Hyperglycemia and Acute Coronary Syndromes

Cardiovascular disease and diabetes Bell DSH. Diabetes Care. 2003;26: Centers for Disease Control (CDC). T2DM = type 2 diabetes mellitus Cardiovascular complications of T2DM ~65% of deaths are due to CV disease Coronary heart disease deaths  2- to 4-fold Stroke risk  2- to 4-fold Heart failure  2- to 5-fold

Abnormal glucose metabolism in CAD n = 2107 inpatients with acute CAD; n = 2854 outpatients with stable CAD Bartnik M et al. Eur Heart J. 2004;25: Total patients (%) OGTT* *n = 1920 without known diabetes OGTT = oral glucose tolerance test; IGT = impaired glucose tolerance; IFG = impaired fasting glucose Known diabetes IGTIFGNew DM Patients* (%)

ADA criteria for IGT and T2DM 126 mg/dL 100 mg/dL* 140 mg/dL 200 mg/dL *WHO: 110 mg/dL American Diabetes Association (ADA). Diabetes Care. 2007;30(suppl 1)S4-41. World Health Organization (WHO). Fasting plasma glucose 2-Hour plasma glucose during 75-g OGTT T2DM IGT Normal T2DM IGT Normal

New-onset hyperglycemia linked to highest rate of in-hospital mortality N = 2030 hospital patients Umpierrez GE et al. J Clin Endocrinol Metab. 2002;87: *P < 0.01 vs normoglycemia and known diabetes ICU patientsNon-ICU patients * *

Admission glucose in AMI associated with mortality, independent of T2DM diagnosis N = 141,680 hospitalized with AMI Kosiborod M et al. Circulation. 2005;111: Admission glucose (mg/dL) 30 days 1 year Mortality (%) AMI = acute myocardial infarction ≤110> > > >240 DiabetesNo diabetes ≤110> > > >240

Stress hyperglycemia in AMI: Association with mortality risk in patients without known diabetes Reference Hyperglycemia definition (mg/dL) 013 Unadjusted RR of in-hospital mortality after MI* Capes SE et al. Lancet. 2000;355: *vs patients with normoglycemia 1991 O’Sullivan 1991 > Lewandowicz 1979 ≥ Soler 1981 ≥ Oswald 1986 ≥ Bellodi 1989> Ravid 1975> Sewdarsen 1989 ≥144 Pooled

Baseline fasting plasma glucose levels predict HF hospitalization in high-risk patients  23% in HF hospitalization per  18 mg/dL glucose in patients with no known diabetes Log rank P < Held C et al. Circulation. 2007;115; ONTARGET/TRANSCEND; N = 31,546 with CVD or DM + end-organ damage Proportion with incident HF hospitalization Follow-up (days) Normal low Normal high IFG New DM DM

*Multivariate analysis  Glucose (24 hr vs baseline) ≥30 mg/dL decrease No change to <30 mg/dL decrease Increase Admission glucose and glucose change within 24 hours predict mortality risk Goyal A et al. Eur Heart J. 2006;27: N = 1469 with AMI (n = 1219 without DM) 30-day mortality (%) Baseline glucose (mg/dL) <125125–<140140–<170≥170 0  9% in 30-day mortality per  11 mg/dL glucose in first 24 hr (P = 0.002)*