Utility of Glycated Hemoglobin for Assessment of Glucose Metabolism in Patients With ST-Segment Elevation Myocardial Infarction

Prevalence, clinical characteristics, and long-term outcomes of new diabetes diagnosis in elderly patients undergoing percutaneous coronary intervention

Previous studies have reported associations between newly diagnosed diabetes and poor outcomes after percutaneous coronary intervention (PCI), but there is limited data focusing on elderly patients (age ≥ 65). This study aimed to analyze the prevalence and clinical implications of newly diagnosed diabetes in elderly patients who underwent PCI. From 2004 to 2021, a total of 2456 elderly patients who underwent invasive PCI at Korea University Guro Hospital were prospectively enrolled and followed up for a median of five years. The primary endpoint was five-year major adverse cardiovascular events (MACE). Cox regression was used to evaluate whether newly diagnosed diabetes impacted on long-term clinical outcomes. Newly diagnosed diabetes was presented in approximately 8.1% to 10.9% of elderly patients who underwent PCI. Those who had a new diagnosis of diabetes had a higher risk of MACE than previously known diabetes (25.28% vs. 19.15%, p = 0.039). After adjusting for significant factors, newly diagnosed diabetes remained an independent predictor of MACE (HR [hazard ratio] 1.64, 95% confidence interval [CI] 1.24-2.17, p < 0.001), cardiac death (HR 2.15, 95% CI 1.29-3.59, p = 0.003) and repeat revascularization (HR 1.52, 95% CI 1.09-2.11, p = 0.013), but not for non-fatal myocardial infarction (HR 1.66, 95% CI 0.94-2.12, p = 0.081). Newly diagnosed diabetes was associated with an increased risk of 5-year MACE compared with non-diabetes and previously diagnosed diabetes in elderly patients underwent PCI. More attention should be given to those elderly newly diagnosed diabetes population.

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.

Stress hyperglycemia and poor outcomes in patients with ST-elevation myocardial infarction: a systematic review and meta-analysis

Background

Hyperglycemia, characterized by elevated blood glucose levels, is frequently observed in patients with acute coronary syndrome, including ST-elevation myocardial infarction (STEMI). There are conflicting sources regarding the relationship between hyperglycemia and outcomes in STEMI patients. We aimed to compile evidence to assess the association between hyperglycemia and adverse outcomes.

Methods

We conducted a comprehensive search for articles on PubMed and Embase using search strategies which yielded 4,061 articles. After full-text screening, 66 articles were included for systematic review, and 62 articles were further selected for meta-analysis.

Results

The 66 included articles spanned the years 2005-2023. Of these, 45 articles reported admission blood glucose, 13 articles used HbA1c, and 7 articles studied fasting blood glucose. Most studies defined STEMI with primary PCI as their inclusion criteria. Mortality was the most often outcome reported related to hyperglycemia. Overall, 55 (83.3%) studies were at low risk of bias. Both admission and fasting blood glucose were significantly related to short- and long-term mortality after STEMI, with a pooled risk ratio (RR) of 3.02 (95%CI: 2.65-3.45) and 4.47 (95% CI: 2.54-7.87), respectively. HbA1c showed substantial association with long-term mortality (HR 1.69, 95% CI: 1.31-2.18)) with a pooled RR of 1.58 (95% CI 1.26-1.97). In subsequent analyses, admission hyperglycemia was associated with an increased risk of reinfarction (pooled RR 1.69, 95% CI 1.31-2.17), heart failure (pooled RR 1.56, 95% CI: 1.37-1.77), cardiogenic shock (pooled RR 3.68, 95% CI 2.65-5.11), repeat PCI or stent thrombosis (pooled RR 1.99, 95% CI 1.21-3.28), and composite major adverse cardiac and cerebrovascular events (MACCE) (pooled RR 1.99, 95% CI: 1.54-2.58).

Conclusions

Our study demonstrated that hyperglycemia has a strong association with poor outcomes after STEMI. Admission and fasting blood glucose are predictors for short-term outcomes, while HbA1c is more appropriate for predicting longer-term outcomes in STEMI patients.

Systematic Review Registration

PROSPERO 2021 (CRD42021292985).

An exploratory human study investigating the influence of type 2 diabetes on macrophage phenotype after myocardial infarction

Background

Myocardial infarction (MI) is the primary cause of death in subjects with type 2 diabetes (T2D) and their in-hospital mortality after MI is still elevated compared with those without T2D. Therefore, it is of crucial importance to identify possible mechanisms of worse clinical outcomes and mortality in T2D subjects. Monocyte/macrophage-mediated immune response plays an important role in heart remodelling to limit functional deterioration after MI. Indeed, first pro-inflammatory macrophages digest damaged tissue, then anti-inflammatory macrophages become prevalent and promote tissue repair. Here, we hypothesize that the worse clinical outcomes in patients with T2D could be the consequence of a defective or a delayed polarization of macrophages toward an anti-inflammatory phenotype.

Methods and results

In an exploratory human study, circulating monocytes from male patients with or without T2D at different time-points after MI were in vitro differentiated toward pro- or anti-inflammatory macrophages. The results of this pilot study suggest that the phenotype of circulating monocytes, as well as the pro- and anti-inflammatory macrophage polarization, or the kinetics of the pro- and anti-inflammatory polarization, is not influenced by T2D.

Conclusion

Further studies will be necessary to understand the real contribution of macrophages after MI in humans.

Diabetes Mellitus in Acute Coronary Syndrome

The global prevalence of diabetes mellitus (DM) has led to a pandemic, with significant microvascular and macrovascular complications including coronary artery disease (CAD), which worsen clinical outcomes and cardiovascular prognosis. Patients with both acute coronary syndrome (ACS) and DM have worse prognosis and several pathophysiologic mechanisms have been implicated including, insulin resistance, hyperglycemia, endothelial dysfunction, platelet activation and aggregations as well as plaque characteristics and extent of coronary lesions. Therefore, regarding reperfusion strategies in the more complex anatomies coronary artery bypass surgery may be the preferred therapeutic strategy over percutaneous coronary intervention while both hyperglycemia and hypoglycemia should be avoided with closed monitoring of glycemic status during the acute phase of myocardial infraction. However, the best treatment strategy remains undefined. Non-insulin therapies, due to the low risk of hypoglycemia concurrently with the multifactorial CV protective effects, may be proved to be the best treatment option in the future. Nevertheless, evidence for the beneficial effects of glucagon like peptide-1 receptor agonists, dipeptidyl-peptidase 4 inhibitors and sodium glycose cotransporter 2 inhibitors, despite accumulating, is not robust and future randomized control trials may provide more definitive data.

Prognostic value of the prognostic nutritional index for patients with acute myocardial infarction undergoing percutaneous coronary intervention with variable glucose metabolism statuses: a retrospective cohort study

BACKGROUND

The prognostic nutritional index (PNI) and different glucose metabolisms have been separately reported to be correlated with long-term prognosis in patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI). However, PNI application in patients with an impaired glucose metabolism has not been well validated, especially in pre-diabetic patients. This study evaluated whether PNI influences a long-term risk of mortality along different glucose metabolism statuses.

METHODS

A total of 17,697 patients with AMI and a history of PCI were enrolled in this retrospective observational cohort study from January 2007 to December 2020. Three subgroups with different glucose metabolism statuses, including normal glucose regulation (NGR), pre-diabetes mellitus (pre-DM), and diabetes mellitus (DM), were divided into three groups according to the tertiles of PNI, respectively.

RESULTS

All-cause mortality occurred in 2613 (14.8%) patients within a median of 4.1 years of follow-up. Upon analyzing the Kaplan-Meier plots for the NGR, pre-DM, and DM groups, the incidence of all-cause or cardiovascular mortality in the low PNI (PNI-L, ≤ 42.7) subgroup was significantly higher than that in the median PNI (PNI-M, > 42.7 and ≤ 48.2) and high PNI (PNI-H, > 48.2) subgroups (all, P < 0.001). After adjusting for confounding factors, the hazard ratio (HR) for all-cause mortality in the PNI-L group significantly increased compared to that in the PNI-H subgroups of the NGR group (HR, 1.35; 95% CI 1.14-1.66; P < 0.001), pre-DM group (HR, 1.29; 95% CI 1.02-1.62; P < 0.001), and DM group (HR, 1.36; 95% CI 1.13-1.63; P < 0.001). Given that there was evidence of interactions between PNI and different glucose statuses (P for interaction < 0.001), patients were divided into nine subgroups, and we found that DM patients with PNI-L statuses had the highest risk of all-cause mortality compared to NGR patients with PNI-H statuses (HR, 1.69; 95% CI 1.42-2.01; P < 0.001).

CONCLUSION

Lower PNI is a significant and independent risk factor for all-cause mortality in AMI patients undergoing PCI with different glucose metabolism statuses, and this risk further increases with DM compared to NGR or pre-DM statuses.

Outcomes of Prediabetes Compared with Normoglycaemia and Diabetes Mellitus in Patients Undergoing Percutaneous Coronary Intervention: A Systematic Review and Meta-analysis

Background: Patients with prediabetes are at increased risk of coronary artery disease (CAD). However, the association between prediabetes and adverse clinical outcomes following percutaneous coronary intervention (PCI) is inconsistent, in contrast to outcomes in patients with diabetes mellitus (DM). Thus, this meta-analysis evaluated the impact of dysglycaemia on PCI outcomes. Methods: The PubMed, Embase, Cochrane, and ClinicalTrials.gov databases were systematically reviewed from inception of databases until June 2022. In 17 studies, outcomes of PCI in patients with prediabetes were compared with patients who were normoglycaemic, and patients with DM. The primary outcome was all-cause mortality at the longest follow-up. Results: Included were 12 prospective and five retrospective studies, with 11,868, 14,894 and 13,536 patients undergoing PCI in the prediabetes, normoglycaemic and DM groups, respectively. Normoglycaemic patients had a statistically lower risk of all-cause mortality, (risk ratio [RR] 0.66, 95% confidence interval [CI] 0.52-0.84), myocardial infarction (MI; RR 0.76, 95% CI 0.61-0.95) and cardiac mortality (RR 0.58, 95% CI 0.39-0.87) compared with prediabetic patients undergoing PCI at the longest follow-up. Patients with prediabetes had a lower risk of all-cause mortality (RR=0.72 [95% CI 0.53-0.97]) and cardiac mortality (RR =0.47 [95% CI 0.23-0.93]) compared with patients with DM who underwent PCI. Conclusion: Among patients who underwent PCI for CAD, the risk of all-cause and cardiac mortality, major adverse cardiovascular events and MI in prediabetic patients was higher compared with normoglycaemic patients but lower compared with patients with DM.

The Profile of Glucose Lowering Therapy in Persons with Type 2 Diabetes Mellitus in an Aging Russian Population

We aimed to analyze the profile of glucose lowering therapy (GLT) in persons with diabetes mellitus type 2 (DM2) in an aging Russian population. A random population sample (n = 3898, men/women, 55−84) was examined in Novosibirsk, during 2015−2018 (HAPIEE Project). The design of the present work is a cross-sectional study. DM2 was defined in those with a history of DM2 receiving GLT, or at a level of fasting plasma glucose (FPG) ≥7.0 mmol/L. The entire DM2 group was included in the analysis (n = 803); of these, 476 persons were taking GLT and were included in the analysis at stage 2. Regular GLT medication intake for 12 months was coded with ATC. In studied sample, the prevalence of DM2 was 20.8%. Among subjects with DM2, 59% of individuals received GLT, 32% did not. Glycemic control (FPG < 7.0 mmol/L) was achieved in every fifth participant with DM2 (35% in those receiving GLT). In frequency of GLT use, biguanides ranked in first place (75%), sulfonylurea derivatives in second (35%), insulins in third (12%), and iDPP-4 in fourth (5%). Among those receiving GLT, 24% used combined oral therapy, and 6% used insulin-combined therapy. In conclusion, in a population sample aged 55−84 examined in 2015−2018, glycemic control was achieved in every fifth participant with DM2, and in every third participant receiving GLT. The proportion of participants using new GLT drugs was small, and there was a lack of HbA1c monitoring for intensive glycemic control.

Undiagnosed Impaired Glucose Tolerance and Type-2 Diabetes in Acute Myocardial Infarction Patients: Fequency, Characteristics and Long-Term Mortality

Background

In this study we investigated the prevalence of undiagnosed impaired glucose tolerance and type-2-diabetes (T2D) among patients with acute myocardial infarction (AMI) and prospectively analyzed whether these patients have a higher long-term mortality.

Methods

The analysis was based on 2,317 AMI patients aged 25–84 years from the population-based Myocardial Infarction Registry Augsburg, recruited between 2009 and 2014 and followed-up until 2019 (median follow-up time 6.5 years [IQR: 4.9–8.1]). AMI patients with a diagnosis of diabetes were divided into a high (>7.0%) and a low HbA1c group (≤7.0%) according to HbA1c values at admission. The remaining patients (without known diabetes) were grouped into normal (<5.7%), elevated (5.7–6.4%), and high (≥6.5%) HbA1c groups. In a multivariable-adjusted COX regression analysis, the association between HbA1c groups and long-term mortality was investigated. Linear regression models were used to identify AMI patients with elevated HbA1c values by means of personal characteristics.

Results

At admission, 29.5% of all patients reported a diagnosis of diabetes. Of all patients without known diabetes, 5.4% had HbA1c values of ≥ 6.5 and 37.9% had HbA1c values between 5.7 and 6.4%. The fully adjusted Cox regression model showed a non-significant trend toward higher long-term mortality for AMI patients with increased HbA1c values (HbA1c 5.7–6.4% HR: 1.05 [0.79–1.38], HbA1c > 6.5% HR: 1.34 [0.77–2.31]). A linear regression model including the variables admission serum glucose, BMI, age, sex and type of infarction (STEMI, NSTEMI) showed only poor prediction of HbA1c values (R²: 11.08%).

Conclusion

A fairly high number of AMI patients without known diabetes have elevated HbA1c values. Though we could not prove a higher risk of premature mortality in these patients, early detection and adequate therapy might lead to reduced diabetes-associated complications and improve long-term outcomes.

Postload glucose spike but not fasting glucose determines prognosis after myocardial infarction in patients without known or newly diagnosed diabetes

BACKGROUND

The effect of postload glucose spikes (PGS), the difference between 2 hour post-load plasma glucose (2hPLPG) and fasting plasma glucose (FPG), on post-myocardial infarction (post-MI) prognosis in nondiabetic patients is unexplored.

METHODS

This is a retrospective cohort analysis of 847 nondiabetic post-MI survivors who underwent a predischarge oral glucose tolerance test (median PGS: 2.4 mmol/L). Patients were divided into the unmatched groups 1 and 2 (PGS ≤ and > 2.4 mmol/L) and the propensity score-matched groups 1M and 2M (355 pairs assembled from the overall cohort), and these groups were compared. Major adverse cardiac events (MACE: death and nonfatal reinfarction) were recorded during follow-up (median: 3.4 years). Event-free survival was compared by the Kaplan-Meier method. Multivariate Cox proportional hazards regression determined the predictors of MACE. C-statistics (change in area under the curve, δAUC), continuous net reclassification improvement (NRI^>0 ), and integrated discrimination improvement (IDI) were used to compare models.

RESULTS

The number of MACE was higher in groups 2 (27.3% vs 14.2%, P < .001) and 2M (24.5% vs 15.5%, P < .001). Event-free survival was worse in groups 2 (hazard ratio [HR] 2.01; 95% CI, 1.49-2.71; P < .001) and 2M (HR 1.63; 95% CI, 1.17-2.27; P = .004). PGS independently predicted MACE-free survival in the whole (HR 1.16; 95% CI, 1.06-1.26; P = .002) and matched cohort (HR 1.12; 95% CI, 1.02-1.24; P = .021). PGS, but not FPG or 2hPPG, improved the predictive performance of the base model (δAUC 0.013, P = .046), with greater improvement seen when PGS was added and compared to 2hPPG (δAUC 0.005, P = .034; NRI^>0 0.2107, P = .013; IDI 0.0042, P = .046).

CONCLUSION

PGS is a better predictor of post-MI prognosis than 2hPPG in nondiabetic patients.

Prognostic significance of the hemoglobin A1c level in non-diabetic patients undergoing percutaneous coronary intervention: a meta-analysis

Background

The predictive value of hemoglobin A1c (HbA1c) levels in non-diabetic patients with myocardial infarction undergoing percutaneous coronary intervention (PCI) is still controversial. This study aimed to evaluate whether HbA1c levels were independently associated with adverse clinical outcomes in non-diabetic patients with coronary artery disease (CAD) who had undergone PCI by performing a meta-analysis of cohort studies.

Methods

This meta-analysis included non-diabetic patients with CAD who had undergone PCI. A systematic search for publications listed in the PubMed, Embase, and Cochrane Library databases from commencement to December 2018 was conducted. Studies evaluating the adverse clinical outcomes according to abnormal HbA1c levels in non-diabetic patients diagnosed with CAD who had undergone PCI were eligible. The primary outcomes were long-term all-cause deaths and long-term major adverse cardiac events, and the secondary outcome was short-term all-cause deaths. The meta-analysis was conducted with RevMan 5.3 and Stata software 14.0. Odds ratios (ORs) were pooled using a random or fixed-effects model, depending on the heterogeneity of the included studies. Sub-group analysis or sensitivity analysis was conducted to explore potential sources of heterogeneity, when necessary.

Results

Six prospective cohort studies involving 10,721 patients met the inclusion criteria. From the pooled analysis, abnormal HbA1c levels were associated with increased risk for long-term all-cause death (OR 1.39, 95% confidence interval [CI] 1.16–1.68, P = 0.001, I² = 45%). Sub-group analysis suggested that abnormal HbA1c levels between 6.0% and 6.5% predicted higher long-term major adverse cardiac event (including all-cause deaths, non-fatal myocardial infarction, target lesion revascularization, target vessel revascularization, recurrent acute myocardial infarction, heart failure requiring hospitalization, and stent thrombosis) risk (OR 2.05, 95% CI 1.46–2.87, P < 0.001, I² = 0). Contrarily, elevated HbA1c levels were not associated with increased risk of short-term all-cause death (OR 1.16, 95% CI 0.88–1.54, P = 0.300, I² = 0).

Conclusions

An abnormal HbA1c level is an independent risk factor for long-term adverse clinical events in non-diabetic patients with CAD after PCI. Strict control of HbA1c levels may improve patient survival. Further studies in different countries and prospective cohort studies with a large sample size are required to verify the association.

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.

Three-year clinical outcome in all-comers with "silent" diabetes, prediabetes, or normoglycemia, treated with contemporary coronary drug-eluting stents: From the BIO-RESORT Silent Diabetes study

BACKGROUND

Patients with coronary disease may have unknown diabetes or prediabetes. We evaluated 3-year outcomes after percutaneous coronary intervention (PCI) with contemporary drug-eluting stents (DES) in patients with silent diabetes, prediabetes, and normoglycemia.

METHODS

All BIO-RESORT trial (NCT01674803) participants without known diabetes, enrolled at our center, were invited for oral glucose tolerance testing (OGTT) and measurements of fasting plasma glucose and glycated hemoglobin (HbA1c).

RESULTS

OGTT detected silent diabetes in 68 (6.9%), prediabetes in 132 (13.4%), and normoglycemia in 788 (79.8%) of all 988 study participants. Follow-up was available in 986 (99.8%) patients. The main endpoint target vessel failure (TVF: cardiac death, target vessel-related myocardial infarction [MI], or target vessel revascularization) differed between groups (14.8, 9.9, and 5.6%; p = .002), driven by MI during the first 48 hr and by cardiac death (p < .001; p = .026). Between 48 hr and 3-years, there was no significant between-group difference in TVF, target vessel MI, and target vessel revascularization. Multivariable analysis demonstrated that silent diabetes was independently associated with TVF (adjusted HR: 2.52, 95%-CI: 1.26-5.03). An alternative diagnostic approach-HbA1c and fasting plasma glucose-detected silent diabetes and prediabetes in 33 (3.3%) and 217 (22.0%) patients, and normoglycemia in 738 (74.7%); TVF rates were 12.1, 7.9, and 6.0% (p = .23).

CONCLUSION

In patients without known diabetes, abnormal glucose metabolism by OGTT was independently associated with higher 3-year TVF rates after PCI with contemporary DES. This difference was driven by periprocedural MI and cardiac death. After the first 48 hr, the rates of TVF, target vessel MI, and target vessel revascularization were low and did not differ significantly between metabolic groups.

Newly Discovered Abnormal Glucose Tolerance in Patients With Acute Myocardial Infarction and Cardiovascular Outcomes: A Meta-analysis

BACKGROUND

The prevalence of unrecognized abnormal glucose tolerance (AGT) and the incidence of recurrent cardiovascular (CV) events in patients with acute myocardial infarction (MI) has not been systematically evaluated.

PURPOSE

The purposes of this study were to define the prevalence of newly discovered AGT and examine the risk of recurrent major adverse cardiac events (MACE) and mortality in patients with acute MI.

DATA SOURCES

Medline, Embase, Cochrane Library, and Google Scholar were searched for relevant articles.

STUDY SELECTION

Inclusion criteria included prospective studies in patients with acute MI without known history of diabetes; AGT diagnosed using fasting plasma glucose, 2-h oral glucose tolerance test, or HbA_1c; and incidence of MACE and/or all-cause mortality in newly discovered AGT.

DATA EXTRACTION

Two investigators extracted the data. Pooled prevalence, incidence rate ratios, and hazard ratios (HRs) were calculated using random-effects models.

DATA SYNTHESIS

In 19 studies (n = 41,509, median follow-up 3.1 years), prevalence of newly discovered AGT was 48.4% (95% CI 40.2-56.6). Prediabetes had a higher mortality risk than normal glucose tolerance (NGT) (HR 1.36 [95% CI 1.13-1.63], P < 0.001) and MACE (1.42 [1.20-1.68], P < 0.001). Newly diagnosed diabetes had higher mortality risk than NGT (1.74 [1.48-2.05], P < 0.001) and MACE (1.54 [1.23-1.93], P < 0.001).

LIMITATIONS

This is not a meta-analysis of individual patient data. Time-to-event analysis and covariate-adjusted analysis cannot be conducted to examine heterogeneity reliably. Few studies reported CV death and heart failure hospitalizations.

CONCLUSIONS

Patients with acute MI have a high prevalence of newly discovered AGT. Aggressive risk reduction strategies in this population, especially in those with prediabetes, are warranted.

Effects of prediabetes on long-term clinical outcomes of patients with acute myocardial infarction who underwent PCI using new-generation drug-eluting stents

AIMS

We investigated the 2-year clinical outcomes of patients with acute myocardial infarction (AMI) and prediabetes after new-generation drug-eluting stents implantation.

METHODS

A total of 11,962 patients with AMI were classified into normoglycemia (group A; 3,080), prediabetes (group B; 3,709), and diabetes (group C; 5,173) groups. The primary outcomes were the patient-oriented composite outcomes (POCOs) defined as all-cause death, recurrent myocardial infarction (Re-MI), and any repeat revascularization. Secondary outcomes were the individual components of POCOs and stent thrombosis (ST).

RESULTS

POCOs in groups B and C were significantly higher than those in group A. Cardiac death (adjusted hazard ratio [aHR]: 1.957, 95% confidence interval [CI]: 1.126-3.402; p = 0.017) and any repeat revascularization (aHR: 1.597, 95% CI: 1.052-2.424; p = 0.028) rates were significantly higher in group B than in group A. Re-MI (aHR: 1.884, 95% CI: 1.201-2.954; p = 0.006) and death or MI (aHR: 1.438, 95% CI: 1.098-1.884; p = 0.008) were significantly higher in group C than in group B.

CONCLUSIONS

In this study, prediabetes showed bad clinical outcomes post AMI. However, larger randomized controlled studies including ethnically diverse population are needed to confirm these harmful cardiovascular effects of prediabetes in the future.

Diabetes and Mortality in Acute Coronary Syndrome: Findings from the Gulf COAST Registry

BACKGROUND

The prevalence of traditional risk factors such as diabetes mellitus (DM) and obesity are increasing in patients with acute coronary syndrome (ACS). Furthermore, outcomes after ACS are worse in patients with DM. The high prevalence of DM and an early age at onset of ACS have been described in prior publications from the Gulf Coast Database.

AIMS

We aimed to define the effect of DM on total mortality following ACS presentation at 30-days and 1 year based on the Gulf COAST registry database.

METHODS

The Gulf COAST registry is a prospective, multinational, longitudinal, observational cohort study conducted among Gulf citizens admitted with a diagnosis of ACS. The outcomes among patients with DM following ACS were stratified into 2 groups based on their DM status. Cumulative survival stratified by groups and subgroup categories was assessed by the Kaplan-Meier method.

RESULTS

Of 3,576 ACS patients, 2,730 (76.3%) presented with non ST-segment elevation myocardial infarction (NSTEMI) and 846 (23.6%) with STEMI. Overall, 1906 patients (53.3%) had DM. A significantly higher in-hospital (4.8%), 30-day (6.7%) and 1-year (13.7%) mortality were observed in patients with DM compared with those without DM. The Kaplan-Meier survival curve showed significant differences in survival of ACS patients with or without DM, with a short period of time-to-event for DM patients with STEMI (30-days) and the longest (1-year) for NSTEMI patients without DM.

CONCLUSION

DM patients presenting with ACS-STEMI have poor short-term outcomes while DMNSTEMI patients have poor long-term outcomes. This highlights the need for strategies to evaluate DM control and integration of care to control vascular risk among this high-risk population.

Prognostic value of HbA1c for in-hospital and short-term mortality in patients with acute coronary syndrome: a systematic review and meta-analysis

Background

HbA1c, the most commonly used indicator of chronic glucose metabolism, is closely associated with cardiovascular disease. However, the relationship between HbA1c and the mortality of acute coronary syndrome (ACS) patients has not been elucidated yet. Here, we aim to conduct a systematic review assessing the effect of HbA1c on in-hospital and short-term mortality in ACS patients.

Methods

Relevant studies reported before July 2019 were retrieved from databases including PubMed, Embase, and Central. Pooled relative risks (RRs) and the corresponding 95% confidence interval (CI) were calculated to evaluate the predictive value of HbA1c for the in-hospital mortality and short-term mortality.

Results

Data from 25 studies involving 304,253 ACS patients was included in systematic review. The pooled RR of in-hospital mortality was 1.246 (95% CI 1.113–1.396, p: 0.000, I² = 48.6%, n = 14) after sensitivity analysis in studies reporting HbA1c as categorial valuable. The pooled RR was 1.042 (95% CI 0.904–1.202, p: 0.57, I² = 82.7%, n = 4) in random-effects model for studies reporting it as continuous valuable. Subgroup analysis by diabetic status showed that elevated HbA1c is associated increased short-term mortality in ACS patients without diabetes mellitus (DM) history and without DM (RR: 2.31, 95% CI (1.81–2.94), p = 0.000, I² = 0.0%, n = 5; RR: 2.56, 95% CI 1.38–4.74, p = 0.003, I² = 0.0%, n = 2, respectively), which was not the case for patients with DM and patients from studies incorporating DM and non-DM individuals (RR: 1.16, 95% CI 0.79–1.69, p = 0.451, I² = 31.9%, n = 3; RR: 1.10, 95% CI 0.51–2.38), p = 0.809, I² = 47.4%, n = 4, respectively).

Conclusions

Higher HbA1c is a potential indicator for in-hospital death in ACS patients as well as a predictor for short-term mortality in ACS patients without known DM and without DM.

Pre-diabetes mellitus newly diagnosed after myocardial infarction adversely affects prognosis in patients without known diabetes

BACKGROUND

Effect of pre-diabetes mellitus on post-myocardial infarction prognosis is unclear.

METHODS

Retrospective cohort analysis of 1056 myocardial infarction survivors with fasting plasma glucose and 2-h post-load plasma glucose measured. Major adverse cardiovascular events included death, non-fatal reinfarction and ischaemic stroke. Cox proportional hazard regression identified predictors of event-free survival. Continuous net reclassification improvement and integrated discrimination improvement determined the added predictive value of glycaemic indices.

RESULTS

Major adverse cardiovascular events occurred in 25.1% and 16.4% patients with and without pre-diabetes mellitus (hazard ratio with pre-diabetes mellitus: 1.56; 95% confidence interval: 1.17-2.08; p = 0.003) in the whole cohort and in 24.1% and 17.2% patients (hazard ratio with pre-diabetes mellitus, 1.43; 95% confidence interval: 1.03-1.98; p = 0.033) in the matched cohort, respectively. Pre-diabetes mellitus predicted major adverse cardiovascular events-free survival in whole (hazard ratio: 1.39; 95% confidence interval: 1.03-1.89; p = 0.033) and matched cohorts (hazard ratio: 1.42; 95% confidence interval: 1.01-1.99; p = 0.043). The 2-h post-load plasma glucose, but not fasting plasma glucose, predicted major adverse cardiovascular events-free survival in the whole (hazard ratio: 1.16; 95% confidence interval: 1.07-1.26; p < 0.0001) and matched cohorts (hazard ratio: 1.20; 95% confidence interval: 1.09-1.31; p < 0.0001). Adding 2-h post-load plasma glucose to models containing fasting plasma glucose, significantly improved net reclassification improvement and integrated discrimination improvement for both cohorts, but not vice versa.

CONCLUSION

Pre-diabetes mellitus predicts major adverse cardiovascular events after myocardial infarction. The 2-h post-load plasma glucose predicts prognosis better than fasting plasma glucose in these patients.

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.

Two-hour post-challenge glucose is a better predictor of adverse outcome after myocardial infarction than fasting or admission glucose in patients without diabetes

AIMS

We evaluate prevalence of new abnormal glucose tolerance (AGT) in post-MI survivors without known diabetes (DM) if guidelines are followed and compare the ability of admission (APG), fasting (FPG) and 2-h post-load plasma glucose (2h-PG) to predict prognosis.

METHODS

A total of 674 patients were followed up for 4 years for incidence of major adverse cardiovascular events (MACE) of cardiovascular death, non-fatal re-infarction or non-haemorrhagic stroke. Ability of models including APG, FPG and 2h-PG to predict MACE was compared.

RESULTS

Of the total, 93-96% of impaired glucose tolerance and 64-75% of DM would be missed with current guidelines. MACE was higher in the upper quartiles of 2h-PG. When 2h-PG and FPG were included simultaneously in models, only 2h-PG predicted MACE (HR 1.12, CI 1.04-1.20, p = 0.0012), all cause mortality (HR 1.17, CI 1.05-1.30, p = 0.0039), cardiovascular mortality (HR 1.17, CI 1.02-1.33, p = 0.0205) and non-fatal MI (HR 1.10, CI 1.01-1.20, p = 0.0291). Adding 2h-PG significantly improved ability of models including FPG (χ² = 16.01, df = 1, p = 0.0001) or FPG and APG (χ² = 17.36, df = 1, p = 0.000) to predict MACE. Model including 2h-PG only had the lowest Akaike's information criteria and highest Akaike weights suggesting that this was the best in predicting events. Adding 2h-PG to models including FPG or APG with other co-variates yielded continuous net reclassification improvement (NRI) of 0.22 (p = 0.026) and 0.27 (p = 0.005) and categorical NRI of 0.09 (p = 0.032) and 0.12 (p = 0.014), respectively. Adding 2 h-PG to models including only FPG, only APG and both yielded integrated discrimination improvement of 0.012 (p = 0.015), 0.022 (p = 0.001) and 0.013 (p = 0.014), respectively.

CONCLUSIONS

AGT is under-diagnosed on current guidelines. 2h-PG is a better predictor of prognosis compared to APG and FPG.

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.

Relationship between diabetes and ischaemic injury among patients with revascularized ST-elevation myocardial infarction

AIMS

Studies comparing reperfusion efficacy and myocardial damage between diabetic and non-diabetic patients with ST-elevation myocardial infarction (STEMI) are scarce and have reported conflicting results. The aim was to investigate the impact of preadmission diabetic status on myocardial salvage and damage as determined by cardiac magnetic resonance (CMR), and to evaluate its prognostic relevance.

MATERIALS AND METHODS

We enrolled 792 patients with STEMI at 8 sites. CMR core laboratory analysis was performed to determine infarct characteristics. Major adverse cardiac events (MACE), defined as a composite of all-cause death, non-fatal re-infarction and new congestive heart failure, were recorded at 12 months. Patients were categorized according to preexisting diabetes mellitus (DM), and according to insulin-treated DM (ITDM) and non-insulin-treated DM (NITDM).

RESULTS

One-hundred and sixty (20%) patients had DM and 74 (9%) were insulin-treated. There was no difference in the myocardial salvage index, infarct size, microvascular obstruction and left ventricular ejection fraction between all patient groups (all P > .05). Patients with DM were at higher risk of MACE (11% vs 6%, P = .03) than non-DM patients. After stratification according to preadmission anti-diabetic therapy, MACE rate was comparable between NITDM and non-DM (P > .05), whereas the group of ITDM patients had significantly worse outcome (P < .001).

CONCLUSIONS

Diabetic patients with STEMI, especially those having ITDM, had an increased risk of MACE. The adverse clinical outcome was, however, not explained by an impact of DM on reperfusion success or myocardial damage. Clinical trial registry number: NCT00712101.

Glycosylated hemoglobin levels and clinical outcomes in nondiabetic patients with coronary artery disease: A meta-analysis

A number of studies assessed the prognostic value of HbA1c level in nondiabetic patients with coronary artery disease (CAD). The purpose of this meta-analysis was to assess the association between the HbA1c level and clinical outcomes.We searched PubMed, EMBASE, MEDLINE, and the Cochrane Library from their inception to 10 April 2016. Studies evaluated the outcomes according to HbA1c levels in CAD patients without diabetes mellitus were eligible.Twenty studies involving 22,428 patients were included. In nondiabetic patients with CAD, a high HbA1c level was associated with a higher rate of long-term death (odds ratio 1.76, 95% confidence interval 1.44-2.16, P < .001), and myocardial infarction (MI, odds ratio 1.69, 95% confidence interval 1.07-2.67, P = .026), but not a higher rate of early deaths (odds ratio 1.08, 95% confidence interval 0.92-1.27, P = .359). These findings for death remained the same after sensitivity analyses and the trim and fill method, but the risk difference for MI became nonsignificant after adjustment for potential publication bias.Elevated HbA1c level increased the risks of long-term mortality and MI, but not the risk for early deaths in nondiabetic patients with CAD. High-quality large-scale studies with less bias are needed to confirm these findings.

Impact of prior permanent pacemaker on long-term clinical outcomes of patients undergoing percutaneous coronary intervention

BACKGROUND

The impact of permanent pacemaker (PPM) on long-term clinical outcomes of patients undergoing percutaneous coronary intervention (PCI) has not been studied.

HYPOTHESIS

PPM may increase heart failure (HF) burden on patients undergoing PCI.

METHODS

We recruited consecutive patients undergoing PCI and carried out a nested case-control study. Patients with confirmed PPM undergoing first PCI were identified and matched by age and sex in 1:1 fashion to patients without PPM undergoing first PCI. Clinical data were collected and analyzed. The primary endpoint outcomes were all-cause mortality and hospitalization for HF.

RESULTS

The final analysis included 156 patients. The mean follow-up period was 4.6 ± 2.9 years. The overall all-cause mortality was 21.15%, without significant difference between the 2 groups (21.79% vs 20.51%; P = 0.85). However, the rate of HF-related hospitalization was significantly higher in patients with PPM than in controls (26.92% vs 10.26%; P = 0.008). After adjustment for hypertension, type 2 diabetes mellitus, hyperlipidemia, chronic kidney disease, stroke, left ventricular ejection fraction, brain natriuretic peptide, and acute coronary syndrome (ACS), PCI patients with PPM were still associated with a greater hospitalization rate for HF (odds ratio: 4.31, 95% confidence interval: 0.94-19.80, P = 0.061). Further analysis in the ACS subgroup showed VVI-mode pacing enhanced the risk for HF-associated hospitalization (adjusted odds ratio: 8.27, 95% confidence interval: 1.37-49.75, P = 0.02).

CONCLUSIONS

PPM has no effect on all-cause mortality in patients undergoing first PCI but significantly increases the HF-associated hospitalization rate, especially in ACS patients.

Two-year prognosis of admission hemoglobin A1c following a primary percutaneous coronary intervention

OBJECTIVE

We sought to assess the effect of hemoglobin A1c (HbA1c) on the outcomes of a primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI).

BACKGROUND

Many studies have shown the diagnostic and predictive value of HbA1c levels in patients with acute myocardial infarction. We assessed the prognostic role of HbA1c in short-term and long-term mortality in 796 consecutive patients with STEMI.

METHODS AND RESULTS

A total of 796 patients with STEMI undergoing primary PCI were prospectively enrolled between December 2013 and June 2015. The patients were divided into three groups on the basis of admission HbA1c levels: group I (HbA1c≤5.6%), group II (HbA1c 5.7-6.4%), and group III (HbA1c≥6.5%). The in-hospital and 2-year cardiovascular (CV) mortality and morbidity of all three patient groups were followed up. A significant association was found between HbA1c level and 2-year primary clinical outcomes, including CV mortality, heart failure/shock, and major adverse cardiovascular event (P<0.001).

CONCLUSION

HbA1c is an independent predictor of the in-hospital and long-term mortality, nonfatal reinfarction, and target vessel revascularization in STEMI patients treated with primary PCI.

Update on pre-diabetes: Focus on diagnostic criteria and cardiovascular risk

Pre-diabetes, which is typically defined as blood glucose concentrations higher than normal but lower than the diabetes threshold, is a high-risk state for diabetes and cardiovascular disease development. As such, it represents three groups of individuals: Those with impaired fasting glucose (IFG), those with impaired glucose tolerance (IGT) and those with a glycated haemoglobin (HbA_1c) between 39-46 mmol/mol. Several clinical trials have shown the important role of IFG, IGT and HbA_1c-pre-diabetes as predictive tools for the risk of developing type 2 diabetes. Moreover, with regard to cardiovascular disease, pre-diabetes is associated with more advanced vascular damage compared with normoglycaemia, independently of confounding factors. In view of these observations, diagnosis of pre-diabetes is mandatory to prevent or delay the development of the disease and its complications; however, a number of previous studies reported that the concordance between pre-diabetes diagnoses made by IFG, IGT or HbA_1c is scarce and there are conflicting data as to which of these methods best predicts cardiovascular disease. This review highlights recent studies and current controversies in the field. In consideration of the expected increased use of HbA_1c as a screening tool to identify individuals with alteration of glycaemic homeostasis, we focused on the evidence regarding the ability of HbA_1c as a diagnostic tool for pre-diabetes and as a useful marker in identifying patients who have an increased risk for cardiovascular disease. Finally, we reviewed the current evidence regarding non-traditional glycaemic biomarkers and their use as alternatives to or additions to traditional ones.