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In-hospital peak glycemia in non-diabetic patients with heart failure complicating acute coronary syndrome
IJCA-18273; No of Pages 3 International Journal of Cardiology xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
In-hospital peak glycemia in non-diabetic patients with heart failure complicating acute coronary syndrome Chiara Lazzeri ⁎, Serafina Valente, Marco Chiostri, Maria Grazia D'Alfonso, Serena Fatucchi, Valerio Mecarocci, Gian Franco Gensini Intensive Cardiac Coronary Unit, Heart and Vessel Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
a r t i c l e
i n f o
Article history: Received 27 April 2014 Accepted 28 June 2014 Available online xxxx Keywords: Peak glycemia Acute heart failure Prognosis
Acute heart failure syndromes (AHF) remain a major cause of morbidity and mortality, in part because of the lack of definitive evidence for AHF management and risk stratification parameters [1], and there is a clinical need to identify clinical and/or laboratory tools useful for risk stratification in the AHF population [2]. The relation between glucose values and insulin resistance and mortality, both at short and long term [3–5], is still poorly understood and previous studies were based only on admission glucose level [6–10], while data on in-hospital glucose values are still lacking. The present investigation was aimed at assessing the prognostic role of admission and peak in-hospital glycemia in 273 consecutive patients with AHF complicating acute coronary syndrome (ACS) and without previously known diabetes, admitted to our Intensive Cardiac Care Unit (ICCU) from June 30, 2009 to December 31, 2012. Even if in all cases data were collected prospectively, the current study is a retrospective analysis of those data. The study population includes 141 patients with ST-elevation myocardial infarction (STEMI) (51.6%) and 132 (48.4%) patients with Non ST Elevation myocardial infarction (NSTEMI). All patients were submitted to coronary angiography. STEMI patients were admitted to our ICCU after mechanical revascularization. Among NSTEMI patients, 24 (18%) patients underwent urgent coronary artery bypass graft, while percutaneous coronary intervention was performed in 65 NSTEMI patients (49%) and medical therapy was administered to the remaining 43 NSTEMI patients (33%).
⁎ Corresponding author at: Intensive Cardiac Care Unit, Heart and Vessel Department, Viale Morgagni 85, 50134 Florence, Italy. Tel./fax: +39 55 7947518. E-mail address: [email protected] (C. Lazzeri).
The presence of comorbidities was determined by taking the patients' history directly [11]. On ICCU admission, in a fasting blood sample, the following parameters were measured: glucose (g/l), insulin (UI/L), troponin I (Tn I, ng/ml), uric acid (mg/dl), glycated hemoglobin (%), NT-pro Brain Natriuretic Peptide (NT-proBNP) (pg/ml), leukocytes count (*103/μl), fibrinogen (mg/dl) and lactate (mmol/l). Creatinine (mg/dl) was also measured in order to calculate glomerular filtration rate (ml/min/1.73 m 2 ) [12]. In all patients, glucose levels and Tn I were measured three times a day, and peak glycemia [13,14] and peak Tn I were considered, respectively. Acute insulin resistance was investigated by means of the homeostatic model assessment index (HOMA index), as previously described [15–17]. Intensive insulin therapy was administered in patients with significant hyperglycemia (that is plasma glucose N 180 g/l) [18]. The study population was divided according to tertiles of peak glycemia. Outcome was in-ICCU mortality. The study protocol was in accordance with the Declaration of Helsinki and approved by the local Ethics Committee. Informed consent was obtained in all patients before enrolment. Categorical values have been reported as frequency (percentage); continuous variables have been reported as mean ± SD or median (interquartile range, IR) as appropriate. Between-group comparisons were made by means of chi-square and ANOVA or Kruskal–Wallis test as needed. Logistic regression analysis, both uni- and multivariable, were carried out considering as outcome intra-ICCU mortality. Variables were chosen as those clinically related to in-ICCU death. A receiver operating characteristic (ROC) curve was plotted to identify a cutoff of peak glycemia with respect to in-ICCU death. A p value less than 5% has been taken as statistically significant (IBM-SPSS 20.0 for Windows® statistical software (IBM-SPSS Inc., USA)). Clinical characteristics of the study population are depicted in Table 1. Patients in the third tertile showed the highest percentage of STEMI, the highest incidence of COPD and the lowest values of admission and discharge LVEF. The highest in-ICCU mortality rate was observed in patients in the third tertile. Patients with the highest values of peak glycemia showed the highest admission glycemia levels and the highest incidence of HOMA-index and HOMA positivity. In the third subgroup, it was observed a progressive increase in leukocytes count, in NT-pro BNP levels and in peak Tn I.
http://dx.doi.org/10.1016/j.ijcard.2014.06.055 0167-5273/© 2014 Published by Elsevier Ireland Ltd.
Please cite this article as: Lazzeri C, et al, In-hospital peak glycemia in non-diabetic patients with heart failure complicating acute coronary syndrome, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.06.055
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C. Lazzeri et al. / International Journal of Cardiology xxx (2014) xxx–xxx
Table 1 Clinical characteristics according to peak glycemia tertiles.
STEMI (%) Age (years) Males/females BMI (kg/m2), mean ± SD History of, n (%) Previous CAD COPD Chronic renal failure Hypertension n (%) 0 comorbidity 1 comorbidity 2 comorbidities N2 comorbidities Admission EF (%) Discharge EF (%) In-ICCU mortality, n (%)
1st tertile n = 91 pts
2nd tertile n = 91 pts
3rd tertile n = 91 pts
p
39 (42.9) 70.7 ± 15.5 60/31 (65.9/34.1) 25.4 ± 3.9
43 (47.3) 72.6 ± 12.2 57/34 (62.6/37.4) 25.8 ± 5.3
59 (64.8) 73.3 ± 13.3 56/35 (61.5/38.5) 25.4 ± 3.8
0.007 0.396 0.815
30 (33.0) 8 (8.8) 5 (5.5) 53 (58.2) 9 (9.9) 25 (27.5) 29 (31.9) 28 (30.7) 39.1 ± 8.9 41.1 ± 8.3 1 (1.1)
29 (31.9) 13 (14.3) 13 (14.3) 55 (60.4) 4 (4.4) 18 (19.8) 34 (37.4) 35 (38.4) 36.4 ± 9.0 38.3 ± 8.3 9 (9.9)
34 (37.4) 21 (23.1) 8 (8.8) 56 (61.5) 11 (12.1) 32 (35.2) 20 (22.0) 28 (30.7) 30.7 ± 9.4⁎ 33.4 ± 8.3⁎ 30 (33.0)
0.710 0.027 0.125 0.899 0.117
0.783
b0.001 b0.001 b0.001
Pts: patients; SD: standard deviation; STEMI: ST elevation myocardial infarction; BMI: body mass index; CAD: coronary artery disease; COPD: chronic obstructive pulmonary disease; EF: ejection fraction. ⁎ p b 0.05 vs. other groups at Bonferroni post hoc test.
Fig. 1. A receiver operating characteristic (ROC) curve. Cutoff of peak glycemia with respect to in-ICCU death.
Devices and inotropes were more frequently used in patients in the third tertiles (Table 2). A cutoff of 1.91 g/l peak glycemia was identified with C-statistic as significantly related to an in-ICCU higher mortality rate: AUC, 0.81 (95% CI = 0.74 to 0.87), p b 0.001; sensitivity, 75% (95% CI = 69% to 81%); specificity, 76% (95% CI = 59% to 87%); predictive value of positive test, 95% (95% CI = 90% to 97%); predictive value of negative test, 34% (95% CI = 24% to 45%) (Fig. 1). Peak glycemia showed a higher unadjusted OR (crude OR = 5.37; 95% CI = 3.01 to 9.58, p b 0.001, Wald 32.49) than admission glycemia (crude OR = 3.18; 95% CI = 1.94 to 5.21, p b 0.001, Wald 21.09).
At logistic regression analysis, peak glycemia and admission left ventricular ejection fraction were independent predictors of inICCU mortality (Peak glycemia (1 g/L step): OR = 3.76, 95% CI = 1.71 to 8.23, p b 0.001; admission LVEF (1% step) OR = 0.93, 95% CI = 0.88 to 0.99, p = 0.022, respectively), whereas admission insulin values were not (Insulin (1 IU/L step) OR = 0.99, 95% CI =0.98 to 1.01, p = 0.253). The main finding of the present investigation is that in-hospital peak glycemia is an independent predictor for in-ICCU death in consecutive patients with AHF complicating ACS and without previously known diabetes.
Table 2 Laboratory data, devices and inotropic drugs. 1st tertile n = 91 pts
2nd tertile n = 91 pts
3rd tertile n = 91 pts
p
Admission GFR (ml/min/1.73 m2) Nadir GFR (ml/min/1.73 m2) Discharge GFR (ml/min/1.73 m2) Admission glucose (g/l) Peak glucose (g/l) HbA1c ≥ 6.5% HbA1c (%) Insulinemia (IU/L) HOMA positivity HOMA index (units) Uric acid Peak Tn I (ng/ml) NT-proBNP (pg/ml) Positive CRP Fibrinogen (mg/dl) Leukocytes (*1000/μL)
83.7 (61.8 to 108.2) 65.1 (50.1 to 88.7) 78.9 (55.7 to 102.0) 1.05 (0.95 to 1.18) 1.21 (1.09 to 1.31) 7/66 (10.6) 5.7 (5.4 to 6.0) 6.6 (4.5 to 12.4) 0/68 (0.0) 0.29 (0.21 to 0.56) 6.4 ± 1.7 27.6 (5.8 to 181.9) 2811 (1201 to 8472) 52/70 (74.3) 479 ± 115 9.18 (7.03 to 11.30)
69.4 (46.1 to 95.8) 56.5 (33.0 to 76.7) 65.7 (40.6 to 86.8) 1.42 (1.20 to 1.56) 1.61 (1.50 to 1.74) 7/69 (10.1) 5.9 (5.6 to 6.2) 8.3 (5.0 to 15.7) 9/76 (11.8) 0.49 (0.28 to 1.03) 6.9 ± 2.3 72.0 (18.6 to 229.1) 6182 (2065 to 15099) 60/78 (76.9) 491 ± 126 12.30 (9.39 to 14.50)
60.9 (41.8 to 83.9)§,‡ 40.7 (26.9 to 60.7) 58.3 (35.6 to 76.9) 1.92 (1.42 to 2.42) 2.30 (2.04 to 2.68) 14/60 (23.3) 5.9 (5.6 to 6.4) 14.2 (15.6 to 41.2) 25/65 (38.5) 1.16 (0.49 to 4.04) 6.9 ± 2.5 117.0 (43.4 to 299.9) 5578 (1685 to 14381) 54/67 (80.6) 481 ± 157 13.03 (10.10 to 15.10)
b0.001 b0.001 b0.001 b0.001 b0.001 0.058 0.025 b0.001 b0.001 b0.001 0.198 b0.001 0.020 0.677 0.817 b0.001
Devices Mechanical ventilation Non invasive ventilation CVVHDF IABP
7 (7.7) 4 (4.4) 2 (2.2) 16 (17.6)
11 (12.1) 15 (16.5) 12 (13.2) 24 (26.4)
33 (36.3) 20 (22.0) 23 (25.3) 38 (41.8)
b0.001 0.002 b0.001 0.001
Inotropic agents Norepinephrine Dobutamine Dopamine
3 (3.3) 6 (6.6) 17 (18.7)
12 (13.2) 20 (22.0) 44 (48.4)
34 (37.4) 26 (28.6) 56 (61.5)
b0.001 b0.001 b0.001
Values are medians (IQR), means ± SD or frequencies (%) as appropriate. BMI: body mass index; GFR: glomerular filtration rate; HbA1c: glycosilated hemoglobin; HOMA: homeostatic model assessment; AST: aspartate transferase.; ALT: alanine transferase; GGT: gamma glutamyl transferase; Tn: troponin; NT-proBNP: N terminal-pro brain natriuretic peptide; CRP: C-reactive protein; HDL: high-density lipoprotein; LDL: low-density lipoprotein. CVVHDF: continuous venous-venous ultradiafiltration, IABP: intra-aortic balloon pump.
Please cite this article as: Lazzeri C, et al, In-hospital peak glycemia in non-diabetic patients with heart failure complicating acute coronary syndrome, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.06.055
C. Lazzeri et al. / International Journal of Cardiology xxx (2014) xxx–xxx
This is the first investigation assessing the prognostic role of in-ICCU glucose values, since previous studies considered only admission glycemia [6–10]. No clear recommendation is available concerning in-hospital management of hyperglycemia in AHF patients, especially in those without previously known diabetes. The only recommendation provided by guidelines [2–4] is that elevated glucose values should be treated with tight glycemic control in patients with diabetes mellitus, but no glucose threshold is provided. In our series, a cutoff glucose value of 1.91 g/dl was found to be related to a higher in-ICCU mortality, which should be confirmed in a treatment trial performed in a larger cohort of AHF patients. In our population, a worse in-ICCU glycemic control (as indicated by higher values of peak glycemia) was detectable in the sickest patients characterized a greater hemodynamic instability (as inferred by lower LVEF values and a higher use of devices and inotropic drugs) and a more severe renal impairment. On a clinical ground, our data strongly suggest that glucose values should be strictly monitored and controlled during ICCU stay, especially in the sickest AHF patients, since glycemia is a modifiable factor with a high prognostic impact. Conflict of interest No conflict of interests. References [1] Allen LA, Hernandez AF, O'Connor CM, Felker GM. End points for clinical trials in acute heart failure syndromes. J Am Coll Cardiol 2009;53(24):2248–58. [2] Weintraub NL, Collins SP, Pang PS, et al. Acute heart failure syndromes: emergency department presentation, treatment, and disposition: current approaches and future aims. A scientific statement from the American Heart Association. Circulation 2010;122(19):1975–96. [3] Task Force for Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of European Society of Cardiology, Dickstein K, Cohen-Solal A, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the
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Please cite this article as: Lazzeri C, et al, In-hospital peak glycemia in non-diabetic patients with heart failure complicating acute coronary syndrome, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.06.055
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
In-hospital peak glycemia in non-diabetic patients with heart failure complicating acute coronary syndrome Chiara Lazzeri ⁎, Serafina Valente, Marco Chiostri, Maria Grazia D'Alfonso, Serena Fatucchi, Valerio Mecarocci, Gian Franco Gensini Intensive Cardiac Coronary Unit, Heart and Vessel Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
a r t i c l e
i n f o
Article history: Received 27 April 2014 Accepted 28 June 2014 Available online xxxx Keywords: Peak glycemia Acute heart failure Prognosis
Acute heart failure syndromes (AHF) remain a major cause of morbidity and mortality, in part because of the lack of definitive evidence for AHF management and risk stratification parameters [1], and there is a clinical need to identify clinical and/or laboratory tools useful for risk stratification in the AHF population [2]. The relation between glucose values and insulin resistance and mortality, both at short and long term [3–5], is still poorly understood and previous studies were based only on admission glucose level [6–10], while data on in-hospital glucose values are still lacking. The present investigation was aimed at assessing the prognostic role of admission and peak in-hospital glycemia in 273 consecutive patients with AHF complicating acute coronary syndrome (ACS) and without previously known diabetes, admitted to our Intensive Cardiac Care Unit (ICCU) from June 30, 2009 to December 31, 2012. Even if in all cases data were collected prospectively, the current study is a retrospective analysis of those data. The study population includes 141 patients with ST-elevation myocardial infarction (STEMI) (51.6%) and 132 (48.4%) patients with Non ST Elevation myocardial infarction (NSTEMI). All patients were submitted to coronary angiography. STEMI patients were admitted to our ICCU after mechanical revascularization. Among NSTEMI patients, 24 (18%) patients underwent urgent coronary artery bypass graft, while percutaneous coronary intervention was performed in 65 NSTEMI patients (49%) and medical therapy was administered to the remaining 43 NSTEMI patients (33%).
⁎ Corresponding author at: Intensive Cardiac Care Unit, Heart and Vessel Department, Viale Morgagni 85, 50134 Florence, Italy. Tel./fax: +39 55 7947518. E-mail address: [email protected] (C. Lazzeri).
The presence of comorbidities was determined by taking the patients' history directly [11]. On ICCU admission, in a fasting blood sample, the following parameters were measured: glucose (g/l), insulin (UI/L), troponin I (Tn I, ng/ml), uric acid (mg/dl), glycated hemoglobin (%), NT-pro Brain Natriuretic Peptide (NT-proBNP) (pg/ml), leukocytes count (*103/μl), fibrinogen (mg/dl) and lactate (mmol/l). Creatinine (mg/dl) was also measured in order to calculate glomerular filtration rate (ml/min/1.73 m 2 ) [12]. In all patients, glucose levels and Tn I were measured three times a day, and peak glycemia [13,14] and peak Tn I were considered, respectively. Acute insulin resistance was investigated by means of the homeostatic model assessment index (HOMA index), as previously described [15–17]. Intensive insulin therapy was administered in patients with significant hyperglycemia (that is plasma glucose N 180 g/l) [18]. The study population was divided according to tertiles of peak glycemia. Outcome was in-ICCU mortality. The study protocol was in accordance with the Declaration of Helsinki and approved by the local Ethics Committee. Informed consent was obtained in all patients before enrolment. Categorical values have been reported as frequency (percentage); continuous variables have been reported as mean ± SD or median (interquartile range, IR) as appropriate. Between-group comparisons were made by means of chi-square and ANOVA or Kruskal–Wallis test as needed. Logistic regression analysis, both uni- and multivariable, were carried out considering as outcome intra-ICCU mortality. Variables were chosen as those clinically related to in-ICCU death. A receiver operating characteristic (ROC) curve was plotted to identify a cutoff of peak glycemia with respect to in-ICCU death. A p value less than 5% has been taken as statistically significant (IBM-SPSS 20.0 for Windows® statistical software (IBM-SPSS Inc., USA)). Clinical characteristics of the study population are depicted in Table 1. Patients in the third tertile showed the highest percentage of STEMI, the highest incidence of COPD and the lowest values of admission and discharge LVEF. The highest in-ICCU mortality rate was observed in patients in the third tertile. Patients with the highest values of peak glycemia showed the highest admission glycemia levels and the highest incidence of HOMA-index and HOMA positivity. In the third subgroup, it was observed a progressive increase in leukocytes count, in NT-pro BNP levels and in peak Tn I.
http://dx.doi.org/10.1016/j.ijcard.2014.06.055 0167-5273/© 2014 Published by Elsevier Ireland Ltd.
Please cite this article as: Lazzeri C, et al, In-hospital peak glycemia in non-diabetic patients with heart failure complicating acute coronary syndrome, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.06.055
2
C. Lazzeri et al. / International Journal of Cardiology xxx (2014) xxx–xxx
Table 1 Clinical characteristics according to peak glycemia tertiles.
STEMI (%) Age (years) Males/females BMI (kg/m2), mean ± SD History of, n (%) Previous CAD COPD Chronic renal failure Hypertension n (%) 0 comorbidity 1 comorbidity 2 comorbidities N2 comorbidities Admission EF (%) Discharge EF (%) In-ICCU mortality, n (%)
1st tertile n = 91 pts
2nd tertile n = 91 pts
3rd tertile n = 91 pts
p
39 (42.9) 70.7 ± 15.5 60/31 (65.9/34.1) 25.4 ± 3.9
43 (47.3) 72.6 ± 12.2 57/34 (62.6/37.4) 25.8 ± 5.3
59 (64.8) 73.3 ± 13.3 56/35 (61.5/38.5) 25.4 ± 3.8
0.007 0.396 0.815
30 (33.0) 8 (8.8) 5 (5.5) 53 (58.2) 9 (9.9) 25 (27.5) 29 (31.9) 28 (30.7) 39.1 ± 8.9 41.1 ± 8.3 1 (1.1)
29 (31.9) 13 (14.3) 13 (14.3) 55 (60.4) 4 (4.4) 18 (19.8) 34 (37.4) 35 (38.4) 36.4 ± 9.0 38.3 ± 8.3 9 (9.9)
34 (37.4) 21 (23.1) 8 (8.8) 56 (61.5) 11 (12.1) 32 (35.2) 20 (22.0) 28 (30.7) 30.7 ± 9.4⁎ 33.4 ± 8.3⁎ 30 (33.0)
0.710 0.027 0.125 0.899 0.117
0.783
b0.001 b0.001 b0.001
Pts: patients; SD: standard deviation; STEMI: ST elevation myocardial infarction; BMI: body mass index; CAD: coronary artery disease; COPD: chronic obstructive pulmonary disease; EF: ejection fraction. ⁎ p b 0.05 vs. other groups at Bonferroni post hoc test.
Fig. 1. A receiver operating characteristic (ROC) curve. Cutoff of peak glycemia with respect to in-ICCU death.
Devices and inotropes were more frequently used in patients in the third tertiles (Table 2). A cutoff of 1.91 g/l peak glycemia was identified with C-statistic as significantly related to an in-ICCU higher mortality rate: AUC, 0.81 (95% CI = 0.74 to 0.87), p b 0.001; sensitivity, 75% (95% CI = 69% to 81%); specificity, 76% (95% CI = 59% to 87%); predictive value of positive test, 95% (95% CI = 90% to 97%); predictive value of negative test, 34% (95% CI = 24% to 45%) (Fig. 1). Peak glycemia showed a higher unadjusted OR (crude OR = 5.37; 95% CI = 3.01 to 9.58, p b 0.001, Wald 32.49) than admission glycemia (crude OR = 3.18; 95% CI = 1.94 to 5.21, p b 0.001, Wald 21.09).
At logistic regression analysis, peak glycemia and admission left ventricular ejection fraction were independent predictors of inICCU mortality (Peak glycemia (1 g/L step): OR = 3.76, 95% CI = 1.71 to 8.23, p b 0.001; admission LVEF (1% step) OR = 0.93, 95% CI = 0.88 to 0.99, p = 0.022, respectively), whereas admission insulin values were not (Insulin (1 IU/L step) OR = 0.99, 95% CI =0.98 to 1.01, p = 0.253). The main finding of the present investigation is that in-hospital peak glycemia is an independent predictor for in-ICCU death in consecutive patients with AHF complicating ACS and without previously known diabetes.
Table 2 Laboratory data, devices and inotropic drugs. 1st tertile n = 91 pts
2nd tertile n = 91 pts
3rd tertile n = 91 pts
p
Admission GFR (ml/min/1.73 m2) Nadir GFR (ml/min/1.73 m2) Discharge GFR (ml/min/1.73 m2) Admission glucose (g/l) Peak glucose (g/l) HbA1c ≥ 6.5% HbA1c (%) Insulinemia (IU/L) HOMA positivity HOMA index (units) Uric acid Peak Tn I (ng/ml) NT-proBNP (pg/ml) Positive CRP Fibrinogen (mg/dl) Leukocytes (*1000/μL)
83.7 (61.8 to 108.2) 65.1 (50.1 to 88.7) 78.9 (55.7 to 102.0) 1.05 (0.95 to 1.18) 1.21 (1.09 to 1.31) 7/66 (10.6) 5.7 (5.4 to 6.0) 6.6 (4.5 to 12.4) 0/68 (0.0) 0.29 (0.21 to 0.56) 6.4 ± 1.7 27.6 (5.8 to 181.9) 2811 (1201 to 8472) 52/70 (74.3) 479 ± 115 9.18 (7.03 to 11.30)
69.4 (46.1 to 95.8) 56.5 (33.0 to 76.7) 65.7 (40.6 to 86.8) 1.42 (1.20 to 1.56) 1.61 (1.50 to 1.74) 7/69 (10.1) 5.9 (5.6 to 6.2) 8.3 (5.0 to 15.7) 9/76 (11.8) 0.49 (0.28 to 1.03) 6.9 ± 2.3 72.0 (18.6 to 229.1) 6182 (2065 to 15099) 60/78 (76.9) 491 ± 126 12.30 (9.39 to 14.50)
60.9 (41.8 to 83.9)§,‡ 40.7 (26.9 to 60.7) 58.3 (35.6 to 76.9) 1.92 (1.42 to 2.42) 2.30 (2.04 to 2.68) 14/60 (23.3) 5.9 (5.6 to 6.4) 14.2 (15.6 to 41.2) 25/65 (38.5) 1.16 (0.49 to 4.04) 6.9 ± 2.5 117.0 (43.4 to 299.9) 5578 (1685 to 14381) 54/67 (80.6) 481 ± 157 13.03 (10.10 to 15.10)
b0.001 b0.001 b0.001 b0.001 b0.001 0.058 0.025 b0.001 b0.001 b0.001 0.198 b0.001 0.020 0.677 0.817 b0.001
Devices Mechanical ventilation Non invasive ventilation CVVHDF IABP
7 (7.7) 4 (4.4) 2 (2.2) 16 (17.6)
11 (12.1) 15 (16.5) 12 (13.2) 24 (26.4)
33 (36.3) 20 (22.0) 23 (25.3) 38 (41.8)
b0.001 0.002 b0.001 0.001
Inotropic agents Norepinephrine Dobutamine Dopamine
3 (3.3) 6 (6.6) 17 (18.7)
12 (13.2) 20 (22.0) 44 (48.4)
34 (37.4) 26 (28.6) 56 (61.5)
b0.001 b0.001 b0.001
Values are medians (IQR), means ± SD or frequencies (%) as appropriate. BMI: body mass index; GFR: glomerular filtration rate; HbA1c: glycosilated hemoglobin; HOMA: homeostatic model assessment; AST: aspartate transferase.; ALT: alanine transferase; GGT: gamma glutamyl transferase; Tn: troponin; NT-proBNP: N terminal-pro brain natriuretic peptide; CRP: C-reactive protein; HDL: high-density lipoprotein; LDL: low-density lipoprotein. CVVHDF: continuous venous-venous ultradiafiltration, IABP: intra-aortic balloon pump.
Please cite this article as: Lazzeri C, et al, In-hospital peak glycemia in non-diabetic patients with heart failure complicating acute coronary syndrome, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.06.055
C. Lazzeri et al. / International Journal of Cardiology xxx (2014) xxx–xxx
This is the first investigation assessing the prognostic role of in-ICCU glucose values, since previous studies considered only admission glycemia [6–10]. No clear recommendation is available concerning in-hospital management of hyperglycemia in AHF patients, especially in those without previously known diabetes. The only recommendation provided by guidelines [2–4] is that elevated glucose values should be treated with tight glycemic control in patients with diabetes mellitus, but no glucose threshold is provided. In our series, a cutoff glucose value of 1.91 g/dl was found to be related to a higher in-ICCU mortality, which should be confirmed in a treatment trial performed in a larger cohort of AHF patients. In our population, a worse in-ICCU glycemic control (as indicated by higher values of peak glycemia) was detectable in the sickest patients characterized a greater hemodynamic instability (as inferred by lower LVEF values and a higher use of devices and inotropic drugs) and a more severe renal impairment. On a clinical ground, our data strongly suggest that glucose values should be strictly monitored and controlled during ICCU stay, especially in the sickest AHF patients, since glycemia is a modifiable factor with a high prognostic impact. Conflict of interest No conflict of interests. References [1] Allen LA, Hernandez AF, O'Connor CM, Felker GM. End points for clinical trials in acute heart failure syndromes. J Am Coll Cardiol 2009;53(24):2248–58. [2] Weintraub NL, Collins SP, Pang PS, et al. Acute heart failure syndromes: emergency department presentation, treatment, and disposition: current approaches and future aims. A scientific statement from the American Heart Association. Circulation 2010;122(19):1975–96. [3] Task Force for Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of European Society of Cardiology, Dickstein K, Cohen-Solal A, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the
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Please cite this article as: Lazzeri C, et al, In-hospital peak glycemia in non-diabetic patients with heart failure complicating acute coronary syndrome, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.06.055