The prognostic effect of known and newly detected type 2 diabetes in patients with acute coronary syndrome

Examining the impact of renal dysfunction and diabetes on post-myocardial infarction mortality: insights from a comprehensive retrospective cohort study across different age groups

Aim. Chronic kidney disease (CKD) and diabetes mellitus (DM) contribute significantly to cardiovascular disease (CVD) and mortality, with prevalence increasing. The evolving demographic of myocardial infarction (MI) patients, influenced by sedentary lifestyles and advanced medical care, lacks understanding regarding the interplay of CKD, DM, age, and post-MI mortality. This study aims to address this gap by evaluating the long-term impact of CKD and DM on post-MI mortality across age groups. Methods. A retrospective cohort study utilized data from the Estonian Myocardial Infarction Registry (EMIR), Estonian Population Register (EPR), and six major hospitals in Estonia, covering AMI hospitalizations from 2012 to 2019. Statistical analyses included Cox proportional hazards regression models and Kaplan-Meier's curves. Results. Analysis of 17,085 MI patients revealed age-dependent associations between renal function and mortality. In patients <65 years, even minor decreases in renal function increased both short-term (HR 2.79, 95% CI 1.71-4.55) and long-term (HR 1.24, 95% CI 1.05-1.47) mortality. Mortality significantly increased in patients >80 years only below an estimated glomerular filtration rate (eGFR) of 44 ml/min/1.73 m2. Newly diagnosed DM patients exhibited higher mortality rates (average HR 1.53, 95% CI 1.45-1.62), while pre-DM did not significantly differ from non-DM patients across all age groups. The DM-renal failure interaction did not significantly influence mortality. Conclusions. An age-dependent association between eGFR and post-MI outcomes emphasizes the need for personalized therapeutic approaches considering age-specific eGFR thresholds and comorbidities to optimize patient management.

Newly detected diabetes mellitus patients with acute coronary syndrome have an adverse cardiometabolic profile similar to patients with prior diabetes and a more extensive ischemic myocardial insult

AIMS

The impact of newly detected diabetes mellitus (NDDM) on metabolic parameters and extent of myocardial necrosis in patients with acute coronary syndrome (ACS) is not fully explored. We examined the impact of NDDM on cardiometabolic characteristics and myocardial necrosis in ACS patients.

METHODS

CALLINICUS-Hellas Registry is an ongoing prospective multicenter observational study evaluating the adherence to lipid-lowering therapy (LLT) among ACS patients in Greece. Three groups were created: a) patients with NDDM (abnormal fasting glucose, HbA1c ≥ 6.5 % and no previous history of DM), b) patients without known DM and HbA1c < 6.5 % (non-DM) and c) patients with prior DM.

RESULTS

The prevalence of NDDM among 1084 patients was 6.9 %. NDDM patients had lower HDL-C [38 (32-45) vs 42 (36-50) mg/dL] and higher triglycerides levels [144 (104-231) vs 115 (87-152) mg/dL] compared to non-DM patients (p < 0.05). NDDM patients featured both higher body mass index [29.5 (26.4-34.3) vs 27.1 (24.9-29.9) kg/m2] and waist circumference [107 (100-114) vs 98 (91-106) cm] compared to non-DM patients (p < 0.05). In addition, NDDM patients had more extensive myocardial necrosis than patients with prior DM.

CONCLUSIONS

ACS patients with NDDM have an adverse cardiometabolic profile similar to patients with prior DM and have more extensive myocardial insult.

Predictive value of bilirubin and serum γ-glutamyltranspeptidase levels in type-2 diabetes mellitus patients with acute coronary syndrome

BACKGROUND

Cardiovascular disease is a major complication of diabetes mellitus (DM). Type-2 DM (T2DM) is associated with an increased risk of cardiovascular events and mortality, while serum biomarkers may facilitate the prediction of these outcomes. Early differential diagnosis of T2DM complicated with acute coronary syndrome (ACS) plays an important role in controlling disease progression and improving safety.

AIM

To investigate the correlation of serum bilirubin and γ-glutamyltranspeptidase (γ-GGT) with major adverse cardiovascular events (MACEs) in T2DM patients with ACS.

METHODS

The clinical data of inpatients from January 2022 to December 2022 were analyzed retrospectively. According to different conditions, they were divided into the T2DM complicated with ACS group (T2DM + ACS, n = 96), simple T2DM group (T2DM, n = 85), and simple ACS group (ACS, n = 90). The clinical data and laboratory indices were compared among the three groups, and the correlations of serum total bilirubin (TBIL) levels and serum γ-GGT levels with other indices were discussed. T2DM + ACS patients received a 90-day follow-up after discharge and were divided into event (n = 15) and nonevent (n = 81) groups according to the occurrence of MACEs; Univariate and multivariate analyses were further used to screen the independent influencing factors of MACEs in patients.

RESULTS

The T2DM + ACS group showed higher γ-GGT, total cholesterol, low-density lipoprotein cholesterol (LDL-C) and glycosylated hemoglobin (HbA1c) and lower TBIL and high-density lipoprotein cholesterol levels than the T2DM and ACS groups (P < 0.05). Based on univariate analysis, the event and nonevent groups were significantly different in age (t = 3.3612, P = 0.0011), TBIL level (t = 3.0742, P = 0.0028), γ-GGT level (t = 2.6887, P = 0.0085), LDL-C level (t = 2.0816, P = 0.0401), HbA1c level (t = 2.7862, P = 0.0065) and left ventricular ejection fraction (LEVF) levels (t=3.2047, P = 0.0018). Multivariate logistic regression analysis further identified that TBIL level and LEVF level were protective factor for MACEs, and age and γ-GGT level were risk factors (P < 0.05).

CONCLUSION

Serum TBIL levels are decreased and γ-GGT levels are increased in T2DM + ACS patients, and the two indices are significantly negatively correlated. TBIL and γ-GGT are independent influencing factors for MACEs in such patients.

Effects of Prediabetes on Long-term Risk of Developing Cardiac Events in Patients Presenting With Acute Coronary Syndrome

OBJECTIVES

The aim of this work was to identify the long-term risk associated with prediabetes and developing subsequent cardiac events in patients presenting with acute coronary syndrome (ACS) at a tertiary health-care centre.

METHODS

In this retrospective cohort study, we analyzed patients admitted with ACS between January and December 2013. Two hundred thirty patients with prediabetes were matched to a comparison cohort of patients with no diabetes based on age, sex, and diagnosis code of the International Statistical Classification of Diseases and Related Health Problems---10th revision. The primary outcome was incidence of ACS readmission over a 5-year period.

RESULTS

There were 46 (20%) readmissions for ACS in the prediabetes cohort and 33 (14.3%) in the no-diabetes cohort. Univariable conditional logistic regression showed that prediabetes was not a significant risk factor for ACS readmission (odds ratio, 1.481; 95% confidence interval, 0.909 to 2.414; p=0.115). After accounting for other major risk factors for coronary disease, prediabetes was not shown to be a significant risk factor for ACS readmission (odds ratio, 1.333; 95% confidence interval, 0.795 to 2.233; p=0.276).

CONCLUSIONS

Among patients presenting with ACS, prediabetes was not associated with increased risk of readmission for subsequent cardiac events compared with patients with no diabetes after 5 years of follow-up. A longer follow-up duration is needed.

Establishment and validation of a clinical nomogram model based on serum YKL-40 to predict major adverse cardiovascular events during hospitalization in patients with acute ST-segment elevation myocardial infarction

Objective

This study aimed to investigate the predictive value of a clinical nomogram model based on serum YKL-40 for major adverse cardiovascular events (MACE) during hospitalization in patients with acute ST-segment elevation myocardial infarction (STEMI).

Methods

In this study, 295 STEMI patients from October 2020 to March 2023 in the Second People's Hospital of Hefei were randomly divided into a training group (n = 206) and a validation group (n = 89). Machine learning random forest model was used to select important variables and multivariate logistic regression was included to analyze the influencing factors of in-hospital MACE in STEMI patients; a nomogram model was constructed and the discrimination, calibration, and clinical effectiveness of the model were verified.

Results

According to the results of random forest and multivariate analysis, we identified serum YKL-40, albumin, blood glucose, hemoglobin, LVEF, and uric acid as independent predictors of in-hospital MACE in STEMI patients. Using the above parameters to establish a nomogram, the model C-index was 0.843 (95% CI: 0.79-0.897) in the training group; the model C-index was 0.863 (95% CI: 0.789-0.936) in the validation group, with good predictive power; the AUC (0.843) in the training group was greater than the TIMI risk score (0.648), p < 0.05; and the AUC (0.863) in the validation group was greater than the TIMI risk score (0.795). The calibration curve showed good predictive values and observed values of the nomogram; the DCA results showed that the graph had a high clinical application value.

Conclusion

In conclusion, we constructed and validated a nomogram based on serum YKL-40 to predict the risk of in-hospital MACE in STEMI patients. This model can provide a scientific reference for predicting the occurrence of in-hospital MACE and improving the prognosis of STEMI patients.

HbA1c-based rather than fasting plasma glucose-based definitions of prediabetes identifies high-risk patients with angiographic coronary intermediate lesions: a prospective cohort study

BACKGROUND

Prediabetes is common and associated with poor prognosis in patients with acute coronary syndrome and those undergoing revascularization. However, the impact of prediabetes on prognosis in patients with coronary intermediate lesions remains unclear. The objective of the current study is to explore the impact of prediabetes and compare the prognostic value of the different definitions of prediabetes in patients with coronary intermediate lesions.

METHODS

A total of 1532 patients attending Fuwai hospital (Beijing, China), with intermediate angiographic coronary lesions, not undergoing revascularization, were followed-up from 2013 to 2021. Patients were classified as normal glucose tolerance (NGT), prediabetes and diabetes according to various definitions based on HbA1c or admission fasting plasma glucose (FPG). The primary endpoint was defined as major adverse cardiovascular events (MACE), the composite endpoint of all-cause death, non-fatal myocardial infarction and repeated revascularization therapy. Multivariate cox regression model was used to explore the association between categories of abnormal glucose category and MACE risk.

RESULTS

The proportion of patients defined as prediabetes ranged from 3.92% to 47.06% depending on the definition used. A total of 197 MACE occurred during a median follow-up time of 6.1 years. Multivariate cox analysis showed that prediabetes according to the International Expert Committee (IEC) guideline (6.0 ≤ HbA1c < 6.5%) was associated with increased risk of MACE compared with NGT (hazard ratio [HR]: 1.705, 95% confidence interval [CI] 1.143-2.543) and after confounding adjustment (HR: 1.513, 95%CI 1.005-2.277). Consistently, the best cut-off point of glycated haemoglobin (HbA1c) identified based on the Youden's index was also 6%. Restricted cubic spline analysis delineated a linear positive relationship between baseline HbA1c and MACE risk. Globally, FPG or FPG-based definition of prediabetes was not associated with patients' outcome.

CONCLUSIONS

In this cohort of patients with intermediate coronary lesions not undergoing revascularization therapy, prediabetes based on the IEC-HbA1c definition was associated with increased MACE risk compared with NGT, and may assist in identifying high-risk patients who can benefit from early lifestyle intervention.

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.

Admission fasting plasma glucose is associated with in-hospital outcomes in patients with acute coronary syndrome and diabetes: findings from the improving Care for Cardiovascular Disease in China - Acute Coronary Syndrome (CCC-ACS) project

Background

The discrepancy between glycosylated hemoglobin (HbA_1c) and fasting plasma glucose (FPG) in clinical practice may be related to factors such as acute stress, renal dysfunction, and anemia, and its relationship with in-hospital outcomes is uncertain. The aim of this study was to investigate the association between the type of discrepancy between HbA_1c and FPG and in-hospital outcomes in patients with acute coronary syndrome (ACS) and diabetes.

Methods

The Improving Care for Cardiovascular Disease in China - Acute Coronary Syndrome (CCC-ACS) project is a national, hospital-based quality improvement project with an ongoing database. Patients with ACS, diabetes and complete HbA_1c and FPG values at admission were included. The consistent group included patients with HbA_1c < 6.5% and FPG < 7.0 mmol/L or HbA_1c ≥ 6.5% and FPG ≥ 7.0 mmol/L. The discrepancy group included patients with HbA_1c ≥ 6.5% and FPG < 7.0 mmol/L (increased HbA_1c group) or HbA_1c < 6.5% and FPG ≥ 7.0 mmol/L (increased FBG group).

Results

A total of 7762 patients were included in this study. The numbers of patients in the consistent and discrepancy groups were 5490 and 2272 respectively. In the discrepancy group, increased HbA_1c accounted for 77.5% of discrepancies, and increased FPG accounted for 22.5% of discrepancies. After adjusting for confounders, patients in the increased FPG group had a 1.6-fold increased risk of heart failure (OR, 1.62; 95% CI, 1.08–2.44), a 1.6-fold increased risk of composite cardiovascular death and heart failure (OR, 1.63; 95% CI, 1.09–2.43), and a 1.6-fold increased risk of composite major adverse cardiovascular and cerebrovascular events (MACCEs) and heart failure (OR, 1.56; 95% CI, 1.08–2.24) compared to patients in the increased HbA_1c group.

Conclusions

Patients with an increased FPG but normal HbA_1c had a higher risk of in-hospital adverse outcomes than those with increased HbA_1c but normal FPG. This result may indicate that when HbA_1c and FPG are inconsistent in patients with ACS and diabetes, the increased FPG that may be caused by stress hyperglycemia may have a more substantial adverse effect than increased HbA_1c, which may be caused by chronic hyperglycemia. These high-risk patients should be given more attention and closer monitoring in clinical practice.

Trial registry

Clinicaltrial.gov, NCT02306616. Registered 29 November 2014.

Triglyceride glucose index for predicting cardiovascular outcomes after percutaneous coronary intervention in patients with type 2 diabetes mellitus and acute coronary syndrome

BACKGROUND

The triglyceride glucose (TyG) index, a simple surrogate estimate of insulin resistance, has been demonstrated to predict cardiovascular (CV) disease morbidity and mortality in the general population and many patient cohorts. However, to our knowledge, the prognostic usefulness of the TyG index after percutaneous coronary intervention (PCI) in patients with type 2 diabetes mellitus (T2DM) and acute coronary syndrome (ACS) has not been determined. This study aimed to evaluate the association of the TyG index with adverse CV outcomes in patients with T2DM and ACS who underwent PCI.

METHODS

The TyG index was calculated using the formula ln[fasting triglycerides (mg/dL) × fasting glucose (mg/dL)/2]. The primary endpoint was the composite of all-cause mortality, non-fatal stroke, non-fatal myocardial infarction, or unplanned repeat revascularization. The association between the TyG index and adverse CV outcomes was assessed by Cox proportional hazards regression analysis.

RESULTS

In total, 776 patients with T2DM and ACS who underwent PCI (mean age, 61 ± 10 years; men, 72.2%) were included in the final analysis. Over a median follow-up of 30 months, 188 patients (24.2%) had at least 1 primary endpoint event. The follow-up incidence of the primary endpoint rose with increasing TyG index tertiles. The multivariate Cox proportional hazards regression analysis adjusted for multiple confounders revealed a hazard ratio for the primary endpoint of 2.17 (95% CI 1.45-3.24; P for trend = 0.001) when the highest and lowest TyG index tertiles were compared.

CONCLUSIONS

The TyG index was significantly and positively associated with adverse CV outcomes, suggesting that the TyG index may be a valuable predictor of adverse CV outcomes after PCI in patients with T2DM and ACS.

Low Expression of FFAR2 in Peripheral White Blood Cells May Be a Genetic Marker for Early Diagnosis of Acute Myocardial Infarction

Objective

To find molecular markers for the diagnosis of acute myocardial infarction (AMI), this research further verified the relationship between the expression level of FFAR2 gene and AMI by expanding the sample size based on the previous gene chip results.

Methods

Peripheral venous leukocytes were collected from 113 patients with AMI and 94 patients with noncoronary artery disease as the experimental group and the control group, respectively. Real-time fluorescence quantitative polymerase chain reaction was used to detect the expression of the FFAR2 gene. Western blot analysis was applied to detect the relative expression of the FFAR2 gene at the level of protein. Furthermore, the relationship between gene expression and clinical data was also analyzed and compared.

Results

The level of expression of FFAR2 gene in peripheral blood of patients with AMI was significantly lower than that of the control group (0.33 [0.04–1.08], 0.62 [0.07–1.86], respectively; p < 0.05), which was 0.53 times that of the control group. Western blot results presented that the FFAR2 protein level in the peripheral blood of the AMI group was lower than that of the control group (0.114; p=0.004). Analyzing clinical data of the subjects indicated that the average age of the AMI group was significantly higher than the age of control group (p < 0.01). Also, the fasting blood glucose level was higher (p < 0.01), and the high-density lipoprotein cholesterol (HDL-C) level was lower (p=0.03). The FFAR2 mRNA level correlated positively with the HDL-C level (p < 0.01). Logistic regression analysis suggested that the low expression of the FFAR2 gene in peripheral blood may be a risk factor for AMI independent of age, family history of diabetes, fasting blood glucose level, and HDL-C level (p=0.025). Compared with the high FFAR2 expression group, the risk of AMI in the low FFAR2 expression group was 6.308 times higher.

Conclusion

The expression level of the FFAR2 gene in peripheral blood of patients with AMI was significantly lower than that in the control group. Low expression of the FFAR2 gene in peripheral blood is an independent risk factor for AMI. Hence, it may also be a potential biomarker to predict AMI.