Prognostic Significance of Relative Hyperglycemia after Percutaneous Coronary Intervention in Patients with and without Recognized Diabetes

Author(s): Qi Zhao, Ting-Yu Zhang, Yu-Jing Cheng, Yue Ma, Ying-Kai Xu, Jia-Qi Yang, Yu-Jie Zhou*

Journal Name: Current Vascular Pharmacology

Volume 19 , Issue 1 , 2021

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Graphical Abstract:


Background: The research on the association between the relative glycemic level postpercutaneous coronary intervention (PCI) and adverse prognosis in non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients is relatively inadequate.

Objective: The study aimed to identify whether the glycemic level post-PCI predicts adverse prognosis in NSTE-ACS patients.

Methods: Patients (n=2465) admitted with NSTE-ACS who underwent PCI were enrolled. The relative glycemic level post-procedure was calculated as blood glucose level post-PCI divided by HbA1c level, which was named post-procedural glycemic index (PGI). The primary observational outcome of this study was major adverse cardiovascular events (MACE) [defined as a composite of all-cause death, non-fatal myocardial infarction (MI) and any revascularization].

Results: The association between PGI and MACE rate is presented as a U-shape curve. Higher PGIs [hazard ratio (HR): 1.669 (95% confidence interval (CI): 1.244-2.238) for the third quartile (Q3) and 2.076 (1.566-2.753) for the fourth quartile (Q4), p<0.001], adjusted for confounding factors, were considered to be one of the independent predictors of MACE. The association between the PGI and the risk of MACE was more prominent in the non-diabetic population [HR (95%CI) of 2.356 (1.456-3.812) for Q3 and 3.628 (2.265-5.812) for Q4, p<0.001]. There were no significant differences in MACE risk between PGI groups in the diabetic population.

Conclusion: Higher PGI was a significant and independent predictor of MACE in NSTE-ACS patients treated with PCI. The prognostic effect of the PGI is more remarkable in subsets without pre-existing diabetes than in the overall population. The predictive value of PGI was not identified in the subgroup with diabetes.

Keywords: Non-ST-segment elevation, acute coronary syndrome, percutaneous coronary intervention, post-procedural glycemic index, hyperglycemia, diabetes.

Ueda H, Mitsusada N, Harimoto K, Miyawaki M, Yasuga Y, Hiraoka H. Glycosylated hemoglobin is a predictor of major adverse cardiac events after drug-eluting stent implantation in patients with diabetes mellitus. Cardiology 2010; 116(1): 51-7.
[] [PMID: 20453503]
Capes SE, Hunt D, Malmberg K, Gerstein HC. Stress hyperglycaemia and increased risk of death after myocardial infarction in patients with and without diabetes: a systematic overview. Lancet 2000; 355(9206): 773-8.
[] [PMID: 10711923]
Monteiro S, Monteiro P, Gonçalves F, Freitas M, Providência LA. Hyperglycaemia at admission in acute coronary syndrome patients: prognostic value in diabetics and non-diabetics. Eur J Cardiovasc Prev Rehabil 2010; 17(2): 155-9.
[] [PMID: 20110816]
Stranders I, Diamant M, van Gelder RE, et al. Admission blood glucose level as risk indicator of death after myocardial infarction in patients with and without diabetes mellitus. Arch Intern Med 2004; 164(9): 982-8.
[] [PMID: 15136307]
Kosiborod M, Rathore SS, Inzucchi SE, et al. Admission glucose and mortality in elderly patients hospitalized with acute myocardial infarction: implications for patients with and without recognized diabetes. Circulation 2005; 111(23): 3078-86.
[] [PMID: 15939812]
Petursson P, Herlitz J, Caidahl K, et al. Admission glycaemia and outcome after acute coronary syndrome. Int J Cardiol 2007; 116(3): 315-20.
[] [PMID: 16854479]
Roberts GW, Quinn SJ, Valentine N, et al. Relative hyperglycemia, a marker of critical illness: introducing the stress hyperglycemia ratio. J Clin Endocrinol Metab 2015; 100(12): 4490-7.
[] [PMID: 26485219]
Yang CJ, Liao WI, Wang JC, et al. Usefulness of glycated hemoglobin A1c-based adjusted glycemic variables in diabetic patients presenting with acute ischemic stroke. Am J Emerg Med 2017; 35(9): 1240-6.
[] [PMID: 28363620]
Su YW, Hsu CY, Guo YW, Chen HS. Usefulness of the plasma glucose concentration-to-HbA1c ratio in predicting clinical outcomes during acute illness with extreme hyperglycaemia. Diabetes Metab 2017; 43(1): 40-7.
[] [PMID: 27663631]
Yang Y, Kim TH, Yoon KH, et al. The stress hyperglycemia ratio, an index of relative hyperglycemia, as a predictor of clinical outcomes after percutaneous coronary intervention. Int J Cardiol 2017; 241: 57-63.
[] [PMID: 28256326]
Liao WI, Wang JC, Chang WC, Hsu CW, Chu CM, Tsai SH. Usefulness of glycemic gap to predict ICU mortality in critically ill patients with diabetes. Medicine (Baltimore) 2015; 94(36)e1525
[] [PMID: 26356728]
Roffi M, Patrono C, Collet JP, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: task force for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation of the European society of cardiology (ESC). Eur Heart J 2016; 37(3): 267-315.
[] [PMID: 26320110]
Norhammar A, Tenerz A, Nilsson G, et al. Glucose metabolism in patients with acute myocardial infarction and no previous diagnosis of diabetes mellitus: a prospective study. Lancet 2002; 359(9324): 2140-4.
[] [PMID: 12090978]
Zhao W, Katzmarzyk PT, Horswell R, Wang Y, Johnson J, Hu G. HbA1c and coronary heart disease risk among diabetic patients. Diabetes Care 2014; 37(2): 428-35.
[] [PMID: 24130365]
Selvin E, Steffes MW, Zhu H, et al. Glycated hemoglobin, diabetes, and cardiovascular risk in nondiabetic adults. N Engl J Med 2010; 362(9): 800-11.
[] [PMID: 20200384]
Verdoia M, Schaffer A, Cassetti E, et al. Glycosylated hemoglobin and coronary artery disease in patients without diabetes mellitus. Am J Prev Med 2014; 47(1): 9-16.
[] [PMID: 24750972]
Aziz Emara AA, Samy NI, Hammad AA. Relationship between glycated haemoglobin and complexity of coronary artery disease in diabetic patients. Atheroscler Suppl 2017; 25e8
Dutta B, Neginhal M, Iqbal F. Glycated hemoglobin (HbA1c) correlation with severity of coronary artery disease in non-diabetic patients - a hospital based study from north-eastern India. J Clin Diagn Res 2016; 10(9): OC20-3.
[] [PMID: 27790487]
Hong LF, Li XL, Guo YL, et al. Glycosylated hemoglobin A1c as a marker predicting the severity of coronary artery disease and early outcome in patients with stable angina. Lipids Health Dis 2014; 13: 89.
[] [PMID: 24884794]
Dungan KM, Braithwaite SS, Preiser JC. Stress hyperglycaemia. Lancet 2009; 373(9677): 1798-807.
[] [PMID: 19465235]
Braithwaite SS. Through the eyes of the A1C: a call to re-examine stress hyperglycemia. Crit Care Med 2010; 38(2): 717-9.
[] [PMID: 20083943]
Moorthy V, Sim MA, Liu W, Chew STH, Ti LK. Risk factors and impact of postoperative hyperglycemia in nondiabetic patients after cardiac surgery: A prospective study. Medicine (Baltimore) 2019; 98(23)e15911
[] [PMID: 31169705]
Davis G, Fayfman M, Reyes-Umpierrez D, et al. Stress hyperglycemia in general surgery: Why should we care? J Diabetes Complications 2018; 32(3): 305-9.
[] [PMID: 29273446]
Buehler L, Fayfman M, Alexopoulos AS, et al. The impact of hyperglycemia and obesity on hospitalization costs and clinical outcome in general surgery patients. J Diabetes Complications 2015; 29(8): 1177-82.
[] [PMID: 26355027]
Frisch A, Chandra P, Smiley D, et al. Prevalence and clinical outcome of hyperglycemia in the perioperative period in noncardiac surgery. Diabetes Care 2010; 33(8): 1783-8.
[] [PMID: 20435798]
Timmer JR, Hoekstra M, Nijsten MW, et al. Prognostic value of admission glycosylated hemoglobin and glucose in nondiabetic patients with ST-segment-elevation myocardial infarction treated with percutaneous coronary intervention. Circulation 2011; 124(6): 704-11.
[] [PMID: 21768543]
Kim EJ, Jeong MH, Kim JH, et al. Clinical impact of admission hyperglycemia on in-hospital mortality in acute myocardial infarction pa-tients. Int J Cardiol 2017; 236: 9-15.
[] [PMID: 28126258]
Ekmekci A, Cicek G, Uluganyan M, et al. Admission hyperglycemia predicts inhospital mortality and major adverse cardiac events after primary percutaneous coronary intervention in patients without diabetes mellitus. Angiology 2014; 65(2): 154-9.
[] [PMID: 23657174]
Lee TF, Burt MG, Heilbronn LK, et al. Relative hyperglycemia is associated with complications following an acute myocardial infarction: a post-hoc analysis of HI-5 data. Cardiovasc Diabetol 2017; 16(1): 157.
[] [PMID: 29233143]
Esposito K, Nappo F, Marfella R, et al. Inflammatory cytokine concentrations are acutely increased by hyperglycemia in humans: role of oxidative stress. Circulation 2002; 106(16): 2067-72.
[] [PMID: 12379575]
Ray KK, Cannon CP, Morrow DA, et al. Synergistic relationship between hyperglycaemia and inflammation with respect to clinical outcomes in non-ST-elevation acute coronary syndromes: analyses from OPUS-TIMI 16 and TACTICS-TIMI 18. Eur Heart J 2007; 28(7): 806-13.
[] [PMID: 17403721]
Ceriello A, Esposito K, Piconi L, et al. Oscillating glucose is more deleterious to endothelial function and oxidative stress than mean glucose in normal and type 2 diabetic patients. Diabetes 2008; 57(5): 1349-54.
[] [PMID: 18299315]
Gresele P, Guglielmini G, De Angelis M, et al. Acute, short-term hyperglycemia enhances shear stress-induced platelet activation in patients with type II diabetes mellitus. J Am Coll Cardiol 2003; 41(6): 1013-20.
[] [PMID: 12651051]
Pandolfi A, Giaccari A, Cilli C, et al. Acute hyperglycemia and acute hyperinsulinemia decrease plasma fibrinolytic activity and increase plasminogen activator inhibitor type 1 in the rat. Acta Diabetol 2001; 38(2): 71-6.
[] [PMID: 11757804]
Bauters C, Ennezat PV, Tricot O, et al. Stress hyperglycaemia is an independent predictor of left ventricular remodelling after first anterior myocardial infarction in non-diabetic patients. Eur Heart J 2007; 28(5): 546-52.
[] [PMID: 17314113]
Undas A, Wiek I, Stêpien E, Zmudka K, Tracz W. Hyperglycemia is associated with enhanced thrombin formation, platelet activation, and fibrin clot resistance to lysis in patients with acute coronary syndrome. Diabetes Care 2008; 31(8): 1590-5.
[] [PMID: 18487475]
Van den Berghe G, Wilmer A, Milants I, et al. Intensive insulin therapy in mixed medical/surgical intensive care units: benefit versus harm. Diabetes 2006; 55(11): 3151-9.
[] [PMID: 17065355]
Krinsley JS, Egi M, Kiss A, et al. Diabetic status and the relation of the three domains of glycemic control to mortality in critically ill patients: an international multicenter cohort study. Crit Care 2013; 17(2): R37.
[] [PMID: 23452622]
Umpierrez G, Cardona S, Pasquel F, et al. Randomized controlled trial of intensive versus conservative glucose control in patients undergoing coronary artery bypass graft surgery: GLUCO-CABG trial. Diabetes Care 2015; 38(9): 1665-72.
[] [PMID: 26180108]
Díaz R, Goyal A, Mehta SR, et al. Glucose-insulin-potassium therapy in patients with ST-segment elevation myocardial infarction. JAMA 2007; 298(20): 2399-405.
[] [PMID: 18042917]
Timmer JR, Svilaas T, Ottervanger JP, et al. Glucose-insulin-potassium infusion in patients with acute myocardial infarction without signs of heart failure: the glucose-insulin-potassium study (GIPS)-II. J Am Coll Cardiol 2006; 47(8): 1730-1.
[] [PMID: 16631017]
Goyal A, Mahaffey KW, Garg J, et al. Prognostic significance of the change in glucose level in the first 24 h after acute myocardial infarction: results from the CARDINAL study. Eur Heart J 2006; 27(11): 1289-97.
[] [PMID: 16611669]
de Mulder M, Umans VA, Cornel JH, et al. Intensive glucose regulation in hyperglycemic acute coronary syndrome: results of the randomized BIOMarker study to identify the acute risk of a coronary syndrome-2 (BIOMArCS-2) glucose trial. JAMA Intern Med 2013; 173(20): 1896-904.
[] [PMID: 24018647]
Mehta SR, Yusuf S, Díaz R, et al. Effect of glucose-insulin-potassium infusion on mortality in patients with acute ST-segment elevation myocardial infarction: the CREATE-ECLA randomized controlled trial. JAMA 2005; 293(4): 437-46.
[] [PMID: 15671428]
van der Horst IC, Zijlstra F, van ’t Hof AW, et al. Glucose-insulin-potassium infusion inpatients treated with primary angioplasty for acute myocardial infarction: the glucose-insulin-potassium study: a randomized trial. J Am Coll Cardiol 2003; 42(5): 784-91.
[] [PMID: 12957421]

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Article Details

Year: 2021
Published on: 17 March, 2020
Page: [91 - 101]
Pages: 11
DOI: 10.2174/1570161118666200317145540

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