Hyperglycemia andAcute Coronary Syndromes

Cardiovascular disease and diabetes

Bell DSH. Diabetes Care. 2003;26:2433-41.Centers for Disease Control (CDC). www.cdc.gov.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 risk2- to 4-fold

Heart failure 2- to 5-fold

Abnormal glucose metabolism in CAD

0

20

40

60

Inpatients Outpatients

n = 2107 inpatients with acute CAD; n = 2854 outpatients with stable CAD

Bartnik M et al. Bartnik M et al. Eur Heart J.Eur Heart J. 2004;25:1880-90. 2004;25:1880-90.

Totalpatients

(%)

OGTT*

*n = 1920 without known diabetesOGTT = oral glucose tolerance test; IGT = impaired glucose tolerance; IFG = impaired fasting glucose

32 30

0

20

40

60

Inpatients Outpatients

Known diabetes

58 51

IGT IFG New 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). www.who.int/diabetes.

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 mortalityN = 2030 hospital patients

Umpierrez GE et al. J Clin Endocrinol Metab. 2002;87:978-82.

0

10

20

30

40

Normoglycemia Known diabetes New hyperglycemia

Mortality (%)

*P < 0.01 vs normoglycemia and known diabetes

ICU patients Non-ICU patients

*

*

Admission glucose in AMI associated with mortality, independent of T2DM diagnosisN = 141,680 hospitalized with AMI

Kosiborod M et al. Circulation. 2005;111:3078-86.

Admission glucose (mg/dL)

30 days 1 year

Mortality(%)

AMI = acute myocardial infarction

0

10

20

30

40

50

60

≤110 >110-140

>140-170

>170-240

>240

Diabetes No diabetes

0

10

20

30

40

50

60

≤110 >110-140

>140-170

>170-240

>240

Stress hyperglycemia in AMI: Association with mortality risk in patients without known diabetes

ReferenceReference

Hyperglycemia Hyperglycemia definition definition

(mg/dL)(mg/dL)

00 1313

Unadjusted RR of in-hospital mortality after MI*

Capes SE et al. Capes SE et al. Lancet.Lancet. 2000;355:773-8. 2000;355:773-8.*vs patients with normoglycemia

O’Sullivan 1991 1991 >144>144

Lewandowicz 1979 1979 ≥≥121121

Soler 1981 1981 ≥≥110110

Oswald 1986 1986 ≥≥144144

Bellodi 19891989 >121>121

Ravid 19751975 >121>121

Sewdarsen 19891989 ≥≥144144

PooledPooled

11 22 33 44 55 66 77 88 99 1010 1111 1212

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 < 0.001 Held C et al. Circulation. 2007;115;1371-5.

ONTARGET/TRANSCEND; N = 31,546 with CVD or DM + end-organ damage

Proportion with incident HF hospitalization

12001000800600

Follow-up (days)

4002000

0.0

0.01

0.02

0.03

0.04

0.05

0.06 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;27:1289-97.

N = 1469 with AMI (n = 1219 without DM)

0

2

4

6

8

10

12

30-day mortality

(%)

Baseline glucose (mg/dL)

<125 125–<140 140–<170 ≥170

0

9% in 30-day mortality per 11 mg/dL glucose in first 24 hr (P = 0.002)*