Impaired glucose metabolism predicts mortality after a myocardial infarction

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Abstract

Diabetes is a risk factor for increased mortality after a myocardial infarction. Whether this applies for patients with hyperglycemia during the acute phase of a acute myocardial infarction is unclear. Therefore we determined the relation between admission plasma glucose level and mortality in a prospectively collected series of 336 consecutive AMI patients. Patients were divided in four groups based on WHO criteria for glucose levels: I: <5.6 mmol/l, II: 5.6–8.3 mmol/l, III: 8.4–11.0 mmol/l, IV: 11.1 mmol/l. The average age was 68±11 years with a peak CK of 1378±160 U/l, 34% were anterior wall AMIs and 52% were treated with thrombolysis. All patients had a long-term follow-up control at an average of 14.2 months. One year mortality rate was 19.3% and rose to 44% in patients with glucose levels >11.1 mmol/l. The mortality was higher in diabetic patients than in non-diabetic patients (40 vs. 16%; P<0.05). Multivariate analysis revealed an independent effect of glucose level on mortality. In conclusions, our study in an unselected patient population demonstrates that admission plasma glucose level independently predicts 1 year mortality even in absence of diagnosed diabetes mellitus. Further studies evaluating the effect of acute insulin intervention in reducing mortality are warranted.

Introduction

Cardiovascular disease is a well-known complication of non-insulin dependent diabetes and a major cause of morbidity and mortality in diabetic patients [1], [2], [3]. Once coronary heart disease has been established the mortality rate of diabetic patients is higher than in nondiabetic patients, both in the acute phase as on long-term follow-up [3], [4], [5]. Various pathophysiologic substrates may explain this clinical course. Diabetic patients have more extensive coronary artery disease [6], [7], a higher incidence of left ventricular failure [7], [8] and are more likely to develop fatal arrhythmias after myocardial infarction [9]. Strict glycemic control can prevent micro vascular complications [10], however an association with prevalence of macro vascular disease could not be found [1], [11]. The prevalence of diabetes in patients with myocardial infarction is high [12], [13]. Impaired glucose tolerance in patients with myocardial infarction has not been systematically recorded, although correlation between plasma glucose levels on admission in patients with myocardial infarction and mortality has been documented [14].

The aim of this study was to make an exploration of the extent of hyperglycaemia in an unselected patient population with myocardial infarction in daily clinical practice and to determine the relation between admission plasma glucose levels and major adverse cardiovascular events in the thrombolysis era.

Section snippets

Patients

From January 1st 1996 through January 1997, 352 consecutive patients were admitted to the CCU of our hospital with an acute myocardial infarction. All these patients were considered for inclusion in this study. For the purpose of this study, the late clinical outcome after an acute myocardial infarction was correlated to the glucose level of admission. Therefore 16 patients were excluded from the analysis because no admission glucose level was available (n=10), while six patients could not be

Characteristics

Characteristically the majority of the patients were males (71%) with a mean age of 68±11 years. Fifteen percent of these infarcted patients have a previous myocardial infarction, while 2 and 9% had undergone a coronary angioplasty or coronary bypass surgery, respectively. Twelve percent of these patients were previous diagnosed as diabetics, at admission 34% were treated with insulin (Table 1). Mean cholesterol and HDL-cholesterol were 5.7±1.1 and 1.0±0.3 mmol/l, respectively (data not shown).

Discussion

Our study in an unselected patient population has demonstrated that the prognostic importance of impaired glucose levels among patients admitted with myocardial infarction is high and that admission glucose level in these patients is independently correlated with late mortality. Overall the 1-year mortality rate is 19.3%, this is higher with increasing admission plasma glucose levels. The significance of hyperglycaemia among patients with myocardial infarction is not yet explained. Whether it

Conclusions

Increased admission plasma glucose levels among patients with myocardial infarction are significantly and independently correlated with mortality. Given its deleterious effects, the challenge for the future is to recognise these hyperglycemic patients in an early stage and to explore the possibilities of risk reducing. The decompensated metabolic glucose status, either due to catecholamine-induced effects or to an impaired insulin–glucose metabolism has a particular important effect on the

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