Early glucose variability in cardiogenic shock following acute myocardial infarction: a pilot study

Retrospective observational study of the association of peak blood glucose during the second 24 hours of admission with hospital-acquired complications in non-critical care admissions to a tertiary referral teaching hospital

INTRODUCTION

Stress hyperglycaemia at hospital presentation is associated with poorer outcomes. Less is known about the risk of poorer outcomes according to achieved glycaemia early in the admission.

RESEARCH DESIGN/METHODS

This was a retrospective observational study of patients admitted to non-critical care wards. The aim was to determine the relationship between the day 2 peak blood glucose and the occurrence of hospital-acquired complications (HACs) or in-hospital mortality. A Cox proportional hazards model, adjusted for relevant covariates, was used to evaluate the impact of day 2 peak glucose on HACs and in-hospital mortality, and we identified peak glucose thresholds correlating with an increase in risk.

RESULTS

For the whole cohort, day 2 peak glucose was associated with an increased risk of any HAC, aHR=1.06, 95% CI: 1.04, 1.07; but not in-hospital mortality, aHR=0.98, 95% CI: 0.94, 1.01. The risk of HAC infection increased by 4.6% for every mmol/L rise in day 2 peak glucose (aHR=1.05, 95% CI: 1.02, 1.08) in the diabetes cohort compared with 5.5% (aHR=1.06, 95% CI: 1.00, 1.11) in the non-diabetes cohort. The risk of HAC cardiac in the diabetes cohort increased by 5.3% (aHR=1.05, CI: 1.01, 1.10) per mmol/L increase in day 2 peak glucose; no association was found in the non-diabetes cohort (aHR=1.03, 95% CI: 0.94, 1.13). The risk for in-hospital mortality was associated with day 2 peak glucose, aHR=1.11, 95% CI: 1.03, 1.20, in patients without diabetes, but not in patients with diabetes, aHR=1.00, 95% CI: 0.95, 1.06. There was an increase in the risk of HAC once day 2 peak blood glucose exceeded 19.0 mmol/L (whole cohort), with thresholds of 13.6 mmol/L in the non-diabetes group and 19.5 mmol/L in the diabetes group.

CONCLUSION

The peak glucose on day 2 was a predictor of HAC in the entire cohort and in-hospital mortality in patients without diabetes.

Short-term Glycemic Variability and Its Association With Macrovascular and Microvascular Complications in Patients With Diabetes

The introduction of continuous glucose monitoring inaugurated a new era in clinical practice by shifting the characterization of glycemic control from HbA1c to novel metrics. The one that gained widespread attention over the past decades was glycemic variability (GV), which typically refers to peaks and nadirs of blood glucose measured over a given time interval. GV can be dichotomized into two main categories: short-term and long-term. Short-term GV reflects within-day and between-day glycemic oscillations, and its contribution to diabetic complications remains an enigma. In this review, we summarize the available data about short-term GV and its possible association with both microvascular and macrovascular complications, evaluating different pathogenic mechanisms and demonstrating nonpharmaceutical, as well as pharmaceutical, therapeutic interventions.

Glycemic Variability As a Prognostic Factor for Mortality in Patients With Critical Illness: A Systematic Review and Meta-Analysis

OBJECTIVES

To perform a systematic review and meta-analysis to evaluate the association of various measures of glycemic variability, including time-domain and complexity-domain, with short-term mortality in patients with critical illness.

DATA SOURCES

We searched Embase Classic +, MEDLINE, and the Cochrane Database of Systematic Reviews from inception to November 3, 2023.

STUDY SELECTION

We included English language studies that assessed metrics of glycemic variation or complexity and short-term mortality in patients admitted to the ICU.

DATA EXTRACTION

Two authors performed independent data abstraction and risk-of-bias assessments. We used a random-effects model to pool binary and continuous data and summarized estimates of effect using odds ratios and mean difference. We used the Quality in Prognosis Studies tool to assess risk of bias and the Grading of Recommendations, Assessment, Development and Evaluations to assess certainty of pooled estimates.

DATA SYNTHESIS

We included 41 studies (n = 162,259). We demonstrate that increased sd, coefficient of variance, glycemic lability index, and decreased time in range are probably associated with increased mortality in critically ill patients (moderate certainty) and that increased mean absolute glucose, mean amplitude of glycemic excursion, and detrended fluctuation analysis may be associated with increased mortality (low certainty).

CONCLUSIONS

We found a consistent association between increased measures of glycemic variability and higher short-term mortality in patient with critical illness. Further research should focus on standardized measurements of glycemic variation and complexity, along with their utility as therapeutic targets and prognostic markers.

The prognostic role of hyperglycemia and glucose variability in covid-related acute respiratory distress Syndrome

AIMS

Due to heterogeneity on the prognostic role of glucose values and glucose variability in Novel Coronavirus (COVID) disease, we aimed at assessing the prognostic role for Intensive Care Unit (ICU) death of admission hyperglycaemia, peak glycemia and glucose variability in critically ill COVID patients: METHODS: 83 patients consecutively admitted for COVID-related Acute Respiratory Distress Syndrome (ARDS) from from 1st March to 1st October 2020.

RESULTS

Non survivors were older, with more comorbidities and a more severe disease. Corticosteroids were used in the majority of patients (54/83, 65%) with no difference between survivors and non survivors. Mean blood glucose values, (during the first 24 and 48 h, respectively), were comparable between the two subgroups, as well as SD 24 and CV 24. During the first 48 h, survivors showed significantly lower values of SD 48 (p < 0.001) and CV 48, respectively (p < 0.001) than non survivors.

CONCLUSIONS

in consecutive COVID-related ARDS patients admitted to ICU hyperglycemia (>180 mg/dl) is more common in non survivors who also showed a significantly higher glucose variability in the first 48 h since ICU admission. Our findings point to the clinical significance of in-ICU glucose control in severe COVID patients.

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.

The prognostic role of peak glycemia and glucose variability in trauma: a single-center investigation

AIM

Admission hyperglycemia and glucose variability were associated with mortality in critically ill patients, but data on trauma patients are to date scarce and heterogeneous.

METHODS

We assessed the prognostic role of ICU death of admission and peak glycemia and glucose variability (indicated by the standard deviation of mean glucose levels and the coefficient of variation of glucose) in 252 patients consecutively admitted for trauma in our ICU (January 1, 2016-December 31, 2018).

RESULTS

The in-ICU mortality rate was 17% (43/252). When compared to patients who died during ICU stay, survivors were younger (p = 0.001), more frequently males (p = 0.002), with a lower incidence of hypertension (p = 0.023). Higher values of SAPS II, SOFA and ISS were observed in nonsurvivors (p < 0.001, p < 0.001, p < 0.001, respectively). Survivors exhibited significantly lower values of admission glycemia (p = 0.001), peak glycemia (p = 0.002) and mean glucose values measured during the first 24 h since ICU admission (p = 0.001). Glucose variability was significantly higher in nonsurvivors, as indicated by higher values of SD and CV (p = 0.001 and p = 0.001, respectively). At multivariate regression analysis, admission glycemia (Model 1), peak glycemia (Model 2) and glucose variability (Model 3 and 4) were independent predictors for in-ICU mortality.

CONCLUSIONS

Our findings indicate that not only admission glycemia but also peak glycemia and glucose variability show a correlation with in-ICU mortality in trauma patients.

Lactate and other biomarkers as treatment target in cardiogenic shock

PURPOSE OF REVIEW

Cardiogenic shock remains beside sudden cardiac death the most outcome relevant complication of acute myocardial infarction. Over the last two decades as confirmation of the benefit of early revascularization no further relevant improvement in outcome could be achieved. Biomarkers are important for diagnosis, monitoring, and management in cardiogenic shock patients.

RECENT FINDINGS

A bunch of different biomarkers have been associated with prognosis in patients with cardiogenic shock. In routine use standard parameters such as serum lactate or serum creatinine are still most important in monitoring these patients. These established markers outperformed novel markers in prognostic impact in recent trials.

SUMMARY

Biomarkers serve as important treatment targets and may help physicians in therapeutic decision-making. Furthermore, the complex pathophysiology of cardiogenic shock may be better understood by investigation of different biomarkers.