes. As reported previously, higher and lower blood glucose levels measured within 100 days after allogeneic HCT were associated with an increased risk of NRM; however, this association was more pronounced among patients without a pre-HCT diagnosis of diabetes compared to those with a pre-HCT diagnosis of diabetes, suggesting that patients with diabetes are relatively protected from the downstream effects of hyperglycemia. These data support the notion that patients with pre-HCT diabetes may need a different approach to blood glucose management after transplantation compared to those without diabetes. © 2024 American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc.

Stress hyperglycemia ratio: an independent predictor for in-hospital major adverse cardiovascular and cerebrovascular events in patients with st-segment elevation myocardial infarction

BACKGROUND

To assess the predictive accuracy of the stress hyperglycemia ratio (SHR) for in-hospital major adverse cardiovascular and cerebrovascular events (MACCE) in patients with ST-segment elevation myocardial infarction (STEMI).

METHODS

A total of 1,944 patients were enrolled within 24 h of a new STEMI diagnosis. The SHR was obtained by dividing the blood glucose level at admission by the estimated average glucose. MACCE were defined as acute cerebral infarction, mechanical complications of myocardial infarction, cardiogenic shock, and all-cause death. Patients were then categorized into the MACCE and non-MACCE groups according to the occurrence of in-hospital MACCE. Propensity score matching was used to balance confounding factors, and logistic regression was used to identify the potential predictive factors for MACCE.

RESULTS

A total of 276 patients were included after 1:1 matching, and the confounding factors were balanced between the two groups. The SHR was an independent predictor of in-hospital MACCE (odds ratio = 10.06, 95% confidence interval: 4.16-27.64, P < 0.001), while blood glucose at admission was not. The SHR was also an independent predictor for in-hospital MACCE in nondiabetic patients with STEMI (odds ratio = 11.26, 95% confidence interval: 3.05-55.21, P < 0.001).

CONCLUSION

SHR is an independent predictor of in-hospital MACCE in patients with acute STEMI, especially in nondiabetic patients.

Comparing the accuracy of point-of-care with laboratory (capillary, venous, and arterial) blood glucose levels in critically ill patients with and without shock

OBJECTIVES

To compare the accuracy of point-of-care capillary and venous/arterial samples to laboratory testing of venous/arterial samples in critically sick shocked and non-shocked patients. This is a prospective case-control study including capillary, venous, and arterial blood samples from 268 critically ill patients. The King Fahd Military Medical Complex in Dhahran, Saudi Arabia, was the site of this investigation.

RESULTS

We were able to obtain data on 268 patients for this investigation. POCT and lab findings of venous and central blood did not differ significantly (P = 0.389 and 0.208), while POCT indicated somewhat higher results with venous glucose concentrations of 10.18 and 10.05 (POCT and lab tests respectively) and 9.18 and 9.54 (POCT and lab tests respectively). In addition, the mean differences between POC and laboratory analyses of venous, arterial, and central glucose were 0.13, - 1.75, and - 0.36 mmol/L for venous, arterial, and central glucose, respectively. Except for arterial blood glucose, we did not observe a significant difference between POCT and routine laboratory analysis of glucose concentrations in critically ill patients. Compared to laboratory blood analysis, the use of POCT is marginally accurate, with no difference between shocked and non-shocked patients.

Predicting Blood Glucose Concentration after Short-Acting Insulin Injection Using Discontinuous Injection Records

Diabetes is an increasingly common disease that poses an immense challenge to public health. Hyperglycemia is also a common complication in clinical patients in the intensive care unit, increasing the rate of infection and mortality. The accurate and real-time prediction of blood glucose concentrations after each short-acting insulin injection has great clinical significance and is the basis of all intelligent blood glucose control systems. Most previous prediction methods require long-term continuous blood glucose records from specific patients to train the prediction models, resulting in these methods not being used in clinical practice. In this study, we construct 13 deep neural networks with different architectures to atomically predict blood glucose concentrations after arbitrary independent insulin injections without requiring continuous historical records of any patient. Using our proposed models, the best root mean square error of the prediction results reaches 15.82 mg/dL, and 99.5% of the predictions are clinically acceptable, which is more accurate than previously proposed blood glucose prediction methods. Through the re-validation of the models, we demonstrate the clinical practicability and universal accuracy of our proposed prediction method.

Acute coronary syndromes in diabetic patients, outcome, revascularization, and antithrombotic therapy

Diabetes exacerbates the progression of atherosclerosis and is associated with increased risk of developing acute coronary syndrome (ACS). Approximatively 25-30% of patients admitted for ACS have diabetes. ACS occurs earlier in diabetics and is associated with increased mortality and a higher risk of recurrent ischemic events. An increased proinflammatory and prothrombotic state is involved in the poorer outcomes of diabetic patients. In the past decade advancement in both percutaneous coronary intervention (PCI) and coronary artery by-pass graft (CABG) techniques and more potent antiplatelet drugs like prasugrel and ticagrelor improved outcomes of diabetic patients with ACS, but this population still experiences worse outcomes compared to non-diabetic patients. While in ST elevation myocardial infarction urgent PCI is the method of choice for revascularization, in patients with non-ST elevation ACS an early invasive approach is suggested by the guidelines, but in the setting of multivessel (MV) or complex coronary artery disease (CAD) the revascularization strategy is less clear. This review describes the accumulating evidence regarding factors involved in promoting increased incidence and poor prognosis of ACS in patients with diabetes, the evolution over time of prognosis and outcomes, revascularization strategies and antithrombotic therapy studied until now.

Admission Glucose Levels and Associated Risk for Heart Failure After Myocardial Infarction in Patients Without Diabetes

Background

Dysglycemia at acute myocardial infarction (AMI) is common and is associated with mortality. Information on other outcomes is less well explored in patients without diabetes in a long‐term perspective. We aimed to explore the relationship between admission glucose level and long‐term outcomes in patients with AMI without diabetes in a nationwide setting.

Methods and Results

Patients without diabetes (n=45 468) with AMI registered in SWEDEHEART (Swedish Web–System for Enhancement and Development of Evidence‐Based Care in Heart Disease Evaluated According to Recommended Therapies) and admission glucose ≤11 mmol/L (≤198 mg/dL) were followed for outcomes (AMI, heart failure, stroke, renal failure, and death) between 2012 and 2017 (mean follow‐up time 3.3±1.7 years). The association between categorized glucose levels and outcomes was assessed in adjusted Cox proportional hazards regression analyses (glucose levels 4.0–6.0 mmol/L [72–109 mg/dL] as reference). Further nonfatal complications and their associated mortality were explored (patients without events served as a reference). A glucose level of 7.8–11.0 mmol/L (140–198 mg/dL) was associated with hospitalization for heart failure (hazard ratio [HR] 1.40 [95% CI, 1.30–1.51], P<0.001), renal failure (1.17; 1.04–1.33, P=0.009), and death (1.31; 1.20–1.43, P<0.001), but not with recurrent myocardial infarction (0.99; 0.92–1.07, P=0.849) or stroke (1.03; 0.88–1.19, P=0.742). Renal failure had the strongest association with future mortality (age‐adjusted HR 4.93 [95% CI, 4.34–5.60], P<0.001), followed by heart failure (3.71; 3.41–4.04, P<0.001), stroke (3.39; 2.94–3.91, P<0.001), and myocardial infarction (2.08; 1.88–2.30, P<0.001).

Conclusions

Elevated glucose levels at AMI admission identifies patients without diabetes at increased risk of long‐term complications: in particular, hospitalization for heart and renal failure. These results emphasize that glucose levels at admission could be useful in risk assessment after myocardial infarction.

Association between admission blood glucose and prognosis in non-diabetic patients with first-ever acute myocardial infarction

Background: Admission hyperglycemia has been associated with major adverse cardiovascular and cerebrovascular events (MACCEs) in patients with acute coronary syndrome.Methods: In this study we sought to determine the association between admission blood sugar (ABS) and the outcomes of non-diabetic patients with first-ever acute myocardial infarction (MI). Non-diabetic patients with MI were evaluated from March 2016 to March 2019. Baseline characteristics, laboratories, electrocardiogram, and baseline left ventricular ejection fraction (LVEF) were recorded. All patients were followed up and outcomes were obtained. Follow-up data comprised of repeating electrocardiogram and echocardiography at 1 year, and MACCE, including re-MI, stroke, and mortality.Results: A total of 312 patients with a mean age of 54.2 ± 11.9 years were evaluated. All patients were followed up for a median of 38 months. The frequencies of in-hospital mortality and MACCE at late follow-up were higher in third tertile of ABS compared with those in first and second tertiles (both p <0.05). Based on the Cox regression analysis, the independent predictors of MACCE included age (hazard ratio [HR] 1.068, 95% confidence interval [CI] 1.033 - 1.105, p <0.001), third tertile of ABS >172 mg/dL (HR 21.257, 95% CI 2.832 - 159.577, p=0.003), and baseline LVEF (HR 0.947, 95% CI 0.901 - 0.995, p=0.031).Conclusion: Admission stress hyperglycemia is associated with increased rates of in-hospital mortality and MACCE at late follow-up in non-diabetic patients with MI. Moreover, elevated ABS, older ages, and a decreased value of baseline LVEF predicted MACCE during follow-up.

Association Between Stress Hyperglycemia Ratio and In-hospital Outcomes in Elderly Patients With Acute Myocardial Infarction

Backgrounds: Emerging evidence suggests that stress hyperglycemia ratio (SHR), an index of relative stress hyperglycemia, is of great prognostic value in acute myocardial infarction (AMI), but current evidence is limited in elderly patients. In this study, we aimed to assess whether SHR is associated with in-hospital outcomes in elderly patients with AMI.

Methods: In this retrospective study, patients who were aged over 75 years and diagnosed with AMI were consecutively enrolled from 2015, January 1st to 2019, December 31th. Admission blood glucose and glycosylated hemoglobin (HbA1C) during the index hospitalization were used to calculate SHR. Restricted quadratic splines, receiver-operating curves, and logistic regression were performed to evaluate the association between SHR and in-hospital outcomes, including in-hospital all-cause death and in-hospital major adverse cardiac and cerebrovascular events (MACCEs) defined as a composite of all-cause death, cardiogenic shock, reinfarction, mechanical complications of MI, stroke, and major bleeding.

Results: A total of 341 subjects were included in this study. Higher SHR levels were observed in patients who had MACCEs (n = 69) or death (n = 44) during hospitalization. Compared with a SHR value below 1.25, a high SHR was independently associated with in-hospital MACCEs (odds ratio [OR]: 2.945, 95% confidence interval [CI]: 1.626–5.334, P < 0.001) and all-cause death (OR: 2.871 95% CI: 1.428–5.772, P = 0.003) in univariate and multivariate logisitic analysis. This relationship increased with SHR levels based on a non-linear dose-response curve. In contrast, admission glucose was only associated with clinical outcomes in univariate analysis. In subgroup analysis, high SHR was significantly predictive of worse in-hospital clinical outcomes in non-diabetic patients (MACCEs: 2.716 [1.281–5.762], P = 0.009; all-cause death: 2.394 [1.040–5.507], P = 0.040), but the association was not significant in diabetic patients.

Conclusion: SHR might serve as a simple and independent indicator of adverse in-hospital outcomes in elderly patients with AMI, especially in non-diabetic population.

Reducing Cardiac Injury during ST-Elevation Myocardial Infarction: A Reasoned Approach to a Multitarget Therapeutic Strategy

The significant reduction in ‘ischemic time’ through capillary diffusion of primary percutaneous intervention (pPCI) has rendered myocardial-ischemia reperfusion injury (MIRI) prevention a major issue in order to improve the prognosis of ST elevation myocardial infarction (STEMI) patients. In fact, while the ischemic damage increases with the severity and the duration of blood flow reduction, reperfusion injury reaches its maximum with a moderate amount of ischemic injury. MIRI leads to the development of post-STEMI left ventricular remodeling (post-STEMI LVR), thereby increasing the risk of arrhythmias and heart failure. Single pharmacological and mechanical interventions have shown some benefits, but have not satisfactorily reduced mortality. Therefore, a multitarget therapeutic strategy is needed, but no univocal indications have come from the clinical trials performed so far. On the basis of the results of the consistent clinical studies analyzed in this review, we try to design a randomized clinical trial aimed at evaluating the effects of a reasoned multitarget therapeutic strategy on the prevention of post-STEMI LVR. In fact, we believe that the correct timing of pharmacological and mechanical intervention application, according to their specific ability to interfere with survival pathways, may significantly reduce the incidence of post-STEMI LVR and thus improve patient prognosis.

Impact of admission hyperglycaemia on clinical outcomes in non-diabetic heart failure with preserved ejection fraction

Aims

At present, the clinical significance of admission hyperglycaemia in heart failure with preserved ejection fraction (HFpEF) patients remains unknown. This study was designed to evaluate the relationship between admission hyperglycaemia and clinical outcome in HFpEF patients, especially in non‐diabetic patients.

Methods and results

We enrolled 486 non‐diabetic HFpEF (left ventricular ejection fraction ≥50%) patients hospitalized due to acute decompensated heart failure from the PURSUIT‐HFpEF registry, a prospective, multicentre observational study. We divided non‐diabetic patients into two groups, an admission hyperglycaemia group whose blood glucose on admission was ≥7.0 mmol/L (148 patients) and a normoglycaemic group whose blood glucose on admission was <7.0 mmol/L (338 patients). The primary endpoint was all‐cause mortality, and the secondary endpoints were heart failure death and other causes of cardiac death. During a mean follow‐up period of 400 ± 335 days, all‐cause mortality was 69 patients. Twenty‐five patients suffered cardiac death. All‐cause mortality (P = 0.002), cardiac death (P = 0.009), and heart failure death (P = 0.001) were significantly more frequent in the admission hyperglycaemia group than in the normoglycaemic group. Admission hyperglycaemia was independently and significantly associated with all‐cause mortality and cardiac death (HR 2.01, 95% CI 1.20–3.34, P = 0.008 and HR 3.03, 95% CI 1.35–6.96, P = 0.007, respectively).

Conclusions

Non‐diabetic HFpEF patients with admission hyperglycaemia when hospitalized for heart failure had poorer clinical outcomes than normoglycaemic patients.

Access to inpatient diabetes resources: hospital characteristics from the inaugural Queensland Inpatient Diabetes Survey

AIMS

To establish the prevalence of diabetes in Queensland hospitals and assess the availability of specialised diabetes staff, educational resources and policies for inpatient diabetes management, including assessing equity of access to these resources.

METHODS

The hospital capacity, prevalence of diabetes, diabetes-related resources and the availability of diabetes-related guidelines were assessed in 25 hospitals medical, surgical, mental health, high-dependency and intensive care wards of level 2-6 public hospitals across Queensland. Diabetes-dedicated staffing measured in full-time equivalents, care delivery resources, access to educational resources, standard policies and procedures for care were assessed.

RESULTS

Twenty-five hospitals included 4265 occupied beds. The median prevalence of diabetes was 22.9% (IQR 17.3-28.5%) with an average 2.9 FTE per 100 patients with diabetes (IQR 0-6.3). There was difficulty in accessing a diabetes educator in 48% (n = 12), diabetes specialist in 44% (n = 11), orthopaedic surgeon in 48% (n = 12), podiatrist in 58% (n = 14) and vascular surgeon in 64% (n = 16) of hospitals. Small hospitals had more difficulty accessing all members of the diabetes team compared to large hospitals including credentialled diabetes educators 33% (n = 4) versus 62% (n = 8) (p = 0.0001), diabetes specialists 17% (n = 2) versus 69% (n = 9) (p < 0.00001) and vascular surgeons 33% (n = 4) versus 92% (n = 12) (p < 0.000001). Diabetes-related staff education and regular nurse training was available in 40% (n = 10) of hospitals. A multi-disciplinary foot care team was available in 28% (n = 7) of hospitals.

CONCLUSIONS

Queensland's has a high prevalence of diabetes in hospitalised patients and they have limited and inequitable access to inpatient diabetes-related care. This article is protected by copyright. All rights reserved.

Stress Induced Hyperglycemia in the Context of Acute Coronary Syndrome: Definitions, Interventions, and Underlying Mechanisms

Elevation of glucose level in response to acute coronary syndrome (ACS) has been recognized as stress induced hyperglycemia (SIH). Plenty of clinical studies have documented that SIH occurs very common in patients hospitalized with ACS, even in those without previously known diabetes mellitus. The association between elevated blood glucose levels with adverse outcome in the ACS setting is well-established. Yet, the precise definition of SIH in the context of ACS remains controversial, bringing confusions about clinical management strategy. Several randomized trials aimed to evaluate the effect of insulin-based therapy on outcomes of ACS patients failed to demonstrate a consistent benefit of intensive glucose control. Mechanisms underlying detrimental effects of SIH on patients with ACS are undetermined, oxidative stress might play an important role in the upstream pathways leading to subsequent harmful effects on cardiovascular system. This review aims to discuss various definitions of SIH and their values in predicting adverse outcome in the context of ACS, as well as the effect of intensive glucose control on clinical outcome. Finally, a glimpse of the underlying mechanisms is briefly discussed.

Association between glycosylated haemoglobin and outcomes for patients discharged from hospital with diabetes: A health informatics approach

Aims/Objectives

Extensive research considers associations between inpatient glycaemic control and outcomes during hospital admission; this cautions against overly tight glycaemic targets. Little research considers glycaemic control following hospital discharge. This is despite a clear understanding that people with diabetes are at increased risk of negative outcomes, following discharge. We evaluate absolute and relative Hba1c values, and frequency of Hba1c monitoring, on readmission and mortality rates for people discharged from hospital with diabetes.

Methods

All discharges (n = 46,357) with diabetes from a major tertiary referral centre over 3 years were extracted, including biochemistry data. We conducted an evaluation of association between Hba1c, mortality and readmission, statistical significance and standardised Cohen's D effect size calculations.

Results

399 patients had a Hba1c performed during their admission. 3,138 patients had a Hba1c within 1 year of discharge. Mean average Hba1c for readmissions was 57.82 vs 60.39 for not readmitted (p = 0.009, Cohen's D 0.28). Mean average number of days to Hba1c testing in readmitted was 97 vs 113 for those not readmitted (p = 0.00006, Cohen's D 0.39). Further evaluation of mortality outcomes, cohorts of T1DM and T2DM and association of relative change in Hba1c was performed.

Conclusions

Lower Hba1c values following discharge from hospital are significantly associated with increased risk of readmission, as is a shorter duration until testing. Similar patterns observed for mortality. Findings particularly prominent for T1DM. Further research needed to consider underlying causation and design of appropriate risk stratification models.

Data-driven curation process for describing the blood glucose management in the intensive care unit

Analysis of real-world glucose and insulin clinical data recorded in electronic medical records can provide insights into tailored approaches to clinical care, yet presents many analytic challenges. This work makes publicly available a dataset that contains the curated entries of blood glucose readings and administered insulin on a per-patient basis during ICU admissions in the Medical Information Mart for Intensive Care (MIMIC-III) database version 1.4. Also, the present study details the data curation process used to extract and match glucose values to insulin therapy. The curation process includes the creation of glucose-insulin pairing rules according to clinical expert-defined physiologic and pharmacologic parameters. Through this approach, it was possible to align nearly 76% of insulin events to a preceding blood glucose reading for nearly 9,600 critically ill patients. This work has the potential to reveal trends in real-world practice for the management of blood glucose. This data extraction and processing serve as a framework for future studies of glucose and insulin in the intensive care unit.

Prescribing in Type 2 Diabetes Patients With and Without Cardiovascular Disease History: A Descriptive Analysis in the UK CPRD

PURPOSE

Some classes of glucose-lowering medications, including sodium-glucose co-transporter 2 inhibitors (SGLT2is) and glucagon-like peptide 1-receptor agonists (GLP1-RAs) have cardio-protective benefit, but it is unclear whether this influences prescribing in the United Kingdom (UK). This study aims to describe class-level prescribing in adults with type 2 diabetes mellitus (T2DM) by cardiovascular disease (CVD) history using the Clinical Practice Research Datalink (CPRD).

METHODS

Four cross-sections of people with T2DM aged 18-90 and registered with their general practice for >1 year on 1st January 2017 (n = 166,012), 1st January 2018 (n = 155,290), 1st January 2019 (n = 152,602) and 31st December 2019 (n = 143,373) were identified. Age-standardised proportions for class use through time were calculated separately in those with and without CVD history and by total number of medications prescribed (one, two, three, four+). An analysis by UK country was also performed.

FINDINGS

Around 31% of patients had CVD history at each cross-section. Metformin was the most common treatment (>70% of those with and without CVD had prescriptions across all treatment lines). Overall use of SGLT2is and GLP1-RAs was low, with slightly less use in patients with CVD (SGLT2i: 9.8% and 13.8% in those with and without CVD respectively; GLP1-RA: 4.3% and 4.9%, December 2019). Use of SGLT2is as part of dual therapy was low but rose throughout the study. In January 2017, estimated use was 8.0% (95% CI 6.9-9.1%) and 8.9% (8.6-9.3%) in those with and without CVD. By December 2019 this reached 18.3% (17.0-19.5%) and 21.2% (20.6-21.7%) for those with and without CVD respectively. SGLT2i use as triple therapy increased: 22.7% (21.0-24.4%) and 25.9% (25.2-26.6%) in January 2017 to 41.3% (39.5-43.0%) and 45.5% (44.7-46.3%) in December 2019. GLP1-RA use also increased, but observed usage remained lower than SGLT2 inhibitors. Insulin use remained stable throughout, with higher use observed in those with CVD (16% vs 9.7% Dec 2019). Time trends in England, Wales, Scotland and Northern Ireland were similar, although class prevalence varied.

IMPLICATIONS

Although use of SGLT2is and GLP1-RAs has increased, overall usage remains low with slightly lower use in those with CVD history, suggesting there is opportunity to optimise use of these medicines in T2DM patients to manage CVD risk. Insulin use was substantially more prevalent in those with CVD despite no evidence of CVD benefit. Further investigation of factors influencing this finding may highlight strategies to improve patient access to the most appropriate treatments, including those with evidence of cardiovascular benefit.

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.

Care maps are an effective tool for optimizing quality of care of infectious diseases in a resource-constrained short-stay ambulatory care setting

ABSTRACT

Care maps (CMs), which are innovative, comprehensive, educational, and simple medical tools, were developed for 6 common diseases, including heart failure, stroke, hyperglycemia, urinary tract infection, dengue infection, and upper gastrointestinal bleeding, were implemented in a short-stay ambulatory ward. This study aimed to investigate the effectiveness of and level of clinician satisfaction with CMs in an ambulatory care setting.A retrospective chart review study comparing the quality of care between before and after CM implementation was conducted. The medical records of patients who were admitted to a short-stay ambulatory ward in a tertiary referral center were reviewed. Demographic data, severity of disease, quality of care, length of stay (LOS), admission cost, and CM user satisfaction were collected and recorded.The medical records of 1116 patients were evaluated. Of those, 589 and 527 patients were from before (non-CM group) and after CM (CM group) implementation, respectively. There were no significant differences between groups for age, gender, or disease-specific severity the median (interquartile range) total and essential quality scores were significantly higher in the CM group than in the non-CM group [total quality score 85.3 (75.0-92.9) vs 61.1 (50.0-75.0); P < .001, and essential quality scores 90.0 (75.0-100.0) vs 60.0 (40.6-80.0); P < .0001, respectively]. All aspects of quality of care were significantly improved between before and after CM implementation. Overall median LOS was significantly decreased from 3.8 (2.5-5.7) to 3.0 (2.0-4.9) days, but there was no significant decrease for admission cost. However, CMs were able to significantly reduce both LOS and admission cost in the infectious disease-related subgroup. Most CM users reported satisfaction with CMs.CMs were shown to be an effective tool for improving the quality of care in patients with ambulatory infectious diseases. In that patient subgroup, LOS and admission cost were both significantly reduced compared to pre-CM implementation.

Stress hyperglycemia, cardiac glucotoxicity, and critically ill patient outcomes current clinical and pathophysiological evidence

Stress hyperglycemia is a transient increase in blood glucose during acute physiological stress in the absence of glucose homeostasis dysfunction. Its's presence has been described in critically ill patients who are subject to many physiological insults. In this regard, hyperglycemia and impaired glucose tolerance are also frequent in patients who are admitted to the intensive care unit for heart failure and cardiogenic shock. The hyperglycemia observed at the beginning of these cardiac disorders appears to be related to a variety of stress mechanisms. The release of major stress and steroid hormones, catecholamine overload, and glucagon all participate in generating a state of insulin resistance with increased hepatic glucose output and glycogen breakdown. In fact, the observed pathophysiological response, which appears to regulate a stress situation, is harmful because it induces mitochondrial impairment, oxidative stress-related injury to cells, endothelial damage, and dysfunction of several cellular channels. Paradigms are now being challenged by growing evidence of a phenomenon called glucotoxicity, providing an explanation for the benefits of lowering glucose levels with insulin therapy in these patients. In the present review, the authors present the data published on cardiac glucotoxicity and discuss the benefits of lowering plasma glucose to improve heart function and to positively affect the course of critical illness.

Stress-Induced Hyperglycaemia in Non-Diabetic Patients with Acute Coronary Syndrome: From Molecular Mechanisms to New Therapeutic Perspectives

Stress-induced hyperglycaemia (SIH) at hospital admission for acute coronary syndrome is associated with poor outcome, especially in patients without known diabetes. Nevertheless, insulin treatment in these subjects was not correlated with the reduction of mortality. This is likely due to the fact that SIH in the context of an acute coronary syndrome, compared to that in known diabetes, represents an epiphenomenon of other pathological conditions, such as adrenergic and renin-angiotensin system over-activity, hyperglucagonaemia, increase of circulating free fatty acids and pancreatic beta-cell dysfunction, which are not completely reversed by insulin therapy and so worsen the prognosis. Thus, SIH may be considered not only as a biomarker of organ damage, but also as an indicator of a more complex therapeutic strategy in these subjects. The aim of this review is to analyse the molecular mechanisms by which SIH may favour a worse prognosis in non-diabetic patients with acute coronary syndrome and identify new therapeutic strategies, in addition to insulin therapy, for a more appropriate treatment and improved outcomes.

Cardioprotective Natural Compound Pinocembrin Attenuates Acute Ischemic Myocardial Injury via Enhancing Glycolysis

Purpose

Emerging evidence has shown that pinocembrin protects the myocardium from ischemic injury in animals. However, it is unknown whether it has cardioprotection when given at the onset of reperfusion. Also, mechanisms mediating the cardioprotective actions of pinocembrin were largely unknown. Thus, this study is aimed at investigating the effects of pinocembrin postconditioning on ischemia-reperfusion (I/R) injury and the underlying mechanisms.

Methods

The in vivo mouse model of myocardial I/R injury, ex vivo isolated rat heart with global I/R, and in vitro hypoxia/reoxygenation (H/R) injury model for primary cardiomyocytes were used.

Results

We found that pinocembrin postconditioning significantly reduced the infarct size and improved cardiac contractile function after acute myocardial I/R. Mechanically, in primary cardiomyocytes, we found that pinocembrin may confer protection in part via direct stimulation of cardiac glycolysis via promoting the expression of the glycolytic enzyme, PFKFB3. Besides, PFKFB3 inhibition abolished pinocembrin-induced glycolysis and protection in cardiomyocytes. More importantly, PFKFB3 knockdown via cardiotropic adeno-associated virus (AAV) abrogated cardioprotective effects of pinocembrin. Moreover, we demonstrated that HIF1α is a key transcription factor driving pinocembrin-induced PFKFB3 expression in cardiomyocytes.

Conclusions

In conclusion, these results established that the acute cardioprotective benefits of pinocembrin are mediated in part via enhancing PFKFB3-mediated glycolysis via HIF1α, which may provide a new therapeutic target to impede the progression of myocardial I/R injury.

Diabetes Impairs Cellular Cholesterol Efflux From ABCA1 to Small HDL Particles

RATIONALE

HDL (high-density lipoprotein) may be cardioprotective because it accepts cholesterol from macrophages via the cholesterol transport proteins ABCA1 (ATP-binding cassette transporter A1) and ABCG1 (ATP-binding cassette transporter G1). The ABCA1-specific cellular cholesterol efflux capacity (ABCA1 CEC) of HDL strongly and negatively associates with cardiovascular disease risk, but how diabetes mellitus impacts that step is unclear.

OBJECTIVE

To test the hypothesis that HDL's cholesterol efflux capacity is impaired in subjects with type 2 diabetes mellitus.

METHODS AND RESULTS

We performed a case-control study with 19 subjects with type 2 diabetes mellitus and 20 control subjects. Three sizes of HDL particles, small HDL, medium HDL, and large HDL, were isolated by high-resolution size exclusion chromatography from study subjects. Then we assessed the ABCA1 CEC of equimolar concentrations of particles. Small HDL accounted for almost all of ABCA1 CEC activity of HDL. ABCA1 CEC-but not ABCG1 CEC-of small HDL was lower in the subjects with type 2 diabetes mellitus than the control subjects. Isotope dilution tandem mass spectrometry demonstrated that the concentration of SERPINA1 (serpin family A member 1) in small HDL was also lower in subjects with diabetes mellitus. Enriching small HDL with SERPINA1 enhanced ABCA1 CEC. Structural analysis of SERPINA1 identified 3 amphipathic α-helices clustered in the N-terminal domain of the protein; biochemical analyses demonstrated that SERPINA1 binds phospholipid vesicles.

CONCLUSIONS

The ABCA1 CEC of small HDL is selectively impaired in type 2 diabetes mellitus, likely because of lower levels of SERPINA1. SERPINA1 contains a cluster of amphipathic α-helices that enable apolipoproteins to bind phospholipid and promote ABCA1 activity. Thus, impaired ABCA1 activity of small HDL particles deficient in SERPINA1 could increase cardiovascular disease risk in subjects with diabetes mellitus.

Enhancing Glycolysis Protects against Ischemia-Reperfusion Injury by Reducing ROS Production

After myocardial ischemia-reperfusion, fatty acid oxidation shows fast recovery while glucose oxidation rates remain depressed. A metabolic shift aimed at increasing glucose oxidation has shown to be beneficial in models of myocardial ischemia-reperfusion. However, strategies aimed at increasing glucose consumption in the clinic have provided mixed results and have not yet reached routine clinical practice. A better understanding of the mechanisms underlying the protection afforded by increased glucose oxidation may facilitate the transfer to the clinic. The purpose of this study was to evaluate if the modulation of reactive oxygen species (ROS) was involved in the protection afforded by increased glucose oxidation. Firstly, we characterized an H9C2 cellular model in which the use of glucose or galactose as substrates can modulate glycolysis and oxidative phosphorylation pathways. In this model, there were no differences in morphology, cell number, or ATP and PCr levels. However, galactose-grown cells consumed more oxygen and had an increased Krebs cycle turnover, while cells grown in glucose had increased aerobic glycolysis rate as demonstrated by higher lactate and alanine production. Increased aerobic glycolysis was associated with reduced ROS levels and protected the cells against simulated ischemia-reperfusion injury. Furthermore, ROS scavenger N-acetyl cysteine (NAC) was able to reduce the amount of ROS and to prevent cell death. Lastly, cells grown in galactose showed higher activation of mTOR/Akt signaling pathways. In conclusion, our results provide evidence indicating that metabolic shift towards increased glycolysis reduces mitochondrial ROS production and prevents cell death during ischemia-reperfusion injury.

Impact of Hyperglycemia on Long-Term Outcome in Patients With ST-Segment Elevation Myocardial Infarction

In patients with ST-segment elevation myocardial infarction (STEMI), the association between stress-induced hyperglycemia (SIH) and long-term outcomes, as well as the effects of baseline diabetic status on this association remain elusive. To clarify the association between SIH and long-term outcomes, and the effects of baseline diabetic status on this association, we studied 6,287 STEMI patients who were discharged alive. SIH was estimated using the stress hyperglycemia ratio (SHR), which is defined as [(admission glucose (mg/dl))/(28.7 × HbA1c (%) - 46.7)]. End points were all-cause death and admission for heart failure (HF). We compared prognosis between patients in the highest SHR quartile and those in other quartiles of the nondiabetic and diabetic population. Over a follow-up of 5 years (median 1,522 days), 464 (7.4%) and 401 (6.4%) cases of all-cause death and HF admission were observed. In the nondiabetic population, the highest SHR quartile (Q4) group was significantly associated with worse long-term outcomes (adjusted hazard ratio [HR] (95% confidence interval [CI]), all-cause death; 1.45 (1.06 to 1.98), p = 0.021, HF admission; 1.48 (1.04 to 2.10), p = 0.031). However, in the diabetic population, SHR Q4 group was not significantly associated with worse long-term outcomes (adjusted HR (95% CI), all-cause death; 1.00 (0.68 - 1.48), p = 0.996, HF admission; 1.31 (0.90 to 1.89), p = 0.154). In conclusion, in STEMI patients discharged alive, high SHR was significantly associated with worse long-term prognosis in the nondiabetic population. In contrast, high SHR was not significantly associated with worse long-term prognosis in the diabetic population.

Prognostic Value of Hyperglycemia on Admission on In-hospital Outcomes in Patients Presenting with ST-elevation Myocardial Infarction

Background

Type 2 diabetes mellitus (T2DM) is associated with acute coronary syndrome, and elevated blood glucose levels on hospital admission may influence outcomes in patients with ST-elevated myocardial infarction (STEMI). We conducted this study to determine the prognostic outcome of hyperglycemia at admission on in-hospital outcomes of STEMI patients with and without T2DM.

Methods

This prospective study was conducted from June 13, 2018, to October 12, 2019, and included patients older than 18 years diagnosed with STEMI. For our purposes, hyperglycemia was defined as blood glucose levels >140 mg/dl. Hypertension was considered as systolic blood pressure >140 mmHg or diastolic pressure > 90 mmHg. The predictive value of glycemia on admission for outcomes was assessed via patient mortality following thrombolysis or percutaneous coronary intervention (PCI).

Results

Our study included 256 patients (196 men, 76.5%; 60 women, 23.5%) with a mean age of 55 ± 11 years. A total of 92 patients (35.9%) were admitted with known T2DM diagnoses: 72 of them had hyperglycemia and 20 patients had euglycemia (p = 0.0001). Post-PCI mortality was six (18.8%) in the hyperglycemic group and one (2.2%) in the euglycemic group (p = 0.03). In-hospital mortality was higher in the hyperglycemic group (n = 12, 12.5%) compared to the euglycemic group (n = 6, 3.7%; p = 0.015). Significant risk factors of mortality for STEMI patients with hyperglycemia on admission were age 60 years or older (odds ratio [OR], 5.63 [1.54-20.58]; p = 0.007), heart failure on admission (OR, 6.84 [1.85-25.22)]; p = 0.003), T2DM (OR, 4.14 [0.50-33.96]; p = 0.05), and presenting with renal failure (OR, 6.78 [1.74-26.42]; p = 0.009).

Conclusion

Thrombolysis and PCI are effective and safe treatments in STEMI patients. Hyperglycemia has a great adverse impact on hospital outcomes in patients with or without T2DM. STEMI patients with hyperglycemia on hospital admission have higher mortality rates.

Nitric Oxide Resistance, Induced in the Myocardium by Diabetes, Is Circumvented by the Nitric Oxide Redox Sibling, Nitroxyl

Aim: Impairment of tissue responsiveness to exogenous and endogenous nitric oxide (NO^•), known as NO^• resistance, occurs in many cardiovascular disease states, prominently in diabetes and especially in the presence of marked hyperglycemia. In this study, we sought to determine in moderate and severe diabetes (i) whether NO^• resistance also occurs in the myocardium, and (ii) whether the NO^• redox sibling nitroxyl (HNO) circumvents this. Results: The spectrum of acute NO^• effects (induced by diethylamine-NONOate), including vasodilation, and enhanced myocardial contraction and relaxation were impaired by moderately diabetic rats ([blood glucose] ∼20 mM). In contrast, acute HNO effects (induced by isopropylamine-NONOate) were preserved even in more severe diabetes ([blood glucose] >28 mM). Intriguingly, the positive inotropic effects of HNO were significantly enhanced in diabetic rat hearts. Further, progressive attenuation of soluble guanylyl cyclase (sGC) contribution to myocardial NO^• responses occurred with increasing severity of diabetes. Nevertheless, activation of sGC by HNO remained intact in the myocardium. Innovation: Diabetes is associated with marked attenuation of vascular and myocardial effects of NO and NO donors, and this NO^• resistance is circumvented by HNO, suggesting potential therapeutic utility for HNO donors in cardiovascular emergencies in diabetics. Conclusion: These results provide the first evidence that NO^• resistance occurs in diabetic hearts, and that HNO largely circumvents this problem. Further, the positive inotropic and lusitropic effects of HNO are enhanced in a severely diabetic myocardium, a finding that warrants further mechanistic interrogation. The results support a potential role for therapeutic HNO administration in acute treatment of ischemia and/or heart failure in diabetics.

Diabetes Mellitus and Acute Myocardial Infarction: Impact on Short and Long-Term Mortality

Diabetes mellitus (DM) is an important risk factor for acute myocardial infarction (AMI) and a frequent co-morbidity in patients hospitalized with AMI, being present in about 30% of cases. Although current treatment of AMI has considerably improved survival in both patients with and without DM, the presence of DM still doubles the case fatality rate during both the acute phase of AMI and at long-term follow-up. This higher mortality risk of DM patients strongly indicates a particular need for better treatment options in these patients and suggests that intensive medical treatment, prolonged surveillance, and stringent control of other risk factors should be carefully pursued and maintained for as long as possible in them.In this review, we will focus on the close association between DM and in-hospital and long-term mortality in AMI patients. We will also aim at providing current evidence on the mechanisms underlying this association and on emerging therapeutic strategies, which may reduce the traditional mortality gap that still differentiates AMI patients with DM from those without.

Glucose-lowering therapy and cardiovascular outcomes in patients with type 2 diabetes mellitus and acute coronary syndrome

Diabetes is a common comorbidity in patients hospitalized for an acute coronary syndrome event, and prevalence is increasing. Among patients hospitalized with acute myocardial infarction, diabetes can be an independent predictor of mortality and new cardiovascular events; both short- and long-term outcomes are worse for patients with diabetes relative to those without, and undiagnosed diabetes is associated with greater mortality. The impact of glycemic control on cardiovascular outcomes and the best approach to treat hyperglycemia upon hospital admission for acute coronary syndrome in patients with or without known diabetes remain open questions. This review assesses available evidence for hyperglycemia management at the time of admission for acute coronary syndrome and, thereafter, finds that (1) admission plasma glucose plays a role in predicting adverse events, especially in patients with unknown diabetes; (2) glycated haemoglobin is a likely predictor of events in patients with unknown diabetes; and (3) hypoglycemia at the time of acute myocardial infarction hospital admission is an important predictor for mortality in patients with and without diabetes. Whether glucose-targeted insulin and glucose infusion have advantages over glucose-insulin-potassium infusion remains controversial. Evidence for the effect of novel glucose-lowering agents used at the time of an acute cardiovascular event is limited and requires more dedicated studies.

Does stress hyperglycemia affect mortality? Acute myocardial infarction - case control study

Introduction

We aimed to investigate the effect of stress (acute) hyperglycemia in patients with acute coronary syndrome who had not been previously diagnosed with diabetes mellitus (DM) on the prognosis of the disease in terms of mortality.

Material and methods

Patients who were admitted to the Adana Numune Training and Research Hospital Emergency Service Clinic between August 2010 and August 2013 and whose plasma blood glucose level was over 140 mg/dl at the time of admission but were not previously diagnosed with DM, who were over the age of 18 and considered to have acute myocardial infarction were included.

Results

A total of 259 patients whose data were fully attainable were included in the study. 80.3% (n = 208) of the patients were male and 19.7% (n = 41) were female. Non-ST elevation myocardial infarction was found in 71.6%, ST elevation myocardial infarction was found in 28.4% of the patients with stress hyperglycemia. It was determined that 10.1% of patients with stress-related hyperglycemia and 1.3% of patients without stress-related hyperglycemia had died.

Conclusions

The plasma blood glucose level at presentation of patients diagnosed with acute myocardial infarction at the emergency room is associated with early in-hospital mortality.

2019 Clinical Practice Guidelines for Type 2 Diabetes Mellitus in Korea

The Committee of Clinical Practice Guidelines of the Korean Diabetes Association revised and updated the 6th Clinical Practice Guidelines in 2019. Targets of glycemic, blood pressure, and lipid control in type 2 diabetes mellitus (T2DM) were updated. The obese and overweight population is increasing steadily in Korea, and half of the Koreans with diabetes are obese. Evidence-based recommendations for weight-loss therapy for obesity management as treatment for hyperglycemia in T2DM were provided. In addition, evidence from large clinical studies assessing cardiovascular outcomes following the use of sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide 1 receptor agonists in patients with T2DM were incorporated into the recommendations.

Overexpression of Axl reverses endothelial cells dysfunction in high glucose and hypoxia

The receptor tyrosine kinase Axl is involved in diabetic vascular disease. This study aims to investigate the effect of high glucose on endothelial cells injury and Axl expression in hypoxia condition in vitro, and we present details of the mechanism associated with overexpression of Axl rescue the high glucose injury. Our results showed that high glucose impaired both human umbilical vein endothelial cells (HUVECs) and EAhy926 cells angiogenesis in hypoxia condition. In addition, high glucose inhibits Axl and hypoxia-inducible factor 1-α (HIF-1α) protein expression in hypoxia condition. Axl overexpression significantly reversed endothelial cells dysfunction in high glucose/hypoxia. Furthermore, Axl overexpression in EAhy926 cells increases HIF-1α protein synthesis through PI3K/Akt/mTOR/p70 ^S6K signal pathway but not Mek/Erk in high glucose/hypoxia condition. This study demonstrates that high glucose can alter Axl signaling and HIF-1α in hypoxia condition. Overexpression of Axl may rescue endothelial cells dysfunction and HIF-1α expression through its downstream signals in high glucose/hypoxia.

Direct cardiovascular impact of SGLT2 inhibitors: mechanisms and effects

Diabetes is a global epidemic and a leading cause of death with more than 422 million patients worldwide out of whom around 392 million alone suffer from type 2 diabetes (T2D). Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are novel and effective drugs in managing glycemia of T2D patients. These inhibitors gained recent clinical and basic research attention due to their clinically observed cardiovascular protective effects. Although interest in the study of various SGLT isoforms and the effect of their inhibition on cardiovascular function extends over the past 20 years, an explanation of the effects observed clinically based on available experimental data is not forthcoming. The remarkable reduction in cardiovascular (CV) mortality (38%), major CV events (14%), hospitalization for heart failure (35%), and death from any cause (32%) observed over a period of 2.6 years in patients with T2D and high CV risk in the EMPA-REG OUTCOME trial involving the SGLT2 inhibitor empagliflozin (Empa) have raised the possibility that potential novel, more specific mechanisms of SGLT2 inhibition synergize with the known modest systemic improvements, such as glycemic, body weight, diuresis, and blood pressure control. Multiple studies investigated the direct impact of SGLT2i on the cardiovascular system with limited findings and the pathophysiological role of SGLTs in the heart. The direct impact of SGLT2i on cardiac homeostasis remains controversial, especially that SGLT1 isoform is the only form expressed in the capillaries and myocardium of human and rodent hearts. The direct impact of SGLT2i on the cardiovascular system along with potential lines of future research is summarized in this review.

Impact of an inpatient multidisciplinary glucose control management program

OBJECTIVE

Glycemic control has been increasingly recognized as a critical element in inpatient care, but optimal management of blood glucose in the hospital setting remains challenging. The aims of this study were to describe and evaluate the impact of the implementation of an inpatient multidisciplinary glucose control management program on glucose control in hospitalized patients.

MATERIALS AND METHODS

Retrospective analysis of medical records and glucose monitoring data obtained by point- of-care testing (POCT) in hospitalized patients before (May 2014) and after (June 2015 and May 2017) the implementation of the program.

RESULTS

We analyzed 6888, 7290, and 7669 POCTs from 389, 545, and 475 patients in May 2014, June 2015, and May 2017, respectively. Hyperglycemia (≥ 180 mg/ dL) occurred in 23.5%, 19.6%, and 19.3% POCTs in May 2014, June 2015, and May/2017, respectively (p < 0.001), while severe hyperglycemia (≥ 300 mg/dL) was observed in 2.5%, 2.2%, and 1.8% of them, respectively (p = 0.003). Hyperglycemia (≥ 180 mg/dL) reduced significantly from May 2014 to June 2015 (16.3%, p < 0.001) and from May 2014 to May 2017 (178%, p < 0.001). No significant changes occurred in hypoglycemic parameters.

CONCLUSIONS

The implementation of an inpatient multidisciplinary glucose control management program led to significant reductions in hyperglycemic events. The key elements for this achievement were the development of institutional inpatient glycemic control protocols, establishment of a multidisciplinary team, and continuing educational programs for hospital personnel. Altogether, these actions resulted in improvements in care processes, patient safety, and clinical outcomes of hospitalized patients.

Prognostic value of hyperglycemia on-admission in diabetic versus non-diabetic patients presenting with ST-elevation myocardial infarction in Tunisia

BACKGROUND

Hyperglycemia on-admission is a powerful predictor of adverse events in patients presenting for ST-elevation myocardial infarction (STEMI).

AIM

In this study, we sought to determine the prognostic value of hyperglycemia on-admission in Tunisian patients presenting with STEMI according to their diabetic status.

METHODS

Patients presenting to our center between January 1998 and September 2014 were enrolled. Hyperglycemia was defined as a glucose level ≥11mmol/L. In-hospital prognosis was studied in diabetic and non-diabetic patients. The predictive value for mortality of glycemia level on-admission was assessed by mean of the area under receiver operating characteristic (ROC) curve calculation.

RESULTS

A total of 1289 patients were included. Mean age was 60.39±12.8years and 977 (77.3%) patients were male. Prevalence of diabetes mellitus was 70.2% and 15.2% in patients presenting with and without hyperglycemia, respectively (p<0.001). In univariate analysis, hyperglycemia was associated to in-hospital death in diabetic (OR: 8.85, 95% CI: 2.11-37.12, p<0.001) and non-diabetic patients (OR: 2.57, 95% CI: 1.39-4.74, p=0.002). In multivariate analysis, hyperglycemia was independently predictive of in-hospital death in diabetic patients (OR: 9.6, 95% CI: 2.18-42.22, p=0.003) but not in non-diabetic patients (OR: 1.93, 95% CI: 0.97-3.86, p=0.06). Area under ROC curve of glycemia as a predictor of in-hospital death was 0.792 in diabetic and 0.676 in non-diabetic patients.

CONCLUSION

In patients presenting with STEMI, hyperglycemia was associated to hospital death in diabetic and non-diabetic patients in univariate analysis. In multivariate analysis, hyperglycemia was independently associated to in-hospital death in diabetic but not in non-diabetic patients.

Effects of curcumin on hypoxia-inducible factor as a new therapeutic target

Hypoxia-inducible factor-1 (HIF-1) is a transcription factor that consists of two subunits, the HIF-1α and HIF-1β (ARNT). Under hypoxic conditions, HIF-1 is an adaptive system that regulates the transcription of multiple genes associated with growth, angiogenesis, proliferation, glucose transport, metabolism, pH regulation and cell death. However, aberrant HIF-1 activation contributes to the pathophysiology of several human diseases such as cancer, ischemic cardiovascular disorders, and pulmonary and kidney diseases. A growing body of evidence indicates that curcumin, a natural bioactive compound of turmeric root, significantly targets both HIF-1 subunits, but is more potent against HIF-1α. In this review, we have summarized the knowledge about the pharmacological effects of curcumin on HIF-1 and the related molecular mechanisms that may be effective candidates for the development of multi-targeted therapy for several human diseases.

Insulin therapy, weight gain and prognosis

Insulin therapy is mainly used by people with type 2 diabetes who have failed other therapies and have become insulin-deficient. This group represents about a quarter of all people with type 2 diabetes. Almost all those with type 2 diabetes who start insulin therapy or intensify it gain weight, which may potentially diminish the prognostic advantage of improved glycaemia. To date, all available guidelines emphasize both the attainment of glycated haemoglobin (HbA1c) goals and weight control, without directing the clinician as to which element is of a higher priority. The following review attempts to clarify the issue using the available literature. The body of evidence presented in this review indicates that glycaemic management with exogenous insulin replacement is of a much higher priority than weight gain. Lower weight or weight loss do not show prognostic benefit in advanced stages of diabetes; therefore, weight gain should not discourage providers from achieving and maintaining HbA1c goals with insulin therapy, regardless of insulin dosage or other medications.

Cardiac Autonomic Neuropathy in Diabetes: A Predictor of Cardiometabolic Events

Autonomic nervous system (ANS) imbalance manifesting as cardiac autonomic neuropathy in the diabetic population is an important predictor of cardiovascular events. Symptoms and signs of ANS dysfunction, such as resting heart rate elevations, diminished blood pressure responses to standing, and altered time and frequency domain measures of heart rate variability in response to deep breathing, standing, and the Valsalva maneuver, should be elicited from all patients with diabetes and prediabetes. With the recognition of the presence of ANS imbalance or for its prevention, a rigorous regime should be implemented with lifestyle modification, physical activity, and cautious use of medications that lower blood glucose. Rather than intensifying diabetes control, a regimen tailored to the individual risk of autonomic imbalance should be implemented. New agents that may improve autonomic function, such as SGLT2 inhibitors, should be considered and the use of incretins monitored. One of the central mechanisms of dysfunction is disturbance of the hypothalamic cardiac clock, a consequence of dopamine deficiency that leads to sympathetic dominance, insulin resistance, and features of the metabolic syndrome. An improvement in ANS balance may be critical to reducing cardiovascular events, cardiac failure, and early mortality in the diabetic population.

Role of plasma glucose level on myocardial perfusion in ST-segment elevation myocardial infarction patients

AIMS

Hyperglycemia is frequent in patients with ST elevation myocardial infarction (STEMI) and is associated with adverse outcome. Aim of our study was to evaluate the correlation between admission plasma glucose level (PGL) and coronary arteries flow velocity.

METHODS

We enrolled 149 STEMI patients successfully treated with primary percutaneous coronary intervention (pPCI). The study population was divided into two groups based on PGL (< or >140 mg/dl) and on history of diabetes, and the groups compared in terms of corrected TIMI frame count (cTFC).

RESULTS

Hyperglycemic patients had a significantly higher cTFC in both the culprit (p < 0.0001) and non-culprit vessel (p: 0.0002); diabetes history impairs as well cTFC of the culprit (p < 0.0001) and non-culprit vessel (p: 0.0001). Within the subpopulation of diabetic patients hyperglycemic ones showed higher cTFC in both the culprit (p 0.0013) and non-culprit vessel (p: 0.0006). Moreover in the whole population cTFC values of both arteries increase linearly with the increment of admission PGL.

CONCLUSIONS

Admission PGL affects coronary flow of both culprit and non-culprit vessel. The impairment of coronary flow is also demonstrated in known diabetic patients, suggesting to consider hyperglycemia an additional risk factor. We finally demonstrated for the first time a positive linear relationship between PGL and cTFC.

THE MANAGEMENT OF HYPERGLYCEMIA IN NONCRITICALLY ILL HOSPITALIZED PATIENTS TREATED WITH CONTINUOUS ENTERAL OR PARENTERAL NUTRITION

OBJECTIVE

Hyperglycemia is a common problem in hospitalized patients receiving artificial nutrition, and this development of hyperglycemia during parenteral nutrition therapy (PNT) and enteral nutrition therapy (ENT) increases the risks of hospital-related complications and mortality. This review aims to discuss the pathogenesis of hyperglycemia from artificial nutrition in the hospital, summarize current evidence on the treatment of hyperglycemia with insulin in these patients, and review current guidelines.

METHODS

A systematic literature review using PubMed and the Medical Subject Headings (MeSH) terms "hyperglycemia," "enteral nutrition," and "parenteral nutrition" were used to evaluate the current evidence available for treating noncritically ill patients with hyperglycemia who were receiving artificial nutrition.

RESULTS

The literature review showed that few randomized control trials exist regarding treatment of hyperglycemia in this cohort of patients, and the multiple retrospective evaluations that have addressed this topic provided varied results. In general, intravenous (IV) continuous insulin infusion offers the best glycemic control; however, this route of insulin administration is often burdensome for floor patients and their care teams. Administration of scheduled subcutaneous (SQ) insulin in patients on ENT or PNT is a safe and effective way to manage hyperglycemia, however limited data exist on an appropriate insulin regimen.

CONCLUSION

Further prospective, randomized control trials are necessary to determine the optimal treatment of hyperglycemia for patients receiving ENT or PNT.

ABBREVIATIONS

BG = blood glucose; CG = conventional glycemic control; ENT = enteral nutrition therapy; GIP = glucose-dependent insulinotropic polypeptide; GLP-1 = glucagon-like peptide 1; IG = intensive glycemic control; IV = intravenous; NPH = neutral protamine Hagedorn; PNT = parenteral nutrition therapy; SQ = subcutaneous; T2DM = type 2 diabetes mellitus; TDD = total daily dose; TPN = total parenteral nutrition.

Diabetes Mellitus and Cardiogenic Shock Complicating Acute Myocardial Infarction

BACKGROUND

Diabetes mellitus (diabetes) increases the risk of acute myocardial infarction, which can result in cardiogenic shock. Data on the relation of diabetes and the occurrence and prognosis of cardiogenic shock postacute myocardial infarction are scant.

METHODS

Among the National Inpatient Sample patients aged ≥18 years and hospitalized for acute myocardial infarction during the 2012-2014 period, we examined the association between diabetes and the incidence and outcomes of cardiogenic shock complicating acute myocardial infarction, using multivariable logistic and linear regression models.

RESULTS

Of 1,332,530 hospitalizations for acute myocardial infarction, 72,765 (5.5%) were complicated by cardiogenic shock. In acute myocardial infarction patients, cardiogenic shock incidence was higher among those with vs without diabetes (5.8% vs 5.2%; adjusted odds ratio [aOR] 1.14; 95% confidence interval [CI], 1.11-1.19; P < .001), with 42.8% (n = 31,135) of patients with acute myocardial infarction and cardiogenic shock having diabetes. Diabetic patients were less likely to undergo revascularization (percutaneous coronary intervention or coronary artery bypass grafting) (67.1% vs 68.7%; aOR 0.88; 95% CI, 0.80-0.96; P = .003). Diabetes was associated with higher in-hospital mortality in patients with acute myocardial infarction and cardiogenic shock (37.9% vs 36.8%; aOR 1.18; 95% CI, 1.09-1.28; P < .001). Among survivors, patients with diabetes had a longer hospital stay (mean ± SEM: 11.6 ± 0.16 vs 10.9 ± 0.16 days; adjusted estimate 1.12; 95% CI, 1.06-1.18; P < .001) and were more likely to be discharged to a skilled nursing home or with home health care (56.0% vs 50.5%; aOR 1.19; 95% CI, 1.07-1.33; P = .001).

CONCLUSIONS

In a large cohort of acute myocardial infarction patients, preexisting diabetes was associated with an increased risk of cardiogenic shock and worse outcomes in those with cardiogenic shock.

Intensified blood glucose treatment in diabetic patients undergoing a liver transplant: impact on graft evolution at 3 months and at 5 years

PURPOSE

The debate about the impact of intensified hyperglycemia treatment is still ranging. The main objective was to assess whether intensive glycemic control in hospitalized diabetic patients undergoing a liver transplant is associated with a lower rate of graft rejection at 3 months and at 5 years post-transplant.

METHODS

Cross-sectional study comparing a cohort of patients undergoing liver transplant in 2010 and 2011, in whom an intensive insulin protocol was applied, with a retrospective group of patients undergoing a liver transplant in 2005 and 2006, in whom a conventional insulin protocol was applied. Both diabetics and non-diabetics were compared. As intensive insulin therapy is applied mainly in diabetic patients, it is expected that, when comparing both periods, the treatment would only benefit those patients.

RESULTS

The logistic regression model showed a statistically significant interaction between the treatment group and the presence of diabetes for the rejection rate 3 months and 5 years post-transplant. At both time points, the intensive insulin treatment group had lower rejection rates in the case of diabetic patients, which did not occur in non-diabetic patients.

CONCLUSIONS

Our study shows a decrease in the rate of liver graft rejection in diabetic patients undergoing intensive insulin treatment.

Insulin therapy for type 2 diabetes - are we there yet? The d-Nav® story

Insulin replacement therapy is mostly used by patients with type 2 diabetes who become insulin deficient and have failed other therapeutic options. They comprise about a quarter of those with diabetes, endures the majority of the complications and consumes the majority of the resources. Adequate insulin replacement therapy can prevent complications and reduce expenses, as long as therapy goals are achieved and maintained. Sadly, these therapy goals are seldom achieved and outcomes have not improved for decades despite advances in pharmacotherapy and technology.

There is a growing recognition that the low success rate of insulin therapy results from intra-individual and inter-individual variations in insulin requirements. Total insulin requirements per day vary considerably between patients and constantly change without achieving a steady state. Thus, the key element in effective insulin therapy is unremitting and frequent dosage adjustments that can overcome those dynamics. In practice, insulin adjustments are done sporadically during outpatient clinic. Due to time constraints, providers are not able to deliver appropriate insulin dosage optimization.

The d-Nav® Insulin Guidance Service has been developed to provide appropriate insulinization in insulin users without increasing the burden on healthcare systems. It relies on dedicated clinicians and a spectrum of technological solutions. Patients are provided with a handheld device called d-Nav® which advises them what dose of insulin to administer during each injection and automatically adjust insulin dosage when needed. The d-Nav care specialists periodically follow-up with users through telephone calls and in-person consultations to bestow user confidence, correct usage errors, triage, and identify uncharacteristic clinical courses.

The following review provide details about the service and its clinical outcomes.

Diabetes: Prevalence, prognosis and management of a potent cardiovascular risk factor

This review highlights the increased risk of cardiovascular disease and the dismal prognosis after acute coronary events when diabetes is present. Although there have been improvements in this area, diabetes still confers an increased risk. In order to achieve successful outcomes in individuals with diabetes, extensive treatment of risk factors and the use of all available evidence-based therapies are needed. In this context, glucose-lowering therapies and antithrombotic and revascularisation strategies are detailed in this review. Emerging data indicate that novel glucose-lowering drugs may impact cardiovascular outcome with mechanisms that are beyond glucose control. In addition, this review addresses hidden diabetes and impaired glucose tolerance in patients with acute and stable coronary artery disease and how they influence future cardiovascular risk.

AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY POSITION STATEMENT ON TESTING FOR AUTONOMIC AND SOMATIC NERVE DYSFUNCTION

This document represents the official position of the American Association of Clinical Endocrinologists and the American College of Endocrinology. Where there were no randomized controlled trials or specific U.S. FDA labeling for issues in clinical practice, the participating clinical experts utilized their judgment and experience. Every effort was made to achieve consensus among the committee members. Position statements are meant to provide guidance, but they are not to be considered prescriptive for any individual patient and cannot replace the judgment of a clinician.