U-Shaped Relationship of Blood Glucose With Adverse Outcomes Among Patients With ST-Segment Elevation Myocardial Infarction

Functional and Therapeutic Roles of Plant-Derived Antioxidants in Type 2 Diabetes Mellitus: Mechanisms, Challenges, and Considerations for Special Populations

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a chronic metabolic disorder characterized by persistent hyperglycemia, oxidative stress, and inflammation, contributing to insulin resistance and long-term complications. Dietary antioxidants from plant sources, such as polyphenols, flavonoids, carotenoids, and phenolic acids, have been increasingly studied for their potential to modulate these pathophysiological mechanisms.

OBJECTIVE

This review aims to summarize and critically analyze the current evidence on the biological effects, therapeutic potential, and translational challenges of plant-derived antioxidants in the prevention and management of T2DM.

METHODS

This narrative review was conducted using peer-reviewed literature from PubMed, Scopus, and Web of Science. Emphasis was placed on mechanistic studies, clinical trials, bioavailability data, and advances in formulation technologies related to antioxidant compounds in the context of T2DM.

RESULTS

Plant antioxidants exert beneficial effects by modulating oxidative stress, reducing systemic inflammation, and improving insulin signaling pathways. However, their clinical application is limited by low bioavailability, chemical instability, and high interindividual variability. Recent developments, such as nanoencapsulation, synergistic functional food formulations, and microbiome-targeted strategies, have shown promise in enhancing efficacy. Additionally, personalized nutrition approaches and regulatory advances are emerging to support the integration of antioxidant-based interventions into diabetes care.

CONCLUSIONS

Plant-derived antioxidants represent a promising complementary tool for T2DM management. Nonetheless, their effective clinical use depends on overcoming pharmacokinetic limitations and validating their long-term efficacy in well-designed trials. Integrating food technology, microbiome science, and precision nutrition will be crucial to translate these compounds into safe, scalable, and personalized therapeutic options for individuals with or at risk of T2DM.

Insulin Autoimmune Syndrome: A Chinese Expert Consensus Statement

Insulin autoimmune syndrome (IAS) is a rare autoimmune disorder characterized by spontaneous hypoglycemia. The incidence of IAS is higher in East Asian populations compared to other populations. Delayed diagnosis and treatment can lead to recurrent hypoglycemia, significant glucose fluctuations, and adverse clinical outcomes, including life-threatening situations. Currently, no standardized guidelines exist for the diagnosis and treatment of IAS. This consensus aims to provide a systematic summary of the epidemiology, triggers, pathogenesis, clinical manifestations, diagnosis, differential diagnosis, treatment, and prognosis of IAS, with the objective of standardizing its clinical management.

Glycaemic control in people with diabetes following acute myocardial infarction

Diabetes is a highly prevalent disease associated with considerable cardiovascular end organ damage and mortality. Despite significant changes to the management of acute myocardial infarction over the last two decades, people with diabetes remain at risk of complications and mortality following a myocardial infarct for a multitude of reasons, including increased coronary atherosclerosis, associated coronary microvascular dysfunction, and diabetic cardiomyopathy. Dysglycaemia causes significant endothelial dysfunction and upregulation of inflammation within the vasculature and epigenetic changes mean that these deleterious effects may persist despite subsequent efforts to tighten glycaemic control. Whilst clinical guidelines advocate for the avoidance of both hyper- and hypoglcyaemia in the peri-infarct period, the evidence base is lacking, and currently there is no consensus on the benefits of glycaemic control beyond this period. Glycaemic variability contributes to the glycaemic milieu and may have prognostic importance following myocardial infarct. The use of continuous glucose monitoring means that glucose trends and parameters can now be captured and interrogated, and its use, along with newer medicines, may provide novel opportunities for intervention after myocardial infarction in people with diabetes.

Characteristics and outcomes of patients with type 1 diabetes admitted with acute coronary syndromes

AIMS

This study explored characteristics and outcomes of patients with type 1 diabetes mellitus (T1DM) and acute coronary syndromes (ACS).

METHODS

A retrospective analysis of patients with T1DM admitted with ACS to an Australian hospital was conducted. Risk factor targets were defined by 2021 European Society of Cardiology Guidelines. Outcomes were defined as an adverse cardiovascular event (ACS, unplanned revascularisation, heart failure, stroke, or cardiovascular death) or all-cause mortality within six-months after discharge.

RESULTS

61 patients were included [age 58.5 ± 12.8 years, 39 % female]. Dyslipidaemia (85 %), hypertension (75 %), smoking (28 %), prior coronary artery disease (CAD) (44 %), and microvascular complications (62 %) were common. HbA1c, low-density lipoprotein cholesterol, and blood pressure targets were attained in 12 %, 36 % and 47 %, respectively. ST-elevation myocardial infarction (65 % versus 7 %, p < 0.001) and revascularisation (77 % versus 41 %, p = 0.008) were more common in those without prior CAD. Peak inpatient blood glucose correlated directly with peak troponin (p = 0.011) and inversely with left ventricular ejection fraction (p = 0.027). Nineteen patients experienced an adverse six-month outcome, with peripheral neuropathy (p = 0.039) and in-hospital hypoglycaemia (p = 0.012) being independent predictors.

CONCLUSIONS

Patients with T1DM and ACS often do not meet guideline targets for cardiovascular risk factors, and frequently present with transmural infarctions. Dysglycemia and microvascular complications predict poorer outcomes.

Role of continuous glucose monitoring in diabetic patients at high cardiovascular risk: an expert-based multidisciplinary Delphi consensus

Background

Continuous glucose monitoring (CGM) shows in more detail the glycaemic pattern of diabetic subjects and provides several new parameters (“glucometrics”) to assess patients’ glycaemia and consensually guide treatment. A better control of glucose levels might result in improvement of clinical outcome and reduce disease complications. This study aimed to gather an expert consensus on the clinical and prognostic use of CGM in diabetic patients at high cardiovascular risk or with heart disease.

Methods

A list of 22 statements concerning type of patients who can benefit from CGM, prognostic impact of CGM in diabetic patients with heart disease, CGM use during acute cardiovascular events and educational issues of CGM were developed. Using a two-round Delphi methodology, the survey was distributed online to 42 Italian experts (21 diabetologists and 21 cardiologists) who rated their level of agreement with each statement on a 5-point Likert scale. Consensus was predefined as more than 66% of the panel agreeing/disagreeing with any given statement.

Results

Forty experts (95%) answered the survey. Every statement achieved a positive consensus. In particular, the panel expressed the feeling that CGM can be prognostically relevant for every diabetic patient (70%) and that is clinically useful also in the management of those with type 2 diabetes not treated with insulin (87.5%). The assessment of time in range (TIR), glycaemic variability (GV) and hypoglycaemic/hyperglycaemic episodes were considered relevant in the management of diabetic patients with heart disease (92.5% for TIR, 95% for GV, 97.5% for time spent in hypoglycaemia) and can improve the prognosis of those with ischaemic heart disease (100% for hypoglycaemia, 90% for hyperglycaemia) or with heart failure (87.5% for hypoglycaemia, 85% for TIR, 87.5% for GV). The experts retained that CGM can be used and can impact the short- and long-term prognosis during an acute cardiovascular event. Lastly, CGM has a recognized educational role for diabetic subjects.

Conclusions

According to this Delphi consensus, the clinical and prognostic use of CGM in diabetic patients at high cardiovascular risk is promising and deserves dedicated studies to confirm the experts’ feelings.

The Impact of Hypoglycemic Therapy on the Prognosis for Acute Coronary Syndrome in Patients with Type 2 Diabetes

The article discusses particular circumstances of acute coronary syndrome (ACS) in patients with type 2 diabetes (T2D). In addition, the available literature data and clinical guidelines reflecting the role of hypoglycemic therapy as a cardioprotection factor in ACS are analyzed. The article considers possible protective molecular mechanisms of various groups of drugs in ischemic cardiomyocytes.

Clinical Impact of Dysglycemia in Patients with an Acute Myocardial Infarction

This study aimed to determine the impact of dysglycemia on myocardial injury and cardiac dysfunction in acute myocardial infarctions (AMIs). From 2005 to 2016, a total of 1,593 patients with AMIs who underwent percutaneous coronary intervention were enrolled. The patients were classified into five groups according to the admission glucose level: ≤80, 81 to 140, 141 to 200, 201 to 260, and ≥261 mg/dL. The clinical and echocardiographic parameters and 30-day mortality were analyzed. The peak troponin I and white blood cell levels had a positive linear relationship to the admission glucose level. The left ventricular ejection fraction had an inverted U-shape trend, and the E/E' ratio was U-shaped based on euglycemia. The 30-day mortality also increased as the admission glucose increased, and the cut-off value for predicting the mortality was 202.5 mg/dL. Dysglycemia, especially hyperglycemia, appears to be associated with myocardial injury and could be another adjunctive parameter for predicting mortality in patients with AMIs.

Vildagliptin vs. insulin treatment alone in diabetic acute coronary syndrome patients

BACKGROUND

Vildagliptin, an oral antidiabetic of the dipeptidyl peptidase-4 (DPP-4) inhibitor drugs, exhibits an overall low risk of hypoglycemia with less frequent hypoglycemic events in type 2 diabetes mellitus (T2DM) patients than other antidiabetic drugs. We hypothesized that among hospitalized acute coronary syndrome (ACS) patients, the addition of vildagliptin to subcutaneous insulin therapy would reduce the risk of hypoglycemic events.

METHODS

One hundred ACS T2DM adult patients naive to DPP-4 inhibitors were enrolled during admission to the ICCU. Patients were divided into two randomized controlled groups: a subcutaneous rapid-acting insulin-only therapy group and an oral vildagliptin plus subcutaneous insulin group. The trial was open label with no placebo arm. Mean glucose values, insulin values given for correction per hospitalization, and the number of hypoglycemic events (glucose < 70 mg/dL) were documented.

RESULTS

Eight hypoglycemia events occurred in the insulin-only group and none in the insulin plus DPP-4 inhibitor group (P < 0.001). Patients with acute myocardial infarction experienced a higher number of hypoglycemic events compared with unstable angina diagnosed patients. No significant differences were found regarding glucose level (P = 0.462) and administered insulin units (P = 0.639).

CONCLUSIONS

In T2DM patients, the addition of DPP-4 inhibitors to routine subcutaneous insulin therapy may significantly reduce hypoglycemic events while maintaining acceptable recommended ranges of glucose. Further studies on a larger scale are required to verify these results and to support that DPP-4 inhibitors added to today's standard insulin-only treatment in hospitalized diabetic ACS patients may improve overall glycemic control and provide a potential treatment option in this challenging clinical setting.

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

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

Devising a new dialogue for nutrition science: how life course perspective, U-shaped thinking, whole organism thinking, and language precision contribute to our understanding of biological heterogeneity and forge a fresh advance toward precision medicine

The process of designing and implementing individualized health-promoting interventions, nutritional or otherwise, is fraught with great difficulty owing to the heterogeneity inherent in factors that influence healthy longevity. This article proposes that careful attention to three principles-life course perspective, U-shaped thinking, and whole organism thinking-creates an attitudinal framework that can be used to reframe biological heterogeneity into the clinically relevant question: Who will benefit? The search for tools to cope with the complexity of this heterogeneity has been dominated by technological advances, including state-of-the-art "-omics" approaches and machine-based handling of "big data." Here, it is proposed that language precision and nuanced category usage could provide critical tools for coping with heterogeneity, thereby enabling interventionalists to design and implement strategies to promote healthy longevity with greater precision. The lack of a clear understanding of "Who will benefit?" stands as a major obstacle to the design and implementation of nutritional strategies to optimize healthy longevity. This article opens a new dialogue situating the principles of life course perspective, U-shaped thinking, and whole organism thinking, along with cultivating an attitude of language precision at the very core of accelerating creative discovery and refining practical advance in the field of nutrition science.

Impact of Long-term Glycosylated Hemoglobin in Patients with Acute Myocardial Infarction: a retrospective cohort study

Little clinical evidence supports the strict implementation of glycemic control for diabetic patients with AMI. We aimed to demonstrate the effect of long-term glycemic control on mortality in patients with diabetes mellitus after acute myocardial infarction (AMI). Eight hundred and twenty-four consecutive diabetic patients were divided into three groups according to the mean hemoglobin (HbA1c) value: <6% (group A), ≥6% to <7.5% (group B), and ≥7.5% (group C). The best long-term mortality outcome was observed in Group B, followed by groups C and A. Groups B and C were further compared in-depth because the baseline characteristics of group A differed significantly. A Cox regression analysis indicated that Group C was associated with an adjusted hazard ratio (HR) of 1.55 [95% confidence interval (CI): 1.02-2.34, P = 0.038]. An inverse probability of treatment weight analysis was performed to compare groups B and C. Group C had significantly higher mortality, compared to group B (adjusted HR: 1.58; 95% CI: 1.21-2.06, P  < 0.001). In conclusion, Glycemic status was associated with the long-term survival outcome in diabetic patients after AMI. However, further study is needed to prove whether HbA1c-targeted glycemic control can effectively improve survival after AMI.

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

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

Hyperglycaemia, adverse outcomes and impact of intravenous insulin therapy in patients presenting with acute ST-elevation myocardial infarction in a socioeconomically disadvantaged urban setting: The Montefiore STEMI Registry

BACKGROUND

Hyperglycaemia occurs frequently in ST-elevation myocardial infarction (STEMI) and is associated with poor outcomes, for which continuous insulin infusion therapy (CIIT) may be beneficial. Information is limited regarding hyperglycaemia in acute STEMI affecting urban minority populations, or how CIIT fares in such real-world settings.

METHODS AND RESULTS

We assembled an acute STEMI registry at an inner-city health system, focusing on patients with initial blood glucose ≥180 mg/dL to determine the impact of CIIT vs usual care. Clinical and outcomes data were added through linkage to electronic records. Inverse-probability-of-treatment weighting using propensity scores (PS) was used to compare CIIT vs no CIIT. The 1067 patients included were mostly Hispanic or African American; 356 had blood glucose ≥180 mg/dL. Such pronounced hyperglycaemia was related to female sex, minority race-ethnicity and lower socioeconomic score, and associated with increased death and death or CVD readmission. CIIT was preferentially used in patients with marked hyperglycaemia and was associated with in-hospital hypoglycaemia (21% vs 11%, P = .019) and, after PS weighting, with increased in-hospital (RR 3.23, 95% CI 0.94, 11.06) and 1-year (RR 2.26, 95% CI 1.02, 4.98) mortality. No significant differences were observed for death at 30 days or throughout follow-up, or death and readmission at any time point.

CONCLUSIONS

Pronounced hyperglycaemia was common and associated with adverse prognosis in this urban population. CIIT met with selective use and was associated with hypoglycaemia, together with increased mortality at specific time points. Given the burden of metabolic disease, particularly among race-ethnic minorities, assessing the benefits of CIIT is a prerogative that requires evaluation in large-scale randomized trials.

Perioperative Management of Hyperglycemia and Diabetes in Cardiac Surgery Patients

Perioperative hyperglycemia is common after cardiac surgery, reported in 60% to 90% of patients with diabetes and in approximately 60% of patients without history of diabetes. Many observational and prospective randomized trials in critically-ill cardiac surgery patients support a strong association between hyperglycemia and poor clinical outcome. Despite ongoing debate about the optimal glucose target, there is strong agreement that improved glycemic control reduces perioperative complications.

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.

Differential Impact of Hyperglycemia in Critically Ill Patients: Significance in Acute Myocardial Infarction but Not in Sepsis?

Hyperglycemia is a common condition in critically ill patients admitted to an intensive care unit (ICU). These patients represent an inhomogeneous collective and hyperglycemia might need different evaluation depending on the underlying disorder. To elucidate this, we investigated and compared associations of severe hyperglycemia (>200 mg/dL) and mortality in patients admitted to an ICU for acute myocardial infarction (AMI) or sepsis as the two most frequent admission diagnoses. From 2006 to 2009, 2551 patients 69 (58-77) years; 1544 male; 337 patients suffering from type 2 diabetes (T2DM)) who were admitted because of either AMI or sepsis to an ICU in a tertiary care hospital were investigated retrospectively. Follow-up of patients was performed between May 2013 and November 2013. In a Cox regression analysis, maximum glucose concentration at the day of admission was associated with mortality in the overall cohort (HR = 1.006, 95% CI: 1.004-1.009; p < 0.001) and in patients suffering from myocardial infarction (HR = 1.101, 95% CI: 1.075-1.127; p < 0.001) but only in trend in patients admitted to an ICU for sepsis (HR = 1.030, 95% CI: 0.998-1.062; p = 0.07). Severe hyperglycemia was associated with adverse intra-ICU mortality in the overall cohort (23% vs. 13%; p < 0.001) and patients admitted for AMI (15% vs. 5%; p < 0.001) but not for septic patients (39% vs. 40%; p = 0.48). A medical history of type 2 diabetes (n = 337; 13%) was not associated with increased intra-ICU mortality (15% vs. 15%; p = 0.93) but in patients with severe hyperglycemia and/or a known medical history of type 2 diabetes considered in combination, an increased mortality in AMI patients (intra-ICU 5% vs. 13%; p < 0.001) but not in septic patients (intra-ICU 38% vs. 41%; p = 0.53) could be evidenced. The presence of hyperglycemia in critically ill patients has differential impact within the different etiological groups. Hyperglycemia in AMI patients might identify a sicker patient collective suffering from pre-diabetes or undiagnosed diabetes with its' known adverse consequences, especially in the long-term. Hyperglycemia in sepsis might be considered as adaptive survival mechanism to hypo-perfusion and consecutive lack of glucose in peripheral cells. AMI patients with hyperglycemic derailment during an ICU-stay should be closely followed-up and extensively screened for diabetes to improve patients' outcome.

Acute Insulin Resistance in Myocardial Ischemia: Causes and Consequences

Diabetes mellitus is associated with increased risk for cardiovascular mortality because of multiple pathophysiologic mechanisms. Acute stress-induced hyper-glycemia during acute myocardial infarction has gained much attention, as blood glucose levels seem to be an independent risk factor for acute myocardial infarction–related death. Clinical studies that identify stress-induced hyperglycemia as a risk factor are reviewed and its causes are discussed. They can be summarized as the consequence of acute insulin resistance, which in its turn is caused by stress hormones and by proinflammatory cytokines. Hyperglycemia causes the release of proinflammatory cytokines, the induction of reactive radicals, alterations in cardiovascular substrate metabolism, and propagation of coagulation and apoptosis. These all have harmful effects during and after acute myocardial infarction. Recommendations are for strict glycemic control in hyperglycemic patients with acute myocar-dial infarction, although the target glucose level is still a subject of debate.

Glucose levels as a prognostic marker in patients with ST-segment elevation myocardial infarction: a case-control study

BACKGROUND

Patients with myocardial infarction (MI) have a high mortality. Therefore, new risk markers and predictors of an adverse outcome for MI are required. The role of hyperglycemia in the development of cardiovascular complications in MI patients is still unclear.

METHODS

A total of 529 consecutive patients with the diagnosis of ST-segment elevation acute coronary syndrome within 24 h of the onset of symptoms were included in the study. All of the patients underwent blood glucose measurement at admission to hospital. The glycemic profile, including measurement of blood glucose levels early in the night and in the morning (3 a.m. and 5 a.m.), was assessed in 77 patients with diabetes on days 6-10 of the course of MI to monitor the efficiency of blood glucose-lowering therapy and to detect hypoglycemic episodes.

RESULTS

In-hospital mortality showed relationship between the level of blood glucose on admission and in-hospital mortality in patients with MI with ST-segment elevation in combination with diabetes mellitus. There was a direct linear relationship between blood glucose levels and in-hospital mortality in patients without diabetes.

CONCLUSION

Episodes of hypoglycemia recorded in MI patients with diabetes in the hospital stage of treatment do not determine the prognosis, but enable identification of patients with an unfavorable course in the postinfarction period.

Association of silent hypoglycemia with cardiac events in non-diabetic subjects with acute myocardial infarction undergoing primary percutaneous coronary interventions

Background

Some studies have shown that hypoglycemic episodes in diabetic patients might be associated with increased cardiovascular events. It is not clear whether episodes of silent hypoglycemia had greater prognostic value on cardiac events compared with normoglycemia or hyperglycemia in non-diabetic patients, so the aim of this study was to investigate the association of silent hypoglycemia and cardiac events in non-diabetic patients with acute ST-segment elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (p-PCI).

Methods

We enrolled non-diabetic patients with STEMI who underwent p-PCI and whose clinical and laboratory data were collected. Interstitial glucose values were recorded using a continuous glucose monitoring system (CGMS), and Holter monitoring was recorded for 3 days in parallel. Cardiac ischemia and ventricular arrhythmia was evaluated.

Results

Based on the inclusion and exclusion criteria, we enrolled 164 STEMI patients undergoing p-PCI for final analysis. A total of 280 episodes of silent hypoglycemia (CGMS glucose <70 mg/dl) were recorded. Episodes of silent cardiac ischemia were recorded in 50 of 280 hypoglycemic episodes. The incidence of silent cardiac ischemia during hypoglycemia was significantly higher than the incidence during both hyperglycemia and normoglycemia(P < 0.01). Moreover, we found a significantly higher frequency of ventricular extrasystoles (VESs) or nonsustained ventricular tachycardias (NSVTs) in patients with silent hypoglycemia. The average number of events of silent cardiac ischemia was also significantly increased in the silent hypoglycemia group (0.91 ± 0.82 vs. 0.35 ± 0.54, P < 0.01) compared with either hyperglycemia or normoglycemia group.

Conclusions

Hypoglycemia was frequent and most of the time asymptomatic in non-diabetic patients with STEMI undergoing p-PCI. Silent hypoglycemia was associated with silent cardiac ischemia. STEMI patients with silent hypoglycemia had a significantly higher frequency of VESs or NSVTs.

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

Glycated hemoglobin (HbA1c) is an approved and widely used laboratory investigation for diagnosis of diabetes that is not affected by acute changes in blood glucose. Our aim was to analyze the extent to which routine HbA1c measurements diagnose unknown diabetes mellitus (DM) in patients presenting with ST-segment elevation myocardial infarction (STEMI). We also compared outcomes in patients with newly diagnosed DM, previously established DM and those without DM. Consecutive patients undergoing PCI for STEMI from January 2005 to December 2012 were included and routinely performed admission HbA1c was used to identify patients with previously undiagnosed DM (HbA1c ≥6.5 and no history of DM or DM therapy) and pre-DM (HbA1c 5.7% to 6.4%). Overall 1,686 consecutive patients underwent primary percutaneous coronary intervention for STEMI during the study period and follow-up data were available for 1,566 patients (90%). A quarter of the patients (24%, n = 405) had history of DM, 7% (n = 118) had previously undiagnosed DM, and 38.7% (n = 652) had pre-DM. Mortality was comparable in patients with known DM and newly diagnosed DM both in-hospital (11.1% vs 11.9%, p = 0.87) and at 3-year follow-up (27.3% and 24%). Patients with DM, including those who were newly diagnosed, had higher mortality at 3 years (26.5%) compared to those with pre-DM (12.1%) or no dysglycemia (11.2%, p <0.01). In conclusion, a substantial number of patients with STEMI have previously undiagnosed DM (7%). These patients have similar in-hospital and long-term mortality as those with known DM, and outcomes are inferior to patients without dysglycemia.

Effect of D-glucose feeding on mortality induced by sepsis

Sepsis is the life-threatening response to infection which can lead to tissue damage, organ failure, and death. In the current study, the effect of orally administered D-glucose on the mortality and the blood glucose level induced by D-Galactosamine (GaLN)/lipopolysaccharide (LPS)-induced sepsis was examined in ICR mice. After various amounts of D-glucose (from 1 to 8 g/kg) were orally fed, sepsis was induced by injecting intraperitoneally (i.p.) the mixture of GaLN /LPS. Oral pre-treatment with D-glucose dose-dependently increased the blood glucose level and caused a reduction of sepsis-induced mortality. The oral post-treatment with D-glucose (8 g/kg) up to 3 h caused an elevation of the blood glucose level and protected the mortality observed in sepsis model. However, D-glucose post-treated at 6, 9, or 12 h after sepsis induction did not affect the mortality and the blood glucose level induced by sepsis. Furthermore, the intrathecal (i.t.) pretreatment once with pertussis toxin (PTX; 0.1 µg/5 ml) for 6 days caused a reduction of D-glucose-induced protection of mortality and hyperglycemia. Furthermore, once the hypoglycemic state is continued up to 6 h after sepsis initiated, sepsis-induced mortality could not be reversed by D-glucose fed orally. Based on these findings, it is assumed that the hypoglycemic duration between 3 and 6 h after the sepsis induction may be a critical time of period for the survival. D-glucose-induced protective effect against sepsis-induced mortality appears to be mediated via activating PTX-sensitive G-proteins in the spinal cord. Finally, the production of hyperglycemic state may be critical for the survival against the sepsis-induced mortality.

LC/MS-based polar metabolite profiling reveals gender differences in serum from patients with myocardial infarction

Myocardial infarction (MI), a leading cause of death worldwide, results from prolonged myocardial ischemia with necrosis of myocytes due to a blood supply obstruction to an area of the heart. Many studies have reported gender-related differences in the clinical features of MI, but the reasons for these differences remain unclear. In this study, we applied ultra-performance liquid chromatography/quadrupole time-of-flight mass spectrometry (UPLC/Q-TOF MS) and various statistical methods-such as multivariate, pathway, and correlation analyses-to identify gender-specific metabolic patterns in polar metabolites in serum from healthy individuals and patients with MI. Patients with diagnosed MI (n=68), and age- and body mass index-matched healthy individuals (n=68), were included in this study. The partial least-squares discriminant analysis (PLS-DA) model was generated from metabolic profiling data, and the score plots showed a significant gender-related difference in patients with MI. Many pathways were associated with amino acids and purines; amino acids, acylcarnitines, and purines differed significantly between male and female patients with MI. This approach could be utilized to observe gender-specific metabolic pattern differences between healthy controls and patients with MI.

Interdisciplinary position statement on management of hyperglycemia in peri-operative and intensive care

Hospitalized patients with diabetes pose numerous clinical challenges, including hyperglycemia, which may often be difficult to control. The therapeutic challenges are further accentuated by the difficulty in practical application of existing guidelines among Indian and South Asian patients. The present review highlights the various clinical challenges encountered during management of different diabetic hospitalized populations, and attempts to collate a set of practical, patient and physician friendly recommendations to manage hyperglycemia in such patients.

Hypoglycemia at admission in patients with acute myocardial infarction predicts a higher 30-day mortality in patients with poorly controlled type 2 diabetes than in well-controlled patients

OBJECTIVE

We aimed to evaluate the association between hypoglycemia at admission and 30-day mortality in patients with acute myocardial infarction (AMI) and to determine whether these associations differed according to diabetes-control status in AMI patients with diabetes.

RESEARCH DESIGN AND METHODS

We analyzed the prognostic significance of hypoglycemia and hyperglycemia in 34,943 AMI patients with or without type 2 diabetes from two AMI registries: the Korea Acute Myocardial Infarction Registry (KAMIR) and the Korea Working Group on Myocardial Infarction (KorMI).

RESULTS

The patients were divided into five groups according to serum-glucose levels at admission: <3.9 mmol/L (<70 mg/dL); 3.9-7.72 mmol/L (70-139 mg/dL); 7.78-11.06 mmol/L (140-199 mg/dL); 11.11-14.39 mmol/L (200-259 mg/dL); and ≥14.44 mmol/L (≥260 mg/dL). The 30-day mortality rates in the lowest and highest glucose groups were higher than those in other groups; the lowest glucose group had the highest mortality for patients with type 2 diabetes, after adjusting for multiple factors. We also extracted and compared four subgroups from the patients with type 2 diabetes, based on hemoglobin A1c and serum-glucose levels at admission: group A, <6.5% (48 mmol/mol) and <3.9 mmol/L; group B, <6.5% (48 mmol/mol) and ≥11.11 mmol/L; group C, ≥8% (64 mmol/mol) and <3.9 mmol/L; and group D, ≥8% (64 mmol/mol) and ≥11.11 mmol/L. Group C had the highest 30-day mortality rate among the groups.

CONCLUSIONS

These data suggest that hypoglycemia at admission affects clinical outcomes differently in AMI patients with type 2 diabetes depending on the diabetes-control status.

Coronary artery disease and diabetes mellitus

Diabetes mellitus (DM) is a major risk factor for cardiovascular disease. Near-normal glycemic control does not reduce cardiovascular events. For many patients with 1- or 2-vessel coronary artery disease, there is little benefit from any revascularization procedure over optimal medical therapy. For multivessel coronary disease, randomized trials demonstrated the superiority of coronary artery bypass grafting over multivessel percutaneous coronary intervention in patients with treated DM. However, selection of the optimal myocardial revascularization strategy requires a multidisciplinary team approach ('heart team'). This review summarizes the current evidence regarding the effectiveness of various medical therapies and revascularization strategies in patients with DM.

Management of diabetes mellitus type-2 in the geriatric population: Current perspectives

The prevalence of diabetes mellitus (DM) has increased exponentially throughout the world and there is rapid increase in elderly diabetics. DM is associated with increased mortality and considerable morbidity including stroke, heart disease, and diminished quality of life in the elderly. However, the unique features of geriatric diabetes have not been given due a prominence in medical literature. Hypoglycemia remains the biggest complicating factor and needs to be avoided in the elderly. Most people in the geriatric age group have some degree of renal insufficiency and medications need to be adjusted wisely with changing renal profile. Because safer and more effective pharmacological therapy is available, an individual approach to DM in the elderly is essential.

Approach to the patient with spontaneous hypoglycemia

Hypoglycemia is common in daily clinical practice and often occurs during the treatment of diabetes mellitus. However, a small minority of hypoglycemia encountered in clinical practice is spontaneous and thus not induced by glycemic lowering agents. These spontaneous hypoglycemic events confront the clinician with a diagnostic enigma. Although the trained clinician can recognize the autonomic and neuroglycopenic symptoms of hypoglycemia even in a patient not on insulin, it remains challenging to decipher the etiology of a spontaneous hypoglycemic event. A logical and stepwise approach to the spontaneous hypoglycemic event allows for a conclusive diagnosis. This diagnostic process consists of adequately diagnosing hypoglycemia by fulfilling Whipple's triad, stratifying patients according to their clinical status and analyzing a full hypoglycemic blood panel. A complete hypoglycemic blood panel should include the analysis of glucose, insulin, C-peptide, pro-insulin, insulin antibodies and the presence of oral hypoglycemic agents. For patients with episodes of hypoglycemia induced by excessive endogenous insulin, additional imaging is often required to detect the presence of an underlying insulinoma. By diagnosing the underlying cause of the spontaneous hypoglycemia, the physician also diagnosis the mechanism by which the hypoglycemic event occurs. Allowing for a problem orientated therapeutic approach.

METHODOLOGY

The present review is based upon a comprehensive PubMed search between 1985 and 2013. This uses search terms of spontaneous hypoglycemia, insulinoma, nesidioblastosis, insulin auto-immunity, noninsulinoma pancreatogenous hypoglycemia syndrome, hormone deficiency, pro-IGF II, and pro-insulin growth factor II, and cross reference searching of pivotal articles in the subject.

Prognostic impact of admission blood glucose for all-cause mortality in patients with acute coronary syndromes: added value on top of GRACE risk score

BACKGROUND

Abnormal glucose metabolism is a predictor of worse outcome after acute coronary syndrome (ACS). However, this parameter is not included in risk prediction scores, including GRACE risk score. We sought to evaluate whether the inclusion of blood glucose at admission in a model with GRACE risk score improves risk stratification.

METHODS

Study of consecutive patients included in a single centre registry of ACS. Our primary endpoint was the occurrence of all-cause mortality at one-year follow-up. The ability of the two logistic regression models (GRACE risk score alone and in combination with blood glucose) to predict death was analysed. Continuous net reclassification improvement (NRI) and integrated discrimination improvement (IDI), with corresponding 95% confidence intervals (CIs), were also calculated.

RESULTS

We included 2099 patients, with a mean age of 64 (SD=13) years, 69% males. In our sample, 55.1% presented with ST-segment elevation ACS and 13.1% in Killip class ≥ 2. Only 25% were known diabetic at admission. In-hospital mortality was 5.8% and 9.7% at one-year follow-up. The best cut-point for blood glucose was 160 mg/dl (sensitivity 62% and specificity 68%), and 35.2% of the patients had increased levels. This group was elderly, had more prevalence of cardiovascular risk factors, worse renal function and GRACE score as well as more frequently Killip class ≥2. Treatment was similar in both groups besides less frequent use of clopidogrel in high glycaemic patients. The hyperglycaemia group had higher one-year mortality (17.2% vs. 5.6%, p<0.001). Moreover, binary blood glucose remained a predictor of death independently of the GRACE risk score and the presence of diabetes (odds ratio (OR) 1.99, 95% CI 1.40-2.84, p<0.001). The inclusion of blood glucose, as a continuous variable, in a logistic regression model with GRACE score, increased the area under the ROC curve from 0.80 to 0.82 (p=0.018) as well as the goodness-of-fit and was associated with an improvement in both the NRI (37%) and the IDI (0.021), suggesting effective reclassification.

CONCLUSIONS

A blood glucose level on admission ≥ 160 mg/dl is an independent predictor of mortality in medium-term follow-up. It offers an incremental predictive value when added to the GRACE risk score, although with a modest magnitude of improvement, probably due to the high predictive performance of the GRACE risk score alone.

The use of non-insulin anti-diabetic agents to improve glycemia without hypoglycemia in the hospital setting: focus on incretins

Patients with hyperglycemia in hospital have increased adverse outcomes compared with patients with normoglycemia, and the pathophysiological causes seem relatively well understood. Thus, a rationale for excellent glycemic control exists. Benefits of control with intensive insulin regimes are highly likely based on multiple published studies. However, hypoglycemia frequency increases and adverse outcomes of hypoglycemia accrue. This has resulted in a 'push' for therapeutic nihilism, accepting higher glycemic levels to avoid hypoglycemia. One would ideally prefer to optimize glycemia, treating hyperglycemia while minimizing or avoiding hypoglycemia. Thus, one would welcome therapies and processes of care to optimize this benefit/ risk ratio. We review the logic and early studies that suggest that incretin therapy use in-hospital can achieve this ideal. We strongly urge randomized prospective controlled studies to test our proposal and we offer a process of care to facilitate this research and their use in our hospitalized patients.

Admission hyperglycemia predicts poorer short- and long-term outcomes after primary percutaneous coronary intervention for ST-elevation myocardial infarction

AIMS/INTRODUCTION

Admission hyperglycemia is associated with poor outcome in patients with myocardial infarction. The present study evaluated the relationship between admission glucose level and other clinical variables in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).

MATERIALS AND METHODS

The 959 consecutive STEMI patients undergoing primary PCI were divided into five groups based on admission glucose levels of <100, 100-139, 140-189, 190-249 and ≥250 mg/dL. Their short- and long-term outcomes were compared.

RESULTS

Higher admission glucose levels were associated with significantly higher in-hospital morbidity and mortality, the overall mortality rate at follow up, and the incidence of reinfarction or heart failure requiring admission or leading to mortality at follow up. The odds ratios (95% confidence interval) for in-hospital morbidity, in-hospital mortality, mortality at follow up and re-infarction or heart failure or mortality at follow up of patients with admission glucose levels ≥190 mg/dL, compared with those with admission glucose levels <190 mg/dL, were 2.12 (1.3-3.4, P = 0.001), 2.74 (1.4-5.5, P = 0.004), 2.52 (1.2-5.1, P = 0.01) and 1.70 (1.03-2.8, P = 0.04), respectively. Previously non-diabetic patients with admission glucose levels ≥250 mg/dL had significantly higher in-hospital morbidity or mortality (44 vs 70%, P = 0.03). Known diabetic patients had higher rates of reinfarction, heart failure or mortality at follow up in the 100-139 mg/dL (8 vs 27%, P = 0.04) and 140-189 mg/dL (11 vs 26%, P = 0.02) groups.

CONCLUSIONS

Admission hyperglycemia, especially at glucose levels ≥190 mg/dL, is a predictor of poor prognosis in STEMI patients undergoing primary PCI.

The proarrhythmic effect of hypoglycemia: evidence for increased risk from ischemia and bradycardia

Hypoglycemia increases the risk for both overall and sudden death. At a cellular level, hypoglycemia causes alterations in the physiology of myocardial tissue that are identical to proarrhythmic medications. Reduced serum glucose blocks the repolarizing K(+) channel HERG, which leads to action potential and QT prolongation and is uniformly associated with risk for torsades de pointes ventricular tachycardia. The sympathetic response induced by hypoglycemia also increases the risk of arrhythmias from Ca(2+) overload, which occur with sympathomimetic medications and excessive beta adrenergic stimulation. Thus, hypoglycemia can be considered a proarrhythmic event. This review focuses on emerging evidence for two other important changes induced by hypoglycemia that promote arrhythmias: ischemia and bradycardia. Studies of patients with "insulin shock" therapy from the early twentieth century and other more recent data strongly suggest that hypoglycemia can cause ischemia of myocardial tissue, both in association with coronary artery obstructions and by cellular mechanisms. Ischemia induces multiple proarrhythmic responses. Since ischemia itself reduces the possibility of using energy substrates other than glucose, hypoglycemia may generate positive feedback for electrophyisologic destabilization. Recent studies also show that hypoglycemia can cause bradycardia and heart block. Bradycardia is known to cause action potential prolongation and potentiate the development of torsades de pointes, particularly with low-serum K(+) which can be induced by hypoglycemic episodes. Thus, hypoglycemia-induced bradycardia may also create a dynamic, positive feedback for the development of arrhythmias and sudden death. These studies further support the hypothesis that hypoglycemia is a proarrhythmic event.

Fasting hyperglycemia increases in-hospital mortality risk in nondiabetic female patients with acute myocardial infarction: a retrospective study

Previous studies had shown that elevated admission plasma glucose (APG) could increase mortality rate and serious complications of acute myocardial infarction (AMI), but whether fasting plasma glucose (FPG) had the same role remains controversial. In this retrospective study, 253 cases of AMI patients were divided into diabetic (n = 87) and nondiabetic group (n = 166). Our results showed that: compared with the nondiabetic patients, diabetic patients had higher APG, FPG, higher plasma triglyceride, higher rates of painless AMI (P < 0.01), non-ST-segment elevation myocardial infarction (NSTEMI), and reinfraction (P < 0.05). They also had lower high density lipoprotein cholesterol and rate of malignant arrhythmia, but in-hospital mortality rate did not differ significantly (P > 0.05). While nondiabetic patients were subgrouped in terms of APG and FPG (cut points were 11.1 mmol/L and 7.0 mmol/L, resp.), the mortality rate had significant difference (P < 0.01), whereas glucose level lost significance in diabetic group. Multivariate logistic regression analysis showed that FPG (OR: 2.014; 95% confidence interval: 1.296-3.131; p < 0.01) but not APG was independent predictor of in-hospital mortality for nondiabetic patients. These results indicate that FPG can be an independent predictor for mortality in nondiabetic female patients with AMI.