Impact of fasting glycemia on short-term prognosis after acute myocardial infarction

Relationship Between Fasting Glucose, HbA1c Levels, and the SYNTAX Score 2 in Patients With Non-ST-Elevation Myocardial Infarction

We evaluated if admission glycosylated hemoglobin (HbA_1c) and fasting glucose levels are correlated with the severity of coronary artery disease (CAD) in non-ST-elevation myocardial infarction (NSTEMI), nondiabetic, patients. Coronary artery disease severity, according to the anatomical synergy between percutaneous coronary intervention (PCI) with taxus and cardiac surgery (SYNTAX) score 2 (SSII), was retrospectively evaluated in 359 nondiabetic patients hospitalized with NSTEMI who underwent coronary angiography. Glucose intolerance was assessed by serum fasting glucose and HbA_1c levels. We stratified patients according to tertiles of SSII (≤21.5, 21.5-30.6, and ≥30.6). These score ranges were defined as SSII low, SSII mid, and SSII high, respectively. The average age of the patients was 57.1 ± 10.9 years; 189 (52.1%) patients were males. The average fasting glucose was 114 ± 52 mg/dL, HbA_1c was 5.8% ± 0.9%, and SSII was 18.9 ± 10.3. A stronger correlation was found between HbA_1c and SSII than fasting glucose and SSII (r1 = 0.901, P < .001, r2 = 0.378, P < .001, respectively), and HbA_1c level and hypertension were independent risk factors for SSII high (odds ratio [OR]: 2.2 (95% CI: 0.5-9.0, P < .001; OR: 1.1 (1.0-1.3), P = .007, respectively). In conclusion, in nondiabetic patients with NSTEMI, HbA_1c levels correlated with CAD severity as measured by the SSII.

Predictive value of random blood glucose versus fasting blood glucose on in-hospital adverse events in patients with ST-segment elevation acute myocardial infarction

Background

We aim to find out the relationship between random blood glucose (RBG), fasting blood glucose (FBG) and in-hospital adverse events in ST-segment elevation acute myocardial infarction (STEMI) patients. We evaluate and compare the predictive value of RBG and FBG on in-hospital adverse events, and give an appropriate cut-off value of RBG and FBG.

Method

A retrospective study enrolled 958 consecutive AMI patients undergoing emergency coronary angiography at Zhongda Hospital were enrolled from January 1, 2016, to December 31, 2018 was performed. RBG and FBG, baseline data and adverse events were recorded. Major adverse cardiovascular and cerebrovascular events (MACCE) were defined as death, nonfatal recurrent myocardial infarction and stroke. Other adverse events included malignant arrhythmia, cardiac shock and hemorrhage. Patients with RBG > 11.1 mmol/L were divided into elevated RBG group. Patients with FBG > 6.1 mmol/L were divided into elevated FBG group. The incidence of in-hospital adverse events were compared in elevated RBG/FBG group and the control group. ROC curve was used to evaluate the predictive value of RBG and FBG on in-hospital adverse events.

Result

The incidence of death, hemorrhage, cardiac shock and malignant arrhythmia significantly increases in elevated RBG and FBG group. Binary logistic regression showed that age, hypertension, diabetes, FBG and RBG were independent risk factors for in-hospital adverse events in STEMI patients. The AUC and 95% CI of RBG and FBG in predicting death of AMI patients were 0.789, 0.759~0.816; 0.810, 0.783~0.835, respectively. The cut-off values ​were 13.82 and 7.35 mmol/L. RBG and FBG also had fine predictive value on cardiac shock and malignant arrhythmia, no statistical difference was found in the predictive value on in-hospital adverse events (P = 0.462, P = 0.570, P = 0.694).

Conclusion

Incidence of in-hospital adverse events significantly increases in AMI patients combined with elevated RBG or FBG. Both RBG and FBG were independent risk factors for in-hospital adverse events, they had good value on predicting in-hospital adverse events and there was no statistical difference in their predictive value.

Hyperglycemia in Acute Coronary Syndromes: From Mechanisms to Prognostic Implications

Numerous studies have documented that hyperglycemia is frequent in patients hospitalized with acute coronary syndromes, affects patients with and without established diabetes, and is associated with adverse outcomes, with incremental increase in risk of mortality and complications observed across the spectrum of glucose elevations. This article reviews present knowledge about the association between glucose levels and outcomes of patients hospitalized with acute coronary syndromes; describes available data regarding inpatient glucose management in this patient group, and comparative data across the spectrum of critically ill hospitalized patients; addresses some controversies in this field; and offers practical recommendations for patient management based on existing data.

Detection of glucose metabolism disorders in coronary patients enrolled in cardiac rehabilitation: Is glycated haemoglobin useful? Data from the prospective REHABDIAB study

Introduction

Diabetes and pre-diabetes are highly prevalent in patients with a history of acute coronary syndrome. This is why screening for glucose metabolism disorders is recommended in patients following an acute coronary syndrome. The aim of our study was to determine whether glycated haemoglobin alone compared with the oral glucose tolerance test could allow effective screening for glucose metabolism disorders in acute coronary syndrome patients undergoing cardiac rehabilitation.

Patients and methods

Among 347 patients with a recent history of acute coronary syndrome enrolled in our cardiac rehabilitation centre, 267 patients without previously known diabetes were recruited for this prospective study with performance of both oral glucose tolerance test and glycated haemoglobin measurement. The patients were divided into three groups: newly diagnosed diabetes mellitus, pre-diabetes and normoglycaemia according to the oral glucose tolerance test and glycated haemoglobin results. The results obtained with glycated haemoglobin were compared with those obtained with the oral glucose tolerance test, considered as the reference.

Results

For the diagnosis of diabetes, glycated haemoglobin had a sensitivity of 72% and a specificity of 100%. Positive and negative predictive values were high at 100% and 96%, respectively. However, for the diagnosis of pre-diabetes the sensitivity of glycated haemoglobin was low at 64% as were the specificity (53%) and the positive predictive values (37%). Glycated haemoglobin overdiagnosed pre-diabetes (52% vs 30%, p < 0.0001). For the diagnosis of normoglycaemia, the sensitivity of glycated haemoglobin was also low (48%).

Conclusion

According to our study, glycated haemoglobin has low sensitivity and specificity for the detection of pre-diabetes in patients with coronary disease enrolled in cardiac rehabilitation, and glycated haemoglobin over-diagnoses pre-diabetes in comparison with the oral glucose tolerance test.

Fasting glucose, NT-proBNP, treatment with eptifibatide, and outcomes in non-ST-segment elevation acute coronary syndromes: An analysis from EARLY ACS

BACKGROUND

Higher N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels have been linked to a more favorable glucometabolic profile. Little is known about the interaction of NT-proBNP and fasting glucose in non-ST-segment elevation acute coronary syndrome (NSTE ACS).

METHODS

Fasting glucose and NT-proBNP were measured in 2240 patients enrolled in the EARLY ACS trial. Multivariable Cox models were used to assess associations between fasting glucose and NT-proBNP and a 96-hour composite of death, myocardial infarction (MI), recurrent ischemia, or thrombotic bailout; 30-day death or MI; and 1-year mortality.

RESULTS

In adjusted Cox models, neither NT-proBNP nor fasting glucose was associated with the 96-hour endpoint (p=0.95 and p=0.87). NT-proBNP was associated with 30-day death or MI (hazard ratio [HR] 1.11, 95% confidence interval [CI] 1.02-1.22, p=0.02) and 1-year mortality (HR 1.63, 95% CI 1.42-1.89, p<0.0001), but fasting glucose was associated only with 1-year death (HR 1.53, 95% CI 1.08-2.16, p=0.02). NT-proBNP×glucose interaction terms were non-significant in all models. As fasting glucose levels increased, the risk of 96-hour and 30-day endpoints increased among patients who received early eptifibatide but not delayed, provisional use (p_int=0.035 and p_int=0.029). Higher NT-proBNP levels were associated with greater 30-day death or MI among patients who received early eptifibatide but not delayed, provisional use (p_int=0.045).

CONCLUSION

NT-proBNP and fasting glucose concentrations were associated with intermediate-term ischemic outcomes and may identify differential response to treatment with eptifibatide. CLINICALTRIALS.

GOV IDENTIFIER

NCT00089895.

[Management of hyperglycemic/diabetic patient during and in the immediate follow-up of an acute coronary syndrome]

Two thirds of the patients hospitalized for an acute coronary syndrome (ACS) show disorders of glucose metabolism (diabetes, impaired fasting glucose, impaired glucose intolerance). Every patient hospitalized for an ACS whose HbA1c is equal or above 6.5% must be considered as diabetic. Each patient hospitalized for an ACS whose HbA1c is less than 6.5% should have measurement of plasma glucose fasting and after an oral glucose load between the 7th and the 28th day following the ACS in order to detect a disorder of glucose metabolism. During the hospitalization in cardiac intensive care unit, a treatment with insulin will be started when plasma glucose is≥1.80g/L (10.0mmol/L). In a patient with previously known diabetes, a treatment with insulin will also be started when preprandial plasma glucose is 1.40g/L (7.8mmol/L). Insulin treatment in cardiac intensive care unit will be performed by continuous IV infusion of insulin including bolus for meals. Insulin dosage will be determined according to the capillary glucose monitoring. After the hospitalization in cardiac intensive care unit, it is often possible to stop insulin treatment, which may be replaced by other antidiabetic treatments. The choice of the optimal antidiabetic treatment depends on the metabolic profile of the patient (insulin-resistance, insulin deficiency). This choice is not always easy and referral to an endocrinologist/diabetolgist may be needed. Because of the increased cardiovascular mortality associated with hypoglycemias, the long-term use of insulin or insulin-secretory agents (sulfonylureas, glinides) must be limited. During and in the immediate follow-up of an ACS, referral to an endocrinologist/diabetologist is recommended in case of diagnosis of diabetes, when HbA1c≥8%, when long-term treatment with insulin has been initiated and in case of frequent or severe hypoglycemias.

A multicenter observational study on the management of hyperglycemia in patients with acute coronary syndrome

AIM

To assess the prevalence, risk and management of hyperglycemia in patients with acute coronary syndrome (ACS).

DESIGN

a multicenter prospective observational study of a representative sample of patients with ACS consecutively admitted to intensive cardiac care units (ICCU).

SETTING

31 out of 61 ICCUs in Lombardy, the most heavily populated Italian region. From May 2009 to April 2010 1260 patients (69.4% male; mean age 68 ± 13 years) were included in the study: 301 (23.9%) were known diabetic patients (D) and 265 (21.0%) had hyperglycemia (H) (blood glucose >180 mg/dL) at hospital admission, 174 with a history of diabetes (D+H+) and 91 without (D-H+). On the first day after admission intravenous insulin infusion was prescribed to 72 D+H+ (41.4%) and 10 D-H+ (11.0%), according to different protocols. Approximately one third of D+H+ patients (59) and one fifth (17) of D-H+ maintained mean blood glucose higher than 180 mg/dL during the first day in the ICCU. Patients with diabetes or hyperglycemia had a higher incidence of major adverse cardiovascular events or death in hospital. However, at multivariable analysis neither diabetes nor blood glucose at admission was associated with a poor prognosis whereas mean blood glucose on the first day was an independent negative prognostic predictor (OR 1.010, 95% CI 1.002-1.018, p = 0.016).

CONCLUSION

Hyperglycemia is frequent in patients with ACS and is independently associated with a poor in-hospital prognosis if it persists in first day. Unfortunately, however, this condition is still poorly treated, with far from optimal blood glucose control.

Selective targeting of glucagon-like peptide-1 signalling as a novel therapeutic approach for cardiovascular disease in diabetes

Glucagon-like peptide-1 (GLP-1) is an incretin hormone whose glucose-dependent insulinotropic actions have been harnessed as a novel therapy for glycaemic control in type 2 diabetes. Although it has been known for some time that the GLP-1 receptor is expressed in the CVS where it mediates important physiological actions, it is only recently that specific cardiovascular effects of GLP-1 in the setting of diabetes have been described. GLP-1 confers indirect benefits in cardiovascular disease (CVD) under both normal and hyperglycaemic conditions via reducing established risk factors, such as hypertension, dyslipidaemia and obesity, which are markedly increased in diabetes. Emerging evidence indicates that GLP-1 also exerts direct effects on specific aspects of diabetic CVD, such as endothelial dysfunction, inflammation, angiogenesis and adverse cardiac remodelling. However, the majority of studies have employed experimental models of diabetic CVD and information on the effects of GLP-1 in the clinical setting is limited, although several large-scale trials are ongoing. It is clearly important to gain a detailed knowledge of the cardiovascular actions of GLP-1 in diabetes given the large number of patients currently receiving GLP-1-based therapies. This review will therefore discuss current understanding of the effects of GLP-1 on both cardiovascular risk factors in diabetes and direct actions on the heart and vasculature in this setting and the evidence implicating specific targeting of GLP-1 as a novel therapy for CVD in diabetes.

Physical activity and type 2 diabetes. Recommandations of the SFD (Francophone Diabetes Society) diabetes and physical activity working group

Although regular physical activity is an integral part of T2D management, few diabetic patients have a sufficient level of physical activity. However over the past decade or so, the beneficial effects of regular physical activity have been well demonstrated, both in T2D prevention (50% reduction in the incidence of T2D in subjects with high metabolic risk) as well as T2D management for the improvement of glycaemic control (mean 0.7% improvement of HbA1c) and the reduction of T2D-related comorbidities (improvement in blood pressure values and lipid profile, decrease in insulin resistance). Physical activity has both acute effects (effects of one exercise session) and more prolonged effects of exercise when it is repeated on a regular basis (training effect). In addition, the physical activity recommendations have been extended to a wide range of physical activities (by combining both endurance and muscle strengthening exercises), thus varying the physical activity practiced according to the patient's available time, practice sites, preferences and interests. Following a pathophysiology review, the effects of physical activity will be discussed and presented in terms of evidence-based medicine. The recommendations will be defined and practical prescribing information will be suggested, while taking into account that clinicians are concerned with answering questions regarding how, where and with whom: how can patients be motivated to practice a physical activity over the long-term? And how can qualified exercise trainers and appropriate practice settings be found?

Prognostic impact of hyperglycemia in nondiabetic and diabetic patients with ST-elevation myocardial infarction: insights from contrast-enhanced magnetic resonance imaging

BACKGROUND

Hyperglycemia on admission is associated with increased mortality rates in patients with ST-elevation myocardial infarction (STEMI). However, data regarding the relationship between hyperglycemia and myocardial damage in STEMI are scarce. The aim of this study was to determine the relationship of diabetes mellitus status and hyperglycemia on myocardial damage assessed by cardiovascular magnetic resonance imaging and to evaluate the long-term prognostic significance of hyperglycemia in a high-risk STEMI population.

METHODS AND RESULTS

Glucose levels were determined on admission in 411 consecutive STEMI patients reperfused by primary angioplasty. Patients were categorized on the basis of diabetes mellitus status and admission glucose level. Magnetic resonance imaging was performed for assessment of infarct size and microvascular obstruction. The primary clinical end point was the occurrence of major adverse cardiovascular events at long-term follow-up. STEMI patients with pre-existing diabetes mellitus were at greater risk for major adverse cardiovascular events (32% versus 11%; P<0.001) despite having similar infarct sizes and extent of reperfusion injury than nondiabetic patients. Glycemic status on admission was associated with greater myocardial damage and an increased risk for major adverse cardiovascular events (P<0.001). In nondiabetic patients, the risk of severe myocardial injury started to rise once admission glucose exceeded 7.8 mmol/L, whereas the threshold was higher among patients with diabetes mellitus (≥11.1 mmol/L).

CONCLUSIONS

The higher mortality rate in diabetic versus nondiabetic STEMI patients is not explained by more pronounced myocardial damage. Hyperglycemia on admission is associated with greater myocardial injury and an increased risk of major adverse cardiovascular events at long-term follow-up. However, hyperglycemia has a stronger relationship to myocardial injury in nondiabetic compared with diabetic patients.

Influence of Abnormal Fasting Plasma Glucose on Left Ventricular Function in Older Patients With Acute Myocardial Infarction

We assessed whether the admission fasting plasma glucose (FPG) levels were associated with all-cause mortality and left ventricular (LV) function in older patients with acute myocardial infarction (AMI). A total of 1854 consecutive patients were categorized into 4 groups: hypoglycemia, euglycemia, mild hyperglycemia, and severe hyperglycemia. The primary outcomes were in-hospital/3-year mortality and LV function. There was a near-linear relationship between FPG and Killip class. However, no significant correlation was found between FPG levels and LV ejection fraction. Both FPG levels and Killip classes were all independent significant predictors of mortality. Compared with the euglycemia group, both the hypo- and hyperglycemia groups were associated with higher in-hospital and 3-year mortality. In older patients with AMI, the FPG values had differential influences on LV function and mortality. There was a U-shaped relationship between FPG and in-hospital/3-year mortality, and a near-linear relationship between increased admission glucose levels and higher Killip classification.

In-hospital complications after invasive strategy for the management of Non STEMI: women fare as well as men

BACKGROUND

To analyze the in-hospital complication rate in women suffering from non-ST elevation myocardial infarction treated with percutaneous coronary intervention (PCI) compared to men.

METHODS

The files of 479 consecutive patients (133 women and 346 men) suffering from a Non STEMI (Non ST-segment elevation myocardial infarction) between the January 1st 2006 and March 21st 2009 were retrospectively analyzed with special attention to every single complication occurring during hospital stay. Data were analyzed using nonparametric tests and are reported as median unless otherwise specified. A p value < .05 was considered significant.

RESULTS

As compared to men, women were significantly older (75.8 vs. 65.2 years; p < .005). All cardiovascular risk factors but tobacco and hypertension were similar between the groups: men were noticeably more often smoker (p < .0001) and women more hypertensive (p < .005). No difference was noticed for pre-hospital cardiovascular drug treatment. However women were slightly more severe at entry (more Killip class IV; p = .0023; higher GRACE score for in-hospital death - p = .008 and CRUSADE score for bleeding - p < .0001). All the patients underwent PCI of the infarct-related artery after 24 or 48 hrs post admission without sex-related difference either for timing of PCI or primary success rate. During hospitalization, 130 complications were recorded. Though the event rate was slightly higher in women (30% vs. 26% - p = NS), no single event was significantly gender related. The logistic regression identified age and CRP concentration as the only predictive variables in the whole group. After splitting for genders, these parameters were still predictive of events in men. In women however, CRP was the only one with a borderline p value.

CONCLUSIONS

Our study does not support any gender difference for in-hospital adverse events in patients treated invasively for an acute coronary syndrome without ST-segment elevation and elevated troponin.

Influence of admission plasma glucose level on short- and long-term prognosis in patients with ST-segment elevation myocardial infarction

BACKGROUND/AIM

Hyperglicemia is common in patients with ST-elevation myocardial infarction (STEMI) and is associated with high risk of mortality and morbidity. Relationship between admission plasma glucose (APG) levels and mortality in diabetic and nondiabetic patients with STEMI needs further investigation. The aim of this study was to analyse the short- and long-term prognostic significance of APG levels in patients with STEMI with and without diabetes.

METHODS

This study included 115 patients with STEMI, 86 (74.8%) nondiabetic and 29 (25.2%) dibaetic patients, in which we performed a prospective analysis of the relationship between APG levels and short- and long-term mortality.

RESULTS

Comparison of APG levels between nondiabetic (8.32 +/- 2.4 mmol/L) and diabetic (10.09 +/- 2.5 mmol/L) patients showed statistically significantly higher average APG levels in diabetic patients (p = 0.001). In all patients observed who died either after one month or one year after STEMI, average APG values were significantly higher in comparison with those in survived patients. There was no statistical significance in average APG levels in the diabetic patients with STEMI who died after one month and those who survived (10.09 +/- 2.68 vs 10.0 +/- 2.51 mmol/L, respectively; p = 0.657), as well as those who died after one year and those who survived (10.1 +/- 1.92 vs 10.09 +/- 2.8 mmol/L, respectively; p = 0.996). There was, however, statistical significance in average APG levels in the nondiabetic patients with STEMI who died after one month and those who survived (9.97 +/- 2.97 vs 7.91 +/- 2.08 mmol/L, respectively; p = 0.001), as well as those who died after one year and those who survived (9.17 +/- 2.49 vs 7.84 +/- 2.24 mmol/L, respectively; p = 0.013).

CONCLUSION

Acute hyperglicemia in the settings of STEMI worsenes the prognosis in patients with and without diabetes. Our study showed that nondiabetic patients with high APG levels are at higher risk of mortality than patients with a known history of diabetes.

Genetic deletion or pharmacological inhibition of dipeptidyl peptidase-4 improves cardiovascular outcomes after myocardial infarction in mice

OBJECTIVE

Glucagon-like peptide-1 (7-36)amide (GLP-1) is cleaved by dipeptidyl peptidase-4 (DPP-4) to GLP-1 (9-36)amide. We examined whether chemical inhibition or genetic elimination of DPP-4 activity affects cardiovascular function in normoglycemic and diabetic mice after experimental myocardial infarction.

RESEARCH DESIGN AND METHODS

Cardiac structure and function was assessed by hemodynamic monitoring and echocardiography in DPP-4 knockout (Dpp4(-/-)) mice versus wild-type (Dpp4(+/+)) littermate controls and after left anterior descending (LAD) coronary artery ligation-induced myocardial infarction (MI). Effects of sustained DPP-4 inhibition with sitagliptin versus treatment with metformin were ascertained after experimental MI in a high-fat diet-streptozotocin model of murine diabetes. Functional recovery from ischemia-reperfusion (I/R) injury was measured in isolated hearts from Dpp4(-/-) versus Dpp4(+/+) littermates and from normoglycemic wild-type (WT) mice treated with sitagliptin or metformin. Cardioprotective signaling in the murine heart was examined by RT-PCR and Western blot analyses.

RESULTS

Dpp4(-/-) mice exhibited normal indexes of cardiac structure and function. Survival post-MI was modestly improved in normoglycemic Dpp4(-/-) mice. Increased cardiac expression of phosphorylated AKT (pAKT), pGSK3beta, and atrial natriuretic peptide (ANP) was detected in the nonischemic Dpp4(-/-) heart, and HO-1, ANP, and pGSK3beta proteins were induced in nonischemic hearts from diabetic mice treated with sitagliptin or metformin. Sitagliptin and metformin treatment of wild-type diabetic mice reduced mortality after myocardial infarction. Sitagliptin improved functional recovery after I/R injury ex vivo in WT mice with similar protection from I/R injury also manifest in hearts from Dpp4(-/-) versus Dpp4(+/+) mice.

CONCLUSIONS

Genetic disruption or chemical inhibition of DPP-4 does not impair cardiovascular function in the normoglycemic or diabetic mouse heart.

An overview of glycemic control in the coronary care unit with recommendations for clinical management

The observation that elevated glucose occurs frequently in the setting of acute myocardial infarction was made decades ago. Since then numerous studies have documented that hyperglycemia is a powerful risk factor for increased mortality and in-hospital complications in patients with acute coronary syndromes. While some questions in this field have been answered in prior investigations, many critical gaps in knowledge continue to exist and remain subjects of intense debate. This review summarizes what is known about the relationship between hyperglycemia, glucose control, and outcomes in critically ill patients with acute coronary syndromes, addresses the gaps in knowledge and controversies, and offers general recommendations regarding glucose management in the coronary care unit.

Usefulness of changes in fasting glucose during hospitalization to predict long-term mortality in patients with acute myocardial infarction

Stress hyperglycemia is a complex phenomenon that incorporates the cumulative effects of multiple factors. Rapid changes in blood glucose may reflect neurohormonal and homodynamic events that affect patient outcome. We prospectively studied the relation between changes in fasting glucose (FG) during a hospital course and long-term mortality in 1,467 nondiabetic patients with acute myocardial infarction. FG was obtained at admission and later during the hospital course and classified at each time point as normal (<100 mg/dl), impaired (100 to 125 mg/dl), or diabetic range (>or=126 mg/dl). The relation between measurements of FG and mortality (median follow-up 30 months) was assessed using Cox models. FG classification improved in 426 (29.0%) and worsened in 248 patients (16.9%) during hospitalization. Mean FG was a better predictor of mortality than baseline or final FG levels alone (C-index 0.670, 0.656, and 0.645, respectively). Changes in FG during hospitalization were strongly associated with changes in mortality risk. Compared to patients with persistent normal FG, the adjusted hazard ratio (HR) for mortality was 2.6 (95% confidence interval [CI] 1.0 to 7.2) for patients in whom FG increased to the diabetic range; the HR was 6.3 (95% CI 4.0 to 10.4) in patients with persistent FG in the diabetic range but decreased substantially when FG normalized during hospitalization (HR 2.7, 95% CI 1.3 to 5.1). In conclusion, persistent increase of FG during hospitalization for acute myocardial infarction has greater prognostic effect than baseline FG. Changes in FG during hospitalization are simple and sensitive indicators of dynamic changes in risk.

Prognostic role of the glucometabolic status assessed in a metabolically stable phase after a first acute myocardial infarction: the SHEEP study

OBJECTIVES

Our objective was to examine fasting glucose and insulin levels in patients surviving 3 months after a first AMI in relation to long-term prognosis.

DESIGN

A total of 1167 consecutive patients between 45 and 70 years with a first nonfatal AMI underwent a standardized clinical examination and were followed for a mean of 8 years for total and cardiac mortality and hospitalization for nonfatal cardiovascular disease. Impaired fasting glucose (IFG) was defined as fasting glucose between 5.6 and 7 mmol L(-1) and a level >or=7 mmol L(-1) as newly detected diabetes. Patients with a fasting glucose level <5.6 mmol L(-1) and without a history of diabetes were classified as normoglycemic (NG). An estimate of insulin resistance was calculated using the homeostasis model assessment (HOMA).

RESULTS

We recorded 219 deaths, 121 deaths from cardiac causes, during the follow-up period. After adjustment for several potential confounders, hazard ratios for total mortality were 1.36 (95% confidence interval 0.93-1.99, P=0.11), 2.27 (1.26-4.09, P=0.006) and 2.15 (1.43-3.21, P<0.001) for patients with IFG, newly detected diabetes and history of diabetes when compared to the NG group. Cardiac mortality, risk of hospitalization for recurrent nonfatal AMI, stroke or heart failure generally showed a similar pattern to that of total mortality. Insulin level and HOMA values were also associated with increased risk for recurrent events.

CONCLUSIONS

We confirmed that both known and newly detected diabetes is a strong prognostic factor in AMI. In addition, our findings suggest that glucose levels below the diabetes cut off value might also predict poor long-term prognosis when assessed in a metabolically stable phase.

[Hyperglycemia in the critically ill: meaning and treatment]

Hyperglycemia is commun in critically ill patients without previously known diabetes. Hyperglycemia occurring in these patients is mainly a consequence of stress associated to complex glucose metabolism abnormalities which have deleterious effects on tissues and vascular function. Several epidemiologic and intervention studies had established that hyperglycemia is related to morbidity and mortality. Maintenance of normoglycemia with intensive insulin therapy seems to decrease morbidity and mortalities in severe acute illnesses. However the benefit of most of these intervention trials remain controversial mainly in stroke, myocardial infarction and severe sepsis. Moreover strict normoglycemia required to obtain an optimal benefit increases the risk of hypoglycaemia which may be particularly harmful in patients in critical state.

Blood glucose and its prognostic implications in patients hospitalised with acute myocardial infarction

Elevated blood glucose and its potential link with adverse outcomes in patients with acute myocardial infarction (AMI) has been the subject of intense study over more than 40 years. The numerous observational studies performed to date have addressed some of the questions in this field, but many critically important questions are still poorly understood, and remain subjects of debate. This review summarises current epidemiological data on the prevalence of hyperglycaemia in the AMI patient population and its relationship to patient outcomes, and addresses some of the existing controversies in the field.

[The prevalence of abnormal glucose regulation after myocardial infarction: Comparative study in two French ethnic groups]

OBJECTIVES

The aim of this study was to compare the prevalence of abnormal glucose tolerance in patients stemming from two French ethnic groups and admitted for acute coronary syndrome (ACS) to intensive coronary care unit.

MATERIALS AND METHODS

During a period of six months, 53 and 60 consecutive patients were enrolled at Fort-de-France (Martinique, French West Indies, Afrocaribbeans, group F) and at Bordeaux (France, Europeans, group B), respectively. Glucometabolic state was classified according to medical history and fasting glycemia measured from the fourth day after ACS.

RESULTS

At baseline, 36% of the patients of group F and 20% of the patients of group B had previously known diabetes (p=0.06). Prevalence of hypertension was higher in Afrocaribbeans than in Europeans (60 versus 40%, p<0.05). According to fasting glycemia, newly detected diabetes were found in six Afrocaribbeans and only one was found in Europeans; two patients in group F and three patients in group B displayed impaired fasting glycemia. As a whole, 51% of Afrocaribbeans and 27% of Europeans showed abnormal glucose tolerance (p<0.05). Furthermore, Afrocaribbeans displayed lower levels of triglycerides and higher levels of HDL cholesterol than Europeans (p<0.05).

CONCLUSION

Our study suggested a higher prevalence of impaired glucose metabolism in French Afrocaribbeans than in European counterparts after ACS. Furthermore, French Afrocaribbeans displayed a more favorable lipoprotein profile. These characteristics look like that of the American and British Afrocaribbeans, maybe because of a common genetic origin.